Deficiency Text Not Available

Deficiency Text Not Available

Deficiency Text Not Available

Deficiency Text Not Available

Based on observation, interview, and record review, the facility failed to maintain a system that assured full, complete, and separate accounting of each resident's personal funds when one staff (Activity Director) had the money of one resident (Resident #49) placed in his/her own personal account for resident shopping without facility maintained record keeping regarding the transactions. The resident census was 104. Review of the facility policy titled, Management of Resident's Personal Funds, revised March 2021, showed the following: -The resident may manage his or her own personal funds; -The resident may designate a representative to manage his or her personal funds; -The resident may apply to the Social Security Administration to have a representative payee designated for purposes of federal and state benefits to which he or she may be entitled; -The resident may have the facility hold, safeguard, and manage his or her personal funds; -Should the resident elect to have the facility manage his or her personal funds, it is authorized in writing by the resident or the resident's representative, and a copy of such authorization is documented in the resident's medical record; -Should the facility manage the resident's funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident. No service charge is levied against the resident for the management of personal funds. -The resident is informed in advance of any charges imposed to his/her personal funds; -Copies of all financial transactions are filed in the resident's permanent records; -The resident may withdraw his or her request for the facility to manage his or her personal funds at any time by submitting a written notice to the administrator; -Inquiries concerning the facility's management of resident funds are referred to the administrator or to the business office. 1. Review of Resident # 49's face sheet showed admission date of 12/03/19. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 03/24/25, showed the resident was cognitively intact and exhibited no behavior symptoms. Observation and interview with the resident on 04/14/25, at 1:30 P.M., showed the following: -The resident said on Tuesday of each week, the Activity Director (AD) goes to Wal-Mart and purchases items for some of the residents, but none of the residents were allowed to go shopping; -The resident said he/she typically looks up his/her items on Wal-Mart.com and places the items in the virtual basket to get a total cost for his/her needed items; -The resident said he/she then cash apps the AD his/her money and the AD goes to Wal-Mart and makes the purchases for the resident; -The resident said when the AD returned to the facility, he/she brought the items to the resident and along with a receipt with the total cost. If the resident sent more money to the AD than what the items cost, the AD refunded the difference to the resident's cash app, if the resident owes more money, the resident sent more to the AD's cash app. The resident kept the receipts and the AD did not have the resident sign anything for proof of the transaction. During an interview on 04/15/25, at 4:30 P.M., the AD said the following: -He/she went to Wal-Mart each Tuesday to shop for the residents; -The resident routinely used a cash app to send the AD money for his/her order in advance of the Wal-Mart trip along with a list of items needed; -The resident sent this money to the AD's personal cash app card on his/her phone; -When the AD returns to the resident with the order, the AD and resident review the amount on the receipt and either the resident cash app's the AD more money or the AD returns any extra money to the resident; -The AD left each receipt with the residents and did not ask for a signature of a copy of the receipt; -The AD said she had done this type of transaction with the resident for six months or more. Review of the resident and facility records showed no signed agreement of staff use of resident funds no tracking of the transaction between the resident, the AD, and the store. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she was not aware of any residents sending money to staff via cash applications, but that should not be happening; -In general, staff cannot take resident money; -All resident money transactions must go through the business office. During an interview on 04/15/25, at 2:35 P.M., the Director of Nursing (DON) said the following: -He/she was not aware the AD was accepting resident funds into his/her private account; -The facility's expectation would be for any resident money transactions to be handled through the business office. During an interview on 04/15/25 at 3:44 P.M., the Administrator said the following: -The AD should not have been receiving money from the resident into his/her personal cash app account for purchases; -The business office was not aware the AD was doing this; -A resident fund account would need to be set up or the resident can make his/her own purchases, if he/she preferred.

Based on observation, interview, and record review, the facility failed to protect each resident's right to be free from abuse from staff, when a staff member continued to provide cares to a resident against the resident's wishes and refusals for one resident (Resident #17). The facility had a census of 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, or misappropriation of resident property (deliberate misplacement, exploitation), by employees, family members, visitors, or other residents; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, or good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents,irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including the abuse facilitated or enabled through the use of technology. Willful, laws used in the definition of abuse, means the individual must have acted deliberately, no that the individual must have intended to inflict injury or harm. 1. Review of Resident #17's face sheet showed the following: -admission date of 11/26/24; -Resident on hospice services; -Diagnoses included stroke with right sided hemiplegia (paralysis of one side of the body) and hemiparesis (partial paralysis on one side of the body), respiratory failure, depression, and osteoarthritis (a degenerative joint disease where the cartilage that cushions the ends of bones wears away over time). Review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated assessment tool completed by facility staff), dated 03/02/25, showed the following: -Cognitively intact; -Did not reject cares of exhibit any behavioral symptoms; -Functional limitation to range of motion in both lower extremities; -Dependent on staff for assistance with toileting hygiene, lower body dressing, and transfers; -Required substantial or maximal mobility assistance of staff with rolling left to right in bed, and with moving from lying to sitting or sitting to lying in bed; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised on 04/11/25, showed the following: -Resident required substantial to dependent staff assistance wish most activities of daily living (ADLs); -Resident was dependent on staff assistance with transfers, lower body dressing, and putting on/taking off footwear; -Resident required substantial assistance with bed mobility; -Resident is noted to be resistive to care, especially during incontinence cares. He/she has multiple bowel movements during the night and does not want to be changed more than a couple of times. He/she believes staff is being rough with him/her if they need to change him/her more that he/she would like; -Resident has noted to swing out at staff during incontinent cares; -Educate the resident/family/caregiver on the possible outcomes of not complying with treatment or care; -Give clear explanation of all care activities prior to and as they occur during each contact; -If the resident resists with ADLs, reassure the resident, leave and return 5 to 10 minutes later and try again; -If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time; -Provide the resident with opportunities for choice during provision; -Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as mush as possible; -Staff to have the charge nurse explain to the resident why changing in necessary due to his/her wound and encourage/assist with changing. Review of the facility's abuse investigation involving the resident showed the following: -On 04/07/25, at 10:30 A.M., a hospice nurse reported the resident said one of the aides, working on the night of 04/06/25, rolled the resident over and the resident said the aide hurt him. The charge nurse and hospice nurse assessed the resident and found no injuries. The resident said the aide wiped his/her buttocks too hard and was rough. The facility began an investigation, notified the Department of Health and Senior Services (DHSS), and suspended the alleged perpetrator (AP), Certified Nurse Assistant (CNA) T. The CNA said he/she was unaware of any issues or concerns with the resident or his/her care of the resident. Other residents and staff interviewed denied any abuse; -On 04/10/25, after completing interviews, the management team met and did not feel this was abuse and that staff needed to involve the charge nurse when the resident was denying cares. Hospice also saw the resident twice per week and had seen no issues with any staff. The hospice aide did say the resident required encouragement to take a shower or a bed bath; -At that time, the facility took CNA T off of suspension and allowed him/her to return to work. The resident said he/she was okay with the CNA taking care of him/her and said, I don't care. I just want to sleep at night. Staff explained to the resident the importance of cleaning up after incontinence for the resident's skin. The resident said, I know, okay, yeah, yeah, I get it. During an interview on 04/14/25, at 11:55 A.M., CNA T said the following: -The facility suspended him/her because the resident said he/she was too aggressive during cares; -He/she recalled a few nights prior when the resident was cranky with CNA T and did not want to be changed after an incontinent episode; -At times, the resident did not like for staff to wake him/her up at night, even to change after incontinence of bowel or bladder; -The aide said when the resident refused to be changed, he/she changed the resident anyway; -The resident would say things like, I'm gonna turn you in, and Leave me alone, I'm trying to sleep, but when the resident said these things the aide continued on with changing the resident; -At times, the resident would yell, No! and would kick at the aide during cares; -When asked if he/she had ever reported the resident's refusals to a nurse, the aide said he/she did not believe so; -The aide said he/she did not want the resident to lay wet or soiled because that would be bad for the resident's skin. Observation and interview of the resident on 04/14/25, at 1:35 P.M., showed the following: -The resident lay on his/her bed. The resident's bed was against the wall one one side; -The resident said there were approximately three aides (unsure of names) on the night shift who insisted on changing his/her incontinent brief/bedding when he/she did not want to be changed; -He refused care at times because these staff wipe his/her buttocks roughly. He/she refused to be changed after incontinent episodes at times due to the aides wiping him/her rough and turn him/her roughly and quickly. -If the staff were not rough, he/she would not refuse to be changed. During an interview on 04/15/25, at 10:16 A.M., Licensed Practical Nurse (LPN) W said the following: -If the resident refused or was resistive to being changed after an incontinent episode, the CNA should notify the charge nurse; -As a charge nurse, LPN W would advise the CNA to step away for a few minutes and attempt to re-approach or get someone else to try to talk with the resident; -Forcing cares on a resident would be considered abuse. During an interview on 04/15/25, at 12:13 P.M., Certified Nurse Aide (CNA) X said the following: -The resident refused to get out of bed at times; -He/she allowed some staff to care for him/her and refused other staff; -The resident said one girl on the night shift was a little rough with cares; -If the resident refused assistance with changing after incontinence, the aide should ask a different co-worker to try; -If the resident refused the second aide, the aides should notify the charge nurse of the resident's refusals; -The resident had the right to refuse cares. During an interview on 04/15/25 at 1:17 P.M., the MDS Coordinator/Infection Preventionist said the following: -He/she worked as an MDS Coordinator and nurse aide educator, but occasionally worked caring for residents; -If a resident refused cares, the aide should stop and notify the charge nurse and the nurse should go in an investigate the reason for the resident's refusal. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -The resident reported CNA T wiped his/her bottom too hard, but did not say staff were forcing care after he/she refused; -If a resident refused care, the CNA should have stopped and reported to the nurse; -The resident has the right of refusal; -The ADON said he/she asked the CNA if he/she rolled the resident too hard or forced him/her to roll over and the aide denied the allegations; -The CNA did not mention the resident was adamantly refusing cares; -It was not appropriate for staff to force a resident to do anything against their will; -The facility suspended the CNA during the investigation, but did not find any abuse. During an interview on 04/15/25 at 2:34 P.M., the Director of Nursing, said the following: -The ADON interviewed the CNA about the resident's allegation and the CNA said the resident had frequent bowel movements; -The aide said the resident declined the cares a lot; -The aide did not report this and he/she continued care after the resident refused; -If the resident refused cares, the aide should have left the room, and asked a different aide to attempt cares and tried a different approach to getting the resident to cooperate or ask the charge nurse for assistance; -Staff should not force cares on the resident because the resident had the right to refuse care and forcing care would be kind of like abuse. During an interview on 04/15/25 at 3:41 P.M., the facility Administrator said the following: -If a resident refused care, the aide should go and get another aide to try and assist the resident; -The aide should never force cares on a resident; -Making a resident do something against their will would be abuse; -The Administrator said the facility would be again suspending CNA T, in light of the new information of him/her allegedly forcing cares and conducting an investigation. MO00252384, MO00252718, MO00252720

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents from misappropriation of personal property when a staff member took two narcotic pain medication tablets from Resident #5's supply and when Resident #6, had over $700 of fraudulent purchases on his/her debit card made by a facility employee. The effected two sampled residents. The facility census was 98. Review of the facility policy titled, Abuse Prevention Program, dated 1999, showed the following: -Objective: Zero tolerance of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, or other residents; -To develop and implement a system for identifying, preventing, and reporting any incident, or suspected incident, of abuse, neglect, mistreatment, or misappropriation of resident property; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent; -The Administrator shall keep the resident and/or his/her responsible party informed of the progress and the results of the investigation. 1. Review of Resident #5's face sheet showed: -Diagnoses of chronic pain, low back pain, anxiety disorder, major depression, and stroke. Review of the resident's care plan, revised on 05/25/25, showed: -Resident is at risk for increased pain and discomfort related to a diagnosis of chronic pain; -Follow up with the resident's physician and pain management as needed; -Medication provided as prescribed; -Monitor for effectiveness of medication; -Monitor for increased pain and discomfort; -Provide diversionary activities as needed; -Therapy to screen quarterly and as needed. Review of the resident's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 05/28/25, showed: -Cognitively intact; -Independent with most activities of daily living (ADLs); -No behavioral symptoms; -Diagnoses of schizophrenia, anxiety, and depression; -Staff administered as needed (PRN) pain medication; -Resident expressed frequent complaints of pain and rated his/her pain at an '8' (on a numeric scale of 0-10, with 10 being the most severe pain). Review of the resident's physician orders showed an order, dated 05/16/25, for Hydrocodone-Acetaminophen (Norco- a pain medication) oral tablet 5/325 milligram (mg). Staff to administer one tablet by mouth every 6 hours as needed for pain. Review of the resident's medication administration record for May 2025, showed: -An order for Hydrocodone-Acetaminophen oral tablet 5/325 mg. Give one tablet by mouth every 6 hours as needed for pain; -On 05/19/25 at 8:20 A.M., staff administered a dose of the medication for a pain level of '8' with effective results; -On 05/19/25 at 7:47 P.M., staff documented administration of a dose of the pain medication for a pain level of '9' with effective results; -Staff did not document administration of any other doses of the pain medication on 05/19/25. -Certified Medication Technician (CMT) D did not document he/she administered any doses of the resident's pain medication on the MAR on 5/19/25. Review of the resident's-controlled medication count sheet showed the following information: -Drug name: Norco 5/325 mg; -Directions: one tablet by mouth every 6 hours as needed for pain (PRN). Review of the facility's-controlled drug count signature page showed the following: -On 05/19/25 at 2:00 P.M., CMT D signed as the incoming staff; -On 05/19/25 at 10:00 P.M., CMT D signed as the outgoing staff; -On 05/19/25 at 10:00 P.M., Registered Nurse (RN) E signed as the incoming staff. Review of the resident's progress notes showed: -No entries dated 05/19/25. Review of the resident's Medication Administration Record (MAR) for May 2025 showed: -An order for Hydrocodone-Acetaminophen oral tablet 5/325 mg. Give one tablet by mouth every 6 hours as needed for pain; -On 05/20/25 at 10:45 A.M., a nurse documented administration of one dose of the medication for a pain level of '8' with effective results. Review of the resident's-controlled medication count sheet showed the following information: -Drug name: Norco 5/325 mg; -Directions: one tablet by mouth every 6 hours as needed for pain (PRN); -On 05/20/25 at 10:45 A.M., LPN A signed out one tablet of the medication for administration; On 05/20/25 at 6:45 P.M., LPN A and the ADON destroyed one tablet of the medication and did a corrected count. Review of the resident's progress notes showed: -No entries dated 05/20/25. During a phone interview on 06/05/25 at 1:21 P.M., Registered Nurse (RN) E said the following: -He/she worked full time at the facility 3:00 P.M. to 3:00 A.M., or sometimes until 7:00 A.M.; -On the night of 05/19/25 at around 11:00 P.M., CMT D was preparing to leave for the night (at the end of the CMT's shift); -RN E counted the controlled medications with CMT D and found Resident #6's Norco card contained 2 pills less than what the controlled medication count showed he/she should have in the medication card; -The CMT was unsure what happened to the medications; -RN E refused to take over responsibility for the cart with 2 missing pills; -The CMT went outside to his/her car and returned and said he/she was now ready to count; -The RN thought the CMT might have brought the pills inside from his/her car, but the replaced pills matched the exact appearance and number as the pills already in the card; -The CMT taped the 2 pills into the card and the nurse assumed responsibility for the cart and the CMT went home; -On 05/20/25 at approximately 5:00 P.M., RN E notified the ADON and the Administrator that CMT D taped two pills into Resident #5's Norco card on 05/19/25; -The ADON immediately audited the entire cart and removed the remaining taped in pill; -RN E said he/she did not think about the potential danger of the medication; -RN E said he/she assumed maybe the CMT had stolen and then returned the medications due to the count being short; -RN E said he/she sat in on a meeting with CMT D on 05/20/25 along with the DON, ADON, and Administrator; -During the meeting, CMT D said he/she had a personal prescription for Norco and on the night of 05/19/25, when he/she could not locate 2 of Resident #5's Norco, he/she went to his/her own car and pulled 2 pills from his/her prescription bottle to replace the resident's missing Norco tablets. He/she then taped the 2 pills into the resident's medication card; -CMT D denied taking any of the resident's pain medications, but said he/she was unsure where the two resident Norco tablets were; -In the meeting, the ADON said the nurse was supposed to sign with the CMT when administering PRN pain medications, but he/she was not aware of that before the meeting; -Generally, RN E assessed a resident's pain and documented the administration of the PRN medications on the resident's MAR, as well as the resident's pain level; -The CMTs generally gave residents their PRN pain medication and signed them off on the controlled medication count sheet. During an interview on 06/04/25 at 1:43 P.M., Resident #5 said the following: -He/she had chronic back pain and staff administered as needed (PRN) pain medication to treat the resident's pain; -The resident was not aware of any misappropriation of his/her property or medications. During an interview on 06/04/25 at 3:21 P.M., the Assistant Director of Nursing (ADON) said the following: -On 05/20/25, RN E reported that on the night of 05/19/25 at approximately 10:00 P.M., RN E began his/her shift and started counting the narcotics with off going Certified Medication Technician (CMT), CMT D. At that time, Resident #5's Norco medication card was short by 2 tablets when compared to the narcotic count sheet. RN E refused to accept the cart because of the missing pills. CMT E told the RN E, he/she had a personal prescription for the exact same medication in his/her vehicle and went out to his/her vehicle and came back in with two loose pills. CMT E then taped the pills into the resident's medication card. On 05/20/25, the ADON checked the resident's Norco card and found Licensed Practical Nurse (LPN) A administered one of the taped in pills earlier on 05/20/25 and the ADON and another nurse destroyed the second taped in pill. During a phone interview on 06/05/25 at 11:38 A.M., Pharmacist H, a representative of the facility's local pharmacy said the following: -It is not acceptable practice for an employee to take their personal prescription medication and place that medication in a resident's medication card and/or to administer that medication to a resident. During a phone interview on 06/05/25 at 4:08 P.M., CMT D said the following: -On the night of 05/19/25, he/she counted the cart by him/herself, and the controlled medication count was correct; -CMT D then gave his/her medication cart keys to RN E and finished his/her charting; -Approximately one hour later, he/she returned to count the controlled medications with RN E and at that time Resident #5's Norco card was 2 pills short according to the count sheet; -The CMT said he/she freaked out and went to his/her car and obtained 2 of his/her own personal Norco which were the same exact strength and taped his/her personal medication into the resident's Norco card, so the count would be correct; -When he/she returned to work on the afternoon of 05/20/25, he/she was told by the DON and ADON to come to the office and he/she told the DON, ADON, Administrator what he/she had done; -He/she had never taken any resident medications out of the facility or for personal use; -RN E was aware the CMT went to his/her car and obtained the 2 pills and RN E did not say anything about not doing it at the time; The CMT said he/she had never misappropriated any resident medication, but was unsure what happened to the resident's two Norco; -CMT D said he/she should not have replaced the resident's missing medication with his/her own personal medication and that it was, The dumbest thing I've ever done in my life. During an interview on 06/05/25 at 5:40 P.M., the Administrator said the following: -Two staff (nurses or CMTs), the oncoming and off going, should count the controlled resident medications at the beginning and end of each shift; -If the count is off, staff should do another count with another nurse, if the count is still off, the staff should contact the Administrator, or the ADON, DON, or on call nurse to notify of the situation; -CMT D should not have used personal medications to replace missing resident medications; -RN E should have reported immediately when this occurred. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed: -admitted to the facility on [DATE] from the hospital; -Cognitively intact; -Resident required partial to moderate assistance of staff with toileting, showers, dressing, and transfers; -Resident required use of a walker or a wheelchair for mobility. Review of the resident's January 2025 monthly bank statement for his/her Direct Express card (provided by the facility with erroneous charges highlighted) showed the following charges allegedly not made by the resident: -On 01/03/25 charge for $81.19 at Wal-Mart; -On 01/03/25 charge for $1.61 at Wal-Mart; -On 01/06/25 charge for $162.80 at Amazon.com; -On 01/07/25 charge for $44.42 at Amazon.com -On 01/07/25 charge for $31.36 at Wal-Mart; -On 01/07/25 charge for $36.10 at Amazon.com; -On 01/11/25 charge for $55.31 at Amazon.com; -On 01/24/25 charge for $60.49 at Amazon.com. Total for January 2025 = $473.28. Review of the resident's February 2025 monthly bank statement for his/her Direct Express Card (provided by the facility with erroneous charges highlighted) showed the following charges allegedly not made by the resident: -On 02/01/25 charge for $17.25 at Amazon.com -On 02/02/25 charge for $96.52 at Amazon.com -On 02/02/25 charge for $63.88 at Amazon.com -On 02/06/25 charge for $89.87 at Amazon.com -On 02/06/25 charge for $41.21 at Amazon.com Total for February 2025 = $308.73. January and February 2025 total charges = $782.01 Review of the resident's care plan, revised on 05/31/25, showed: -Resident is at risk for impaired social interactions and disorganized thought process related to a diagnoses of a personal history of traumatic brain injury and bipolar (manic/depression); -Self report made 05/20/25 of money misappropriation by an ex-staff member; -Resident will ask for assistance from Social Services (SS) or the office manager with his/her funds if he/she has any issues or questions; -Assist with financial concerns as needed. Review of the resident's progress notes showed no notes related to the resident's allegations of misappropriation of property. During an interview on 06/04/25 at 11:05 A.M., the Business Office Manager (BOM) said the following: -Resident #6 received a monthly social security benefit and social security placed the resident's money directly on a debit card, called a Direct Express card. -The previous Activity Director (AD) shopped for the residents at the facility and used the resident's Direct Express card for purchasing items for the resident, such as cigarettes; -On the morning of 05/20/25, Resident #6 told a staff member about a financial issue. The resident said sometime in February 2025, he/she had noticed a money shortage on his/her Direct Express money card. The resident requested a card replacement. Shortly after that occurred, the AD at that time came to the resident and said the AD's daughter had mistakenly used the resident's card for personal purchases. The AD and the resident went through the resident's financial statements and figured out which purchases were allegedly made by the AD's daughter. The AD said he/she would pay the money back by purchasing cigarettes and candy for the resident until the amount was paid off. The resident said he/she was okay with that arrangement, but once the former AD was terminated, the resident did not receive any more cigarettes, candy, or payments from the former AD; -Per the resident, the AD reported the allegation to the Administrator; -After discovering the issue, the BOM reviewed all transaction statements with the resident and came up with approximately $700.00 worth of purchases that the resident did not make. Some of these included items like blackout curtains, curtain rods, cleaning supplies, bras, and storage tubs. The resident did not have any of these items in his/her possession. During an interview on 06/05/25 at 11:37 A.M., Resident #6 said the following: -The resident had money taken from his/her debit card; -In December 2024 or January 2025, the resident had given the Activity Director (AD) his/her debit card to purchase the resident cigarettes and candy; -The resident suspected the AD had misappropriated approximately $700.00 dollars by making unauthorized purchases on his/her debit card during January-February 2025; -He/she discovered the unapproved debits on his/her debit card and the former AD admitted using the resident's debit card for his/her own purchases and promised to reimburse the resident by purchasing the resident cigarettes and candy, but once the facility fired the AD, the resident did not hear from the AD again; -The resident reported the situation to CNA G approximately 2 weeks ago; -This surveyor reviewed bank statements for January and February 2025 with the resident; -Resident #6 said he/she and the BOM had reviewed the bank statements and highlighted transactions which the resident did not authorize, this surveyor reviewed statements with resident and unauthorized purchases made in January and February 2025 totaled $782.01 and resident said that was correct and said he/she did not make those purchases. During a phone interview on 06/05/25 at 3:12 P.M., the former AD said the following: -In February 2025, Resident #6 claimed he/she did not make some of the purchases on his/her debit card; -The resident accused the former AD of making the charges for personal purchases; -The former AD said at that time, in February 2025, he/she reported the allegations to Social Services, and they assisted the resident in canceling his/her debit card and obtaining a new one; -The former AD said he/she overheard Resident #6 tell Staff F from the business office that someone was using his/her debit card for Amazon purchases; -The former AD said he/she had used the resident's card for purchases, but only for items the resident requested, and this occurred during December 2024, January 2025, and part of February 2025, but did not occur after the resident had his/her card canceled in February 2025; -The former AD said he/she did not use the resident's debit card for any personal purchases and did give the resident receipts for all purchases he/she made for the resident. During a phone interview on 06/05/25 at 4:23 P.M., Certified Nurse Assistant (CNA) G said the following: -On 05/19/25, Resident #6 informed CNA G that approximately 5-6 months prior, he/she caught the former AD stealing from him. Resident #6 said the former AD was using his/her debit card for purchases the resident had not approved and for items the resident did not receive; -The resident said he/she estimated the AD had stolen approximately $600.00 from his/her debit card; -The resident said at first the former AD said one of the AD's family members had accidentally used the card, but the former AD eventually confessed to using the resident's debit card for personal purchases; -The former AD told the resident he/she would start paying the resident back by purchasing the resident cigarettes and peanut candy; -The resident then said he/she had informed Social Services about the stolen money; -After the resident told CNA G about the stolen money, the CNA immediately reported the situation to another staff, and they called the DON and reported the resident's allegation. During an interview on 06/05/25 at 4:35 P.M., Social Services (SS) said the following: -During February 2025, Resident #6 came to SS and reported someone else was making purchases on his/her debit card; -SS assisted the resident in canceling the current debit card and ordering a new one so no one would use the card; -SS assisted the resident in reporting the fraudulent charges to the Direct Express Hotline; -The resident had recently been in jail and in the hospital before admitting to the facility in December of 2024; -The resident said the charges were from before becoming a resident of the facility; -The SS said he/she notified the facility Administrator of the resident's allegations of card fraud in February 2025; -The SS said he/she did not notify Adult Protective Services or the elder abuse hotline of the allegation and was unsure if the Administrator made a hotline call. During an interview on 06/05/25 at 4:45 P.M., Staff F said the following: -He/she worked in the business office; -In February 2025, Resident #6 reported to Staff F and to the former AD that he/she suspected someone took money from his/her card and the former AD told the resident he/she would review debit card statements with the resident; -Staff F did not report the resident's concerns to anyone, because he/she thought the former AD reported the issue to the Administrator. During an interview on 06/05/25 at 5:02 P.M., the Director of Nursing (DON) said the following: -Staff should not use resident debit cards for personal purchases or take any money from residents; -If a resident needed an item purchased, that transaction would need to go through the business office. During an interview on 06/05/25 at 5:40 P.M., the Administrator said the following: -The former AD was using Resident #6's debit card for resident purchases; -The AD did not notify the facility staff that she had used the resident's debit card to her own personal purchases; -If the resident reported fraudulent charges on his/her debit card to SS, then SS should have reported that allegation to the Administrator, but the SS had not notified the Administrator; -The Administrator became aware that the former AD was misappropriating money from Resident #6 approximately 2 weeks ago, at which time, the facility hotlined the allegation and began an investigation and notified the police; -The facility educated staff to not make any purchases for residents and not to assist resident's with any purchases -If resident's needed to purchase items, all transactions should go through the business office. MO00254534 MO00254563

Based on observation, interview, and record review the facility failed to ensure complete assessments regarding the appropriate use of a restraint before use when the facility failed to document an evaluation and consent for the use of a restraint, failed to obtain a physician order for restraint use, failed to care plan restraint use, and failed to document ongoing re-evaluations of the need for the restraint for one resident (Resident #77). The facility census was 104. Review of the facility's policy, titled Use of Restraints, revised April 2017, showed the following information: -Restraints may only be used if the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention, and a restraint is required to treat the medical symptom, protect the resident's safety, and help the resident attain the highest level of his/her physical and psychological well-being; -Prior to placing the restraint on the resident, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom to determine if there are less restrictive interventions that may improve symptoms; -Restraints shall only be used upon the written order of the physician after obtaining consent form the resident and/or responsible party; -Orders for restraints will not be enforced longer than twelve hours unless the resident's condition requires continued treatment; -Restraints with locking devices shall not be used; -The resident with restraints will be observed at least every thirty minutes by the nursing personnel and an count of the residents condition will be documented in the residents medical record; -Care plans for residents in restraints will reflect interventions that not only the immediate medical symptom, but underlying problems that may be causing the symptom; -Documentation regarding the restraint shall include a full documentation of the reason for use, a description of the resident's medical symptoms, how the restraint is beneficial, the type of restraint that is used, the length of effectiveness of the restraint time, and observation, range of motion, and repositioning flow sheets. 1. Review of the Resident #77's face sheet (brief look at resident information) showed the following: -admission date of 01/09/23; -Diagnoses included multiple sclerosis (MS - a chronic autoimmune disease that affects the central nervous system, disrupting communication between the brain and body), high blood sugar, diplopia ( double vision), and edema (swelling). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/10/25, showed the following: -Required partial to moderate assistance from staff to dress and undress above the waist, including fasteners; -Required substantial to maximum assistance from staff for mobility; -No physical restraints or alarms are used in or out of bed. Observation on 04/07/25, at 11:00 A.M., showed the resident sat in his/her motorized wheelchair with a seat belt attached around his/her lower abdomen, in his/her room. Observation and interview on 04/09/25, at 10:15 A.M., showed the resident sat in his/her motorized wheelchair with a seat belt attached around his/her lower abdomen. The resident said that he/she had the seat belt as a safety precaution. The resident had MS but did not walk so he/she didn't have any falls. He/she was not asked to sign any kind of consent for the seatbelt and had not been educated on any potential entrapment concerns. Observation on 04/15/25, at 1:00 P.M., showed the resident with his/her eyes closed in his/her motorized wheelchair with a seat belt attached around his/her lower abdomen, outside of the nurses' station on 200 hall. Review of the resident's care plan, revised 04/08/25, showed staff did not care plan related to the use of a restraint. Review of the resident's April 2025 Physician Order Sheet (POS) showed staff did not have a physician's order for the use of a restraint. Review of the resident's progress notes, dated 01/9/25 through 04/15/25, showed staff did not document regarding the use of a restraint and/or the resident's condition requiring need for the restraint. Review of the resident's medical record showed the staff did not have a consent and/or assessment regarding the use of a seatbelt restraint documented for the year of 2024 and the year of 2025. During an interview on 04/15/25, at 10:21 A.M., Certified Nursing Assistant (CNA) Q said the resident used a seatbelt. He/she was not aware of any process that needed to take place for the use of restraints. During an interview on 04/15/25, at 12:17 A.M., Certified Medication Technician, (CMT) R said the following: -Seatbelts can't be in place while the resident is eating; -Seatbelts have to be unbuckled every two hours; -A consent has to be obtained prior to the use of restraints; -Restraint use should be care planned. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the following: -There was an assessment that needed to be completed by the nurse on duty for restraints; -He/she was not sure what the assessment entailed, he/she had never filled one out; -A consent was needed for restraints; -Restraints should be care planned. During an interview on 04/15/25, at 1:17 A.M., the MDS Coordinator/Infection Preventionist (MDS/IP) said the following: -There had been an issue with care plan updates since changing to another electronic medical records (EMR) system in July 2024; -Restraints should be care planned. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -Staff should be able to tell everything about a resident and their care, by the care plan; -Restraints should be care planned; -She was not aware the resident used a seatbelt restraint; -The seatbelt should be assessed for proper fit, and educated on for strangulation; -Restraints require consents; -The seatbelt should be re-assessed quarterly and the findings should be documented. During an interview on 04/15/25, at 2:35 P.M., the Director of Nursing (DON) said the following: -If a resident had a seatbelt restraint, it should be checked on and removed frequently; -There was an assessment that was done on admission and quarterly for restraints, that should be documented; -A consent should also be completed for the use of restraints. During an interview on 04/15/25, at 3:44 P.M., the Administrator said the following: -An assessment for seatbelt restraints should be completed and documented on admission, for change of conditions, and quarterly; -A consent should be obtained prior to the use of the seatbelt restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when possible abuse was witnessed by staff involving two residents (Resident #32 and #57). The facility census was 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, or misappropriation of resident property (deliberate misplacement, exploitation), by employees, family members, visitors, or other residents. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and or injuries of unknown source, shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -An alleged violation involving abuse will be reported by the facility Administrator to the state licensing agency within two hours, local and state ombudsman, the residents represented, law enforcement officials, the resident's physical, and the facilities medical director. 1. Review of Resident #32's face sheet (brief look at resident information) showed the following information: -admission date of 03/20/20; -Diagnoses include high blood pressure, irregular heartbeat, and diabetes. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 03/26/25, showed the following information: -Moderate cognitive impairment; -Required substantial to maximum assistance from staff for bathing, toileting, and mobility; -No behavioral symptoms such as abusing others sexually, screaming at others, or disrobing. Review of the resident's care plan, revised 04/09/25, showed the resident required assistance from staff to complete daily tasks such as dressing and grooming. Review of the resident's progress note, dated 02/06/25, showed the resident was lethargic, felt sick, and was experiencing vomiting and chest pain. The resident was sent to the hospital via ambulance at 11:51 A.M. Review of the resident's admission History and Physical from the admitting hospital, dated 02/06/25, showed the following: -History received from the nurse at the long term care facility; -The nurse reports the resident was in a normal state of health until this morning. There was a naked resident who had jumped on top of him/her this morning and after this the resident became altered and was not able to speak; -The nurse also noticed the resident had a cough on this day, the nurse does not believe the naked resident hurt him/her; -The nurse denied the resident having any symptoms prior to this date; -The resident was diagnosed with sepsis (a life threatening medical emergency caused by the body's overwhelming response to an infection, often triggering a chain reaction that can lead to organ failure and death) and pneumonia ( a lung infection that causes inflammation and fluid buildup in the air sacs) while at the hospital and was discharged back to the facility on [DATE]. Review of the resident's progress notes, dated 02/06/25 through 04/06/25, showed staff did not document regarding the resident being involved in a possible sexual abuse allegations/incident. 2. Review of Resident #57's face sheet showed the following information: -admission date of 02/04/25; -Diagnoses included schizophrenia (a chronic mental disorder that affects a person's ability to think, feel, and behave), depression, and kidney disease. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 02/10/25, showed the following information: -Moderate cognitive impairment; -Requires partial to moderate assistance from staff for bathing and hygiene and is independent for mobility; -No behavioral symptoms such as abusing others sexually, screaming at others, or disrobing. Review of the resident's care plan, revised 04/09/25, showed the resident should be monitored for behaviors every shift related to medication use. Review of the resident's Nurse Practitioner visit note, dated 02/06/25, showed the following: -The resident was being seen for a new admission; -It was noted that this morning (02/06/25) the resident stripped down naked and jumped onto another resident who was lying in bed in his/her own room and this resident was making vulgar statements while on top of the other resident; -Staff reported the resident had been at baseline since the incident and there have been no further behaviors of this nature. Review of the resident's progress notes, dated 02/06/25 through 04/06/25, showed staff did not document regarding the resident being involved in a possible sexual abuse allegations/incident. 3. Review of DHSS records showed staff did not report the allegation of possible abuse involving Resident #32 and Resident #57. 4. During interviews on 04/11/25, at 1:40 P.M. and 2:40 P.M., Licensed Practical Nurse (LPN) W said the following: -Approximately one month ago, Resident #57 got on top of Resident #32; -LPN W could not remember the specifics and could not recall if the residents were clothed or not; -LPN W did not believe there was any sexual penetration and said neither resident had any injuries that he/she recalled; -LPN W said he/she thought he/she documented in the resident progress notes; -The LPN looked in the electronic health record, but was unable to find documentation about the resident to resident interaction in either resident's medical record; -LPN W said he/she guessed he/she did not document in the resident's progress note as he/she should have; -If he/she was working at the time of the situation, he/she would separate the residents from one another, ensure both residents were not injured, notify the residents' next of kin, their physicians, and notify the facility Administrator, Director of Nursing (DON), or the Assistant Director of Nursing (ADON); -The facility would then have two hours to notify DHSS of the events, as this would be an allegation of sexual abuse. During an interview on 4/11/25 at 2:45 P.M., Nurse Assistant (NA) AA said the following: -He/she worked on the day of the interaction between Resident #57 and Resident #32; -Late morning, the NA walked down the hall and observed Resident #57 in Resident #32's room; -Resident #32 was fully dressed sitting in a wheelchair; -Resident #57 was in front of Resident #32 slightly squatted against the resident's legs and was completely naked; -Upon entering the room, Resident #57 asked Resident #32 for sexual intercourse and Resident #32 threw both hands up in the air and said, Help me.; -The NA entered the room and separated the two residents and redirected Resident #57 to return to his/her room and assisted Resident #57 with dressing; -The NA said he/she immediately notified the charge nurse, LPN W and the LPN notified the DON over the phone and then went down the hall to talk to the DON; -This occurrence would be an example of sexual abuse and he/she reported the incident immediately; -The facility should report the allegation of abuse within two hours to DHSS. During an interview on 04/15/25, at 10:51 A.M., Certified Nursing Assistant (CNA) Q said the following: -All allegations of abuse should be reported immediately; -He/she was aware of a recent issue between the two residents. He/she was not on staff that day but did hear about it; -He/she was warned to keep an eye on Resident #57, but since the incident, the resident has kept to his/herself; -As far as he/she knew, the incident was reported; -If he/she were to witness or hear of an allegation of abuse, he/she would report it to the charge nurse, the charge nurse would take it up the ladder from there. During an interview on 04/15/25, at 12:17 P.M., Certified Medication Technician (CMT) R said the following; -A resident getting naked and entering another residents room would be a problem; -He/she was aware of the recent issue between the two residents. He/she was on shift during the incident. By the time he/she got to the residents, they were not on top of each other, however it was verbally apparent what Resident #57 wanted, and Resident #32 was stunned; -He/she reported it to the charge nurse and he/she should have taken it up the ladder from there. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the following -He/she was not on shift the day of the incident, but did hear about it; -If he/she were the nurse on shift, he/she would have separated both residents, assessed both residents, obtained statements from all staff on shift and both residents, documented the occurrence, and contacted whoever was on call that day; -The Director of Nursing (DON) or Administrator should have reported the incident to the state within two hours. During an interview on 04/15/25, at 1:17 P.M., the MDS Coordinator/Infection Preventionist said the following: -If there was ever a resident to resident reported to him, he would report it to management or call the state himself; -The incident between the two residents would be considered an allegation of sexual abuse and should have been reported to the state within two hours by the Assistant Director of Nursing (ADON), DON, or Administrator. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -She was not at the facility when the incident took place, however it could be considered an allegation of sexual abuse; -The nurse handling the incident was expected to put a progress note in regarding the incident, do an assessment of both residents, document an incident report, notify the physician and family, and report it to the nurse on call. The nurse on call should have reported it to the state within two hours. During an interview on 04/15/25, at 2:35 P.M., the DON said the following: -She was on shift the day of the incident and was informed by the nurse; -The nurse reported to her that Resident #57 was found standing in Resident #32's room, but was easily redirected; -She went down to assess Resident # 32 as he/she was feeling ill and needed to be hospitalized ; -She was not aware of the entire situation and had she been, she would have interpreted it as an allegation of sexual abuse and would have reported that to the state within two hours; -The nurse handling the incident should have documented the incident, separated the residents, assessed the residents for injuries and/or trauma, started behavior charting, notified her, the resident's families, and the residents physician. During an interview on 04/15/25, at 3:44 P.M., the Administrator said the following: -She was not ware of the entire situation and had she been, she would have considered it inappropriate; -The nurse handling the incident should have documented, reported and investigated the immediately. MO00252718

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all allegations of possible abuse were thoroughly investigated and the investigation provided to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when possible abuse was witnessed by staff involving two residents (Resident #32 and #57). The facility census was 104. Review of the facility's policy titled Abuse Prevention Program, undated, showed the following: -The facility will not tolerate verbal (any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend, or disability), sexual (non-consensual sexual contact of any type with a resident), physical (not limited to hitting, biting, kicking), or mental (humiliation, harassment, and threat of punishment or deprivation) abuse, corporal punishment, involuntary seclusion (separation of a resident ), neglect, or misappropriation of resident property (deliberate misplacement, exploitation), by employees, family members, visitors, or other residents. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and or injuries of unknown source, shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -The administrator will assign the investigation to an appropriate individual, provide any supporting documents relative to the alleged incident to the person in charge of the investigation, keep the resident and residents representative informed of the progress of the investigation, ensure that any further potential abuse, neglect or mistreatment is prevented, and protect the safety and privacy of the resident; -The individual conducting the investigation will review the completed documentation forms, review the resident's medical record to determine what events led up to the incident, interview the persons reporting the incident, interview any witnesses, interview the resident, interview the resident's physician, interview staff members, interview the residents roommate, and review all events leading up to the alleged incident; -An alleged violation involving abuse will be reported by the facility Administrator to the state licensing agency within two hours, local and state ombudsman, the residents representative, law enforcement officials, the resident's physical, and the facility's medical director. 1. Review of Resident #32's face sheet (brief look at resident information) showed the following information: -admission date of 03/20/20; -Diagnoses include high blood pressure, irregular heartbeat, and diabetes. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 03/26/25, showed the following information: -Moderate cognitive impairment; -Required substantial to maximum assistance from staff for bathing, toileting, and mobility; -No behavioral symptoms such as abusing others sexually, screaming at others, or disrobing. Review of the resident's care plan, revised 04/09/25, showed the resident required assistance from staff to complete daily tasks such as dressing and grooming. Review of the resident's progress note, dated 02/06/25, showed the resident was lethargic, felt sick, and was experiencing vomiting and chest pain. The resident was sent to the hospital via ambulance at 11:51 A.M. Review of the resident's admission History and Physical from the admitting hospital, dated 02/06/25, showed the following: -History received from the nurse at the long term care facility; -The nurse reports the resident was in a normal state of health until this morning. There was a naked resident who had jumped on top of him/her this morning and after this the resident became altered and was not able to speak; -The nurse also noticed the resident had a cough on this day, the nurse does not believe the naked resident hurt him/her; -The nurse denied the resident having any symptoms prior to this date; -The resident was diagnosed with sepsis (a life threatening medical emergency caused by the body's overwhelming response to an infection, often triggering a chain reaction that can lead to organ failure and death) and pneumonia ( a lung infection that causes inflammation and fluid buildup in the air sacs) while at the hospital and was discharged back to the facility on [DATE]. Review of the resident's progress notes, dated 02/06/25 through 04/06/25, showed staff did not document regarding the resident being involved in a possible sexual abuse allegations/incident. 2. Review of Resident #57's face sheet showed the following information: -admission date of 02/04/25; -Diagnoses included schizophrenia (a chronic mental disorder that affects a person's ability to think, feel, and behave), depression, and kidney disease. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 02/10/25, showed the following information: -Moderate cognitive impairment; -Requires partial to moderate assistance from staff for bathing and hygiene and is independent for mobility; -No behavioral symptoms such as abusing others sexually, screaming at others, or disrobing. Review of the resident's care plan, revised 04/09/25, showed the resident should be monitored for behaviors every shift related to medication use. Review of the resident's Nurse Practitioner visit note, dated 02/06/25, showed the following: -The resident was being seen for a new admission; -It was noted that this morning (02/06/25) the resident stripped down naked and jumped onto another resident who was lying in bed in his/her own room and this resident was making vulgar statements while on top of the other resident; -Staff reported the resident had been at baseline since the incident and there have been no further behaviors of this nature. Review of the resident's progress notes, dated 02/06/25 through 04/06/25, showed staff did not document regarding the resident being involved in a possible sexual abuse allegations/incident. 3. Review of DHSS records showed staff did not provide a written investigation completed when the potential abuse was occurred involving Resident #32 and Resident #57. 4. During an interview on 04/15/25, at 10:51 A.M., Certified Nursing Assistant (CNA) Q said the following: -He/she is aware of a recent issue between the two residents. He/she was not on staff that day but did hear about it; -He/she was warned to keep an eye on Resident #57, but since the incident, the resident has kept to his/herself; -As far as he/she knows, the incident was investigated appropriately. During an interview on 04/15/25, at 12:17 P.M., Certified Medication Technician (CMT) R said the following; -A resident getting naked and entering another residents room would be a problem; -He/she was aware of the recent issue between the two residents. He/she was on shift during the incident. By the time he/she got to the residents, they were not on top of each other, however it was verbally apparent what Resident #57 wanted, and Resident #32 was stunned; -Staff checked on the resident's often after the incident with no further concerns. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the following: -He/she was not on shift the day of the incident, but did hear about it; -If he/she were to be the nurse on shift, he/she would have separated both residents, assessed both residents, obtain statements from all staff on shift and both residents, document the occurrence, and contact whoever was on call that day. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -The nurse handling the incident is expected to put a progress note in regarding the incident, do an assessment of both residents, document an incident report, notify the physician and family, and report it to the nurse on call. During an interview on 04/15/25, at 2:35 P.M., the Director of Nursing (DON) said the following: -She was on shift the day of the incident and was informed by the nurse; -The nurse reported to her that Resident #57 was found standing in Resident #32's room, but was easily redirected; -She went down to assess Resident # 32 as he/she was feeling ill and needed to be hospitalized ; -She was not aware of the entire situation and had she been, she would have interpreted it as an allegation of sexual abuse; -The nurse handling the incident should have documented the incident, separated the residents, assessed the residents for injuries and/or trauma, started behavior charting, notified her, the resident's families, and the residents physician -After reporting the incident to the state, an investigation should have taken place and been submitted to the state within five days. During an interview on 04/15/25, at 3:44 P.M., the Administrator said the following: -She was not ware of the entire situation and had she been, she would have considered it inappropriate; -The nurse handling the incident should have documented, reported, and investigated the immediately. MO00252718

Based on interview, and record review, the facility failed to ensure individuals were appropriately screened prior to being placed in nursing home when the facility failed to obtain and/or maintain documentation of a level one and level two Preadmission Screening and Resident Review (PASARR) for one resident (Resident #56) . The facility census was 104. Review of the document the facility provided as their policy titled Pre-admission Screening and Annual Review (PASARR), dated 04/03/25, showed the following: -A PASARR form is required in every record. The discharge planner or facility is to be advised by the person taking the inquiry that the PASARR form must be complete prior to any new admission; -PASARR screenings are required on any resident who is placed in a state licensed only bed, who is directly transferred to your Medicaid bed from a Medicaid bed in another facility, and/or transferred from a hospital for placement in a Medicaid certified bed who occupied a Medicaid bed to hospital to Medicaid bed; -Completion of the PASARR form is the level I screening. A level II screening is done on those persons identified at level I who are known or suspected to have serious mental illness, intellectual disabilities, or a related condition; -After the level I screening is completed, place a copy of the screening in the medical record and maintain the original in the business office with the admission packet; -If a level II screening was required, and admission is approved, the resident will be subject to annual resident review (ARR); -When the level II screening is completed by the appropriate state agency, a letter is sent to the individual seeking admission, stating the facility is or is not appropriate. 1. Review of Resident #56's face sheet (brief look at resident information) showed the following information: -admission date of 05/17/22; -Diagnoses include mental and behavioral disorders, intellectual disabilities, and bipolar disorder type II (a mental health condition characterized by periods of hypomania (a less intense form of mania) and major depressive episodes, without a history of full-blown manic episodes). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 03/26/25, showed the following: -Severe cognitive impairment; -Dependent on staff for all cares and mobility; Review of the resident's care plan, revised 04/09/25, showed the resident had a cognitive deficit that affected his/her activities of daily living, such as feeding, bathing, and mobility. Review of the resident's electronic medical record (EMR) showed staff did not have documentation of a level I or level II PASARR completed. During an interview on 04/09/25, at 3:32 P.M., the Social Services Director (SSD) said all residents should have level I and level II PASARR on file, if indicated. He was unable to locate the resident's level I and/or level II. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said she was not sure of anything related to PASARR. During an interview on 04/15/25, at 2:45 P.M., the Director of Nursing (DON) said she was not sure of anything related to PASARR. During an interview on 04/15/25, at 3:44 P.M., the Administrator said level I and level II PASARR, if indicated, should be completed and maintained in the resident chart prior to admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement comprehensive care plans for all residents when staff failed to care plan regarding dementia, skin integrity, and multiple medications/diagnoses for two residents (Resident #92 and #61). The facility census was 104. Review of a facility policy titled Dementia-Clinical Protocol, revised November 2018, showed the following: -As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia or otherwise impaired cognition; -For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function of life; -For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life; -Direct care staff will support the resident in initiating and completing activities and tasks of daily living; -The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician; -The IDT will adjust interventions and the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. Review of a facility policy titled Care Plans, Comprehensive Person Centered, dated March 2022 showed the following: -The IDT, the resident, and his/her family develops and implements a comprehensive, person-centered care plan for each resident; -The care plan is developed within seven days of the completion of the Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) assessment, and no more then 21 days after admission; -Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being, including services that would be provided for the above; any specialized services as a result of the preadmission screening and resident review (PASARR) recommendations; which professional services are responsible for each element of care. The care plan includes the resident's stated goals and outcomes upon admission, builds on the resident strengths, and reflects standard of practice for problem areas and conditions; -Assessments of residents are ongoing and care plans are revised as resident information changes; -The care plan is reviewed and updated when there is a significant change in condition, the desired outcome is not met, the resident is readmitted to the facility, and at least quarterly. 1. Review of the Resident #92's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 05/15/24; -Diagnoses included dementia (progressive loss of intellectual functioning that interferes with daily functioning), left hemiplegia (muscle weakness or paralysis on one side of the body), and diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Substantial to maximum assistance with dressing, showers, toileting, mobility, and hygiene; -Resident taking an antipsychotic, antianxiety, and antidepressant medications; -No behaviors indicated; -No current skin conditions and not at risk for pressure ulcers. Review of the resident's current Physician Order Sheet (POS) showed the following information: -An order, dated 12/12/24, for Xarelto (blood thinner) 20 milligrams (mg) tablet, give once daily to prevent blood clots; -An order, dated 12/12/24, for Wellbutrin XL (antidepressant) 150 mg tablet, give once daily for major depressive disorder; -An order, dated 12/12/24, for vilazodone (antidepressant) 40 mg tablet, give once daily for major depressive disorder. Review of a resident skin evaluation, dated 02/16/25, showed resident had a stage II (wound with partial thickness skin loss) pressure injury on coccyx (tailbone), measuring 3.9 centimeters (cm) by 2.3 cm by 0.1 cm. Review of a resident's skin evaluation, dated 03/26/25, showed resident had a deep tissue injury (type of pressure ulcer where damage occurs to the underlying soft tissues, like muscle and fat, before the skin shows visible signs of injury) the left outer ankle, measuring 0.8 cm by 0.5 cm and a deep tissue injury to the left heel measuring 0.2 cm by 0.2 cm. Review of the resident's care plan, revised 04/09/25, showed staff did not care plan related to the resident's dementia diagnosis or interventions to maximize the resident's remaining function or quality of life, the resident's depression, the resident's anticoagulant use, or the resident's impaired skin integrity issues. 2. Review of Resident #61's face sheet showed the following: -admission date of 04/01/22; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder, depression, dementia, chronic pain, and emphysema (chronic lung disease that progressively damages the alveoli (tiny air sacs) in the lungs). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Substantial to maximum assistance with dressing, showers, toileting, mobility, and hygiene; -Resident taking an antipsychotic and antianxiety medication; -Shortness of breath when lying flat; -Resident on a scheduled pain medication; -No behaviors indicated. Review of the resident's current POS showed the following: -An order, dated 12/23/24, for risperidone (antipsychotic medication) 0.25 mg tablet, give one tablet two times daily for dementia; -An order, dated 12/23/24, for hydrocodone-acetaminophen (opioid pain medication) 5-325 milligram (mg) tablet, give one tablet every six hours as needed for pain; -An order, dated 12/23/24, for morphine sulfate (opioid pain medication) solution 20 mg/milliliters (ml), give 0.5 ml every four hours as needed for pain; -An order, dated 12/23/24, for tramadol (pain medication) 50 mg tablet, give one tablet two times a day related to pain; -An order, dated 03/13/25, for buspirone (antianxiety medication) 5 mg, give one tab twice daily for anxiety. -An order, dated 03/26/25, to ensure head of the bed is elevated to prevent shortness of breath while resident is lying flat due to emphysema; -An order, dated 04/02/25, to cleanse the back of head where staples are with wound cleanser, apply Vaseline, and leave open to air every day for wound. Review of the resident's current care plan showed staff did not care plan related to the resident's dementia diagnosis, anxiety, or interventions to maximize resident remaining function or quality of life, the resident's psychotropic medication, side effects, or targeted behaviors, or the resident's depression, anxiety, chronic pain, emphysema, or impaired skin integrity issues. 3. During an interview on 04/15/25, at 12:45 P.M., Nurse Assistant (NA) U said dementia and interventions should be in the care plan so staff can help care for residents appropriately. During an interview on 04/15/25, at 12:50 P.M., Certified Medication Technician (CMT) V said the care plan book should tell staff about dementia and interventions for residents. During an interview on 04/15/25, at 10:50 A.M., Licensed Practical Nurse (LPN) N said the care plan should include dementia and interventions. Interventions for dementia could include redirection, providing music therapy, and not to argue with the resident. During an interview on 04/14/25, at 2:55 P.M., Registered Nurse (RN) M said pressure ulcers and any skin conditions should be included in the care plan. Care plans should be reassessed for any change in a resident's condition and quarterly. During an interview on 04/15/25, at 1:19 P.M., the MDS Coordinator said the following: -Staff should be aware of information in the care plan to care for the residents; -Dementia care, medications, target behaviors and side effects should be included in the care plan; -Resident care plans are updated annually during the MDS assessment. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she inputs care plan updates sometimes but does not enter new ones; -Care plans should include everything about a resident; -Dementia, psychotropic medications and side effects, behaviors, pressure ulcers or skin condition should be included in the care plan; -Care plans shows resident's needs and how to care for them. -The care plan should be updated daily; -Nurses can update the care plan and have been educated on how to do it. During an interview on 04/15/25, at 2:34 P.M., the Director of Nursing (DON) said the following: -MDS Coordinators should complete and update care plans; -Facility had care plans on paper and in the electronic medical record; -Every resident should have a up to date care plan; -The care plan should show resident goals and interventions to reduce problems for resident. -Each resident should have an up-to-date care plan that includes smoking, dementia, behaviors, and pressure ulcers. -Nurses do not update the care plans. During an interview on 04/15/25, at 3:41 P.M., the Administrator said care plans were not where they should be. It was important for residents to have a care plan. Dementia, psychotropic medication including targeted behaviors and interventions, pressure ulcers, and a resident seat belt should be included on the care plan.

Based on observation, interview, and record review the facility failed to provide the highest quality of care and ensure that all residents receive treatment and care in accordance with professional standards of practice when the facility failed to document care and treatment refusals for one resident (Resident #2) with skin concerns, that ultimately led to infection. The facility census was 98. Review of the facility's undated policy, titled Wound and Skin Care Protocols, showed the following information: -The Director of Nursing (DON) will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of would care practice; -The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure injuries. Review of the facility's undated policy, titled Assessment and Documentation, showed the following information: -Assess the wound etiology, resident's overall condition, nutritional needs, pain/pain control, need for pressure reducing devices, and management of infection/bacterial burden. Review of the resident's face sheet (brief look at resident information) showed the following information: -re-admission date to the facility of 09/25/24; -Diagnoses include high blood pressure, obesity, and chronic pain. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff) dated 02/18/25, showed the following: -Cognitively intact; -Required substantial to maximum assistance from staff for mobility; -No open lesions on the skin. Review of the resident's care plan, dated 05/21/25, showed the following: -Measure wounds weekly; -Pressure reducing device to bed and wheelchair; -Provide assistance with mobility; -Wound care per physician order. Review of the resident's skin assessment, dated 04/08/25, showed the following: -During skin assessment, LPN A observed three new open areas to reddened right pannus ( an overhand of excess skin and fat that hands below the abdomen) and one open area to the left abdominal fold; -All areas were cleansed with wound wash, patted dry, nystatin (an antifungal medication that treats infections caused by yeast) was applied to closed gaulded (reddened/ chaffed)areas, and interdry (moisture wicking fabric with antimicrobial silver) was applied to open areas; -The residents Physician was notified; -No measurements included. Review of the resident's April 2025 Physician Order Sheet (POS), showed the following information: -An order dated 04/02/25; Cleanse wound to left side fold with wound cleanser, apply skin prep to peri-wound (skin surrounding wound.) Apply polymem pink (non-adhesive hydrophilic pads that are designed to facilitate healing) and cover with opsite (transparent adhesive film), change on Monday, Wednesday, and Friday; -An order dated 04/01/25; Cleanse would and dry area to right pannus. Apply barrier cream, place interdry (moisture wicking fabric with antimicrobial silver) and change daily; Review of the resident's skin assessment, dated 04/15/25, showed the following: -Left abdominal fold MASD (Moisture Associated Skin Damage) measured 0.8 centimeters (cm) by 1.2 cm depth, and 0.1 cm wound bed; -Wound care performed per orders. No significant changes to left abdominal fold. Area continues to remain fragile; -The resident is up in the wheelchair a significant part of the day; -Right pannus not measured but was extremely gaulded. The resident was educated on keeping the area clean and dry; -Physician aware. Review of the resident's skin assessment, dated 04/22/25, showed the following: -Left abdominal fold MASD measured 0.5 cm in width by 0.8 cm depth, with 0.1 cm wound bed; -Would care performed per orders. Left abdominal fold wound measured smaller. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded; -Physician aware Review of the resident's skin assessment, dated 04/29/25, showed the following: -Left abdominal fold MASD measured 0.4 cm in width by 0.6 cm depth, with 0.1 cm wound bed; -Would care performed per orders. Left abdominal fold wound measured smaller. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded, three open areas to the right groin measuring 0.5 cm x 1.0 cm; -Physician aware. Review of the resident's April 2025 Treatment Administration Record, showed the following: -Right Pannus treatment was not administered on 04/02, 04/09, 04/13, 04/16, and 04/25 due to the resident refusing; -Right pannus treatment was not administered on 04/10, 04/15, 04/17, and 04/28. No supporting documentation of reasoning. -Left abdominal fold treatment was not administered on 04/02, 04/09, 04/16, and 04/25 due to the resident refusing; -Left abdominal fold treatment was not administered on 04/28. No supporting documentation of reasoning. Review of the resident's skin assessment, dated 05/06/25, showed the following: -Left abdominal fold MASD measured 0.4 cm in width by 0.6 cm depth, with 0.1 cm wound bed; -Would care performed per orders. Left abdominal fold wound measured smaller. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded, three open areas to the right groin measuring 0.5 cm x 1.0 cm; -Physician aware. Review of the resident's skin assessment, dated 05/14/25, showed the following: -Left abdominal fold MASD measured 0 cm in width by 0 cm depth, with 0 cm wound bed; -Would care performed per orders. Left abdominal fold wound measured smaller. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded; -Right pannus wound number one measuring 1.5 cm x 1.5 cm with 0.2 cm depth. Right pannus wound number two measuring 1.8 cm x 1.2 cm x 0.2 depth; -Physician aware; -Resident refuses to use inderdry and insists staff place pillowcases under his/her abdominal folds instead. The resident was educated. Review of the resident's POS showed the following: -An order dated 05/15/25, at 10:33 P.M., for Cephalexin (a type of antibiotic called cephalosporin, that works by killing bacteria) 500 milligram (mg) tablet; give one tablet by mouth (po) two times a day (bid) for left abdominal wall cellulitis for seven days. Review of the resident's MAR showed the following: -An order dated 05/16/25 for Cephalexin 500 mg tablet; give one tablet po bid for left abdominal wall cellulitis for 12 administrations. Review of the resident's progress notes dated 05/17/25 through 05/20/25, showed the resident remained on antibiotics for cellulitis. The resident's left abdominal fold continued with redness, pain, and warmth to touch. No physician notification documented, and no new order requests. Review of the resident's May 2025 POS showed the following: -An order dated 05/16/25 to cleanse two wounds to abdominal pannus with wound cleanser, apply skin prep to peri-wound, apply calcium alginate to wound beds, cover with 4x4 island dressing and change daily; Review of the resident's May 2025 MAR showed the following: -Right pannus treatment not administered on 05/07, 05/12-13, 05/16, and 05/27. No supporting documentation as to why; -Right pannus treatment not administered on 05/08 or 05/24 due to the resident refusing; -Two wounds to abdominal pannus treatment not administered on 05/16 or 05/27 due to the resident refusing. -Two wounds to abdominal pannus treatment not administered on 05/24 due to the resident refusing; -Left abdominal treatment not administered on 05/07 or 05/12. No supporting documentation as to why; -Left abdominal treatment not administered on 05/14 due to the resident refusing; -Left abdominal treatment was discontinued on 05/15. Review of the resident's skin assessment, dated 05/21/25, showed the following: -Left abdominal fold MASD measured 0 cm in width by 0 cm depth, with 0 cm wound bed; -Would care performed per orders. [NAME] along fold, and continues to be fragile; -Right pannus continued to be gaulded; -Right pannus wound number one measuring 2.0 cm x 2.0 cm with 0.2 cm depth. Right pannus wound number two measuring 2.0 cm x 1.0 cm x 0.2 depth; -Physician aware; -Resident refuses to use inderdry and insists staff place pillowcases under his/her abdominal folds instead. The resident was educated. Review of the resident's progress note dated 05/24/25 at 7:31 P.M.; showed the resident had a change of condition and was lethargic and had worsening of the cellulitis on his/her pannus. Redness and warmth has spread across the entire abdominal fold. Labs and new antibiotics ordered. Review of the resident's May 2025 POS showed the following: -An order dated 05/24/25 for Cefuroxime (antibiotic that belongs to the class of medications known as cephalosporin antibiotics that treats bacterial infections) 500 mg; take one tablet po bid for cellulitis for seven days Review of the resident's EMR, showed no additional skin assessments after 05/21/25. During an interview on 06/04/25, at 3:23 P.M., The Assistant Director of Nursing (ADON) said the following: -The resident often refuses care; -Skin assessments are not being completed on a consistent basis but she is not aware of any not being completed; -If resident refuses care she expects to see it documented in the progress notes; -She expects skin assessments to be completed weekly. During an interview on 06/05/25, at 10:20 A.M., The resident said the following: -He/she feels like a lot of his/her treatments have not been administered; -When staff do complete his/her treatment, it is only once a day and it should be more often; -The staff save him/her for last because he/she has to be in a seated position in the wheelchair otherwise staff are not able to get to it while he/she lays in bed; -The lack of treatment administration is what he/she believes caused the cellulitis; -He/she does not often refuse, unless he/she is in bed. But he/she always tells the staff to just come back when he/she is up in his/her wheelchair and they do not come back. During an interview on 06/04/25, at 3:55 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she completes skin assessments on residents, along with other charge nurses; -He/she is not sure if skin assessments are getting completed weekly, but they should be; -Resident refusals should be documented. During an interview on 06/05/25, at 1:50 P.M., LPN B said the following: -Any wound assessments should be completed by LPN A or the Director of Nursing (DON); -Staff nurses complete weekly skin assessments when they are scheduled; -The resident has two wounds under the pannus, he/she believes it is due to the amount of weight the abdomen is and that causes pulling; -If he/she was alerted of a new wound, he would follow their wound protocol which includes to document the area and initiate a treatment until it can be assessed by the DON; -If a resident refuses treatments, that should be documented and care planned. During an interview on 06/05/25, at 2:15 P.M., The DON said the following: -Wound assessments that include measurements and descriptors are completed by her and/or LPN A, they are done weekly; -Skin assessments are also expected to be completed weekly by the staff nurses; -The resident has two wounds under the pannus which were caused by the weight of the abdomen and pulling; -If a resident refuses treatment, she expects that to be documented and care planned. During an interview on 06/05/25, at 5:32 P.M., The MDS/Care Plan coordinator said all wounds, wound care, and refusal status should be noted in the care plan. During an interview on 06/05/25, at 5:40 P.M., The Administrator said the following: -Skin assessments are expected to be completed weekly; -All resident refusals, wounds, and wound care should be documented and care planned. MO00255059

Based on observation, interview, and record review the facility failed to provide the highest quality of care when the facility failed to accurately and completely monitor and document wounds on the skin assessments and care plan pressure ulcers/injuries (skin injuries caused by prolonged pressure, friction, or shear, resulting in tissue damage) for one resident, Resident #1. The facility census was 98. Review of the facility's undated policy, titled Wound and Skin Care Protocols, showed the following information: -The Director of Nursing (DON) will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of would care practice; -All residents will be assessed by the charge nurse for risk of skin breakdown using the Braden scale ( a tool filled out by facility staff, used to assess a resident's risk of developing pressure injuries) on admission, re-admission, and with any major change in condition; -The interdisciplinary plan of care will address problems, goals, and interventions directed toward the prevention and/or treatment of impaired skin integrity/pressure injuries. Review of the facility's undated policy, titled Assessment and Documentation, showed the following information: -Assess the wound etiology, resident's overall condition, nutritional needs, pain/pain control, need for pressure reducing devices, and management of infection/bacterial burden; -A complete wound assessment and documentation will be done weekly on all pressure injuries until healed; to include the location of the wound, stage, size, appearance of the wound bed, surrounding skin (peri-wound), and drainage. Review of the resident's face sheet (brief look at resident information) showed the following information: -re-admission date to the facility of 03/08/24; -Diagnoses include multiple sclerosis (MS- is a chronic, unpredictable disease of the central nervous system, primarily affecting the brain, spinal cord, and optic nerves), high blood pressure, and kidney failure. Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 02/10/25, showed the following information: -Cognitively intact; -Required substantial to maximum assistance from staff for mobility; -Is at risk for the development of pressure ulcers/injury; -Does not have any unhealed pressure ulcers/injuries at stage 1 (intact skin, non-blanchable redness) or higher. Review of the resident's progress note, dated 04/12/25, showed the following: -Upon re-positioning the resident, a new open sore was found to the left buttock, measuring 3.5 centimeters (cm) in length, 1.5 cm in width , and 0.0 cm depth; -Wound bed had beefy red tissue, no drainage was present, and peri-wound was within normal limits; -Area cleansed and treatment applied. The resident was repositioned, and pillow placed to offload. Physician and hospice notified; -New orders to cleanse wound to left buttock with wound wash; pat dry, and apply silicone bordered dressing, change every other day and as needed until healed. Review of the resident's 04/05/25 through 06/30/25 Physician Order Sheet (POS), showed the following: -Cleanse wound to left buttock with wound wash; pat dry, apply silicone border dressing and change dressing very other day and as needed until healed. Review of the resident's care plan, dated 04/15/25, showed the following information: -At risk for skin break down and pressure injuries related to decreased mobility and incontinence; -Observe skin for changes daily with resident care; -Provide skin audits per schedule and as needed; -Assist with cleaning and repositioning as needed; -The care plan did not address the resident's wound and or treatment. Review of the resident's weekly skin assessment, dated 04/18/25, showed the resident did not have any skin issues. Review of the resident's weekly skin assessment, dated 04/25/25, showed the resident did not have any skin issues and refused to have a skin assessment performed. Review of the resident's April 2025 Treatment Administration Record (TAR) showed the resident did not miss any wound care treatments. Review of the resident's May 2025 TAR showed the resident had one missed treatment on 05/20/25 with no supporting documentation. Review of the resident's weekly skin assessment, dated 05/05/25, showed the resident did not have any skin issues. Review of the resident's weekly skin assessment, dated 05/09/25, showed the resident refused to have a skin assessment performed. Review of the resident's weekly skin assessment, dated 05/16/25, showed the resident did not have any skin issues. Review of the resident's Electronic Medical Record (EMR) showed the resident did not have another skin assessment after 05/16/25. Review of the resident's Braden Scale for Predicting Pressure Ulcer Risk evaluation, dated 05/26/25, showed the resident assessed as at moderate risk for developing pressure ulcers. Review of the resident's June 2025 TAR showed the resident did not miss any wound care treatments. During an interview on 06/04/25, at 1:38 P.M., the resident said the following: -He/she has a wound to his/her buttocks, and he/she has to ask the staff to perform wound care as they do not do it without being told to; -When he/she does get staff to provide care, he/she believes they just put a patch on the wound; -The patch often gets soiled, and the staff don't change it how they should; -He/she does not believe nursing staff measure the wound on a weekly basis. Observation on 06/02/25 at 10:55 A.M., showed both residents buttocks were bright red/purple and non- blanching in areas. The resident had two small- eraser tip sized open areas with an estimated total circumference of a half dollar to his/her left buttock. The peri-wound was dry, peeling, red/purple in color with non-blanchable areas. During an interview on 06/04/25 at 3:23 P.M., The Assistant Director of Nursing (ADON) said the following: -Weekly skin assessments are not being completed as consistently as she should like, but she is not aware of any being missed; -The facility does not have a current wound care nurse, but the DON will be moving to that position soon and taking over those responsibilities. During an interview on 06/04/25, at 3:55 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she performs skin assessments; -He/she is not sure if skin assessments are always getting completed, like they should; -Assessments should include all wounds and their descriptors; -The resident has a pressure wound to his/her left buttock. During an interview on 06/05/25, at 1:50 P.M., LPN B said the following: -The DON or LPN A is typically who completes skin assessments on a weekly basis; -Floor nurses do not measure wounds; -Wounds should be care planned; -He/she believed the resident's wound to be pressure related. During an interview on 06/05/25, at 2:30 P.M., Certified Nursing Assistant C said he/she does not work the resident's hall often but does know there is a patch on the resident's bottom. During an interview on 06/05/25, at 5:26 P.M., The DON said the following: -She expects skin assessments to be completed on a weekly basis and for all wound descriptors to be documented; -The resident's wound is documented as a pressure wound. -Wounds and wound care should be care planned. During an interview on 06/05/25, at 5:32 P.M., The MDS/Care Plan Coordinator said all wounds and wound care should be care planned. During an interview on 06/05/25, at 5:40 P.M., The Administrator said the following: -She expects skin assessments to be completed weekly; -Skin assessments should include all wound descriptors; -Wounds and wound care should be care planned. MO00255059

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify the need for restorative therapy, failed to care plan the need for restorative therapy, and failed to provide restorative therapy services to ensure residents did not experience unavoidable reductions in range of motion and maintained maximum practical independence/range of mobility for two residents (Resident #77 and #49) who were at risk for a decline in mobility. The facility census was 104. Review of the facility's policy titled Restorative Nursing Services, revised July 2017, showed the following information: -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services; -Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care; -Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care; -The resident representative will be included in determining goals and the plan of care; -Restorative goals may include, but are not limited to supporting and assisting the resident in adjusting or adapting to changing abilities, developing, maintaining, or strengthening his/her physiological and psychological resources, maintaining his/her dignity, independence and self esteem, and participating in the development and implementation to his/her plan of care. 1. Review of Resident # 77's face sheet (brief look at resident information) showed the following: -admission date of 01/09/23; -Diagnoses include multiple sclerosis (MS - a chronic autoimmune disease where the body's immune system attacks the protective covering around nerve cells (myelin) in the brain and spinal cord, disrupting nerve signal transmission). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/10/25, showed the following: -Cognitively intact; -Required substantial to maximum assistance from staff for mobility; -Zero number of days in the last 7 days prior to assessment the resident received restorative nursing services. Review of the resident's April 2025 Physician Order Sheet (POS) showed no orders for restorative services, therapy, or active or passive range of motion. Review of the resident's care plan, revised 04/09/25, showed staff did not care plan related to the resident's functional abilities and/or participation in therapy services. Review of the resident's electronic medical record (EMR) showed staff did not document a current and complete restorative assessment. During an interview on 04/09/25, at 9:58 A.M., the resident said the facility would not allow him/her to exercise and/or participate in restorative services. He/she did not understand why and felt like he/she was just going to further decline. During an interview on 04/11/25, at 12:07 P.M., the Therapy Director said the resident had progressing MS. His/her mobility and transfer status was actively declining and he/she would greatly benefit from getting the opportunity to participate in restorative therapy. During an interview on 04/15/25, at 12:17 P.M., Certified Medication Technician (CMT) R said the resident would benefit from having restorative services. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the resident had progressing MS and would benefit from getting the opportunity to participate in restorative therapy. During an interview on 04/15/25, at 2:35 P.M., the Director Of Nursing (DON) said the resident would benefit from restorative therapy services. 2. Review of Resident # 49's face sheet showed the following: -admission date of 12/03/19; -Diagnoses of morbid obesity, pain, and muscle weakness. Review of the resident's occupational therapy discharge summary, date of discharge 10/13/23, showed the following: -Resident's long-term goal (LTG) was resident will increase active range of motion (AROM) to allow for reaching his/her head for grooming tasks and to reach overhead for activities of daily living (ADL) tasks; -Baseline on 07/26/23, resident unable to reach overhead with left upper extremity; -discharge on [DATE], resident able to reach head with some difficulty; -LTG met; -Prognosis to maintain level of functioning with consistent staff follow-through. Review of the resident's current physician orders staff did not document orders related to restorative therapy. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Exhibited no behavioral symptoms; -Functional limitation in range of motion to all four extremities; -Used motorized wheelchair for mobility device; -Dependent on staff for toileting hygiene, showers, lower body dressing, and with transfers; -Required partial/moderate assistance of staff with personal hygiene; -Required substantial/maximal assistance of staff with upper body dressing, and rolling from left to right. (Staff did not care plan related to the resident's physical mobility and restorative therapy needs.) Observation and interview with the resident on 04/15/25, at 3:00 P.M., showed the following: -The resident sat in his/her electric wheelchair in his/her room; -He/she last received occupational therapy services over a year ago due to a torn rotator cuff in his/her left shoulder; -After discharge from skilled therapy, he/she was able to raise his/her left arm up and reach his/her head, but now could only raise his/her left arm to bring his/her hand to about chest height; -The resident demonstrated the limited range of motion of his/her left shoulder by extending his/her arm straight out in front of his/her body and attempted to raise his/her left arm/hand up and had to stop when his/her hand was approximately chest height and said he/she could go no farther; -He/she would have liked to go on the restorative program after discharge from therapy to help maintain the range of motion in his/her left arm and shoulder, but the facility did not offer any restorative program; -As a result of the facility not having a restorative program, his/her range of motion had decreased, making it more difficult for him/her to brush/style hair, change shirts, and reach items stored in higher locations. During an interview on 04/11/25, at 12:07 P.M., the Therapy Director said the resident would benefit from a restorative therapy program, as it would help with his/her upper extremity strength and range of motion. 3. During an interview on 04/11/25, at 12:07 P.M., the Therapy Director said the following: -The facility did not currently have a restorative program and had not had one for nearly two years; -There were more than ten residents that he/she would recommend services for, if the facility had the program; -He/she had been completing the quarterly restorative assessments. The assessments were based off the resident's baseline. He/she hadn't been able to complete them correctly and refer residents to restorative services, because there were no restorative services; -He/she had not recommended restorative services for any resident in over a year due to the program being non-existent; -Not having the restorative program could lead to declines in resident mobility and development or worsening of contractures. During an interview on 04/15/25, at 12:17 P.M., CMT R said the facility did not currently have a restorative program and had not one for over a year due to staffing. During an interview on 04/15/25, at 12:45 P.M., Licensed Practical Nurse (LPN) W said the following: -The facility used to have restorative therapy program, but they no longer have one and have not for several months; -When the facility had a restorative program and restorative aides, the restorative aides would do range of motion and other exercises with the residents and that helped with the residents' mobility and their moods. During an interview on 04/15/25, at 12:49 P.M., RN L said the facility did not currently have a restorative program and had not for nearly two years. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -The facility currently did not have a restorative therapy program; -There was no one doing range of motion with the residents other than aides, while they are providing care; -Benefits of implementing the restorative program again would be keeping residents active, and either improving or maintaining resident mobility; -It was detrimental to not have a functioning restorative program and some residents may be losing their abilities due to not having the program; -At least 25 % of the resident population would benefit from having restorative therapy. During an interview on 04/15/25, at 2:35 P.M., the Director Of Nursing (DON) said the following: -The facility currently did not have a restorative program, and had not for nearly two years; -She believed the facility should have a restorative program; -Aides and other staff members do not have time to do range of motion with the residents, but that is currently the expectation; -Having a restorative program would help the residents maintain their current level of function and prevent further declines. During an interview on 04/15/25, at 3:44 P.M., the Administrator said the following: -Ensuring there is staff on the halls takes priority over offering restorative services; -It would be beneficial to have a restorative program so the residents could maintain mobility; -Therapy does screenings on all residents every 90 days, and if they start to see the residents are having a decline, the therapy department can work with them; -There could be potential for declines in mobility without the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of resident #82's face sheet showed the following: -admission date of 10/12/23; -Diagnoses included schizoaffective disorder (a mental health condition that includes hallucinations, delusions, depression, and mania) and high blood pressure. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with eating, toileting, dressing, and mobility. Review of resident medical record, on 04/08/25, showed staff did not document an admission or quarterly smoking evaluations. During an interview on 04/09/25, at 1:41 P.M., the resident reported they use a vape, which they were allowed to keep in their possession. The facility allowed him/her to go out at any time to smoke as he/she was unsupervised. Review of the resident's care plan, revised on 04/09/25, showed the following: -Updated on 04/09/25, resident was safe to smoke unsupervised; -Updated on 04/09/25, smoking risk assessments will be completed quarterly. 3. During an interview on 04/15/25, at 12:45 P.M., Nurse Assistant (NA) U said smoking should be included in the care plan. Most residents are independent with smoking and others require the cigarette lit. The care plan indicated if a resident was an independent smoker During an interview on 04/15/25, at 10:51 A.M., CNA Q said the following: -There were supervised and unsupervised smokers. Unsupervised smokers can have their cigarettes on them, but lighters must remain with the staff; -Smoking status should be care planned accurately and there should be a completed assessment as well. During an interview on 04/15/25, at 12:17 P.M., CMT R said the following: -Smoking residents required an assessment on admission. The answers to that assessment would tell if the resident needed to be supervised or unsupervised; -Supervised smokers have to keep their supplies behind locked doors in the medication room; -Unsupervised smokers may keep their cigarettes on them, with the exception of lighters; -Smoking status should be care planned accurately. During an interview on 04/15/25, at 10:50 A.M., Licensed Practical Nurse (LPN) N said he/she was unsure if residents required a smoking assessment. Smoking assessments should be done based on acuity or for change of condition. Resident smoking status should be included on the care plan. During an interview on 04/15/25, at 12:49 P.M., RN L said the following: -Smokers had an assessment completed on admission, quarterly, and for any change of condition; The assessment would tell if the resident was supervised or unsupervised; -Supervised smokers had to have their supplies kept behind locked doors in the medication room; -Unsupervised smokers could keep their supplies. During an interview on 04/14/25, at 2:55 P.M., RN M said a smoking assessment was completed upon admission. A resident would be supervised or unsupervised based upon the assessment results. Smoking should be included in the care plan. During an interview on 04/15/25, at 1:17 P.M., the MDS Coordinator/Infection Preventionist said the following: -All residents were currently unsupervised; -Smoking status should be included on the care plan; -Smoking status should be assessed on admission, quarterly, and for any change of condition; -He learned of a resident's smoking status by asking the aides. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -A smoking safety evaluation should be completed on admission and quarterly; -An unsupervised smoker had to be able to exit and enter the building independently, hold and light the cigarette independently, and dispose of the cigarette appropriately; -The smoking assessment included ascertaining if a resident could enter and exit the building without assistance, were able to light the cigarette, use a lighter, place cigarette in proper receptacle, and did not burn themselves; -If a resident could complete the smoking assessment they were unsupervised; -Supervised smokers have smoking supplies stored in a closet that staff had access to; -Unsupervised smokers were allowed to keep cigarettes, vapes, and lighters in their possession. Smoking should be included on a resident care plan. During an interview on 04/15/25, at 2:35 P.M., the DON said the following: -A smoking evaluation was done by a nurse upon admission to the facility to determine unsupervised or supervised status; -Smoking assessments were done for a change in status, but not on a quarterly basis; -The resident must be able to enter and exit the building, not burn themselves, and be alert and oriented for unsupervised smoking; -He/she used to assess residents based upon judgement and a feeling of a resident not being safe; -Unsupervised smokers could keep their smoking supplies; -Staff handled the supervised smokers supplies. During an interview on 04/15/25, at 3:44 P.M., the Administrator said smoking safety evaluations should be completed on admission, quarterly, and as needed. Based on observation, interview, and record review, the facility failed to ensure an environment remained free of accident hazards when the facility failed to document complete and accurate smoking assessments and care plan smoking for two residents (Resident # 1 and Resident #82) and when the facility when one resident (Resident #1) was found to have multiple marijuana vape pens on his/her bedside table. The facility census was 104. Review of the facility's policy titled, Smoking- Residents, revised August 2022, showed the following information: -Prior to and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and to the extent to which the facility can accommodate their smoking or non-smoking preferences; -Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes current level of tobacco consumption, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision (per completed Safe Smoking Evaluation); -A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change, and as determined by staff; -Any smoking-related privileges, restrictions, or concerns are noted in the care plan, and all personnel caring for the resident shall be alerted to these issues; -The facility may impose smoking restrictions on a resident at any time if the resident cannot smoke safely with the available levels of support and supervision; -Any resident with smoking privileges requiring monitoring shall have direct supervision of a staff member, family member, or visitor while smoking; -Residents who have independent smoking privileges are permitted to keep cigarettes, electronic cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted; -Residents without independent smoking privileges may not have or keep any smoking items; -The facility maintains the right to confiscate smoking items if found in violation of the smoking policy; Review of the facility's policy titled, Medical and Recreational Marijuana, undated, showed the following based on the stance held by the Centers of Medicare and Medicare Services (CMS), any Medicare-certified long term care facility that currently allows the use of medical cannabis in its facility risks losing it's Medicare certification. Although, a majority of states currently have legalized some form of cannabis for medical use, cannabis is still illegal under federal law. The facility will not allow the use of medical or recreational marijuana on its premises. 1. Review of Resident # 1's face sheet (brief look at resident information) showed the following: -admission date of 08/08/11; -Diagnoses included cerebral palsy (a group of neurological disorders that affect movement, balance, and posture), bipolar disorder (a mental illness characterized by dramatic swings in mood, energy, and activity levels, ranging from extreme highs (mania) to lows (depression)), convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders such as epilepsy, the presence of certain toxins or other agents in the blood, or fever in children.), and muscle spasm. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 02/17/25, showed the following information: -Cognitively intact; -Dependent upon staff for all cares, including dressing, bathing, hygiene, and mobility. Review of the resident's care plan, revised 04/09/25, showed the following: -Dependent on staff for all aspects of care; -Is a smoker. Notify charge nurse immediately of any smoking violations and observe clothing and skin for signs of cigarette burns; -Requires supervision while smoking. Observation on 04/07/25, at 11:00 A.M., showed one pack of cigarettes and seven vaporizer devices (also known as vapes - used for inhaling products via a mist) with labels of THC (tetrahydrocannabinol - a cannabinoid found in the cannabis plant) and/or CBD (chemical found in marijuana) on the resident's bedside table. Observation and interview on 04/08/25, at 11:08 A.M., showed the resident sat in his/her room on his/her motorized wheelchair. One pack of cigarettes and seven vaporizer devices with labels of THC and CBD on the resident's bedside table. The resident said he/she can smoke whenever he/she wants. He/she was allowed to keep smoking supplies in his/her room. Review of the resident's April 2025 Physician Order Sheet (POS) showed the resident did not have an order for THC or CBD. Review of the resident's Electronic Medical Record (EMR), on 04/08/25, showed staff did not have have a current smoking safety evaluation in the record. Observation on 04/09/25, at 1:34 P.M., showed the resident went down 200 hall on his/her motorized wheelchair with an unlit cigarette hanging out of his/her mouth. Observation on 04/11/25, at 12:33 P.M., showed the resident wheeled through the dining room in his/her motorized wheelchair to go outside for an unsupervised smoke break. During an interview on 04/15/25, at 10:51 A.M., Certified Nursing Assistant (CNA) Q said the following: -The resident was an unsupervised smoker, but he/she struggled to light his/her own cigarettes and needed staff assistance; -He/she did not believe THC and/or CBD vaporizer devices were allowed at the facility and was not aware the resident had them in his/her room. During an interview on 04/15/25, at 12:17 P.M., Certified Medication Technician (CMT) R said the following: -The resident was an unsupervised smoker; -He/she did not believe THC and/or CBD vaporizer devices were allowed at the facility and was not aware the resident had them in his/her room. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the following: -The resident was an unsupervised smoker; -He/she did not believe THC and/or CBD vaporizer devices were allowed at the facility and was not aware the resident had them in his/her room. During an interview on 04/15/25, at 1:17 P.M., the MDS Coordinator/Infection Preventionist said the following: -All residents were currently unsupervised. He/she would not say the resident was a safe smoker; -The resident used some kind of holding device that allowed him to hold the cigarette due to his/her diagnoses; -THC and CBD use was discouraged at the facility. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -The resident was an unsupervised smoker; -She was not aware the resident had THC and CBD vaporizes in his/her room. Those were not allowed at the facility. During an interview on 04/15/25, at 2:35 P.M., the Director of Nursing (DON) said the following: -The resident was an unsupervised smoker; -She was not aware of any residents who have THC and CBD in their rooms; -THC and CBD vaporizer devices have been found around the facility before by staff, but there was no way of telling who they belonged to; -THC and CBD products are not allowed at the facility. During an interview on 04/15/25, at 3:44 P.M., the Administrator said she was not aware any residents had THC and or CBD products. These were not allowed at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to the use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain a complete informed consent for the use of side rails prior to installation; failed to care plan side rails and failed to complete ongoing assessments to ensure the side rails are safe and appropriate for use for two residents (Resident #90 and Resident #92). The facility census was 104. Review of a facility policy titled Bed Safety and Bed Rails, dated August 2022, showed the following: -The use of bed rails is prohibited unless the criteria for bed rails have been met; -Regardless of mattress type, width, length, and/or depth, the bed rail, bed frame, and mattress will leave no gap wide enough to trap a resident's face or body; -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including entrapment risks; -The maintenance department provides a copy of the inspections to the Administrator. Copies of the inspection results are maintained by the Administrator and/or the safety committee; -Bed rails are properly installed and used according to the manufacturer's instructions, specifications, and safety guidance to ensure proper fit; -The use of bed rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent; -Prior to the installation or use of a side rail, alternatives to the use of side rails are attempted. Alternatives may include roll guards, foam bumpers, lowering the bed, and/or concave mattresses. -If attempted alternatives do not adequately meet the resident's need, the resident may be evaluated for the use of side rails. The interdisciplinary evaluation includes an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident needs; resident risk associated with the use of bed rails; input from the resident and/or representative; and consultation with the attending physician. -The resident assessment to determine risk of entrapment includes, but is not limited to medical diagnosis, conditions, symptoms, and/or behavioral symptoms; size and weight; sleep habits; medications; acute medical or surgical interventions; underlying medical conditions; existence of delirium; ability to toilet safely; cognition; communication; mobility; and risk of falling. -The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: accident hazards; restricted mobility; and psychosocial outcomes. -Before using bed rails for any reason, staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: assessed medical needs that will be addressed with the use of bed rails; risks from the use of bed rails and how these will be mitigated; alternatives that were attempted but failed to meet the resident needs; and alternatives that were considered but not attempted and the reasons. 1. Review of Resident #90's face sheet (a document that gives a resident's information at a quick glance) showed the following: -An admission date of 05/10/24; -Diagnoses included bipolar disorder (a mental health condition that causes intense mood swings, affecting a person's energy, mood, and ability to function), diabetes mellitus (a disease that affect how the body uses blood sugar), and vascular dementia (decline in thinking skills caused by reduced or blocked blood flow to the brain). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/26/25, showed the following: -Cognitively intact; -Supervision with dressing, showers, toileting, and hygiene; -Independent with mobility. Observation on 04/08/25, at 2:42 P.M., showed the resident resting in bed with an upper half side rail up. Observation on 04/09/25, at 10:00 A.M. showed the resident in bed with both upper half side rails up. Observation on 04/14/25, at 2:55 P.M., showed the resident in bed with the an upper half side rail up. Review of the resident's care plan, revised on 02/13/25, showed staff did not care plan the resident's use of side rails. Review of an informed consent for use of restraints form signed by the resident, dated 05/10/24, showed staff did not document the type of restraint to used or the indication. Review of the resident's side rail evaluation, dated 05/10/24, showed side rails were not indicated at that time and no side rails were recommended. Review of the resident's current physician order sheet showed an order, dated 01/07/25, for half left upper side rail for positioning and mobility. Review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, or ongoing assessments to ensure the side rails were safe and appropriate for use. 2. Review of the resident #92's face sheet showed the following: -admission date of 05/15/24; -Diagnoses included left hemiplegia (muscle weakness or paralysis on one side of the body), diabetes mellitus, and dementia (progressive loss of intellectual functioning that interferes with daily functioning); -Resident is own responsible party. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Substantial to maximum assistance with dressing, showers, toileting, mobility, and hygiene. Observation and interview on 04/10/25, at 9:57 A.M., with the resident showed both upper half side rails on bed were up. Resident reported he/she used them for repositioning in bed. Observation on 04/14/25, at 2:45 P.M., showed resident in bed with both upper side rails up. Review of the resident's current physician order sheet showed an order, dated 01/07/25, for bilateral U bars in place for positioning and mobility. Review of an informed consent for use of restraints form signed by the resident, dated 05/15/24, showed staff did not document the type of restraint to used or the indication. Review of the resident's side rail use assessment, dated 05/15/24, showed side rails were needed due to left sided weakness. Side rails would assist resident with bed mobility and a left side rail was recommended. Review of the resident's side rail evaluation, dated 05/23/24, showed side rails were not recommended or indicated at that time. Review of the resident's care plan, revised on 04/09/25, showed staff did not care plan related to the resident's side rail use. Review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, or ongoing assessments to ensure the side rails were safe and appropriate for use. 3. During an interview on 11/18/24, at 10:22 A.M., Registered Nurse (RN) M said the following: -Side rails required an assessment before installation; -Therapy or nursing could recommend side rails for a resident; -The nurse would contact the physician for an order, notify family, and maintenance would install side rails if an assessment showed they would be beneficial; -Side rails should be assessed quarterly. During an interview on 04/15/24, at 10:50 A.M., Licensed Practical Nurse (LPN) N said the following: -Side rails should be included in the care plan; -He/she did not know who installed side rails; -He/she did not have any experience with side rail requests; -No consent was required for side rails; -Side rails required an assessment and family notification prior to installation. During an interview on 04/15/25 at 1:07 P.M., the Maintenance Supervisor said the following: -Maintenance staff were responsible for gap assessments on side rails a couple months ago, but it is now the nursing department responsibility; -Maintenance will install side rails, but it depends on the type of bed the resident has; -He/she is notified to install side rails by resident request or a floor staff request; -Gap assessments should be done upon placement of side rails, annually, and if there is a bed change. During an interview on 04/15/25, at 1:19 P.M., the MDS Coordinator said the use of side rails should be included on the care plan. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -Side rails needed a consent; -A restraint assessment should be completed quarterly and upon admission; -Side rail gap assessments should be completed on admission, for a new bed, and quarterly; -Maintenance was responsible for obtaining gap measurements. During an interview on 04/15/25, at 2:34 PM, the Director of Nursing (DON) said the following: -Side rail assessments should be completed on admission, quarterly, or if resident had a new bed; -Maintenance was responsible for documenting and performing bed assessments; -The admission nurse determined what the side rail should be used for and what type was needed; -Nurses were responsible for the consent form. During an interview on 04/15/25, at 3:41 P.M., the Administrator said the following: -Side rails should be included in the care plan; -Restraint assessment should be done quarterly; -They are working on the consent for restraints; -Side rail measurements should be done yearly, upon admission, or for any changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when Certified Medication Technician (CMT) D brought narcotic pain medication tablets into the facility and placed them into the bubble pack medication card for one resident (Resident #5) and a staff member subsequently administered one dose of the medication to the resident. The facility census was 98. 1. Review of Resident #5's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of chronic pain, low back pain, anxiety disorder, major depression, and stroke. Review of the resident's care plan revised on 05/25/25, showed: -Resident is at risk for increased pain and discomfort related to a diagnosis of chronic pain; -Follow up with the resident's physician and pain management as needed; -Medication provided as prescribed; -Monitor for effectiveness of medication; -Monitor for increased pain and discomfort; -Provide diversionary activities as needed; -Therapy to screen quarterly and as needed. Review of the resident's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 05/28/25, showed: -admitted to the facility on [DATE]; -Cognitively intact; -Independent with most activities of daily living (ADLs); -No behavioral symptoms; -Diagnoses of schizophrenia, anxiety, and depression; -Staff administered as needed (PRN) pain medication; -Resident expressed frequent complaints of pain and rated his/her pain at an '8' (on a numeric scale of 0-10, with 10 being the most severe pain). Review of the resident's active physician orders showed the following: -An order dated 05/16/25 for Hydrocodone-Acetaminophen (Norco) oral tablet 5/325 milligram (mg). Staff to administer one tablet by mouth every 6 hours as needed for pain. Review of the resident's medication administration record for May 2025 showed: -An order for Hydrocodone-Acetaminophen oral tablet 5/325 mg. Give one tablet by mouth every 6 hours as needed for pain; -On 05/19/25 at 8:20 A.M., staff administered a dose of the medication for a pain level of '8' with effective results; -On 05/19/25 at 7:47 P.M., staff documented administration of a dose of the pain medication for a pain level of '9' with effective results; -Staff did not document administration of any other doses of the pain medication on 05/19/25. -On 5/19/25, Certified medication technician (CMT) D did not document administration of either of the doses of the residents pain medication on the MAR. Review of the facility's-controlled drug count signature page showed the following: -On 05/19/25 at 2:00 P.M., CMT D signed as the incoming staff; -On 05/19/25 at 10:00 P.M., CMT D signed as the outgoing staff; -On 05/19/25 at 10:00 P.M., Registered Nurse (RN) E signed as the incoming staff. Review of the resident's progress notes showed: -No entries dated 05/19/25. Review of the resident's Medication Administration Record (MAR) for May 2025 showed: -An order for Hydrocodone-Acetaminophen oral tablet 5/325 mg. Give one tablet by mouth every 6 hours as needed for pain; -On 05/20/25 at 10:45 A.M., a nurse documented administration of one dose of the medication for a pain level of '8' with effective results. Review of the resident's-controlled medication count sheet showed the following information: -Drug name: Norco 5/325 mg; -Directions: one tablet by mouth every 6 hours as needed for pain (PRN); -On 05/20/25 at 10:45 A.M., LPN A signed out one tablet of the medication for administration; On 05/20/25 at 6:45 P.M., LPN A and the ADON destroyed one tablet of the medication and did a corrected count. Review of the resident's progress notes showed: -No entries dated 05/20/25. Review of the resident's progress notes showed: -One entry dated 05/21/25 as follows: At 4:57 P.M., a nurse documented Nurse Practitioner here for rounds, no new orders noted at this time. -Staff did not document the medication error, an assessment of the resident's condition, or notification of the resident's physician following the medication error in the resident's progress notes. During an interview on 06/04/25 at 1:43 P.M., Resident #5 said the following: -He/she had chronic back pain and staff administered as needed (PRN) pain medication to treat the resident's pain; -Staff administered the resident's pain medication accurately and on time; -The resident was not aware of any misappropriation of his/her property or medications; -The resident had not had a recent increase in sedation or pain. During an interview on 06/04/25 at 3:21 P.M., the Assistant Director of Nursing (ADON) said the following: -On 05/20/25, RN E reported that on the night of 05/19/25 at approximately 10:00 P.M., he/she was counting the narcotics with Certified Medication Technician (CMT) and Resident #5's Norco was short tablets when compared to the narcotic count sheet. The nurse refused to accept the cart because of the missing pills. The CMT told the nurse, he/she had a prescription for the exact same medication in his/her vehicle and went out to his/her vehicle and came back in with two loose pills. The CMT then taped the pills into the resident's medication card. The ADON checked the resident's Norco card and found Licensed Practical Nurse (LPN) A administered one of the taped in pills earlier on 05/20/25 and the ADON and another nurse destroyed the other taped in pill. During a phone interview on 06/05/25 at 11:38 A.M., Pharmacist H, a representative of the facility's local pharmacy said the following: -It is not acceptable practice for an employee to take their personal prescription medication and place that medication in a resident medication card to administer to a resident. During an interview on 06/05/25 at 12:40 P.M., the ADON said the following: -CMTs administer routine and as needed (PRN) pain medication to residents in the facility; -If a resident expressed pain and had a PRN order for pain medication, the nurse should first assess the resident's pain and then either the CMT or the nurse would administer the PRN medication. The nurse must sign administration of the PRN pain medication in the Medication Administration Record (MAR) along with the resident's numeric pain level, whether the medication it is given by the nurse or the CMT. The nurse of CMT administering the medication would sign the doses off on the narcotic count sheet. During a phone interview on 06/05/25 at 1:21 P.M., Registered Nurse (RN) E said the following: -He/she worked full time at the facility 3:00 P.M. to 3:00 A.M., or sometimes until 7:00 A.M.; -On the night of 05/19/25 at around 11:00 P.M., CMT D was preparing to leave for the night (at the end of the CMT's shift); -RN E counted the controlled medications with CMT D and found Resident #6's Norco card contained 2 pills less than what the controlled medication count showed he/she should have in the card; -The CMT was unsure what happened to the medications; -RN E refused to take over responsibility for the cart with 2 missing pills; -The CMT went outside to his/her car and returned and said he/she was now ready to count; -The RN thought the CMT might have brought the pills inside from his/her car, but replaced pills matched the exact appearance and number as the pills already in the card; -The CMT taped the 2 pills into the card and the nurse assumed responsibility for the cart and the CMT went home; -On 05/20/25 at approximately 5:00 P.M., RN E notified the ADON and the Administrator that CMT D taped two pills into Resident #5's Norco card on 05/19/25; -The ADON immediately audited the entire cart and removed the remaining taped in pill; -RN E said he/she did not think about the potential danger of the medication; -RN E said he/she assumed maybe the CMT had stolen and then returned the medications due to the count being short; RN E did not think to notify management or the ADON, DON at the time of the occurrence, but thought about it the next day and decided he/she needed to report the incident; -In training, the facility had told him/her to immediately report to the RN on-call, the DON, of the Administrator of any allegation of misappropriation of resident property or medications, but he/she failed to do so; -RN E said he sat in on a meeting with CMT D on 05/20/25 along with the DON, ADON, and Administrator; -During the meeting, CMT D said he/she had a personal prescription for Norco and on the night of 05/19/25, when he/she could not locate 2 of Resident #5's Norco, he/she went to his/her own car and pulled 2 pills from his/her prescription bottle to replace the missing resident Norco. He/she then taped the pills into the resident's medication card; -CMT D denied taking any of the resident's pain medications, but said was unsure where the two resident Norco tablets were; -In the meeting, the ADON said the nurse was supposed to sign with the CMT when administering PRN pain medications, but he/she was not aware of that before the meeting; -The CMTs generally gave the PRN pain medication and signed them off on the controlled medication count sheet. The nurse would assess the resident's pain and document the administration of the PRN medications on the resident's MAR, as well as the resident's pain level. During a phone interview on 06/05/25 at 4:08 P.M., CMT D said the following: -On the night of 05/19/25, he/she counted the cart by him/herself, and the controlled medication count was correct; -CMT D then gave his/her medication cart keys to RN E and finished his/her charting; -Approximately one hour later, he/she returned to count the controlled medications RN E and at that time Resident #5's Norco card was 2 pills short according to the count sheet; -The CMT said he/she freaked out and went to his/her car and obtained 2 of his/her own personal Norco which were the same exact strength and taped his/her personal medication into the resident's Norco card, so the count would be correct; -When he/she returned to work, he/she was told by the DON and ADON to go to the front office and he/she told the DON, ADON, Administrator what he/she had done; -He/she had never taken any resident medications out of the facility or for personal use; -RN E was aware CMT went to his/her car and obtained the 2 pills and RN E did not say anything about not doing it at the time; The CMT said he/she had never misappropriated any resident medication, but was unsure what happened to the resident's two Norco; -CMT D said he/she should not have replaced the resident's missing medication with his/her own personal medication and that it was, The dumbest thing I've ever done in my life. During an interview on 06/05/25 at 4:00 P.M., LPN A said the following: -He/she worked on the morning of 05/20/25 and assisted with the administration of pain medication; -He/she gave Resident #5 one Hydrocodone/APAP for complaint of pain; -He/she was in a hurry and did not notice until after administration that the pill was taped into the bubble card. During an interview on 06/05/25 at 5:02 P.M., the Director of Nursing (DON) said the following: -If a resident complained of pain, the nurse would assess the resident's pain, the nurse would then go to the CMT's medication cart, sign for the medication in the controlled medication log and have the CMT unlock the narcotic box, and the nurse would remove and administer the medication; -The nurse would then document the resident's pain level and the administration of the PRN pain medication in the resident's medication administration record (MAR) on the computer; -He/she had heard from staff that the CMTs were giving PRN pain medications to residents at times; -The facility discussed getting new nurse medication carts that contain the resident PRN narcotics so that only the nurses would have access to the PRN controlled medications; -The DON said it was a gray area as to whether CMTs should give as needed pain medications. During an interview on 06/05/25 at 5:40 P.M., the Administrator said the following: -Two staff (nurses or CMTs) should count the controlled resident medications at the beginning and end of each shift; -If the count is off, staff should do another count with another nurse, if count still off, the staff should contact the Administration or the ADON, DON, or on call nurse to notify of the situation; -The CMT should not have used personal medications to replace missing resident medications; -The nurse should have reported immediately when this occur. MO00254563

Based on observation, interview, and record review, the facility failed to ensure a medication regime was free from unnecessary medications when the facility staff failed to document targeted behavioral symptoms supporting the use of an antipsychotic medication and failed to document behaviors warranting the use for one resident (Resident #75) on a physician ordered anti-psychotic medication. The facility had a census of 104. Review of the facility policy titled, Psychotropic Medication Use, dated July 2022, showed the following: -Residents will not receive medications that are not clinically indicated to treat a specific condition; -A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior; -Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: Anti-psychotics, anti-depressants, anti-anxiety, and hypnotics; -Residents, families, and/or the representative are involved in the medication management process. Psychotropic medication management includes: Indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences; and preventing, identifying and responding to adverse consequences; -Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnoses and documented I the medical record; -Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes; -When determining whether to initiate, modify, or discontinue medication therapy, the inter-disciplinary team (IDT) conducts an evaluation of the resident. The evaluation will attempt to clarify whether: Other causes for symptoms have been ruled out; signs and symptoms are clinically significant enough to warrant medication therapy; a particular medication is clinically indicated to manage the symptoms or condition; and the actual or intended benefit of the medication is understood by the resident/representative. 1. Review of Resident #75's face sheet showed: -admission date of 04/12/23; -Diagnoses included dementia without behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, major depression, and type 2 diabetes mellitus. Review of the resident's Social Service History and Initial Assessment, dated 11/15/24, showed the following: -Resident is alert and oriented to person, place, time, and situation; -Resident is cognitively intact; -Mood pleasant; -No signs/symptoms of depression; -Behavior factors: none checked as present; -Dignity factors: Deficit in controlling function; -Strengths and coping mechanisms: Strong support system. Review of the resident's care plan, dated 11/16/24, showed the following: -Resident used antipsychotic drug use and was at risk for side effects; -Assess resident for adverse side effects, document, and report; -Monitor for signs of tremors, report onset or increase; -Monitor patterns of target behaviors; -Pharmacy consultant review of medication monthly. (Staff did not care plan the reason for usage of the anti-psychotic or specific targeted behaviors for staff to monitor for.) Review of the resident's annual Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 02/12/25, showed the following: -Cognitively intact; -No signs/symptoms of delirium (disturbance in mental abilities that result in confused thinking and reduced awareness of surroundings); -No behavioral symptoms; -No changes to behaviors or other symptoms; -Required partial/moderate assistance (caregiver does less than half the effort) with dressing, hygiene, and bathing; -Independent with ambulation. Review of the resident's February 2025 Medication Administration Record (MAR) showed the following: -An order, dated 12/24/24, for Seroquel (an anti-psychotic medication) 25 milligrams (mg) staff to give the resident one tablet by mouth two times per day related to unspecified psychosis not due to a substance or known physiological condition; -Staff documented administration of all doses in February 2025. Review of the resident's March 2025 MAR and March 2025 Treatment Administration Record (TAR) showed the following: -An order, dated 12/24/24, for Seroquel 25 mg staff to give the resident one tablet by mouth two times per day related to unspecified psychosis not due to a substance or known physiological condition (order discontinued on 3/27/25); -An order, dated 3/27/25, to give 0.5 tablet by mouth two times per day related to unspecified psychosis not due to a substance or known physiological condition for 7 days and discontinue after one week (order discontinued on same day as entered 3/27/25); -Staff documented administration of all doses from 3/01/25 to 3/27/25 morning dose; -Staff did not provide documentation of administration of any seroquel doses from evening dose on 03/27/25 to 03/31/25; -From 03/01/25 to 03/27/25, staff did not have an order in place to monitor for behavioral symptoms; -An order, dated 03/28/25, for behavior charting times 28 days due to resident's Seroquel getting decreased and then discontinued. Monitor for any changes in mood or behavior every shift for 28 days. (The order did not indicate specific targeted behaviors to monitor related to use of the antipsychotic medication.) Review of the resident's April 2025 MAR and April 2025 TAR showed the following: -No order for administration of Seroquel for 04/01/25 to 04/03/25; -Staff did not provide documentation of administration of Seroquel from 04/01/25 to 04/03/25; -An order, dated 04/04/25, for Seroquel 25 mg, give 0.5 tablet by mouth two times per day related to unspecified psychosis not due to a substance or known physiological condition for 7 days and after 7 days drop to 12.5 mg daily; -Staff documented administration on Seroquel 25 mg, 0.5 tablet (12.5 mg) two times per day from evening dose on 04/04/25 to evening of 04/11/25; -An order, dated 4/12/25, for Seroquel 25 mg, give 0.5 mg by mouth one time a day for unspecified psychosis not due to a substance or known physiological condition for 7 days; -Staff documented administration of ordered doses through review period; -An order, dated 03/28/25, for behavior charting times 28 days due to resident's Seroquel getting decreased and then discontinued. Monitor for any changes in mood or behavior every shift for 28 days. (The order did not indicate specific targeted behaviors to monitor related to use of the antipsychotic medication.) Observation and interview on 04/07/25, at 10:25 A.M., showed: -The resident in bed with eyes closed, awoke easily; -The resident said had been sleeping a lot lately; -The resident denied having any issues with anxiety, depression, or mood disturbances; -The resident was not aware what all of his/her medications were for; -The resident appeared calm. During an interview on 04/15/25, at 12:15 P.M., Certified Nurse Assistant (CNA) X said the resident exhibited no behaviors and slept a lot. During an interview on 04/15/25 at 1:17 P.M., the MDS/Infection Preventionist Nurse said the following: - He/she and one other (MDS) nurse were primarily responsible for care plans; -He/she and the other MDS nurse attempt to update the care plan during each resident's annual MDS assessment; -Care plans were an important tool for staff use, so the staff were aware of resident issues and interventions; -Each resident on a psychotropic medication should have a care plan about potential side effects and targeted behavioral symptoms related to use; -Staff should have created a care plan for the resident related to his/her anti-psychotic use and symptoms to monitor. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she would expect each resident to have a care plan related to psychotropic; -The person reading the care plan should be able to tell everything about the person by reading the care plan; -The care plan should show staff how to adequately care for the resident; -For the resident, his/her physician orders should include a physician's order for monitoring of behavioral symptoms; -Staff should obtain a physician's order with a list of resident behaviors/symptoms. The targeted behavior should be on the TAR, as well as listed on the resident's care plan. During an interview on 04/15/25 at 2:35 P.M., the Director of Nursing (DON) said the following: -The MDS nurses were in charge of updating/adding resident care plans; -Nurses should document behaviors/behavioral symptoms for any resident on anti-psychotics; -Nurses should document targeted behaviors under behavior monitoring under the TAR; -The TAR should list the resident's specific behaviors, such as delusions; -The nurse that enters the physician order for the anti-psychotic should list the behavioral symptoms; -The resident used to have behaviors related to the use of his/her antipsychotic; -The resident had inappropriate sexual type behaviors of exposing him/herself to others; -The resident no longer exhibited inappropriate behaviors. During an interview on 04/15/25, at 3:41 P.M., the Administrator said the following: -The facility needed to update resident care plans to include psychotropic drug use and include listed targeted behaviors/symptoms for use; -Staff should monitor for these specific documented targeted behaviors and document their presence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of less than 5% when staff made three errors out of 31 opportunities resulting in an 9.68% error rate affecting two residents (Resident #76 and #45). The facility had a census of 104. Review of the facility's policy titled, Administering Medications, revised April 2019, showed the following: -The Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -The individual administering the medication checks the label to verify the right resident, right mediation, right dosage, right time, right documentation, and right method (route) of administration before giving the medication; -Vital signs and medication allergies should be checked prior to administration of medications, if indicated; -The individual administering the medication initials the residents medication administration record (MAR) after giving each medication and before administering the next ones. Review of the facility's policy titled, Adverse Consequences and Medications Errors. revised February 2023, showed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with the physician's orders, manufacturers specifications, or accepted professional standards and principles of the professional providing services; including; omission which occurs when a drug is ordered but is not administered, unauthorized drug which occurs when a drug is administered without a physician's order, wrong dose, wrong route, wrong dosage form, wrong drug, wrong time, and/or failure to follow manufacturers instructions and or accepted professional standards; 1. Review of Resident #76's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 09/05/24; -Diagnoses included high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/24/25, showed the resident had severe cognitive impairment. Record review of the resident's April 2025 Physician Order Sheet (POS) showed and order, dated 04/01/25, for lisinopril (blood pressure medication) 10 milligram (mg) tablet, give 5 mg, one-half tablet, daily for hypertension (high blood pressure). Staff to hold if systolic blood pressure (SBP) 110 millimeters of Mercury (mm/HG) or less and/or pulse less than 60 beats per minute (bpm). Observation and interview on 04/11/25, at 9:20 A.M., showed the following: -Certified Medication Technician (CMT) O obtained a blood pressure cuff and entered the resident's room to obtain a blood pressure and pulse. The blood pressure reported as 98/49 mm/Hg (SBP 98 mm/Hg) and pulse of 53 bpm. -CMT O prepared the resident's medications, including lisinopril, and entered resident's room. -CMT O told the resident it was time to take his/her medications and began to hand the resident the medication cup, including the lisinopril. Surveyor requested CMT O return to the medication cart to verify orders prior to administering medications. -CMT O pulled the medication card containing the lisinopril from the cart and reported there was a whole tab, and the order indicated to give only one-half tab. -CMT O then was asked to verify the blood pressure perimeters and reported the order must have changed and removed the lisinopril tablet from the medication cup. During an interview on 04/14/25, at 2:55 P.M., Registered Nurse (RN) M said physician orders should be followed. Blood pressure medications should not be administered if vital signs are below perimeters listed. During an interview on 04/14/25, at 3:40 P.M., CMT P said staff should be following physician orders. Medications should be administered according to what is indicated on the MAR. He/she would notify the nurse and not administer a medication if the blood pressure or pulse was below the perimeters. 2. Review of Resident #45's face sheet, showed the following information: -admission date of 04/12/19 -Diagnoses included vitamin deficiency and conjunctivitis (inflammation of the conjunctiva in one or both eyes). Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. Review of the resident's April 2025 POS showed the following orders: -An order, dated 01/01/25, for cholecalciferol (also known as Vitamin D3 - a fat soluble vitamin that helps the body absorb calcium and phosphorus from food)) 1000 unit tablet, give two tablets by mouth (po) one time a day; -An order, dated 12/21/24, for acular ophthalmic solution (eye drops) 0.5%, instill two drops in both eyes twice daily. Observation on 04/11/25, at 9:51 A.M., showed CMT S administered the following medications to the resident; -One tablet of cholecalciferol/vitamin D - 1000 unit tablet; -One drop in each eye of acular 0.5% eye drops. During an interview on 04/15/25, at 12:17 P.M., CMT R said the following: -The person administering should make sure the medication is the right resident, dose, drug, route, and time; -Administering one less tablet and/or one less eye drop, would be considered a medication error; -Medication errors should be reported to the charge nurse. During an interview on 04/15/25, at 12:49 P.M., Registered Nurse (RN) L said the following: -Administering one less tablet and/or one less eye drop would be considered a medication error; -All staff are expected to triple check the MAR against the medication for accuracy and prevention of medication errors. 3. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said physician orders should be followed. During an interview on 04/15/25, at 2:35 P.M., the Director of Nursing (DON) said the following: -Staff are expected to follow physian orders; -Staff are expected to check the MAR against the medication and ensure they are following the five rights to prevent medication errors. During an interview on 04/15/25, at 3:44 P.M., The Administrator said she expected staff to follow policy and procedure regarding medication administration.

Based on record review and interview, the facility staff failed ensure all residents were free of significant medication errors when staff administered one resident's (Resident #76) high blood pressure medication against physician orders by not following perimeters included on the order. The facility was census of 104. Review of the facility's policy titled, Administering Medications, revised April 2019, showed the following: -The Director of Nursing (DON) supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -The individual administering the medication checks the label to verify the right resident, right mediation, right dosage, right time, right documentation, and right method (route) of administration before giving the medication; -Vital signs and medication allergies should be checked prior to administration of medications, if indicated; -The individual administering the medication initials the resident's Medication Administration Record (MAR) after giving each medication and before administering the next ones. Review of the facility's policy titled, Adverse Consequences and Medications Errors, revised February 2023, showed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with the physician's orders, manufacturers specifications, or accepted professional standards and principles of the professional providing services including: omission which occurs when a drug is ordered but is not administered, unauthorized drug which occurs when a drug is administered without a physician's order, wrong dose, wrong route, wrong dosage form, wrong drug, wrong time, and/or failure to follow manufacturers instructions and or accepted professional standards. 1. Review of Resident #76's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 09/05/24; -Diagnoses included high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/24/25, showed the resident had severe cognitive impairment. Review of the resident's care plan, revised 04/09/25, showed staff did not care plan related to the resident's high blood pressure or blood pressure medication. Review of the resident's April 2025 Physician Order Sheet (POS) showed an order, dated 04/01/25, for lisinopril (blood pressure medication) 10 milligram (mg) tablet, give 5 mg, one-half tablet, daily for hypertension (high blood pressure). Staff to hold if systolic blood pressure (SBP) was 110 millimeters of Mercury (mm/Hg) or less and/or pulse less than 60 beats per minute (bpm). Review of the resident's April 2025 MAR showed staff administered lisinopril when the resident blood pressure or pulse was below the ordered perimeters on the following dates: -On 04/05/25, administered when resident pulse was 49 bpm; -On 04/06/25, administered when resident pulse was 48 bpm; -On 04/09/25, administered when resident pulse was 54 bpm; -On 04/10/25, administered when resident pulse was 58 bpm; -On 04/12/25, administered when resident pulse was 56 bpm; -On 04/15/25, administered when resident pulse was 57 bpm. During an interview on 04/14/25, at 2:55 P.M., Registered Nurse (RN) M said physician orders should be followed. Blood pressure medications should not be administered if vital signs were below perimeters listed. During an interview on 04/14/25, at 3:40 P.M., Certified Medication Tech (CMT) P said staff should be following physician orders. Medications should be administered according to what was indicated on the MAR. He/she would notify the nurse and not administer a medication if the blood pressure or pulse was below the perimeters. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said physician orders should be followed. During an interview on 04/15/25, at 2:34 P.M., the Director of Nursing (DON) said staff should follow physician orders and should be following the MAR to ensure the correct medication was administered. Medication should not be given to a resident if the blood pressure and/or pulse was below the ordered perimeter. The CMT should hold the medication and notify the nurse. During an interview on 04/15/25, at 3:41 P.M., the Administrator said the CMT's should hold the resident's medication if the blood pressure and/or pulse were below the perimeters set in the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident # 49's face sheet showed the following: -admission date of 12/03/19; -Diagnoses included general anxiety disorder. Review of the resident's annual MDS, dated [DATE], preferences for activities section showed the resident said it was very important to him/her to do things with groups of people, to do his/her favorite activities, and to participate in religious services. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Exhibited no behavioral symptoms; -Functional limitation in range of motion to all four extremities; -Used motorized wheelchair for mobility device; -Independent with eating; -Dependent on staff for toileting hygiene, showers, lower body dressing, and with transfers; -Required partial/moderate assistance of staff with personal hygiene; -Required substantial/maximal assistance of staff with upper body dressing, and rolling from left to right. Review of the resident's current care plan showed staff did not care plan related to the resident's preferred activities or attendance. Observation of and interview with the resident on 04/09/25, at 10:45 A.M., showed the following: -The resident lay on his/her bed; -The resident said the facility did not have activities every day; -The Activities Director had bingo on Monday, Wednesday, and Friday and the facility had someone come in and do church service about one time per month; -The residents have talked with the Activities Director about having more and different activities, but the Activities Director just made up excuses as to why he/she will not do other activities; -The resident would enjoy more activities and a different variety of activities; -The residents were bored at times due to not enough activities. Based on observation, interview, and record review, the facility failed to provide activity programs to meet the needs of all residents when failed to to have activities routinely scheduled and provided on the Special Care Unit (SCU) and failed to care plan regarding activities for two residents (Resident #85 and #88) who resided on the SCU. The facility also failed to provide a varied activity program that met the needs of residents and failed to care plan regarding activities for three residents (Resident #49, #57, and #77) who resident outside of the SCU. The facility census was 104. Review of a facility policy titled Activity Programs, dated June 2018, showed the following: -Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well being of each resident; -The activities program is provided to support the well-being of residents and to encourage independence and community interaction; -Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident; -The activities program is ongoing and includes facility-organized group activities, independent, and assisted individual activities; -Activities are designed to encourage maximum individual participation and are geared to the individual resident needs; -Activities are scheduled seven days a week and residents are given the opportunity to contribute to the planning, preparation, conducting, clean up and critique of the programs; -Activities consist of individual, small and large group activities that are designed to meet the needs and interest of each resident and promote self-esteem, comfort, pleasure, education, creativity, success, and independence; -All activities are documented in the resident medical record; -Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board; -Individual and group activities are provided that reflects the schedules, choices, and rights of the residents, are offered at hours convenient to the residents, including evenings, holidays, and weekends reflects the cultural and religious interests, hobbies, life experiences and personal preferences of the residents, appeal to men and women and residents of various age groups, and incorporate family, visitor, and resident ideas of desired activities, -Residents are encouraged, but not required, to participate in activities. 1. Observation of the SCU during survey showed no activity calendar posted. Review showed staff did not provide an activities calendar for the SCU. 2. Review of Resident #85's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 01/31/24; -Diagnoses included congestive heart failure (CHF - chronic condition where the heart does not pump blood as well as it should), vascular dementia (decline in thinking skills caused by reduced or blocked blood flow to the brain), and depression. Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff), dated 02/06/24, showed the following: -Physical behavioral symptoms (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) directed at others occurred one to three days in look back period; -Behavioral symptoms did not interfere with activity participation or the participation of others; -It was important for resident to listen to music, be around animals, do your favorite activities, be around groups of people, go outside to get fresh air when the weather is good, and participate in religious services or practices; -Limited assistance of one staff person for mobility. Review of the resident's quarterly activities participation review, dated 12/31/24, showed the following: -Resident participated in 75% of group activities and events, and one-to-one activity 100% of the time; -Resident liked to listen to music and rhythm band. Resident liked balloon ball one-on-one and liked to get back rubs; -Activity related focuses remained appropriate/current as per current care plan; -Interventions/approaches have been effective in reaching goals. Review of the resident's care plan, revised on 04/09/25, showed staff did not care plan regarding the resident's preferred activities or participation in activities. Observation on 04/08/25, at 2:38 P.M., showed the resident resting in bed with no television or radio on. No activities were offered at that time. Observation on 04/09/25 10:22 A.M. showed the resident ambulating in hallway. No activities were offered at that time. Observation on 04/09/25, at 12:52 P.M. showed the resident sitting in his/her room. No activities were observed on the unit at that time. Observation on 04/10/25, at 11:20 A.M., showed the resident asleep in his/her room and no activities offered at that time. Observation on 04/11/25, at 9:00 A.M., showed the resident walked down the hall and sat in a dining room chair. No food service or activities were offered at that time. Observation on 04/15/25, at 11:30 A.M., showed the resident walking up and down the hallway with no organized group activity occurring at that time. 3. Review of Resident #88's face sheet showed the following: -admission date of 02/12/25; -Diagnoses included dementia, high blood pressure, and depressive episodes Review of the resident's annual MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Verbal behaviors (threatening, screaming, and cursing) directed at others occurred one to three days; -Other behaviors (hitting, pacing, rummaging, sexual acts, disrobing, throwing or smearing food, or yelling or screaming) not directed at others occurred one to three days in look back period; -Resident preferred listening to music, being around animals, spending time outdoors, and participating in activities; -Behavioral symptoms do not interfere with activity participation or the participation of others; -Independent with mobility, transfers, and dressing. Review of the resident's initial activities review, dated 11/14/24, showed the following: -Resident participated and liked country music, walking with a partner, and short stories; -Resident would like to participate in group and one-on-one activities; -Resident needed encouragement and assistance to attend activities. Review of the resident's care plan, revised on 04/09/25, showed staff did not care plan regarding the resident's preferred activities or participation in activities. Observation on 04/08/25, at 2:32 P.M., showed the resident sitting in wheelchair in the hallway. No activities were offered at that time. Observation on 04/09/25, at 11:32 A.M., showed the resident in his/her wheelchair in the hallway with no activities offered at that time on the SCU. Observation on 04/10/25, at 11:20 A.M., showed the resident sitting in his/her wheelchair roaming around unit. No activities were offered at that time. Observation on 04/11/25, at 9:00 A.M., showed the resident and several other residents sitting in the hallway with no activities offered at that time. Observation on 04/11/25, at 1:23 P.M., showed resident resting in bed with no music or television playing. No activities were offered at that time. 4. During an interview on 04/11/25, at 9:30 A.M., Certified Medication Technician (CMT) P said the Activities Director takes residents to bingo sometimes. There are no scheduled activities on the SCU. During an interview on 04/11/25, at 9:30 A.M., CMT O said the following: -The beautician used to come to the unit to provide activities and provided an activity calendar when not providing hair services; -The beautician quit over a month ago; -More alert residents are taken to bingo which is offered off the unit at times; -No activities are offered on the SCU. During an interview on 04/14/25, at 2:55 P.M., Registered Nurse (RN) M said there was no activity calendar on the SCU. Cognitive residents are taken off the unit to attend bingo offered on Monday, Wednesday, and Friday. During an interview on 04/15/25, at 10:50 A.M., Licensed Practical Nurse (LPN) N they do not do activities on the unit. The Activity Director does not go to the unit. There is no activity calendar on the unit. SCU staff will have residents fold clothes for an activity. During an interview on 04/15/25, at 12:45 P.M., Nurse Assistant (NA) U said the beautician used to come to the unit for activities, but does not come anymore. There was no activity calendar on the unit. Some residents will attend bingo at times. During an interview on 04/15/25, at 12:50 P.M., CMT T said aides provide some activities on the unit and some residents attend bingo off the unit at times. During an interview on 04/15/25, at 1:46 P.M., the Assistant Director of Nursing (ADON) said the following: -There were no activities on the unit; -The beautician provided activities on the unit, but no longer works for the facility; -There is an aide that brought activities at times when he/she worked on the unit; -The Activity Director did not do one-on-one activities in resident rooms. During an interview on 04/15/25, at 2:34 P.M., the Director of Nursing (DON) said the following: -He/she would like to see more activities on the SCU; -There used to be a lot more activities on the unit; -Residents on the SCU just wander so they need activities; -The Activity Director was not doing activities on the unit, and he/she did not know why; -The beautician had been gone about a month and was the one doing activities on the unit. During an interview on 04/15/25, at 3:41 P.M., the Administrator said the following: -There had been no activity person for the unit for four or five weeks; -Unit staff often do activities with SCU residents and keep them busy. 6. Review of Resident #57's face sheet showed the following: -admission date of 02/04/25; -Diagnoses included schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves), kidney disease, depressive episodes, and anemia (a condition where the blood doesn't carry enough oxygen to the body's tissues.) Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment. -Activity preferences included, listening to music, being around animals, watching the news, participating in group activities, going outside, religious activities, and it was very important to have the opportunity to participate in those activities; -No staff assessment of activity preferences completed. Review of the resident's care plan, revised 04/09/25, staff did not care plan the resident's activity preferences or participation. During an interview on 04/10/25, at 9:48 A.M., the resident said the following: -Bingo was offered three times a week; -No other activity was offered to him/her; -He/she wished there was more to do. Review of the resident's progress notes, dated 02/06/25 through 04/10/25, showed staff did not document regarding the resident's activity preferences or participation. Review of the resident's Electronic Medical Record (EMR) showed staff did not document completion of an activity assessment. 7. Review of Resident # 77's face sheet showed the following information: -admission date of 01/09/23; -Diagnoses included multiple sclerosis (a chronic autoimmune disease where the body's immune system attacks the protective covering around nerve cells (myelin) in the brain and spinal cord, disrupting nerve signal transmission), high blood pressure, high blood sugar, and double vision. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Activity preferences included being around pets, participating in group activities, going outside, listening to music, reading books, and it is very important to have the opportunity to participate in those activities; -No staff assessment of activity preferences completed. Review of the resident's care plan, revised 04/09/25, showed staff did not care plan related to the resident's activity preferences or participation. During an interview on 04/09/25, at 10:00 A.M., the resident said the only activity that was offered was bingo three times a week. Review of the resident's progress notes dated February 2025 through April 2025, showed staff did not document regarding the resident's activity preferences or participation. Review of the resident's EMR showed staff did not document completion of an activity assessment. 8. During an interview on 04/15/25, at 4:30 P.M., the Activity Director said the following: -He/she did not have enough time to do all activities for every resident in the building; -The facility had a large number of residents for one Activity Director; -The administration expected the Activity Director to chart on everyone and go shopping one day per week; -He/she had never been able to plan for the activities, because he/she was too busy charting; -Sometimes, he/she could not get the nurse aides to help bring the residents to activities; -He/she tried to make up activity packets, including coloring pages, for the residents to use on the weekends and a volunteer came every other weekend on Sunday to do church service, but otherwise, the facility did not offer activities to the residents on the weekends; -The facility did have a beautician that assisted with resident activities in the dementia unit, but he/she quit a few weeks back and had not been replaced. Some of the staff in the unit try to do activities with the dementia residents when they have time. During an interview on 04/15/25, at 12:45 P.M., LPN W said the following: -He/she worked every other weekend and the facility did not offer activities to the residents on the weekends; -The facility needed to do more activities with the residents because activities helped to improve the residents' spirits/moods. During an interview on 04/15/25, at 12:17 P.M., CMT R said the following: -The Activities Director changes the shopping day a lot and does the shopping his/herself, without the residents; -Bingo was the main activity; -He/she was not sure if there were any activities on the weekends, There use to be a couple who would provide religious service, but they stopped coming over four years ago. During an interview on 04/15/25, at 12:49 P.M., RN L said the following: -Bingo was the main activity and it happened a couple times a week; -Shopping occurred once a week and the Activity Director did that herself, without the residents; -He/she had not seen any other, or individual activities going on in the past year in a half. During an interview on 04/14/25, at 2:55 P.M., RN M said different activities were offered in the facility, but he/she did not know the schedule. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -There were not enough activities offered to residents; -The Activity Director did not do one-on-one activities in resident rooms; -More activities could be done; -Residents had voiced they are unhappy with the activities. During an interview on 04/15/25, at 2:34 P.M., the DON said the following: -He/she has not seen activities offered for bed bound residents; -No church services were offered on the weekend; -No activities were offered by the nurses on the weekend. During an interview on 04/15/25, at 3:41 P.M., the Administrator said the following: -Resident council had voiced complaints about activities; -The Activity Director was not documenting residents on the daily activity record, he/she was completing quarterly or admit assessments only; -The activity program should be more in-depth and comprehensive; -The Activity Director did not do as much as he/she should for residents in room or bed bound; -Residents have self-initiated activities on weekend; -They facility would love to have activities on weekend if the budget would allow it.

Based on observation, interview, and record review, the facility failed to ensure each resident received food and drink that was palatable, attractive and at an appetizing temperature when meals were served colder than resident preference and out of recommended service temperature range. The facility census was 104. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Except during preparation, cooking, or cooling, time/temperature control for safety food shall be maintained at 41 degrees Fahrenheit (° F) or less; -Time/temperature control for safety food that is cooked to a temperature and for a time specified and received hot shall be a temperature of 135° F or above. Review of the facility's policy titled Food Preparation and Service, dated 2001, showed the following: -Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices; -Food Distribution means the processes involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas, etc. When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart; -Proper hot and cold temperatures are maintained during food distribution and service; -The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff. Review of the facility's Food Temperature Log, undated, showed minimum holding temperature for hot greater than 135° F (or check specific state requirements) and cold food less than 41° F. 1. Observation on 04/10/25, at 11:58 A.M., showed the following: -Cook A took temperatures of all food on the steam table prior to food service; -Pork and gravy were 180° F, corn casserole and mashed potatoes were 175° F, green beans were 195° F and mechanical soft pork and puree pork were 165° F. Observation on 04/10/25, at 2:00 P.M., showed the following: -The last hall tray was delivered in the Special Care Unit (SCU) at 2:00 P.M.; -A test tray taken from the hall cart at 2:00 P.M.; -The test tray food temperatures showed the pork was 109° F, the corn casserole was 108.3° F, green beans were 107.5° F, and the milk was 52.8° F. During an interview on 04/08/25, at 1:45 P.M., Resident #23 said he/she ate in the dining room and the food was cold at times, especially the french fries. During an interview on 04/09/25, at 10:23 A.M., Resident #77 said the food was always cold regardless if he/she obtained a hall-tray or ate in the dinning room. During an interview on 04/09/25, at 2:56 P.M., Resident #43 said he/she ate in his/her room. The food was always cold and the drinks were always hot. This has been an issue for a long time. During an interview on 04/10/25, at 9:59 A.M., Resident #92 said he/she ate in the room and breakfast was cold. His/her spouse brought in food for lunch and dinner sometimes. He/she only liked the peanut butter and jelly sandwiches from the facility. During an interview on 04/15/25, at 2:00 P.M., Resident #49 said when staff served the resident meals in his/her room, the hot foods arrived cold. He/she did not enjoy eating the cold meals. During an interview on 04/11/25, at 2:06 P.M., [NAME] B said the following: -Hot food should be 165° or hotter and cold food or milk should be 38° F to 40° F. These should be the same temperatures when they reach the resident; -The cooks were responsible for taking temperatures of food each shift. During an interview on 04/11/25, at 2:09 P.M., [NAME] A said the following: -Hot foods should be 145° F for fish and 165° F for all other meats and hot foods. Cold foods and drinks should be 30° F to 38° F; -Hot foods should maintain that temperature on the steam table and cold foods should remain cold when they reach the resident; -The temperatures of 109° F for the pork, 108.3° F for the corn casserole, 107.5° F for the green beans, and 52.8° F for the milk were not acceptable; -The cooks were responsible for taking temperatures of the food on the steam table and ensuring food was delivered to the residents at an appetizing temperature. During an interview on 04/14/25, at 9:39 A.M., the Dietary Manager (DM) said the following: -Hot foods should be kept at 160° F and cold food between 42° F and 45° F; -When a tray reached a resident, hot food should be 145° F and cold food 35° F; -The temperatures of 109° F for the pork, 108.3° F for the corn casserole, 107.5° F for the green beans, and 52.8° F for the milk were not acceptable; -He/she had no training on food temperatures; -He/she was responsible for ensuring trays reached the residents at an appetizing temperature. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -Hot food was held at 140° F to 160° F, cold food less than 40° F, and cold drinks in the 30s° F; -When a plate reached a resident the hot food should be at least 120° F and milk not over 40° F; -The temperatures of 109° F for the pork, 108.3° F for the corn casserole, 107.5° F for the green beans, and 52.8° F for the milk were not acceptable; -The cooks should ensure the trays leave the kitchen at an appropriate temperature; -The cooks should take temperatures of the food on the steam table before service, in the middle of service and at the end of service; -The DM was ultimately responsible for ensuring trays reach residents at an appetizing temperature.

Based on observation, interview, and record review, the failed to establish and maintain an effective infection prevention and control program when the facility failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely for seven staff members (Certified Medication Technician (CMT) F, DA G, Licensed Practical Nurse (LPN) H, Certified Nursing Assistant (CNA) I, CNA J, Registered Nurse (RN) K, and Dietary Aide (DA) E) of ten sampled staff members. The facility staff also failed to wash their hands after providing catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and incontinent care for one resident (Resident #4) The facility census was 104. 1. Review of the facility's policy titled Employee Screening for Tuberculosis, revised 03/2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease using tuberculin skin test (TST - a skin test used to detect exposure to the bacteria that cause tuberculosis) or interferon gamma release assay (IGRA - a blood test used to diagnose LTBI) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made, but prior to the employee's duty assignment; -Screening included a baseline test for LTBI using either a TST or IGRA and individual risk assessment and symptom evaluation. If the baseline test was negative and individual risk assessment indicated no risk factors for acquiring TB, then no additional screening was indicated. If the baseline test was positive, but the individual risk assessment was negative and the individual was asymptomatic, a second test (either TST or IGRA) was conducted; -The employee health coordinator (or designee) will accept documented verification of TST or IGRA results within the preceding 12 months. If the previous TST or IGRA result was negative and the individual was at low risk of TB infection, the employee would not be retested prior to employment. If the previous TB test was positive, but the individual was at low risk for TB infection, was asymptomatic, and was at low risk of disease progression, a second test would be conducted; -Individuals who have had a Bacillus Calmette-Guérin (BCG - a vaccine that helps prevent TB) vaccination will have an initial screening test. An IGRA is the preferred method of testing for individuals who have received the BCG vaccine; -The decision to perform serial (e.g., annual) testing after baseline is based on individual risk factors of exposure both at work and outside of work; -The infection preventionist determines how to proceed with follow up testing based on individual risk factors and baseline test results. Review of 19 CSR 20-20.100 showed the following: -Long-term care facilities shall screen their residents and staff for tuberculosis; -Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained for all employees and volunteers; -All long-term care facility employees and volunteers who work ten or more hours per week are required to a complete a TB test within one month prior to starting employment in the facility; -If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins; -Employees and volunteers with an initial negative two-step TB test shall be one-step tested annually and the results recorded in a permanent record. 2. Review of CMT F's personnel file showed the following: -Hire date of 03/14/24; -The first TST was administered on 02/17/25 and read on 02/19/25 with a result of 0 millimeters (mm - negative); -The second TST was administered on 02/26/25 and read on 02/28/25 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the Infection Preventionist (IP) said CMT F did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the Assistant Director of Nursing (ADON) said CMT F did not have a negative TST prior to working on the floor. During an interview on 04/11/25, at 11:09 A.M., the Business Office Manager (BOM) said the CMT did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the Director of Nursing (DON) said the CMT did not have a negative TST prior to working the floor. 3. Review of Dietary Aide (DA) G's personnel file showed the following: -Hire date of 12/27/24; -The first TST was administered on 02/17/25 and read on 02/19/25 with a result of 0 mm; -The second TST was administered on 02/26/25 and read on 02/28/25 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said DA G did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said DA G did not have a negative TST prior to working on the floor. During an interview on 04/11/25, at 11:09 A.M., the BOM said the DA did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the DA did not have a negative TST prior to working the floor. 4. Review of LPN H's personnel file showed the following: -Hire date of 10/23/23; -The first TST was administered on 11/02/23 and read on 11/04/23 with a result of 0 mm; -The second TST was administered on 11/30/23 and read on 12/02/23 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said LPN H did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said LPN H did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the LPN did not have a negative TST prior to working the floor. 5. Review of CNA I's personnel file showed the following: -Hire date of 10/29/24; -The first TST was administered on 10/29/24 and read on 10/31/24 with a result of 0 mm; -The second TST was administered on 11/07/24 and read on 11/09/24 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said CNA I did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said CNA I did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the CNA did not have a negative TST prior to working the floor. 6. Review on CNA J's personnel file showed the following: -Hire date on 12/05/24; -The first TST was administered on 12/05/24 and read on 12/07/24 with a result of 0 mm; -The second TST was administered on 12/20/24 and read on 12/22/24 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said CNA J did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said CNA J did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the CNA did not have a negative TST prior to working the floor. 7. Review of Registered Nurse (RN) K's personnel file showed the following: -Hire date of 07/16/24; -The first TST was administered on 07/16/24 and read on 07/18/24 with a result of 0 mm; -The second TST was administered on 08/01/24 and read on 08/04/24 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said RN K did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said RN K did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the RN did not have a negative TST prior to working the floor. 8. Review of DA E's personnel file showed the following: -Hire date of 12/05/24; -The first TST was administered on 12/05/24 and read on 12/07/24 with a result of 0 mm; -The second TST was administered on 12/14/24 and read on 12/16/24 with a result of 0 mm. During an interview on 04/10/25, at 2:46 P.M., the IP said DA E did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said DA E did not have a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the DA did not have a negative TST prior to working the floor. 9. During an interview on 04/10/25, at 2:29 P.M., the Business Office Manager (BOM) said the following: -Staff completed the first TST on their date of hire and read the TST two days later; -New staff completed orientation prior to working on the floor; -He/she did not know if newly hired staff needed their first TST read prior to working on the floor; -The ADON was responsible for ensuring newly hired staff's TST was completed prior to working on the floor. During an interview on 04/10/25, at 2:46 P.M., the IP said the following: -He/she had a nurse administer newly hired staff their first TST during orientation; -Orientation lasted one day and then staff trained on the floor for one day; -He/she or a nurse read the first TST two days later; -The first TST should be read prior to staff working on the floor so residents who have are immunocompromised were not exposed to TB disease; -He/she gave the completed form to the ADON; -The DON was ultimately responsible for ensuring the first TST was administered and read prior to staff working on the floor. During an interview on 04/10/25, at 3:01 P.M., the ADON said the following: -New staff completed one day of orientation and then one day on the floor without hands on the residents; -A nurse administered the first TST during orientation and read the TST two to three days later; -He/she did not know new staff could not work the floor prior to their first TST being read until now; -He/she was responsible for ensuring newly hired staff had a negative TST prior to working on the floor. During an interview on 04/10/25, at 11:28 A.M., the DON said the following: -Newly hired staffs' first TST was administered at orientation and read 48 to 72 hours later; -Newly hired staffs' first TST should be read and be negative prior to working on the floor; -The ADON took care of the TB forms, but he/she was ultimately responsible for ensuring newly hired staff had a negative TST prior to working on the floor. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -Newly hired staff received a TST upon hire and the TST was read within 72 hours; -Newly hired staff should not work the floor until their first TST was read and was negative; -The IP was responsible for administering and reading newly hired staffs TST and the ADON monitored to ensure these were completed. 10. Review of the facility's policy titled Handwashing/Hand Hygiene, revised October 2023, showed the following: -All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors; -Hand hygiene should be performed before applying gloves and after the removal of gloves; -Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal. Review of the facility's policy titled Catheter Care, Urinary, revised August 2022, showed after performing care, staff to discard disposable items into designated containers, remove gloves and discard into designated container, and wash and dry hands thoroughly before repositioning bed covers, handling the call light. Review of Resident #4's face sheet (brief look at resident information) showed the following information: -admission date of 01/24/23; -Diagnoses include heart failure, high blood pressure, diabetes, and pressure ulcers. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 04/07/25, showed the following information: -Cognitively intact; -Dependent on staff for toileting hygiene; -Indwelling catheter use and incontinent of bowel. Review of the resident's care plan, initiated on 04/09/25, showed the following: -Provide peri-care after each incontinent episode; -Provide catheter care each shift. Observation on 04/11/25, at 10:05 A.M., showed Certified Nursing Assistants (CNA)'s Y and Z entered the resident's room, donned gowns and gloves, and performed incontinent and catheter care appropriately. After CNA Y cleansed the resident's catheter, front side, and back side, CNA Y did not change his/her gloves and/or wash his/her hands. CNA Y then adjusted the resident's side rails and placed a new bed pad underneath the resident. CNA Y then unfolded a clean blanket and placed it on top of the resident. CNA Y obtained the resident's call button and bed controller and adjusted the bed height and placed the call light on top of the resident. CNA Y then took off his/her gloves and performed hand hygiene. During an interview on 04/15/25, at 10:51 A.M., CNA Q said the following: -Hand hygiene was expected before, during, and after resident cares; -It would not be appropriate to touch multiple surfaces with soiled gloves and/or hands. During an interview on 04/15/25, at 12:17 A.M., CMT R said the following: -Staff should perform hand hygiene before, during, and after resident cares; -It would not be appropriate to touch multiple surfaces with soiled gloves and/or hands. During an interview on 04/15/25, at 12:49 P.M., RN L said the following: -Staff were expected to perform hand hygiene before, during, and after resident cares; -Staff were expected to removed soiled gloves and perform hand hygiene after performing resident cares and before touching anything else in the resident's room. During an interview on 04/15/25, at 1:17 P.M., the MDS Coordinator/Infection Preventionist said the following: -Staff were expected to perform hand hygiene before, during, and after resident cares; -Anytime gloves need changed, hand hygiene should be performed. During an interview on 04/15/25, at 1:46 P.M., the ADON said the following: -Staff were expected to perform hand hygiene before, during, and after resident cares; -Staff were expected to remove soiled gloves and perform hand hygiene after performing resident cares and before touching anything else in the resident's room. During an interview on 04/15/25, at 2:35 P.M., the DON said the following: -Staff were expected to perform hand hygiene before, during, and after resident cares; -Staff were expected to change their gloves and perform hand hygiene if their gloves become soiled; -The CNA should have removed his/her gloves and performed hand hygiene prior to continuing care. During an interview on 04/15/25, at 3:44 P.M., the Administrator said staff were expected to perform hand hygiene before, during, and after resident cares.

Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 104. Review of the facility's job description titled Director of Food Services, dated 2003, showed the following: -The primary purpose of the job position was to assist the dietician in planning organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner; -Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association; -Must be registered as a Food Services Director in this state; -Must be knowledgeable of food services practices and procedures as well as the laws, regulations and guidelines governing food services functions in nursing care facilities. 1. During interviews on 04/10/25, at 10:00 A.M., on 04/11/25, at 10:17 A.M., and on 04/14/25, at 9:39 A.M., the Dietary Manager (DM) said the following: -He/she became the Dietary Manager in 11/2024; -He/she was not a Certified Dietary Manager (CDM); -He/she was not enrolled in a CDM course; -He/she asked the Administrator and Business Office Manager (BOM) several times about the course and they told him/her they were waiting on an e-mail; -The dietician came every two weeks, but was not employed full time at the facility; -He/she was not a certified food services manager, did not have an associates degree or higher in food services management or hospitality, and did not have two or more years experience as a dietary manager; -He/she did not have a serve safe certificate; -The Administrator and BOM were certified dietary managers, but were not employed as the Dietary Manager; -He/she had no training on food temperatures. During an interview on 04/14/25, at 10:28 A.M., the BOM said the following: -The DM did not have his/her CDM; -He/she did not know if the DM was enrolled in a CDM course; -He/she took the CDM course, but did not work in the capacity of the DM; -He/she did not monitor anything in the kitchen, the DM did. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -The DM was not a CDM; -The DM was not currently enrolled in a CDM course; -He/she did not know if the DM was Serve Safe certified; -He/she and the BOM had their CDM, but were not acting as the DM; -He/she did inservices with kitchen staff, but was not the DM; -The DM monitored the kitchen; -The dietician came twice monthly but was not employed full time; -He/she reviewed at the dietician's report; -The DM was responsible for the kitchen; -He/she was responsible for enrolling the DM in a CDM course.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed and served in a manner to protect against contamination and in accordance with standards of practice when staff failed to know the required temperature and sanitation levels and failed to regularly test the temperature and sanitation level and ensure the appropriate water temperature was reached on the dishwashing machine; staff failed maintain the stove, griddle, coffee pot, and the hand washing sink clean and free from debris; and when staff consumed food in the kitchen and dishwashing areas. The facility census was 104. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the the data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The ware washing machine had been tested and the information on the data plate represented the parameters that ensured effective operation and sanitization and that need to be monitored. Review of the facility's policy titled Sanitization, revised 11/2022, showed the following: -Dishwashing machines were operated according to manufacturer's instructions; -General recommendations for heat and chemical sanitization were low-temperature dishwasher (chemical sanitization) with wash temperature of 120° Fahrenheit (F), final rinse with 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse, and the chemical solution maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Review of the facility's PPM Sanitizer Record Log, dated 03/2025, showed the following: -Columns for breakfast, lunch, and dinner with wash, rinse, PPM, and initials; -The log did not include temperature or PPM parameters for the dishwashing machine; -On 03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/08/25, 03/16/25, 03/18/25 and 03/25/25 in the breakfast column wash and rinse were 100° F and PPM measured 100; -On 03/01/25 and 03/02/25 breakfast column, wash was 110° F, rinse was 100° F and PPM measured 100; -On 03/10/25 through 03/14/25, 03/17/25, 03/19/25 through 03/24/25 and 03/26/25 through 03/31/25 in the breakfast column, wash and rinse were 100° F and PPM measured 110; -On 03/09/25 in the breakfast column, wash and rinse was 110° F and PPM measured 200; -On 03/02/25 through 03/08/25 and 03/10/25 through 03/31/25 in the lunch column, wash was 100°, rinse was 110° F and PPM was 100; -On 03/01/25 in the lunch column wash measured 100° F, rinse was 110° F and PPM measured 200; -On 03/10/25 in the lunch column wash and rinse was 110° F and PPM measured 100; -On 03/01/25 through 03/17/25 in the dinner column, wash and rinse were 100° F and PPM measured 50; -Staff did not document wash or rinse temperature or the PPM in the dinner column from 03/18/25 through 03/31/25. Review of the facility's PPM Sanitizer Record Log, dated 04/2025, showed the following: -On 04/01/25, breakfast and lunch column, on 04/07/25 and 04/28/25 breakfast lunch and dinner column, and on 04/09/25 and 04/10/25, wash and rinse were 100° F and PPM was 100; -On 04/01/25 dinner column, wash and rinse were 110° F and PPM was 50; -Staff did not document wash or rinse temperature or PPM for breakfast, lunch and dinner from 04/02/25 through 04/06/25 and dinner on 04/09/25 and 04/10/25. Observation on 04/10/25, at 11:58 A.M., showed a kitchen staff member tested the dishwashing machine and the wash and rinse was 100° F and sanitation measured between 100 and 200 PPM. Observation on 04/11/25, at 10:01 A.M., showed wash temperature 88° F, rinse 98° F and PPM 200. During an interview on 04/11/25, at 10:01 A.M., Dietary Aide (DA) C said the following: -The temperature for wash and rinse cycles should be 120° F and sanitation should be 240 PPM; -He/she was educated on this when he/she was hired; -If the dishwashing machine did not reach the required temperature or sanitation, he/she reported this to the Dietary Manager (DM) and the DM reported to the Administrator; -He/she also let the Maintenance Supervisor know; -The dishwashing machine just gets the temperature the facility's boiler gave it; -If the dishwashing machine did not reach the proper temperatures or sanitation, the dishes would not be clean and sanitized and could lead to cross contamination and resident illness; -Wash temperature 88° F and rinse 98° F was not appropriately; -He/she was instructed to double wash the dishes and he/she did this a lot of the times and sometimes three times if there was food particles stuck; -The DM was responsible for ensuring the dishwashing machine operated appropriately. During an interview on 04/11/25, at 10:50 A.M., the Maintenance Supervisor said the following: -He was not familiar with the dishwashing machine; -The dishwashing machine was rented and contracted through EcoLab and EcoLab did the maintenance on the machine; -Wash and rinse should be a minimum of 120° F. He did not know what the sanitation PPM should be; -The DAs were instructed to run the dishes through the machine two to three times to ensure they were clean; -If the temperature or sanitation were not at the appropriate levels, kitchen staff should report this to the DM or him; -Either he or the DM called EcoLab for service. EcoLab was just in the facility on 04/10/25 and said the dishwashing machine was still not getting to the appropriate temperature; -Anything under 120° F was not the correct temperature and the dishes may not be sanitized or cleaned properly and could cause illness in the residents; -The DM was responsible for ensuring kitchen staff were educated on the appropriate temperature and sanitation levels of the dishwashing machine; -The PPM Sanitizer Record Log should include the minimum wash and rinse temperature and PPM level for sanitation so staff knew when they were not correct. The log should be filled out daily for breakfast, lunch and dinner. During an interview on 04/11/25, at 11:53 A.M., DA D said the following: -The wash temperature should be 120° F and the PPM 125 to 150. He/she did not know what the rinse temperature should be; -He/she did not know how often the temperatures and PPM needed to be documented in the log; -If the wash and rinse temperatures were not appropriate, he/she notified the DM; -If the wash and rinse temperatures were not appropriate, the dishes were not getting cleaned or sanitized and could cross contaminate and make residents sick. During an interview on 04/11/25, at 2:06 P.M., [NAME] B said the following: -DAs should document the wash, rinse, and PPM of the dishwashing machine each shift; -If the DAs noticed the temperature or PPM was not correct, they notified the DM; -If the temperatures and PPM was not correct, the dishes would not be cleaned and sanitized and could cause resident illness; -The DM was responsible for ensuring staff documented the temperatures and PPM each shift and ensuring the temperature and PPM were appropriate. During an interview on 04/11/25, at 2:09 P.M., [NAME] A said the following: -The dishwasher temperature should be a minimum of 125° F and he/she did not know what the sanitation PPM should be; -If the DAs noticed the temperature and/or sanitation was not correct, they should notify the DM or maintenance; -If the dishwasher temperature and/or sanitation was not correct, the dishes would not be cleaned or sanitized and this could cause resident illness. During an interview on 04/14/25, at 9:30 A.M., DA E said the following: -The dishwasher runs at 100° F and that was what it should be. He/she assumed that was the appropriate temperature because that was what other DAs wrote on the log. The sanitation should be between 50 to 100 PPM and he knew that because that was what the bottle with the strips on it said; -The temperature gauge says the dishwashing machine should be 120° F for wash and rinse; -If the temperature did not reach 120° F, the dishes were still getting clean and sanitized unless they had stains on them; -If the dishes were not cleaned or sanitized correctly, this could cause resident illness; -The PPM Sanitizer Record Log did not show what the wash and rinse temperature or the PPM should be. During interviews on 04/10/25, at 1:25 P.M., and on 04/14/25, at 9:39 A.M., the DM said the following: -He/she called about the heat booster on the dishwashing machine, but he/she had not heard back; -The dishwasher wash and rinse should be 120° F. He/she did not know what the sanitation level should be; -He/she was not sure how the staff should know what the temperature and sanitation levels should be. The temperature and sanitation levels were not included on the PPM Sanitizer Record Log; -He/she assumed the temperatures were supposed to be 100° F since that was what the log showed since she worked at the facility and no one told him/her anything different; -If the dishwasher temperature and/or sanitation level were not correct, the dishes would not be cleaned and sanitized and could cause cross contamination and resident illness; -He/she was responsible for ensuring staff knew the appropriate temperatures and sanitation, filled out the logs every shift and the dishwasher was working appropriately. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -The dishwasher temperature should be 120° F for wash and rinse cycle and the sanitation should be 50 PPM; -The dishwasher was rented from EcoLab and they came out on 04/10/25 to look at it and told staff to wash each load of dishes twice. The EcoLab said the booster was supposed to be in on 04/15/25; -He/she did not know how long the dishwashing machine had not been the correct temperature; -The PPM Sanitizer Record Log did not have the minimum temperature or PPM on it; -Dietary staff were educated upon hire about the appropriate dishwasher temperatures and sanitation PPM; -The DM knew the appropriate temperatures and sanitation levels by the facility's policies and procedures; -If the dishwasher temperatures and/or sanitation level was not appropriate, DAs told the DM. The DM reported this to the Administrator and he/she called EcoLab; -EcoLab will sometimes increase the sanitation level on the dishwasher but he/she did not know if this would effectively clean or sanitize the dishes; -If the dishes were not cleaned or sanitized appropriately, they could grow bacteria and cause resident illness; -Staff should fill out the PPM Sanitizer Record Log daily for each shift; -The DM was responsible for ensuring staff knew the appropriate temperatures and sanitation, filled out the logs every shift and the dishwasher was working appropriately. 2. Review of the FDA 2013 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests; -A handwashing sink that is properly located is one that is available to food employees who are working in food preparation, food dispensing, and warewashing areas. Handwashing sinks that are blocked by portable equipment or stacked full of soiled utensils and other items, are rendered unavailable for employee use. Nothing must block the approach to a handwashing sink thereby discouraging its use, plus it must be kept clean and well stocked with soap and sanitary towels to facilitate frequent use. Therefore, a handwashing sink that is located in the immediate work area, or between work areas that the Code states must be equipped with handwashing sinks, depending upon the size and function of the facility, would be considered properly located. Such placement of handwashing sinks facilitates frequent handwashing by food employees in all work areas. Review of the facility's policy titled Sanitization, revised 11/2022, showed the following: -The food service area is maintained in a clean and sanitary manner; -All kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects; -All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair; -All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Observation on 04/07/25, at 9:50 A.M., showed the griddle was dirty and needed to be cleaned. Observation on 04/10/25, at 10:02 A.M. showed the following: -The backsplash of the griddle and stove top appeared to have food particles stuck on and there was a brownish film that appeared to be grease stain and a blackish colored film that appeared to be carbon build up. The brownish and blackish film also covered the sides of the stove and griddle; -The handwashing sink had reddish and blackish colored spots around the back edge of the sink either side of the faucet. The base around the faucet had a brownish and greenish residue. Observation on 04/11/25, at 9:13 A.M., showed the following: -The backsplash of the griddle and stove top appeared to have food particles stuck on and there was a brownish film that appeared to be grease stain and a blackish colored film that appeared to be carbon build up. The brownish and blackish film also covered the sides of the stove and griddle; -The handwashing sink had reddish and blackish colored spots around the back edge of the sink either side of the faucet. The base around the faucet had a brownish and greenish residue. A large plastic mug sat on the sink and was approximately 1/3 full of a brownish liquid; -The coffee pot on the coffee maker near the dishwashing room had brownish colored residue built up around the top rim and spout area and the glass carafe had a brownish in color build up on the inside. During an interview on 04/11/25, at 11:53 A.M., DA D said the following: -Each staff member had a cleaning list for the job position they held on any certain day; -All kitchen staff were responsible for cleaning the hand washing sink. The sink should not have the reddish and blackish colored spots or the brownish and greenish colored residue. No drinks should be left on the hand washing sink; -The cooks were responsible for cleaning the stove and griddle. The stove top and griddle should not have food particles, blackish and brownish residue on the back splash or blackish and brownish residue on the sides; -All staff were responsible for ensuring their cleaning duties were completed; -If staff did not clean, the food could become cross contaminated and cause resident illness; -The DM was responsible for ensuring staff completed cleaning tasks. During an interview on 04/11/25, at 2:06 P.M., [NAME] B said the following: -Kitchen staff had lists of cleaning responsibilities; -He/she did not know who was responsible for the hand washing sink; -The cooks were responsible for cleaning the stove and griddle. The stove and griddle needed to be cleaned inside and out; -DAs were responsible for cleaning the coffee pot; -The DM was responsible for ensuring staff completed cleaning assignments. During an interview on 04/11/25, at 2:09 P.M., [NAME] A said the following: -Kitchen staff had assigned cleaning duties; -The hand washing sink was not assigned to a certain staff member. All staff should clean it if it was dirty; -The cooks were responsible for cleaning the stove and griddle. It should not have food particles, carbon or grease build up; -The DAs were responsible for cleaning the coffee pot and it should be cleaned each shift. The coffee pot should not have a brownish residue on it; -If staff did not clean the kitchen, it could lead to resident illness. During an interview on 04/14/25, at 9:30 A.M., the DM said the following: -Kitchen staff had cleaning schedules and assignments; -Cook 2 was responsible for hand washing sink. The sink should not have any stains or residue on it and should not have a mug of liquid sitting on it; -The cooks were responsible for cleaning the stove and griddle. The stove and griddle should not have food particles, grease or carbon build up on the back splash or sides and should be cleaned each shift; -The DAs were responsible for cleaning the coffee pot at least each shift. The coffee pot should not have a brownish residue; -Cook 1 was responsible for making sure staff completed cleaning on their shift; -If the kitchen was not cleaned, this could cause cross contamination and resident illness; -He/she had instructed staff to clean and staff say they will but do not get it done. He/she was responsible for ensuring staff completed cleaning tasks. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -The entire kitchen staff and DM were responsible for cleanliness of the kitchen; -The hand washing sink, stove and griddle and coffee pot should all be clean; -Kitchen staff had sprays they could use to remove carbon build up. 3. Review of the FDA 2013 Food Code showed the following: -Except as specified in this section, an employee shall eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. Review showed the facility did not provide a policy related to designated break areas. Observation on 04/11/25, at 9:30 A.M., showed the following: -DA C obtained cereal from a counter above the prep table and poured some into a bowl; -He/she walked with the bowl to the two door refrigerator located near the entrance of the kitchen and obtained milk and poured milk into the bowl. The DA tipped the bowl up and drank some milk out of the bowl, placed the bowl down, and placed the milk back into the refrigerator; -He/she carried the bowl over to the silverware container in front of the steam table and grabbed a spoon; -He/she carried the bowl and spoon into the dishwashing area and placed on a tray over clean dishes. He/she also had an opened banana on the tray; -He/she ate the cereal and banana over the clean dishes, threw the bowl and banana peel away and placed the spoon on the dirty side of the dishwashing area and walked out of the kitchen; -He/she did not clean the tray or remove the clean dishes he/she ate over from the clean side to the dirty side of the dishwashing area. During an interview on 04/11/25, at 10:01 A.M., DA C said the following: -He/she ate in the dishwashing room or in his/her car; -He/she did not go to the break room; -All the dishes on the rack were clean; -He/she ate above them and ate throughout the kitchen; -The only appropriate place to eat was the break room; -The DM was responsible for ensuring staff did not eat in the kitchen. During an interview on 04/11/25, at 11:53 A.M., DA D said the following: -Staff should eat behind the line where food was not prepared; -Staff should not prepare cereal then obtain milk, pour the milk into a bowl and then drink milk out of a bowl and then stand with the bowl over clean silverware in the kitchen area; -Staff should not eat over clean dishes in the dishwashing area; -If staff ate in the kitchen, prep area or over clean dishes in the dishwashing room they could contaminate surfaces and make residents ill. During an interview on 04/11/25, at 2:06 P.M., [NAME] B said the following: -Staff should eat in the break room or their car; -Staff should not prepare cereal then obtain milk, pour the milk into a bowl and then drink milk out of a bowl and then stand with the bowl over clean silverware in the kitchen area; -Staff should not eat over clean dishes in the dishwashing area; -If a staff member ate in the kitchen or dishwashing area over clean dishes, this could cause cross contamination and spread germs which could cause resident illness. During an interview on 04/11/25, at 2:09 P.M., [NAME] A said the following: -Staff should eat in the designated break room; -Staff should not prepare cereal then obtain milk, pour the milk into a bowl and then drink milk out of a bowl and then stand with the bowl over clean silverware in the kitchen area; -Staff should not eat over clean dishes in the dishwashing area; -The DM was responsible for ensuring staff ate in the designated break room. During an interview on 04/14/25, at 9:30 A.M., DA E said the following: -Staff should eat in the break room; -Staff should not eat over clean dishes because that was not sanitary and they could spill and dirty the dishes; -If he/she saw a staff member do this, he/she would tell that staff member to stop and report it to the DM. During an interview on 04/14/25, at 9:39 A.M., the DM said the following: -Staff should eat in the break room and not in the dishwashing room or kitchen; -Staff should not prepare cereal then obtain milk, pour the milk into a bowl and then drink milk out of a bowl and then stand with the bowl over clean silverware in the kitchen area; -Staff should not eat over clean dishes in the dishwashing area; -He/she told staff over and over to not eat in the kitchen or dishwashing room; -He/she was responsible for ensuring staff knew to eat in the break room and not the kitchen or dishwashing room. During an interview on 04/14/25, at 10:30 A.M., the Administrator said the following: -Staff should eat in the break room and not in the kitchen or dishwashing room; -Staff should have the cook make their tray and not make it for themselves; -If staff ate over clean dishes, this could contaminate all of the dishes and cause resident illness; -The DM was responsible for ensuring staff did not eat in the kitchen or dishwashing room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to the State Survey Agency (Department of Health and Senior Services - DHSS) an allegation of resident to resident sexual abuse involving two resident (Resident #1 and Resident #2) within required two hours time frame. The facility census was 91. Review of the facility's policy titled Abuse Investigation and Reporting, dated 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and /or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by the facility management. Findings of abuse investigations will also be reported; -All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of property, will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: state licensing agency responsible for surveying/licensing the facility, local/state Ombudsman, the resident's representative, Adult Protective Services, law enforcement, the resident's physician, and the facility medical director; -An alleged violation of abuse, neglect, and exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or twenty-four hours if it does not involve abuse. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following information: -admission date of 07/05/23; -Diagnoses included Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain. It is the most common cause of premature senility), other frontotemporal neurocognitive disorder (affecting the frontal and temporal lobes of the brain that causes changes in personality and behavior;) and insomnia (trouble falling/staying asleep and can be short term of a few days to a few weeks or become chronic and lasts longer than a month). Review of the resident's admission Minimum Data Set (MDS - federally mandated assessment tool completed by facility staff), dated 07/25/23, showed the resident was severely cognitively impaired. Review of the resident's Care Plan, dated 08/03/23, showed the following: -Talk in a calm voice; -Refer to social services for an evaluation; -Remove from public area when behaviors are disruptive and unacceptable; -Do not argue with resident and administer behavior medications, as ordered by physician. Review of the resident's progress notes showed the following: -On 08/03/23, at 5:04 P.M., resident up, wonders, and easily redirected for the most part. Resident did later in the afternoon became agitated and was throwing cups onto the floor and a fork. Resident was found in bed with another resident at one point and then kissing the same resident at another point. Both easily redirected. Resident was agitated. Staff notified the physician and Administrator. Staff received new order for a one-time dose of Haldol (an antipsychotic medication), 10 milligrams (mg). 2. Review of Resident #2's face sheet showed the following information: -admission date of 08/01/23; -Diagnoses included unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities, which interfere with daily life), mild, with other behaviors. Review of the resident's admission Minimum Data Set, dated [DATE], showed the resident was cognitively impaired. Review of the resident's Care Plan, dated 08/04/23, showed the following: -Talk in a calm voice; -Refer to social services for an evaluation; -Remove from public area when behaviors are disruptive and unacceptable; -Do not argue with resident and administer behavior medications, as ordered by physician. Review of resident's progress notes shows the following: -On 08/03/23, at 5:00 P.M., showed resident alert and oriented to self and surroundings and able to make needs known. The reisdent is up at will. Resident was getting in bed with another resident clothed at one point. Then kissing the same resident at another point. Both easily redirected. Staff notified the physician and the Administrator were notified of both situations. Review of facility records showed the facility did not document reporting the allegation of resident to resident sexual abuse to DHSS. Review of DHSS records showed the facility did not self-report the allegation of resident to resident sexaul abuse on 08/03/23. During an interviewon 08/09/23, at 12:10 P.M., Certified Nurse Aide (CNA) E said the following: -If he/she were there when it happened, he/she would have separated the residents, called for help, notify all parties who are to be informed and document the situation; -He/she would report to the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), the physician and family; -The Administrator would notify the state within two hours. During an interview on 08/09/23, at 12:25 P.M., CNA F said the following: -He/she would report any kind of abuse to the nurse and to the DON to make sure it's reported; -The DON or Administrator should report it to state within two hours; -Any allegation like this must be reported. During an interview on 08/09/23, at 12:55 P.M., CNA G said the following: -He/she was told of what happened between Resident #1 and Resident #2; -He/she would separate the residents and report the incident to the charge nurse, DON, ADON or Administrator to let them know; -Someone needs to contact state within two hours of the incident and family, physician and guardians. During an interview on 08/09/23 at 1:15 P.M., Registered Nurse (RN) H said the following: -As soon as the aides reported this incident to him/her, they informed the DON; -He/she contacted the physician him/herself; -He/she assumed the DON would call the state. During an interview on 08/09/23, at 1:35 P.M., RN A said any abuse allegation must be reported to state. During an interview on 08/09/23, at 1:50 P.M., ADON said the following: -The DON is responsible for reading notes every day and they have a department-head meeting every morning at 8:45 A.M.; -He/she knows it should have been reported on the same day it happened, within two hours. During an interview on 08/09/23, at 2:30 P.M., the Corporate Nurse said the following: -The allegation should have been reported sooner than it was; -It should have been reported within two hours; -It is a reportable offense. MO00222654

Based on record review and interview, the facility failed to ensure two of 19 residents (Resident #19 and #76), in a total sample of 42 residents, was afforded the opportunity to be included in all aspects of person-centered care planning. Review of the facility's policy titled, Resident Participation - Assessment/Care Plan, revised February 2021, showed the resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. Spouses and other members of the family may participate in the resident assessment and development of the person-centered care plan with the resident's permission. 1. Review of Resident #19's Face Sheet, provided by the facility, showed the following: -admission date of 06/05/13; -Diagnoses included morbid (severe) obesity with alveolar hypoventilation (a disorder in which a person does not take enough breaths per minute), and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - federally mandated assessment tool completed by facility staff), provided by the facility, with an Assessment Reference Date (ARD) of 06/19/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates cognitively intact. Review of the resident's Care Plan, dated 11/24/20 and updated on 06/28/23, showed the following: -Potential for weight loss care planned; -Resident will not have significant weight loss through the next review; -Antidepressant medication and risk of side effects care planned; -No injury related to medication usage/side effects. Review of the resident's medical record showed there was no documentation of the resident's participation in the care plan meetings. During an interview on 07/11/23, at 11:09 A.M., the resident said he/she had been in the facility for over nine years and they do not have care plan meetings anymore. The resident indicated she is very aware of what a care plan meeting is about. She said they used use to meet with the dietician, nursing, social services, and talk about any discuss his/her care. It had been a long time since the resident had been involved in a meeting. The resident said it had likely been years. 2. Review of Resident #76's Face Sheet, provided by the facility, showed the following: -admission date of 12/21/22; -Diagnoses included of encephalopathy (a decrease in blood flow or oxygen to the brain), malignant neoplasm of rectosigmoid junction (a malignant tumor involving the rectum and sigmoid colon) and severe protein-calorie malnutrition. Review of the resident's quarterly MDS, provided by the facility, with an ARD of 03/18/23, showed the resident was cognitively intact with a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the resident's Care Plan, dated 02/07/23 and updated 06/01/23, showed the following: -Maintains relationships with family/friends; -Assist to talk privately on the phone; -Resident is unable to care for self in home. Resident has decided to remain at the facility for LTC; -Resident will adjust to living in the community through next review. Review of the resident's medical record showed there was no documentation of the resident's participation in the care plan meetings. During an interview on 07/11/23, at 11:09 A.M., the resident said he/she had never been a part of a meeting to talk about care and discharge planning. 3. During an interview on 07/11/23, at 3:26 P.M., with the Administrator, Regional Nurse Consultant, and Social Service Director (SSD), indicated residents are invited to attend the care planning meeting. Residents that are cognitively intact along with family members are invited to attend. Information on attendance of the meeting, information on the notification of the meeting, and whereabouts of the meeting were not provided. The Administrator, Regional Nurse Consultant and SSD all agreed there was no documentation.

Based on observation, interviews, and record reviews, the facility failed to ensure one of one sampled resident (Resident 51) had a physician's order in the medical record and was assessed and care planned for the self-administration of medications. This failure increased the risk of incomplete or inaccurate administration of medication for the resident. Review of the facility-provided policy titled Self-Administration of Medication, revised 02/21, showed the following: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe; -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan; -Self-administered medications are stored in a safe and secure place, which is not accessible by other residents; -Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party; -Nursing staff review the self-administered medication record for each nursing shift, and transfers pertinent information to the medication administration record (MAR). 1. During an interview and observation on 07/11/23, at 11:05 A.M., Resident #51 was in his/her room laying on his/her bed. Located on the resident's bedside table was a half-full bottle of multi-colored TUMS (a common over-the-counter medication that is used to treat heartburn and other symptoms of indigestion). The resident voiced he had a doctor's order to self-administer the TUMS PRN (as needed). Review of the resident's electronic medical record (EMR) showed the following: -admission date of 05/22/20; -Diagnoses included cardiomegaly (an enlarged heart), cough, anxiety disorder, generalized edema (swelling), major depressive disorder, multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system)), anemia (condition that develops when blood produces a lower-than-normal amount of healthy red blood cells), and chronic respiratory failure. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 07/11/23, located in the EMR under the MDS tab, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. Review of the resident's Physician's Orders, for the duration of his/her stay under the Orders tab in the EMR,showed no order for self-administration of medication. Review of the resident's Medication Administration Record (MAR), on 07/13/23, dated 06/2023 to 07/2023, located under the Orders tab in the EMR, showed no entries indicating the resident had self-administration of the TUMS. Review of the resident's comprehensive Care Plan, located in the EMR located under the Care Plan tab, showed no goal or interventions for self-administration of medication. During an interview on 07/14/23, at 9:36 A.M., Registered Nurse (RN) 1 confirmed the resident self-administers TUMS as needed for indigestion. During an interview and observation on 07/14/23, at 10:02 A.M., the Assistant Director of Nursing (ADON) confirmed there was no doctor's order for the resident to self-administer TUMS, nor was there an assessment completed. ADON said the process to self-administer medication was to obtain a doctor's order, properly educate the resident, review the resident's BIMS, and update the resident's care plan. Review of June 2023 MAR provided by facility staff on 07/14/23, at 11:43 A.M., showed the medication TUMS with an order and start date of 05/20/23. This entry was not on the MARs during an interview and observation on 07/14/23, at 10:02 A.M. with the ADON. During an interview on 07/14/23, at 10:36 A.M., the Administrator said in order for a resident to self-administer medications a doctor's order is obtained, an assessment is completed to determine if the resident can safely self-administer, along with updating the MDS and care plan.

Based on interview and record review, the facility failed to have a process in place to identify and address weight loss for one resident (Resident #25) of one resident with possible weight loss, in a sample of 42 residents. Review of the facility's policy titled, Resident Participation - Assessments/Care Plans, revised on February 2021, showed the following regarding care planning process: -Facilitates the inclusion of the resident and/or representative; -Includes an assessment of the resident's strengths and his/her needs; -Incorporates the residents personal and cultural preferences in establishing goals of care. 1. Review of the Resident #25's Face Sheet, showed the following: -admission date of 03/17/23; -Diagnoses included of chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration.), and type 2 diabetes mellitus with diabetic neuropathy (nerve damage). Review of the resident's Dietician Note, dated 03/21/23, showed the following: -Initial assessment completed; -Resident is on a regular carb consistent diabetic diet with no known food allergy; -Resident is able to get him/herself around very well in wheelchair and is able to express wants and needs clearly to staff; -Current weight is 281 pounds; -Dietician did not think resident would be maintaining diet or losing weight since he/she has already had staff get him/her outside food; -Will continue to monitor for any dietary wants or needs and educate about healthier choices. Review of the resident's weight records showed the following: -On 03/27/23, the resident's weight was 340 pounds; -On 03/31/23, the resident's weight was 242 pounds; -On 07/09/23, the resident's weight was 300 pounds. Review of resident's Care Plan,updated on 07/11/23, showed staff did not care plan any concerns regarding the resident's weight loss, nor a plan on tracking and trending to see if the resident weight was correct, and any supplements needed to be put into place. No notes or documentation from the dietician was identified. During an interview on 07/13/23, at 11:45 A.M., with the MDS Coordinators (MDSC 1 and 2), MDSC1 said that care plans are still a work in progress. MDSC1 indicated she went for over six months by herself trying to keep up with care plans. They have now hired MDSC2 and together they are trying to capture everyone and catch up on care plans. During an interview on 07/11/23, at 5:59 P.M., the Administrator and the Regional Nurse Consultant said the facility was having issues with weights and this is an area they were putting in the home's Performance Improvement Plan. Residents will either be on a weekly schedule or a monthly schedule to weigh. Staff are behind on care planning.

Based on observations, interviews, and record review, the facility failed to ensure one resident (Resident #30) of one resident in the sample of 43 received appropriate and timely assistance and his/her pain was controlled when he/she fell out of bed during the night shift. Review of Lippincott Nursing Procedures, eighth edition, Wolters Kluwer 2019: Pain Management pp. 570-572, showed the following: -To assess pain properly, staff need to consider the resident's description and staff's observations of the resident's physical and behavioral response; -Ask the resident to rank the pain on a scale from 0-10, with 0 denoting lack of pain and 10 denoting the worst pain possible; -Reassess and respond to the resident's pain by evaluating the response to treatment and progress toward pain management goals; -Document each step of the nursing process; -Describe the subjective information elicited from the patient, using the resident's own words; -Note the location, quality, and duration of the pain; -Record the pain-relief method selected and the resident's rating of the pain before and after pain management interventions. 1. Review of Resident #30's admission Record, undated, showed the following: -admission date of 04/13/21; -Diagnoses included generalized anxiety disorder, ankylosing spondylitis (type of arthritis in which there is long term inflammation typically where the spine joins the pelvis) of unspecified sites in spine, and chronic pain, not elsewhere classified. Review of the resident's Physician's Orders, dated 01/30/23, under Orders tab located in the Electronic Medical Record (EMR) showed pain assessment 1 to 10 every shift, 1 to 3 equaled mild pain, 4 to 7 equaled moderate pain, 10 equaled severe/worst pain. Review of the resident's Physician's Orders, dated July 2023, showed he/she received Norco (pain medication used to treat moderate to severe pain) 7.5/325 milligram (mg) for pain every four hours as needed. Review of the resident's Care Plan, dated 06/11/23, under Care Plan tab located in the EMR showed he/she had potential for pain due to diagnoses of Ankylosing Spondylitis and chronic pain. Interventions included assessing what the resident's tolerable pain was and treating it as ordered. During an observation on 07/11/23, at 12:47 P.M., the resident was in bed crying and said he/she fell out of bed at 4:30 A.M. and was in severe pain. The Director of Nursing (DON) came to the room and said they were waiting on x-ray. The resident's spouse and resident said please send the resident to the hospital. The DON said he/she would call the physician. The Assistant Director of Nursing (ADON ) came in the room and said they were waiting on mobile x-ray and said the nurse had called the physician and was awaiting orders. The resident contined to cry and begged for help. The resident was taken to the hospital by ambulance on 07/11/23, at 1:10 P.M. Review of the resident's Progress Notes, dated 07/11/23, showed the resident was found on the floor beside his/her bed at 4:30 AM. The resident was observed sliding out of bed. A certified nursing assistant (CNA) saw resident sitting on the floor beside the bed. Range of motion (ROM) was hard due to assess due to anxiety and resident was crying and scared. The resident was unable to straighten the resident's legs and was given as needed (PRN) pain medication. The physician was notified. During an interview on 07/12/23, at 11:11 A.M., Licensed Practical Nurse (LPN) 3 said he/she took care of the resident and the resident always acts like he/she is in pain. The resident constantly complains of pain. LPN 3 said he/she did not determine whether it is the same pain or caused by something else. LPN 3 said he/she was waiting on x-ray and that was the reason he/she was not sent to hospital. During an interview on 07/12/23, at 2:25 P.M., the Infection Preventionist (IP) said he/she knew the resident had chronic pain. IP said it was hard to tell if he/she was experiencing a different kind of pain. During an interview on 07/12/23, at 3:04 P.M., LPN 1 said the resident had pain all the time and gets medicated. He/She was unsure of when he/she had new pain or if it was her chronic pain. During an interview on 07/12/23, at 3:09 P.M., CNA 2 said he/she tells the nurse when the resident needs pain meds. However, she was unaware of whether it was chronic pain. During an interview on 07/12/23, at 3:10 P.M., CNA 3 said he/she informed the nurse when the resident complained of pain, but the resident always complained of pain. During an interview on 07/12/23, at 4:40 P.M., CNA 4 said he/she takes care of the resident, but did not know when his/her pain was different than normal due to the fact he/she complained all the time. During an interview on 07/13/23, at 4:20 P.M., the DON said she expected the staff to identify when a resident was in pain and know the difference in chronic pain and recognize any new pain such as from a fall. She did not have a policy on pain management.

Based on record review and interivew, the facility failed to ensure that the Facility Assessment listed all the services provided by the facility, inlcuding tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. This affected one of 93 residents (Resident #64). 1. Review of Resident #64's paper medical record Face Sheet revealed showed the following: -admission date of 09/17/20; -Diagnoses included traumatic brain injury (TBI), tracheostomy, and seizures. Review of the resident's paper medical record Physician Orders for July 2023 showed the resident was to have tracheostomy changed out as needed, suction airway as needed, tracheostomy care each shift, and change tracheostomy every month on the 15th. Review of the form titled, Facility Assessment Tool, dated 03/21/23, showed the following: -The facility assessment included an evaluation of the resident populations and available facility resources and services to ensure person centered care needs are completely met; -Table 1.5 Care and Services provided to residents was a list of all care that the facility provides; -Review of the documentation did not reveal that tracheostomy care was provided in the facility, although the facility is rendering care for a resident requiring such services. During an interview on 07/13/23, at 9:44 A.M., with the Administrator and Regional Nurse Consultant, the Administrator confirmed the current Facility Assessment did not list the services of Tracheostomy Care, although this is a service being offered in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one of four halls, the secured dementia care unit. The failure created the potential for an undesirable living situation for the 25 residents residing on the secured unit. Review of the facility Maintenance Service Policy, dated 12/09, revealed the following: -Maintenance service shall be provided to all areas of the building, grounds, and equipment; -The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include, but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; maintaining the building in good repair and free from hazards; maintaining lighting levels that are comfortable, and assuring that exit lights are in good working order; establishing priorities in providing repair service; and providing routinely scheduled maintenance service to all areas; -The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 1. Observations of the secured dementia care unit on 07/11/23, at 10:40 A.M., on 07/12/23, at 12:16 P.M., and on 07/13/23, at 8:55 AM, showed the following conditions: -Upon entering the unit, there was a pervasive urine smell. The smell was not identified to be emitting from a specific room(s), person, or furniture. The urine smell was detected upon entrance through the secured unit doors to the end of the hall and into the dining room; -In room [ROOM NUMBER], there was baseboard, approximately 2 ½ inches tall pulled away from the wall surrounding the sink and vanity. An electrical outlet above the baseboard was not secured to the wall, was loose and falling forward. Two tiles were missing from the shower stall in the bathroom; - In room [ROOM NUMBER], the threshold was missing between the hallway vinyl and the bedroom tiles. An approximate 3 ½ feet of baseboard was missing which exposed a hole in the wall; -In room [ROOM NUMBER], the front facing on the sink, approximately 4 feet, was missing. A triangle size piece of tile, approximately 2 by 3 inches, was missing. The toilet was leaking from the base. The metal window blinds were bent which did not allow for privacy; -In room [ROOM NUMBER], there was an exposed outlet on the wall. The front facing on the sink/vanity was broken and had rough edges; -In room [ROOM NUMBER], the bathroom light cover was missing which exposed two light bulbs. There was wall damage and a hole in the wall behind the toilet; -In room [ROOM NUMBER]; there was an exposed electrical outlet on the wall. The baseboard surrounding the sink and vanity was missing. The light cover was missing which exposed two light bulbs in the bathroom; -In room [ROOM NUMBER], the baseboard surrounding the sink and vanity was missing. The floor baseboard was missing by the bathroom door. The wheelchair arms on the wheelchair were cracked and missing vinyl which exposed the padding underneath; -In room [ROOM NUMBER], the baseboard surrounding the sink and vanity was missing, exposing old glue and marred drywall; -In room [ROOM NUMBER], the four drawer chest, used by a resident, was missing the bottom drawer; -In room [ROOM NUMBER], the in the shared bathroom, was not secured to the floor, which caused it to be unstable. There was a large hole under the sink surrounding the water pipe, approximately 6 inches in diameter. The water pipe was leaking into the trash can' -In room [ROOM NUMBER], the metal window blinds were bent on the ends. The front of the vanity/sink surround was missing. -In room [ROOM NUMBER], the vinyl door protector, covering the bottom half of the bedroom door, was peeling off and hanging away from the door. The residents' wheelchair arms were cracked and torn exposing the padding underneath. -The door to the hallway bathroom, utilized by residents on the unit, would not shut, leaving an open gap approximately two inches; -The unusable water fountain, located in the hallway, had black duct tape across the top which covered the drain. There was rust and grime on top of the duct tape; -There were four circular metal plates, approximately five inches in diameter, in the hallway. Three of the metal plates were covered with black duct tape, which was worn, torn, and peeling; -A glider rocking chair, located in a hallway alcove, was observed to have a soiled seat cushion and food debris on both sides; -The shower room had missing floor tiles across the front of the shower and there was mildew throughout the shower stall; -In the dining room, there were seven windows with horizontal metal blinds. Three of the window blinds were significantly bent, raised up on one side higher than the other, and unusable. The blinds did not lower. The damaged blinds measured approximately 5 feet, 6 feet, and 4 feet across; -The dining room tables, four in total, had bubbled, rough surfaces, where the finish had been damaged making them an uncleanable surface; -The microwave in the dining room was dirty and had a large, rusted area, approximately 3 inches, on the inside front panel. The dining room cabinets were dirty and sticky to touch. A drawer was missing from one cabinet which was located inside the cabinet below where it belonged; -The sitting room, had approximately 6 feet of baseboard missing which exposed many holes in the drywall. The threshold was missing at the entrance to the room which created an uneven, uncleanable surface. During an interview on 07/13/23, at 1:50 P.M., the Maintenance Director (MD) said the following: -He did not conduct room to room checks himself, but relied on the maintenance log kept in the employee break room, to be made aware of concerns throughout the facility; -He was not responsible for replacing wheelchair arms. The rehab staff took care of that; -The facility had new cordless blinds, since January 2023, but he had not installed them; -He was unaware of the missing drawer. During an interview on 07/13/23, at 11:50 A.M., the Rehabilitation Director (RD) she said rehab is not responsible for replacing wheelchair arms, maintenance is responsible. They had received an email from the corporation stating that. During an interview on 07/13/23, at 11:49 A.M., the Housekeeping Director (HD) said she used Vi tech (cleaner), on the floors. She said I think it's under the tile, in regard to the confirmed pervasive urine odor. During an interview on 07/14/23, at 9:51 A.M., the HD said she had used an enzyme on the floors, beds, surfaces which removed the urine odor. When asked why that had not been used prior to 07/14/23, the HD said she had been out of the enzyme and bought some more. During an interview on 07/13/23, at 10:50 A.M., the Administrator, when asked about the identified environmental concerns on the secured unit, said she had a signed contract to have the entire facility painted, however she did not have a start date. Regarding the unsecured toilet, the Administrator said all the toilets on the unit had been replaced in March 2023 and that she was unaware of the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system at all times when the facility did not ensure all residents had working call lights at all times. Review of the facility's policy titled, Call System/Light Policy, dated 09/22, showed the residents call system remains functional at all times. If visual communication is used, the lights remain functional. 1. Review of Resident #53's Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 04/18/23, showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident cognitively intact. The resident's DS also indicated that the resident required total assistance for incontinent care. The resident required a Hoyer lift (which allows a person to be lifted and transferred with a minimum of physical effort) for bed mobility and for toileting. During an interview and observation on 07/13/23 at 10:17 AM, the resident said he/she was very concerned about the call light system. When he/she turned his/her light on, if it is working, it will cause rooms [ROOM NUMBER] to not work properly. The resident has expressed my concerns for years The facility suggested the resident purchase a whistle or a bell. The surveyor observed a whistle used by the resident to alert staff if needed. During an interview and observation on 07/12/23, at 3:53 P.M., the Maintenance Director (MD) stated, The call light system is ancient. There is only one company and technician available to work on the system. During an observation at this same time, the MD shared that if more than two call lights are triggered in rooms 201, 203, 205, 207, and 209 all the lights come on, but are very dim, and if room [ROOM NUMBER] is activated all the lights turn off which makes it very difficult to know which resident needs assistance. During an observation on 07/12/23, at 4:03 P.M., MD triggered the call light system for rooms 201 to 210, 212, and 215-222. The only rooms that worked properly (light-activated above the door and on the nursing station board) were rooms 202, 208, 209, 212, 215, 216, 217, 218, and 222. The remaining rooms did not work properly. During an interview on 07/13/23, at 10:29 A.M., Nursing Assistant (NA) 3 stated, I am aware that many lights do not work properly on this unit. NA further stated for residents whose lights do not work, we do 30-minute checks. During an interview on 07/13/23, at 10:36 A.M., Certified Medication Technician (CMT) 4 stated, I am aware that the call light system does not work properly. It's been like this for years. CMT4 further stated that residents are checked every 15 minutes, and if a resident needs assistance between checks the resident will holler to alert staff. During an interview on 07/13/23, at 10:38 A.M., Licensed Practical Nurse (LPN) 3 stated, I am aware that the system does not work properly. It has been at least 15 years that the lights have not worked. LPN3 further stated, the facility has hired several specialty technicians but has had no long-term success. Staff are very aware that the system does not work properly, and 15-minute checks are put in place to ensure the safety of the residents. During an interview on 07/13/23, at 12:21 P.M., the Administrator stated, The call system is at least [AGE] years old. We used to be able to order our own parts however, the company has gone out of business. The Administrator further shared, the new company we use is having problems providing replacement parts and fixing the wiring system. She continued to share, when the call system is not working, we put in 15-minute checks and provide a bell or a wireless call system to the resident. The administrator expected the call light system to be function all residents at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program, regarding flies, for the entire facility of 93 residents. Review of the facility's Pest Control Contract, showed the contract, dated 12/12/13, was for monthly service for pest management program designed to provide solution to the common pests found around the outside foundation environment including roaches, ants, house spider, mice/rats, millipedes, centipedes, [NAME] and pill bugs, crickets, silverfish, earwigs. There was no identification of fly treatment or service to the blue light, bug zappers. 1. Observations of the facility, by four surveyors, during the survey of 07/11/23 to 07/14/23, showed an excessive number of flies. The flies were all throughout the facility including the kitchen, dining rooms, on residents' food, persons, and equipment. Observations were made from 9:00 A.M. to 6:30 P.M. on 07/11/23; from 8:30 A.M. to 6:30 P.M. on 07/12/23; from 8:30 A.M. to 5:45 P.M. on 07/13/23; and from 8:30 A.M. to 5:00 P.M. on 07/14/23. Observation and interviews in the kitchen on 07/11/23, at 10:17 A.M., showed flies were observed throughout the kitchen, in the food preparation and delivery areas, the dry storage area, and the dish room. The dietary assistants (D) in the kitchen, at the time of the observation (D1, D2, D3, and D4), confirmed that the flies were abundant. D1 said we have to put paper over the clean dishes to keep the flies off. Observation and interview in the kitchen on 07/13/23, at 2:15 P.M., showed flies were observed throughout the kitchen, storage area, and the dish room. In a two compartment sink, at the back of the kitchen, there were numerous dead flies along with live flies. A fly zapper, was observed in the hallway between the kitchen and the dry storage area. D1 stated that doesn't do anything. W need a blower like restaurant kitchens have to keep the flies out. During an interview on 07/13/23, at 1:50 P.M., the Maintenance Director (MD) said that pest control comes every other week and that there are blue lights, bug zappers, on the walls. The MD said the flies are bad here when it's very hot. During an interview on 07/13/23, at 3:45 P.M., the Administrator said every resident has a fly swatter. The Administrator said regarding pest control, it's just really bad this time of year with the heat, and the smokers, in wheelchairs, take a while to get in or out of the door to the smoking area outside and flies do come in. When asked if the facility had utilized any other options to control the flies, the Administrator said, we can have the pest control company give the MD something that was provided last year to help with the flies.

Based on interview and record review, the facility failed to employ a qualified Director of Food and Nutrition services. Failure to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, created the potential for the 93 residents to receive insufficient nutrition services. Review of the job description for the Dietary Manager position was not provided by the facility. 1. Interview during the initial tour of the facility kitchen on 07/11/23, at 10:17 AM, showed the dietary staff stated that they had been without a Dietary Manager for the past three months. During an interview on 07/13/23, at 3:45 P.M., the Administrator stated the Dietary Manager quit on 04/27/23 and that she and the Office Manager were overseeing the kitchen. The Administrator said the Dietician was employed on a consultant basis, not full time or part time. The Dietician was in the facility twice a month for six to eight hours. Neither the Administrator nor the Office Manager held a dietary manger certificate or a food service manager certificate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, homelike environment for all residents when a handrail was left in the floor for an extended period of time. The facility census was 89. Review showed the facility did not provide a policy regarding maintenance of walls or handrails. 1. Observations on 04/14/23, at 10:35 A.M., showed the hand rail between resident room [ROOM NUMBER] and 120 in the floor against the wall. Observations on 04/18/23, at 9:33 A.M., showed the hand rail between resident room [ROOM NUMBER] and 120 in the floor against the wall. During an interview on 04/14/23, at 10:20 A.M., Resident #1 said the hand rail had been down for approximately three months. The resident said he/she had reported to maintenance, but it had never been fixed. The resident said he/she had removed the screws from the railing so no one would get scratched from them. During an interview on 04/18/23, at 11:15 A.M., Resident #2 said the hand rail had been down as long as he/she could remember. During an interview on 04/18/23, at 10:45 A.M., Certified Medication Technician (CMT) A said the hand rail had been down from the wall for at least two to three months. He/she said it had been brought to maintenance's attention. There is a maintenance book in the employee break room where staff write if there is an issue. The CMT believes maintenance would be responsible for making sure the rails are installed properly. He/she was aware of residents complaining about the handrail not being installed. During an interview on 04/18/23, at 12:25 P.M., Certified Nursing Assistant (CNA) B said the hand rail had been down for at least three months. There is a maintenance book in the employee break room for maintenance requests. The aide said maintenance would be responsible for ensuring the hand rail was installed. During an interview on 04/18/23, at 12:30 P.M., Licensed Practical Nurse (LPN) C said the hand rail had been down for months. The rail had been reported to maintenance and nothing had been done. Maintenance would be responsible for making sure the hand rail was properly installed. During an interview on 04/18/23, at 12:45 P.M., LPN D said the hand rail had been down for over three months. If there is a maintenance request it is written in the maintenance book in the employee break room. During an interview on 04/18/23, at 4:40 P.M., the Maintenance Director said he has a maintenance log book if things are broken, and staff are able to do maintenance requests. The request book is kept in the employee break room. Residents are able to just stop him and tell him about issues as well. He was not aware that the hand rail was down at this time, but a few months ago it had been pulled down, and he fixed it then. During an interview on 04/18/23, at 2:40 P.M., the Administrator and Director of Nursing (DON) said they had not been aware that the hand rail was down on the 100 hallway was down. If there is a request for maintenance, staff writes it in a book in the employee break room. MO00214812

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure administer antibiotics (medications to treat infections) as ordered for one resident (Resident # 29) and failed to follow-up with a physician's orders to recheck a urinalysis sample after treatment with an antibiotic for one resident (Resident # 80), both who had UTIs (urinary tract infection). Staff failed to update the care plans of two residents (Resident #29 and #80) regarding recent UTIs. The facility census was 92. Record review of the facility's Urinary Tract Infections/Bacteriuria (bacteria in the urine) - Clinical Protocol Policy, dated April 2018, showed the following: -The physician and nursing staff will review the status of individuals who are being treated for a UTI and adjust treatments accordingly. Record review of the facility's Antibiotic Stewardship Policy, dated December 2016, showed the following: -When a C&S is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. 1. Record review of Resident # 29's face sheet (general resident information) in the medical record (after latest return from hospital) showed the following: -admitted initially on 6/30/16 with a most recent readmission date of 11/9/19; -Diagnoses of heart attack, congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), chronic lung disease, chronic kidney disease, acute respiratory failure with hypoxia (low oxygen level in the blood), and type II diabetes mellitus (a chronic disease associated with abnormally high levels of the sugar glucose in the blood). Record review of a physician's telephone order, dated 9/4/19, showed the following: -Urinalysis (UA - a sample of urine sent to the lab) with C&S (laboratory process where sample is examined for bacteria present and shows which antibiotics could possibly or most likely treat the bacteria); -Cipro (antibiotic) 500 milligrams (mg) by mouth (PO) twice a day (BID) for seven days. Record review of the resident's urinalysis, dated 9/4/19, showed the following: -Clarity - cloudy (normal clear to hazy); -Ketones (proteins) - small amount (normal negative); -Nitrites (byproduct of ammonia that indicates infection if seen on UA results) - small amount (normal negative); -Blood - trace amount (normal negative); -Leukocyte Esterase (white blood cell protein that indicates infection in the urine) - trace amount (normal negative); -White blood cells (WBC's) - 6-10 (normal 0-5); -Red blood cells - 4-10 (normal 0-3); -Bacteria 2+(number used by laboratories to describe amount of bacteria seen under the microscope - normal none); -A hand-written note on the results showed on 9/5/19, started on Cipro pending microbiology report. Vitamin C by mouth every day to acidify urine. Record review of the resident's urine C & S, dated 9/5/19, showed the urine contained Escheri coli ESBL with greater than 100,000 colonies/milliliter gram negative rods; -The susceptibility report showed the organism was resistant to Cipro and susceptible to nitrofurantoin (antibiotic with name brand of Macrobid) in the urine; -A handwritten note, dated 9/6/19, found on the form showed to discontinue the Cipro and start Macrobid 100 mg by mouth twice a day for ten days; -The form showed it was received by the physician's office by fax on 9/6/19 at 10:43 A.M. The bottom of the form showed the form was faxed by the physician's office to the facility on 9/6/19. Record review of a Physician's Fax Request form, faxed to the physician with a date of 9/9/19, timed at 6:59 P.M., showed staff wrote a note to the physician that stated the following: -The resident complains of general malaise (a general feeling of discomfort, illness, or uneasiness). He/she has not been seen eating his/her meals in the dining room. The resident states I don't hurt, not feeling short of breath, just don't have it in me to go to the dining room, and no energy; -The physician response, with a faxed date of 9/10/19, showed the following: -Probably Macrobid. See how he/she is doing after he/she finishes Macrobid. Record review of the resident's September 2019 Medication Administration Record showed staff administered the Cipro 500 mg by mouth twice a day from 9/4/19 at 8:00 P.M. until 9/11/19 at 8:00 A.M. The MAR did not show staff administered the ordered Macrobid. Record review of the Antibiotic Stewardship Infection Control/Prevention Book showed the following; -An entry on 9/4/19 for UTI; -Gram negative rods (seen under a microscope which describes the shape and description of the bacteria only - no named bacteria shown); -Given Cipro for seven days; -Treatment completed on 9/11/19. (Staff did not mention the order for or administration of Macrobid.) Record review of the resident's current comprehensive care plan, dated 9/3/19, showed staff did not update the care plan to reflect the UTI. Record review of the resident's Status Change form dated 11/3/19, at 1:45 A.M., showed the following: -Resident was short of breath; -Temperature 97.0 Fahrenheit (F) (normal range around 98.6 F; -Pulse 123 (normal 60-100); -Respiratory rate 26 (normal 12-20 per minute); -Blood pressure 210/108 (normal 120-140 systolic-top number) and normal 60-80 diastolic (bottom number); -Pulse oxygen level 85% on room air (normal 92-100%); -O2 was administered via nasal cannula at 1.5 Liters per minute. O2 saturation up to 92%; -No complaints of pain; -Physician and Director of Nursing (DON) notified; -As needed nitroglycerin (medication used to relieve chest pain) given as ordered with positive effect; -Incontinence of urine occurred during episode; -Resident reports freezing; -Staff will continue to monitor. Record review of the resident's Status Change form, dated 11/3/19 (untimed), showed the resident complained of dyspnea (difficulty breathing), dizziness, and no energy. Resident stated feel pretty bad. Record review of the resident's Status Change form dated 11/3/19, at 7:15 P.M., showed the following: -No Zithromax (antibiotic) available; -Received new order for Cefdinir (antibiotic) 300 mg by mouth twice a day for seven days. Staff did not document the indication for the antibiotic on the order. Record review of the resident's Nursing Progress Note dated 11/6/19, at 9:50 A.M. showed the following: -Resident lying face down on the floor; -Skin warm, lips blue, respiratory rate is 32 breaths per minute with O2 (oxygen) off; -SAO2 (oxygen saturation in the blood) was 51%, heart rate 120, Blood pressure 220/60; -Eyes open, does not verbalize or follow commands; -Assisted to turn over with assistance of three staff; -O2 placed per nasal cannula. Lips pink, however, SAO2 90% on simple mask at ten liters per minute; -Respiratory rate 32, heart rate 116, temperature 97.0 temporal (taken on the skin on the side of scalp beside the eyes); -Color pale; -Spoke to staff at physician's office; -Received orders to send resident to hospital for evaluation. Resident now able to follow commands. Offers no speech or verbalization. Nods head yes/no appropriately. Record review of the resident's Hospital Transfer form, completed by facility staff, dated 11/6/19, at 10:55 A.M., showed the resident was transferred to the hospital for recurrent bouts of dizziness and dyspnea. The form showed the resident had been taking Ceftin (antibiotic) 300 mg by mouth twice a day for crackles in the lungs and started on 11/3/19. The form showed the resident had diminished lung sounds. Record review of the resident's History and Physical form completed by the physician at the hospital, dated 11/6/19, showed the following: -Chief complaint - shortness of breath and syncope (passing out). The resident was found unconscious on the floor at the nursing facility as he/she has been unwell recently, and has been treated with a couple of antibiotics at the nursing facility for a UTI and possible underlying pneumonia as well as heart failure; -On 11/3/19, the resident received Cefdinir, nitroglycerin, and Lasix (diuretic medication) 40 mg by mouth for possible pneumonia and heart failure. The resident had a urine culture in September 2019 which grew an ESBL E coli and most likely these antibiotics were not sufficient to treat his/her UTI. A repeat UA and blood cultures have been obtained; -The resident meets sepsis criteria based on a temperature of 101.1 F, pulse of 99, and respiratory rate of 30; -Creatinine level was 1.62 when septic; -The resident is now on Meropenem (name brand of a carbapenem antibiotic) and vancomycin (antibiotic), and in the medical intensive care unit; -Chest X-ray revealed pulmonary vascular congestion and cardiomegaly (enlarged heart) suggestive of CHF; -Resident has acute hypoxic (absence of enough oxygen in the tissues to sustain bodily functions) respiratory failure with oxygen saturation in the 50's and is being admitted as a full inpatient in the medical intensive care unit because he/she will need to be here at least two midnights. The resident may have aspirated and will be on Meroperem one gram IV every eight hours and vancomycin per pharmacy dose for coverage of possible pneumonia and ESBL UTI. Resident had urine cultures in September 2019 revealing ESBL E. Coli UTI. Has been on multiple antibiotics at the nursing facility that likely failed because it was an ESBL organism. Cultures are pending; -Resident meets severe sepsis criteria based on temperature of 101.1 F, pulse 99, respiratory rate of 30, in combination with an obvious UTI and lactate (can be caused by lack of oxygen in the blood. Lactic acid-elevated levels can indicate that organs are not functioning and can be caused by heart failure or sepsis) greater than 2 (normal 0.5-1). He/she also has end organ damage (organ damage that occurs in major organs fed by the circulatory system such as heart, kidneys, brain, eyes) with a creatinine of 1.62 (normal 0.55-1.02 (elevated creatinine levels signify impaired kidney function or kidney disease. The creatinine level in the blood will rise due to poor clearance of creatinine by the kidneys. Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys); -Urinalysis showed urine dark yellow, cloudy, blood large amount, leukocyte esterase large amount, Bacteria 4+. -Sputum culture to be ordered, blood and urine cultures sent to lab. Record review of the resident's Hospital Discharge summary, dated [DATE], showed the following: -Discharge diagnoses of obstructive sleep apnea, Type II diabetes mellitus (much improved), acute exacerbation of COPD (resolved), acute non-traumatic kidney injury (creatinine has fallen from 1.62 down to 1.34, and believe this is his/her baseline), acute CHF (no acute exacerbation), respiratory failure (resolved), sepsis (resident has ESBL E. coli UTI and has been treated with Meropenem now day four. He/she no longer needs antibiotics), and acute UTI (resident completed four days of Meropenem for treatment of ESBL E coli UTI) and secondary sepsis; -Resident had minimal elevation in his/her troponins, and was likely due to chronic kidney disease in combination with syncope and tachycardia presumably due to hypoglycemic event due to receiving his/her insulin without eating (did not show heart attack documented); -Chest x-ray revealed suggestive of CHF (pneumonia not diagnosed). Urine culture revealed ESBL E. coli UTI again. Blood cultures negative so far. Record review of the resident's most recent 48 hour care plan, dated 11/9/19, showed staff did not care plan prior UTI or of recent diagnosis of sepsis. Record review of the resident's Five Day Minimum Data Set (MDS), a federally mandated resident assessment tool completed by facility staff, dated 11/16/19, showed the following: -Cognitively intact; -Always continent of bowel and bladder; -Had medically complex conditions including heart disease, lung disease, kidney disease, and diabetes. (The MDS did not show diagnosis of UTI or pneumonia.) During an interview on 11/19/19, at 11:00 A.M., the Assistant Director of Nursing (ADON) said the following: -The Director of Nursing (DON) and him/herself monitor infections in the facility along with the infection control program; -He/she reviews the infections and the antibiotics, along with the cultures, if obtained, and make sure they match (that the organism is susceptible to the antibiotic). During an interview on 11/19/19, at 1:17 P.M., and 11/21/19, at 2:37 P.M., the resident said the following: -He/she had had a bladder infection and passed out; -He/she was sent to the hospital afterward; -He/she thought he/she had gotten better after being on the antibiotic for a week, but he/she had also stopped drinking soda pop during that time which had helped. During phone interviews on 11/21/19, at 1:40 P.M. and 1:44 P.M., and on 11/25/19, at 11:15 A.M., the physician said the following: -He/she had discontinued the Cipro on the 6th and started on Macrobid which was susceptible; -The resident had said he/she felt better and was fine when asked on 9/24/19 and 10/24/19; -He/she thought it was a coincidence that teh resident had a UTI again and was sent to the hospital; -The facility had told him/her they had not received the faxed order for the Macrobid; -He/she did not believe the resident had had the UTI for months before the hospitalization since during his visits with the resident, in the meantime, the resident was not symptomatic; -It would be hard to determine what caused the sepsis with the resident with the respiratory illness or UTI. During an interview on 11/22/19, at 10:57 A.M., Licensed Practical Nurse (LPN) B said the following: -Signs and symptoms of a UTI would be running a temperature, burning and painful urination, and confusion. If signs and symptoms are reported, the nurse will call the physician and see if an order for an UA can be obtained; -Lab results are received on the fax machine; -He/she checks the fax machine during the day. Several people check the fax machine during the day; -Staff send the physician the UA and the culture and sensitivity results right away; -If no orders have been received by the end of the day he/she will call him; -He/she always checks to see if the bacteria is susceptible to the antibiotic; -If not, he/she will notify the physician. During an interview on 11/22/19, at 11:43 A.M., the DON said the following: -Signs and symptoms of a UTI would be burning, pain, frequent urination, and confusion. He/she would expect staff to notify the Charge Nurse who then would notify the physician and see if staff could obtain a UA; -When staff get results from the lab, they notify the physician by fax or phone. Staff are expected to check for faxes even on the weekends; -Charge nurses look at the results and check to see if the organism is susceptible to the organism; -The ADON follows up on those reports as well. He/she keeps the information in a log book and makes sure the antibiotic prescribed works with the organism. If it doesn't work, he/she calls the physician; -Staff would expect a new order if it didn't work; -If a UTI was not treated with the proper antibiotic, the infection could become worse or the organism could become colonized. A resident could become septic; -A technical issue caused staff to not receive the fax regarding the resident's antibiotic change. 2. Record review of Resident # 80's face sheet in the medical record showed the following: -Initial admission date of 2/1/18 and most recent admission date of 9/2/19; -Diagnosis of chronic kidney disease. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Continent of bladder; -No diagnosis of UTI. Record review of the resident's physician's order dated 10/14/19, at 12:49 P.M., showed an order for a UA with C&S if indicated. Record review of the resident's UA lab results, dated 10/14/19, showed the following: -Color cloudy - nitrites positive (normal negative); -Blood - small amount (normal none); -Leukocyte esterase - moderate (normal none); -WBC - 26-40 (normal 0-5); -Bacteria - 1+ (normal none). Record review of the resident's urine C&S, dated 10/16/19, showed ESBL E. Coli present. Record review of the resident's physician's order dated 10/17/19, at 8:25 P.M., showed an order Trimethoprim (antibiotic) 100 mg, give ½ tablet by mouth twice a day for seven days and recheck the UA in 7 to 10 days. Record review of the resident's nursing progress note dated 10/18/19, at 12:58 P.M., showed the following: -The resident had a non-responsive episode at lunch that lasted two minutes. Afterwards, the resident was alert to person and place, but not time (normal). The resident was cold, clammy, but is fine now; -Resident has chronic lung disease (COPD), coronary artery disease (CAD) (heart disease), and transient ischemic attack (TIA - also known as mini-stroke which mimics stroke symptoms but the symptoms go away) on 11/25/13. -Physician was faxed. Record review of the resident's October MAR showed the Trimethoprim was administered to the resident from 10/18/19 at 8:00 P.M. until 10/25/19 at 8:00 P.M. Record review of the resident's lab work, dated 10/24/19, showed the following: -Creatinine level was 1.47 (normal 0.55-1.02); -White blood cells 14.84 (normal 3.98-10.04). Record review of the resident's lab work dated 10/30/19 showed the creatinine level was 1.21. Record review of the resident's current care plan, dated 9/4/19 showed the following: -Continent of bladder; -Offer toileting and assist with peri-care (cleansing of the private area) to ensure resident clean, dry, and odor-free. (Staff did not care plan the resident's UTI.) During an interview on 11/19/19, at 10:24 A.M., the resident said he/she was having some pain and pointed to his/her peri-area. The resident said he/she thought he/she had a possible bladder infection. During an interview on 11/20/19, at 3:24 P.M., the DON said the following: -Staff missed getting the last ordered UA for the resident. The resident toilets himself/herself and walks to the bathroom; -He/she will check with the resident for discomfort if present or not; -He/she was not aware of any reports of discomfort. Record review of the resident's physician's order, dated 11/21/19, showed an order for a UA with C & S if indicated. Record review of the resident's UA lab result, dated 11/21/19, showed the following: -Cloudy; -Leukocyte esterase - moderate; -WBC 26-40; -Bacteria 2+. During an interview on 11/22/19, at 1:07 P.M., LPN B said the following: -It is important to follow up with physician's orders; -It is important to recheck a UA after an antibiotic is given to assure infection is gone; -Sometimes a physician orders a recheck of a UA and sometimes not. During an interview on 11/22/19, at 1:11 P.M., the DON said the following: -He/she expects staff to follow the physician's orders; -Physicians sometimes order rechecks of UA's after antibiotics are taken to assure infection is gone or improving; -If an order is missed for a recheck of a UA, the resident could have worsening symptoms, become septic, or have adverse effects to the antibiotics; -A recheck of the resident's UA yesterday. Record review of the resident's urine C&S, dated 11/23/19, showed the organism was ESBL E. coli with greater than 100,000 colonies/ml gram negative rods.

Based on observation, interview, and record review, the facility staff failed to properly disinfect glucometers (small hand-held devices that check blood glucose levels in residents) when collecting blood glucose (sugar that the bloodstream carries to all cells in the body to supply energy) levels on residents and failed to protect the glucometer test strips from potential contamination. This practice affected two residents (Resident #51 & #238). The facility census was 92. Record review of the Centers for Disease Control and Prevention (CDC) website showed the following information: -Blood glucometers approved for use for more than one person must be cleaned and disinfected. When blood glucose monitoring devices are shared between individuals, there is a risk of transmitting viral hepatitis (infection that causes liver inflammation and damage) and other blood borne pathogens (infectious microorganisms in human blood that can cause disease in humans). Record review of the facility's Cleaning & Disinfecting the Microdot Blood Glucose Meter, undated, showed the following information: -Cleaning guidelines: Use a lint free cloth dampened with soapy water or isopropyl (70%-80%) alcohol to clean the outside of the blood glucose meter; -Disinfecting guidelines: Use an approved disinfecting wipe to thoroughly wipe down the meter. Follow the disinfectant product label instructions to ensure proper drying time. Record review of the Sani-cloth germicidal disposable wipe showed the following information: -One step cleaner and disinfectant; -A two minute contact time is required to kill up to 30 microorganisms, including 6 multi-drug resistant organisms (MDROs); -Use a new wipe and thoroughly wet the surface; -Allow treated surface to remain wet for a full two minutes; -For heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting; -Let air dry. 1. Record review of Resident #238's face sheet (brief resident information sheet) showed the resident's diagnosis of type two diabetes mellitus (chronic condition that affects the way your body metabolizes sugar). Record review of the resident's November 2019 to December 2019 physician's orders showed the following: -An order, dated 7/29/19, for accucheck (blood glucose checks performed in order to get results needed for insulin administration amount) before meals and at bedtime; -An order, dated 7/29/19, to administer Humalog (insulin) 100 unit/ml per sliding scale before meals and at bedtime subcutaneously (under the skin). Observation and interview on 11/21/19, at 11:28 A.M., showed the following: -Certified Medication Technician (CMT) E prepared to provide blood glucose testing to the resident; -CMT E had two glucometers on the top of the medication cart; -CMT E picked up one of the glucometers and obtained the blood glucose level of the resident; -At 11:31 A.M., CMT E wiped the glucometer off for about 4 seconds and sat the glucometer on the cart. The glucometer was wet briefly and dried in about fifteen seconds. (The CMT did not wrap the glucometer with in a sani-wipe.); -The CMT placed the glucometers in the first drawer of the medication cart after the procedure; -CMT E said that the glucometer had to sit for two minutes after being wiped. And said it will not be wet for the whole two minutes. Observation on 11/21/19 showed the following: -At 5:01 P.M., CMT J prepared to check a blood glucose of the resident. The CMT took the glucometer, the container with test strips, alcohol wipe, and a lancet to the room. The CMT put on gloves and prepared the resident's finger. The CMT then squeezed the finger to produce a drop of blood. The CMT then turned to bedside table and picked up the container of test strips and removed one from the container with the same gloved hands used to poke resident finger (potentially contaminating other strips) and put it into the glucometer, obtained the blood same and then left the room, removed gloves, and hand sanitized. -At 5:04 P.M., the CMT wiped the glucometer with the sani-wipe, then set the glucometer onto the cloth next to another glucometer on the cart. 2. Record review of Resident #51's face sheet showed the resident's diagnosis of type two diabetes mellitus. Observation on 11/21/19 showed the following: -At 4:01 P.M., CMT J prepared to check a glucose level on the resident. He/she prepared glucometer and went to the resident's room; -At 4:05 P.M., CMT wiped the glucometer for about 3 seconds with a sani-wipe, placed the glucometer on a wash cloth on top of the medication cart and threw the sani-wipe in the trash. 3. During an interview on 11/21/19, at 5:11 P.M., CMT J said to put gloves on when preparing to check blood glucose. The CMT said that after the procedure staff cleans the glucometer with a sani-wipe and set it down on something clean for two minutes, then use the second glucometer. 4. During an interview on 11/22/19, at 9:44 A.M., CMT I said the following: -He/she would only take one test strip into the resident's room, would not poke a resident's finger and then get a test strip out of the container because there might be blood on the glove and it would then get on all the other test strips; -After the procedure staff should wipe the glucometer with a sani-wipe and then put in the medication cart for two minutes. 5. During an interview on 11/22/19, at 11:54 A.M., the Director of Nursing said the staff, CMT or nurse, should gather all equipment needed for glucose testing, including one test strip, lancet, and alcohol wipe, apply gloves, and perform the procedure. After the procedure is completed the staff should wipe the glucometer with a sani-wipe and then wrap it in the sani-wipe for two minutes, then allow to air dry. The glucometer is wrapped to disinfect it, if this is not done the glucometer could be contaminated with a blood borne pathogen and/or spread germs to other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to document completion of measurements to ensure the there were no gaps that's could potentially cause injury or entrapment for ten residents (Resident #8, #19, #27, #29, #44, #47, #57, #77, #80, and #85). Staff failed to obtain physician's orders for, care plan, or obtain signed consent for the use of side rails for one resident (Resident #29). The facility census was 92. Record review of the facility's policy titled Bed Safety, dated December 2007, included the following information: -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent death/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: -Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; -Review that gaps within the bed system are within the dimensions established by the Food and Drug Administration (FDA), the review shall consider situations that could be caused by the resident's weight, movement, or bed position; -Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; -If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; -The staff shall obtain consent for use of the side rails from the resident or the resident's legal representative prior to their use; -After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident sense of security (such as fear of falling, movement compromised, or used to sleeping in a larger bed); -Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; -When using side rails for any reason, the staff shall take measures to reduce related risks. Record review of the guidance for industry and Food and Drug Administration (FDA) staff, hospital bed system dimensional and assessment guidance to reduce entrapment, issued on 3/10/2006, from the FDA, Center for Devices and Radiological Health, showed the following information: -The term medical bed and hospital bed are used interchangeably and include adult medical beds with siderails; -Evaluating the dimensional limits of the gaps in hospital beds may be one component of a bed safety program which includes a comprehensive plan for patient and bed assessment; -Bed safety programs may also include plans for reassessment of hospital bed systems; -Reassessment may be appropriate when there is reason to believe that some components are worn, such as rails wobble, rails have been damaged, mattresses are softer, and could cause increased spaces within the bed system; when accessories such as mattress overlays or positioning poles are added or removed; when components in the bed system are changed or replaced, such as new bed rails or mattresses; -Bed rails are rigid bars that are attached to the bed and are available in a variety of sizes and configurations from full length to half, one-quarter, and one-eighth length and are used as restraints, reminders, or as assistive devices; -Zone 1 is the measurement within the rail, any open space within the perimeter of the rail, a loosened bar or rail can change the size of the space; -Zone 2 is the gap under the rail between a mattress compressed by the weight of a patient's head and the bottom edge of the rail at a location between the rail supports or next to a size rail support. Factors to consider are the mattress compressibility which may change over time due to wear, the lateral shift of the mattress or rail, and any degree of play from loosened rails or rail supports. A restless patient may enlarge the space by compressing the mattress beyond the specified dimensional limit. This space may also change with different rail height positions and as the head or foot sections are raised or lowered; -Zone 3 is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head; -Zone 4 space is the gap that forms between the mattress compressed by the patient and the lowermost portion of the rail, at the end of the rail. Factors that may increase the gap size are mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails; -General testing considerations include for ease of mattress movement and measurement, and general safety, the patient should not be in the bed during the measurement procedures. 1. Record review of Resident #8's face sheet (basic resident information sheet) showed the following information: -admitted to the facility on [DATE]; -re-admitted on [DATE]; -Diagnosis included chronic obstructive pulmonary disease (chronic progressive lung diseases), hypoxemia (abnormally low level of oxygen in the blood), borderline personality disorder (condition characterized by difficulties regulating), pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred), and osteoarthritis (most common form of arthritis, occurs when the protective cartilage that cushions the ends of your bones wears down over time). Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 4/2/19, showed the following information: -Cognitively intact; -Moderate fall risk; -No staff assistance needed for bed mobility, transfer, dressing, or personal hygiene; -No restraints or alarms. Record review of the resident's medical record showed an evaluation for use of bed rails, dated 5/13/19, and consent for bed rails, signed and dated 3/4/19. Observation on 11/19/19, at 9:17 A.M., showed half side rails in the raised position on the bed. The resident said he/she used for mobility while in bed. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 2. Record review of Resident #27's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admitted on [DATE]; -Diagnosis include chronic kidney disease (gradual loss of kidney function over time), difficulty in walking, morbid obesity (a person 100 pounds over his/her ideal body weight), hypertension (high blood pressure), and sleep apnea (sleep disorder in which breathing repeatedly stops and starts). Record review of the resident's admission Minimum Data Set, dated [DATE], showed the following information: -Cognitive intact; -One staff limited assistance required for transfers, bed mobility, and dressing; -Staff oversight for required for personal hygiene and eating; -Locomotion by electric wheel chair; -No restraints or alarms. Record review of the resident's medical record showed the following information documented by staff: -Evaluation for side rails dated 5/31/18 and last reviewed on 11/15/19; -Primaris Device Decision Guide dated 7/18/18; -Informed consent for restraints signed on 6/17/15 for partial upper bed rails. Observation on 11/19/19, at 3:00 P.M., showed half side rails in the raised position on the bed. Resident said he/she used for mobility while in bed. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 3. Record review of Resident #44's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admitted on [DATE]; -Diagnosis included bacterial pneumonia (inflammation of the lungs due to bacterial infection), hypertension, hypothyroidism (underactive thyroid gland), heart failure (condition which the heart cannot pump enough blood to meet the body's needs), paranoid schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, behaves and includes delusions and hallucinations), type 2 diabetes mellitus (chronic condition that affects the way your body metabolizes sugar), and anxiety disorder (significant feelings of anxiety and fear). Record review of the resident's quarterly review MDS, dated [DATE], showed the following information: -Mild cognitive impairment; -Extensive assistance from staff for bed mobility, transferring, personal hygiene, toilet use; -Oversight for meals; -No restraints or alarms. Record review of resident's medical records showed staff documented the following: -Care plan, dated 6/21/19, showed that resident used half upper side rails to assist with bed mobility; -Side rail evaluation dated 6/11/19 and last reviewed on 9/16/19 for use of bilateral upper side rails on the resident's bed; -Informed consent form signed 7/24/13. Observation on 11/19/19, at 1:56 P.M., showed half side rails in the raised position on the bed. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 4. Record review of Resident #47's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admitted on [DATE]; -Diagnosis included pressure ulcer, major depressive disorder, anxiety disorder, chronic pain, reduced mobility, paraplegia (paralysis), osteomyelitis (infection of the bone), and acute kidney failure. Record review of the resident's quarterly review MDS, dated [DATE], showed the following information: -Cognitively intact; -No assistance from staff for bed mobility, transferring, personal hygiene; -Extensive staff assistance for toilet use; -No restraints or alarms. Observation on 11/19/19, at 2:39 P.M., showed upper bed rails in the raised position with a trapeze reposition bar above the resident's bed. Record review of the resident's medical record showed the following information documented by staff: -Side rail evaluation completed on 3/27/18, and last reviewed on 9/18/19; -Primaris device decision guide in chart was dated 3/30/18; -Informed consent for bed rails signed by the resident and dated 11/2/17. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 5. Record review of Resident #57's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admitted on [DATE]; -Diagnosis included bacterial pneumonia, thyrotoxicosis (excess of thyroid hormone in the body), adult failure to thrive (weight loss of more than 5%, decreased appetite poor nutrition, and physically inactive), generalized muscle weakness, and chronic pain. Record review of the resident's change in status MDS, dated [DATE], showed the following information: -Cognitively intact; -No assistance from staff for bed mobility, transferring, personal hygiene, or toileting; -Staff oversight for eating; -No restraints or alarms. Record review of the resident's medical record showed an evaluation for bed rails dated 4/8/19 and last reviewed on 10/14/19. Record review of the resident's medical record showed consent benefits/risks signed by the resident on 6/5/18. Record review of the resident's care plan, last updated 10/15/19, showed the resident at risk for falls and the use of 1/2 upper outer side rail to assist with bed mobility. Observation on 11/18/19, at 4:23 P.M., showed upper bed rails in the raised position, and the resident was resting in bed. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 6. Record review of Resident #85's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admitted on [DATE]; -Diagnosis included paraplegia, TBI (traumatic brain injury), seizure disorder, hemiplegia (paralysis on one side of the body), and heart failure. Record review of the resident's quarterly review MDS, dated [DATE], showed the following information: -Cognitively intact; -Extensive staff assistance for bed mobility, transferring, personal hygiene, or toileting; -Staff set up only required for eating; -No alarms or restraints. Record review of the resident's medical record showed the following information documented by staff: -Evaluation for use of bed rails, dated 7/26/19 and last reviewed on 10/30/19, recommended continue use of both upper side rails to assist with mobility; -Primaris device decision guide dated 7/29/19; -Care plan conference summary dated 11/4/19, continue use of side rails for mobility while in bed. Observation on 11/19/19, at 2:34 P.M., showed upper bed rails in the raised position on the resident's bed. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 7. Record review of Resident # 19's face sheet in the medical record showed the following: -Original admission date of 11/21/17 and most recent readmission date of 4/20/18; -Diagnoses that included heart failure, dementia, falls, muscle weakness, and difficulty walking. Record review of the resident's Significant Change MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required maximum assistance of two staff for bed mobility and transfers; -Did not walk. Record review of the resident's most recent care plan showed the following: -Resident used side rails, had dementia, and history of falls. Record review of the November 2019 Physician's Orders showed an undated order for an air mattress with four side rails or two upper side rails and bolsters. Record review of a Side Rail Assessment Evaluation for Use of Side Rails form in the resident's medical record, with dated entries, showed the following: -The assessment was completed on 5-10-19 per request for safety and security; -The resident was frequently incontinent and had dementia; -Will not impede movement or view; -One fourth rails placed on left and right upper sides; -Re-evaluation on 8/2019: Air mattress evaluation with side rails; -Evaluation on 11-4-19: Using one half side rails times two presently. Not a restraint. Record review of a Device Decision Guide form, dated 10/14/19, showed the side rails were not a restraint. During an observation on 11/20/19, at 9:03 A.M., the bed showed one half side rails on both sides of the upper portion of the resident's bed. The bed showed an air mattress on the bed. Record review of an Informed Consent form showed the Durable Power of Attorney signed consent for the side rails on 11/21/19. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 8. Record review of Resident # 77's face sheet in the medical record showed the following: -admission date of 6/18/18; -Diagnoses that included Alzheimer's dementia, chronic pain, muscle weakness, and difficulty walking. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required assistance of one staff for bed mobility, transfers, and walking. Record review of the resident's care plan, dated 7/23/19, showed the resident used one half side rails times two for bed mobility. Record review of the resident's November 2019 Physician's Orders showed the following: -An undated order for one half upper side rails times two. Record review of a Side Rail Assessment Evaluation for Use of Side Rails form, dated 6/18/18, and updated on 10-21-19, showed the resident continued to use both upper side rails. The form showed consent for the side rails was signed on 6-18-18 by the responsible party. Record review of the Device Decision Guide form, completed on 10/14/19, showed the side rails were not a restraint. During an observation on 11/18/19, at 2:00 P.M., the resident was curled up in bed with his/her eyes closed. The bed showed one half side rail on the left upper side of bed, and one half side rail on the right upper side of the bed. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 9. Record review of Resident # 80's face sheet in the medical record showed the following: -Initial admission date of 2/01/18 and readmission date of 9/02/19; -Diagnoses that included chronic lung disease, rheumatoid arthritis, chronic pain, lack of coordination, unsteadiness on feet, muscle weakness, and difficulty walking. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with bed mobility, transfers, and walking in room. Record review of a Side Rail Assessment Evaluation for Use of Side Rails form, dated 2/01/18, showed consent was signed by the resident for left and right side rails for mobility. Record review of the Device Decision Guide form, completed on 9/05/19, showed the side rails were not a restraint. During an observation and interview on 11/21/19, at 3:28 P.M, the resident's bed showed one half side rail on the right side of the bed. The resident said he/she used the side rail for positioning. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 10. Record review of Resident # 29's face sheet in the medical record showed the following: -Initial admission date of 6/30/16 and most recent readmission date of 11/09/19; -Diagnoses that included heart failure, chronic lung disease and morbid obesity. Record review of the resident's most recent 5 Day MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with bed mobility, transfers, and walking. Record review of the resident's most current care plan, dated 9/03/19, showed side rails not addressed on the care plan. Record review of the resident's November 2019 Physician's orders showed no order for side rails. Record review of a Side Rail Assessment Evaluation for Use of Side Rails form, dated 11/09/19, showed bed rails were not indicated at that time. During an observation and interview on 11/19/19, at 1:24 P.M., showed one half side rail was seen on the left upper portion of the resident's bed next to the wall. The resident said he/she used the side rail for positioning. Record review of the resident's medical record showed no Device Decision Guide form had been completed for the resident. Record review of the resident's medical record showed no Informed Consent form for side rails had been signed by the resident. Record review of the resident's medical record showed the facility did not document completion of measurements to ensure there were no gaps that's could potentially cause injury or entrapment. 11. During an interview on 11/21/19, at 10:38 A.M., the maintenance staff said that measurements to ensure there were no gaps that's could potentially cause injury or entrapment were not completed on any bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Record review of Resident # 238's face sheet showed the following: -admission date 6/4/18; -re-admission date 7/29/19; -Diagnosis included type 2 diabetes mellitus, anemia (lack of healthy red blood cells to carry adequate oxygen to the body's tissues), muscle weakness (lack of strength in muscles), and congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs). Record review of the resident's November 2019 Physician's Orders showed the following: -An order, dated 7/29/19, to administer Humalog (Insulin Lispro) sliding scale (S/S) one unit for each ten points over 180 milligrams/deciliter (mg/dL) for type 2 diabetes mellitus; -An order, dated 7/29/19, for accucheck (blood sugar level check) before meals (AC) and bedtime (HS) for type 2 diabetes mellitus. Observation on 11/21/19, of CMT J, showed the following: -At 5:01 P.M., the resident's blood glucose level was 242 mg/dL. The registered nurse calculated the insulin dose needed; -At 5:08 P.M., CMT J administered six units of Humalog subcutaneous (below the skin) to the resident's abdomen; -At 5:40 P.M., the staff assisted the resident to the dining room, a cup of water was placed on the table; -At 5:48 P.M. the resident was given glass of ice tea with one added packet of sugar; -At 5:49 P.M. the resident took a small sip of ice tea; -At 6:22 P.M. the resident received a french dip sandwich, french fries, and bowl of fruit, one hour and 14 minutes after receiving fast acting insulin dose. During an interview on 11/22/19, at 9:43 A.M., CMT K said the following: -He/she administers insulins; -He/she determines when to check the blood sugar first. Then, depending on the result, he/she will look at MAR and the sliding scale and administer the dose of insulin as prescribed; -He/she gives the insulin as close to the meal as possible. Some insulins work faster than others. Fast acting insulins are given before meals. He/she will give those 30 minutes before meals; -If for some reason the resident doesn't go to the dining room afterward, he/she will make sure and offer a snack if they are not hungry. During an interview on 11/22/19, at 10:01 A.M., CMT E said the following: -He/she usually administer insulins about 30 minutes before meals. Fast-acting insulins such as Humalog and Novolog can be administered about 30 minutes early; -He/she waits to see if the resident will eat. I make sure they have a snack available. During an interview on 11/22/19, at 11:34 A.M., the DON said the following: -Some insulins are very fast acting and could drop a resident's blood sugar; -Staff would want to make sure and give with a snack; -Staff should give the fast-acting insulins within 30 minutes of a meal. Based on observation, interview, and record review, the facility failed to assure the medication error rate was less than five percent when facility staff failed to administer medications according to the physician's orders and standards of practice resulting in 18 medication errors out of 26 opportunities. This practice affected five residents (Resident #54, #59, #74, #80, and #238). The medication error rate was 69.23%. The facility census was 92. Record review of the facility's Administering Medications Policy, dated April 2019, showed the following: -The Director of Nursing (DON) Services supervises and directs all personnel who administer medications and/or have related functions; -Medications are administered in accordance with prescriber orders, including any required time frame; -Medications are administered within one hour of their prescribed time unless otherwise specified (for example, before and after meal orders). 1. Record review of Resident # 54's face sheet (general resident information) in the medical record showed the following: -readmission date of 8/15/14; -Diagnoses of Alzheimer's disease (form of dementia), gastro-esophageal reflux disease (GERD - a condition that causes food and stomach acid to back up the esophagus from the stomach), and convulsions (seizures), and hypertension (high blood pressure). Record review of the resident's November 2019 Physician's Orders showed the following: -An order, dated 8/15/14, to administer Colace (stool softener) 100 milligrams (mg) by mouth (PO) twice a day (BID) for constipation, administer at 8:00 A.M. and 8:00 P.M.; -An order, dated 12/20/14, to administer ranitidine (treats GERD, ulcers, heartburn) 150 mg PO BID for GERD, administer at 8:00 A.M. and 8:00 P.M.; -An order, dated 1/12/16, to administer levetiracetam (treats seizures) 500 mg PO BID for seizures, administer 8:00 A.M. and 8:00 P.M.; -An order, dated 3/11/18, to administer salt tabs one gram two tablets PO BID supplement, administer 8:00 A.M. and 8:00 P.M.; -An order, dated 9/21/19, to administer donezepil hydrochloride (HCL) (treats dementia-manufacturer's insert showed medication should be administered just prior to bedtime) ten mg PO at hour of sleep (HS) for dementia, administer at HS. During an observation on 11/21/19, at 4:12 P.M., Certified Medication Technician (CMT) K administered the following medications to the resident in his/her room; -Colace 100 mg (scheduled for 8:00 A.M. and 8:00 P.M.); -Ranitidine 150 mg (scheduled for 8:00 A.M. and 8:00 P.M.); -Salt tabs one gram two tabs (scheduled for 8:00 A.M. and 8:00 P.M.); -Levetiracetam 500 mg (scheduled for 8:00 A.M. and 8:00 P.M.); -Donepezil ten mg (scheduled for bedtime). 2. Record review of Resident # 74's face sheet showed the following: -admission date of 7/10/19; -Diagnoses of chronic lung disease, anxiety disorder, depression, and low back pain. Record review of the resident's November 2019 Physician's Orders showed the following: -An order, dated 7/10/19, to administer Tessalon [NAME] (treats cough) 100 mg one capsule PO TID for a cough, administer at 8:00 A.M., 2:00 P.M., and 8:00 P.M.; -An order, dated 7/10/19, to administer trazadone (antidepressant with possible side effects of dizziness, sleepiness, and tiredness) 150 mg one half tablet PO at HS, administer at HS; -An order, dated 11/8/19, to administer ibuprofen (non-steroidal anti-inflammatory medication) 600 mg one tab daily PO BID for pain, administer at 8:00 A.M. and 8:00 P.M. During an observation on 11/21/19, at 4:21 P.M., CMT K administered the following medications to the resident in his/her room: -Tessalon [NAME] 100 mg (scheduled for 8:00 A.M., 2:00 P.M., and 8:00 P.M.); -Trazadone 150 mg (scheduled for bed time); -Ibuprofen 600 mg PO BID (scheduled for 8:00 A.M. and 8:00 P.M.). 3. Record review of Resident # 80's face sheet in the medical record showed the following: -readmission date of 9/2/19; -Diagnoses of chronic lung disease, rheumatoid arthritis, hypertension (high blood pressure), chronic pain, dementia, heart disease, chronic kidney disease, lack of coordination, unsteadiness on feet, and muscle weakness. Record review of the resident's November 2019 Physician's Orders showed the following: -An order, dated 9/2/19, to administer carvedilol (treats blood pressure)12.5 mg one tab PO with food BID, administer 8:00 A.M. and 6:00 P.M.; -An order, dated 9/2/19, to administer bisacodyl (treats constipation) five mg one tab PO BID for constipation, administer 8:00 A.M. and 8:00 P.M.; -An order, dated 9/2/19, to administer potassium chloride (KCL) extended release (ER) 20 millequivalents one half tab PO BID for hypokalemia (low potassium level in the blood), administer 8:00 A.M. and 8:00 P.M.; -An order, dated 9/2/19, to administer Eliquis (blood thinner) 2.5 mg one tab PO BID; administer 8:00 A.M. and 8:00 P.M.; -An order, dated 9/2/19, to administer donepezil HCL ten mg one tab at HS for dementia. administer at HS; -An order, dated 9/2/19, to administer gabapentin (treats nerve pain)100 mg one capsule PO at HS for neurogenic pain, administer at 8:00 P.M.; -An order, dated 9/2/19, to administer 12 Hour Mucous Relief (guaifenesin - treats cough) one 12 hour tab PO BID for cough, administer at 8:00 A.M. and 8:00 P.M. During an observation on 11/21/19, at 4:28 P.M., CMT K administered the following medications to the resident in his/her room: -12 hour mucousrelief (scheduled 8:00 A.M. and 8:00 P.M.); -Carvedilol 12.5 mg without food (ordered with food and scheduled at 8:00 A.M. and 6:00 P.M.); -Bisocodyl 5 mg one tab (scheduled 8:00 A.M. and 8:00 P.M.); -Eliquis 2.5 mg (scheduled for 8:00 A.M. and 8:00 P.M.); -KCL ER 10 mg (scheduled 8:00 A.M. and 8:00 P.M.); -Donepezil 10 mg (scheduled at HS); -Gabapentin 100 mg (scheduled at 8:00 P.M.). 4. Record review of Resident #59's face sheet showed the following: -admission date 5/20/13; -re-admission date 11/4/19; -Diagnosis included hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) affecting right dominant side, mild intellectual disabilities, gastro-esophageal reflux disease (digestive disorder that affects the ring of muscle between the esophagus and stomach), seizure disorder, and muscle weakness. Record review of the resident's November 2019 Physician's Orders showed the following: -An order, dated 1/10/19, to administer Tums 500 mg PO three times per day (TID) after meals (PC) for indigestion, administer at 8:00 A.M., 12:00 P.M., and 6:00 P.M.; -An order, dated 12/19/18, to administer salt tabs (sodium chloride) 1 gram (gm) two tablets PO TID for supplement, administer at 8:00 A.M., 2:00 P.M., and 8:00 P.M.; -An order, dated 1/18/18, to administer lorazepam 1 mg one tablet PO four times a day (QID) for seizure disorder, administer at 6:00 A.M., 12:00 P.M., 6:00 P.M., and 12:00 A.M.; -An order, dated 5/20/13, to administer carbamazepine 200 mg, one tablet PO TID for seizure disorder, administer at 5:00 A.M., 12:00 P.M., and bedtime. During an observation on 11/21/19, at 12:05 P.M., CMT E administered the following medications to the resident in his/her room; -Tums 500 mg 1 tablet (given before meal instead of after); -Sodium Chloride 1 gm two tablets (scheduled 8:00 A.M., 2:00 P.M., and 6:00 P.M.). 4. During an interview on 11/22/19, at 9:43 A.M., CMT K said the following: -CMT's are responsible for passing medication; -He/she passes medications as close to the scheduled times as possible; -He/she was told to pass medications one hour before or one hour after shown when due; -If a medication was due at 8:00 P.M., he/she would pass it as close to 8:00 P.M. as possible; -An 8:00 P.M. medication would not be administered at 4:00 P.M.; -If the order says to give the medication with food, he/she would ask a nurse. If the resident is in the dining room, he/she would give the medication and offer a snack. 5. During an interview on 11/22/19, at 10:01 A.M., CMT E said the following: -CMT's are responsible for administering medications; -The policy is to administer the medication 30 minutes after and 30 minutes before they are due within an hour time frame; -If he/she cannot give the medication on time, he/she will let the Charge Nurse know he/she is ehind or cannot give the medication; -He/she starts administration of 8:00 P.M. medications about 7:30 P.M. to 8:00 P.M. He/she would not give them at 4:00 P.M. -If the order shows to give with food, he/she would give a snack. 6. During an interview on 11/22/19, at 11:34 A.M., the Director of Nursing (DON) said the following: -CMT's or nurses pass medications and insulins, but mostly CMT's; -They should pass them according to orders as far as the times to be administered. Within an hour before and an hour after they are due is the policy to administer medications; -The 8:00 P.M. medications should be passed at 8:00 P.M., give or take an hour. It is not acceptable to pass those at 4:00 P.M. without a physician's order.

Based on observation, interview, and record review the facility failed to protect food from possible contamination when the staff failed to complete hand hygiene or change gloves between tasks; failed to dry dishes properly and stacked dishes wet; and when staff stored dented cans on the shelf to be used in food preparation. The facility census was 92. 1. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. - Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observation of the kitchen on 11/18/19, at 1:43 P.M., showed seven 4-quart storage containers stacked wet on shelves in the walk-in storage space. Observation on 11/19/19, at 8:45 A.M., showed the following: -Seven 4-quart containers stacked wet in storage area; -Two cereal containers stacked wet in storage area. Observation on 11/20/19, at 11:10 A.M., showed the following: -Seven plate chargers and lids stacked wet and waiting for serve out; -Six stacks of eight dessert cups showed the inside of the bowls were stacked wet; -Seven 4-qt containers stacked wet in storage area. During an interview on 11/20/19, at 2:05 P.M., Dietary Aide (DA) L said that he/she tries to let the dishes air dry before putting away, there is a rinse aide that helps dishes dry quicker. The dishes are usually dry when put away. During an interview on 11/20/19, at 2:58 P.M., the Dietary Manager said that staff should be putting all dishes away after allowing them to be fully air dried. Dishes should not be stacked wet. 2. Record review of the 2013 Food Code showed the following information: - Food packages should be in good condition and protect the integrity of the contents so the food is not exposed to potential contamination. - Food held for credit, such as damaged products, should be segregated and held in an area separate from other food storage. - Food packages that are damaged, spoiled or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods and should be kept in separate and segregated areas. - Damaged packaging may allow the entry of bacteria or other contaminants into the contained food. Observation of the kitchen on 11/18/19, at 1:43 P.M., showed two 6 pound 12 ounce dented cans of lima beans in dry storage with dents approximately 3 inches in width. Observation on 11/19/19, at 8:45 A.M., showed the following: -The two cans of lima beans with dents remained in the storage area; -One can of green beans with a dent along the top of the can in the storage area. Observation on 11/20/19, at 2:04 P.M., showed two cans of lima beans and one can of green beans with dents on dry storage shelves. During an interview on 11/20/19, at 2:58 P.M., the Dietary Manager said dented or damaged foods should be brought to the dietary manager office for return to the vendor. 3. Record review of the 2013 Food Code showed the following: -Single-service and single-use articles shall be handled and dispensed so that contamination of food-contact surfaces is prevented; -Even though bare hands should never contact exposed, ready-to-eat food, thorough handwashing is important in keeping gloves or other utensils from becoming vehicles for transferring microbes to the food; -Food employees shall clean their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination; -The handles of utensils, even if manipulated with gloved hands, are particularly susceptible to contamination. Observation on 11/20/19, at 11:10 A.M., showed the following: -At 11:32 A.M., DA F had gloves on and used the spoons and tongs to serve first tray; -At 11:37 A.M., the DA handled resident menu papers with gloved hands and then placed the same gloved hands on top of a ready to eat sandwich to cut in half; -At 11:52 A.M., [NAME] G moved two stacks of plates from left side of plate warmer to right side, pushing each stack down with gloved hand on food contact area that had been used on utensils, microwave door and serving utensils at stove; -At 12:13 P.M., DA F went to check on noodles cooking at stove, tasted one of the noodles off the spoon by picking a noodle up off the spoon with his/her fingers and put the noodle in his/her mouth and put the spoon on edge of stove top. The DA returned to serving line and put on new gloves, but did not wash or sanitize hands; -At 12:48 P.M., the serving spatula rested across the corn bread, including the handle, touching the bread surface. During an interview on 11/20/19, at 2:10 P.M., [NAME] H said that he/she would change gloves after touching many items and before cutting a sandwich. During an interview on 11/20/19, at 2:58 P.M., the Dietary Manager said he/she had not thought about how to cut a sandwich after touching many other items in the kitchen.