Based on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure oxygen and nebulizer tubing were stored properly when not in use when the nebulizer tubing and mouthpiece was noted to be on the floor and not in protective cover for one resident (Resident #2 ), noted to be on the chair and not in protective covering for one resident (Resident #4), and oxygen nasal cannula (thin, flexible tube that delivers oxygen through the nose) and tubing was on the back of the resident's wheelchair not in a protective bag for one resident (Resident #3) in a common area. The facility census was 74. Review of facility policy titled Oxygen Administration, undated, showed the following: -Purpose of policy was to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Connect nasal cannula tubing to humidifier outlet and adjust liter flow as ordered; -Place prongs of cannula into the resident's nares (nose); -Adjust elastic loosely around head above ears; -At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; -Place cannula tubing in plastic bag attached to concentrator when tubing is not in use. Review of facility policy titled Aerosol Therapy Treatments (medical procedure that involves delivering medications in the form of tiny droplets (aerosols) into the respiratory tract), undated, showed the following: -Medication can be given in many forms. One way is to inhale the medication in aerosol form; -Staff should gather all equipment needed for the procedure; -Remove the top part of the nebulizer cup (small, cup-shaped device that holds liquid medicine that is then turned into a mist); -Place medication in the bottom of the nebulizer cup; -Attach the top portion of the nebulizer cup and connect the mouthpiece or face mask to the cup; -Turn on the compressor; -Continue the treatment until all the medication is gone; -Turn off the compressor; -Clean equipment per guidelines after each use. 1. Review of Resident #2's face sheet (brief information sheet about the resident) showed the following: -admission date of 09/08/22; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure (medical condition where the lungs are unable to adequately exchange gases, resulting in low levels of oxygen (hypoxemia) and/or high levels of carbon dioxide (hypercapnia) in the blood) with hypercapnia, and bronchitis (inflammation of the lining of bronchial tubes, which carry air to and from the lungs). Review of the resident's care plan, last updated 01/02/25, showed the following: -Resident had shortness of breath related to COPD and chronic respiratory failure; -Staff should administer oxygen at 2 liters (amount to be delivered through oxygen device) via nasal cannula; -Staff should observe oxygen precautions; -Staff should administer albuterol via nebulizer and ipratropium-albuterol via nebulizer; -Staff should change oxygen tubing weekly and nebulizer tubing per facility protocol. Review of the resident's physician orders, active as of 02/25/25, showed the following: -An order, dated 12/24/24, for albuterol sulfate solution (used to prevent and treat wheezing and shortness of breath caused by breathing problems) for nebulization: 2.5 milligram (mg)/3 milliliter (ml), one vial inhalation every 4 hours as needed; -An order, dated 01/21/25, ipratropium-albuterol solution (combination solution used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema) for nebulization: 0.5 mg-3 mg/3 ml, one vial twice per day with mask; -An order, dated 05/04/24, to change nebulizer tubing monthly. Observation on 02/25/25, at 8:50 A.M., showed the resident resting in bed with oxygen on by nasal cannula. A nebulizer machine with tubing and mouthpiece attached was setting directly on the floor with the mouthpiece touching the tile with no protective covering. 2. Review of Resident 3's face sheet showed the following: -admission date of 09/02/10; -Diagnoses included Parkinson's disease (progressive neurological disorder that affects movement, balance, and coordination), bacterial pneumonia (lung infection caused by bacteria), and acute respiratory disease (number of conditions that affect the lungs). Review of the resident's care plan, last updated 02/04/25, showed staff did not care plan related to oxygen usage; -No information related to use of oxygen. Review of the resident's physician orders, active as of 02/25/25, showed the following: -Standard wheelchair. -No order noted for oxygen. Observation on 02/25/25, at 9:00 A.M., showed the resident in the hallway in his/her wheelchair. The resident had his/her eyes closed. There was an oxygen tank on the back of the resident's wheelchair with tubing and nasal cannula attached. The nasal cannula was setting on the back side of the wheelchair exposed to air with no protective covering. 3. Review of Resident #4's face sheet showed the following: -admission date of 11/25/24; -Diagnoses included shortness of breath and cognitive communication deficit. Review of the resident's physician orders, active as of 02/25/25, showed an order, dated 11/25/24, for ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg/3 ml; amount to administer: one vial every 6 hours as needed. Review of the resident's care plan, last updated 12/16/24, showed staff did not care plan regarding nebulizer use. Observation on 02/25/25, at 9:15 A.M., showed the resident in bed with staff in the room for catheter care. There was a nebulizer machine with tubing and mouthpiece attached setting on a bedside chair, with the mouthpiece touching the chair with no protective covering. 4. During an interview on 02/25/25, at 12:40 P.M., Certified Nurse Aide (CNA) C said when a resident had oxygen or nebulizer tubing that was not in use, the tubing should be in a plastic bag next to the machine to keep the tubing clean until the next use. The tubing, mouthpiece, or nasal cannula should not be touching the floor or open to air. During an interview on 02/25/25, at 12:50 P.M., Certified Medication Tech (CMT) D said oxygen and nebulizer tubing should not be on the floor or bedside chair. It should be protected and in a plastic bag when not in use. During an interview on 02/25/25, at 1:10 P.M., Registered Nurse (RN) A said oxygen and nebulizer tubing should be covered when not in use and should not be on the floor or in a chair. During an interview on 02/25/25, at 1:20 P.M., RN E said oxygen and nebulizer tubing should be in a plastic bag when not in use. The tubing should not be on the floor. During an interview on 02/25/25, at 1:29 P.M., Licensed Practical Nurse (LPN) F said oxygen and nebulizer tubing should be in a plastic bag when not in use to keep clean. During an interview on 02/25/25, at 2:05 P.M., the Director of Nursing (DON) said oxygen and nebulizer tubing should be in a plastic bag when not in use. The tubing should not be on the floor or exposed to air without protection to keep clean until next use. During an interview on 02/25/25, at 2:25 P.M., the Administrator said oxygen and nebulizer tubing should be in a plastic bag when not in use. Tubing should not be on the floor or any other non-clean surface.

Based on observation, record review, and interview, the facility failed to establish and maintain an effective infection prevention and control program when staff failed to educate staff on and implement a process for Enhanced Barrier Protection (EBP - are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) policy and procedure when staff did not wear gowns when completing catheter (a flexible tube that drains urine from the bladder) care for two residents (Resident #2 and #4). The facility census was 74. Review of the Centers for Disease Control and Prevention (CDC)'s Considerations for Use in Skilled Nursing Facilities, dated 06/2021, showed the following information: -MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents and increased costs for the health care system; -EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices); -EBP may be applied (when Contact Precautions do not otherwise apply) to residents with wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO; -Effective implementation of EBP required staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care; -EBP to routine care of residents with wounds or indwelling medical devices requires that staff participate in initial and on-going training on the facility ' s expectations about hand hygiene and gown and glove use, along with proof of competency regarding appropriate use and donning and doffing technique for PPE; -Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities; -Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room); -A trash can (or laundry bin, if applicable) large enough to dispose of multiple gowns should be available for each room. Review of the facility policy titled Enhanced Barrier Precautions to Infection Control Guidance, dated March 2024, showed the following: -Purpose to prevent broader transmission of MDROs and to help protect patients with chronic wounds and indwelling devices; -EBP should be implemented for the period of the stay or until wounds have resolved or indwelling medical devices have been removed; -Resident who are known to be infected or colonized with a MDRO, residents with an indwelling medical device including urinary catheter regardless of their MDRO status, and residents with a wound, regardless of the MDRO status a require EBP; -Use EBP when providing high-contact resident care activities such as bathing, transferring resident from one position to another, providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device, performing wound care; -Conduct proper hand hygiene before starting care; -Gloves and donning and doffing of gown are required when conducting high-contact resident care activities; -Gloves and gown should be removed and discarded after each resident care encounter; -Attempt to arrange cares to be grouped together to assist in reducing consumption of supplies with practical; -EBP should be performed when performing transfers or assisting during bathing in a shared/common shower and when working with residents in the therapy gym; -Residents that are placed on EBP should have PPE in close proximity outside the door and a trash can in the resident's room for disposal prior to leaving the room; -Multi-resident medical equipment must be sanitized between resident uses. 1. Review of Resident #2's face sheet (brief information sheet about the resident) showed the following: -admission date of 09/08/22; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe) and urinary tract infection (bacterial infection of urinary tract, which includes kidneys and bladder). Review of the resident's physician orders, active as of 02/25/25, showed the following: -An order, dated 12/24/24, for catheter type indwelling, size 16 French (universal sizing system for internal urinary catheters), 10 ml balloon (inflated to hold catheter in place); -An order, dated 12/24/24, to change catheter at physician discretion; -An order, dated 12/24/24, for catheter care every shift; -An order, dated 12/24/24, to change catheter monthly. Review of the resident's care plan, last updated 01/02/25, showed the following: -Resident had an indwelling urinary catheter; -Staff should change catheter per physician orders; -Staff should provide catheter care per physician orders. (Staff did not care plan related to EBP.) Observation on 02/25/25, at 11:00 A.M., showed Certified Nurse Aide (CNA) C entered the resident's room to drain the resident's catheter bag. The CNA applied prepared supplies and applied gloves. The aide opened the drain tip of the catheter bag (opening that allows urine to drain from the catheter into a collection container) and drained the urine into a collection cup. The aide then wiped the drain tip with an alcohol wipe and secured to the catheter bag. The aide disposed of the urine into the toilet and rinsed the container with water. The aide removed his/her gloves and washed hands and left the room. The aide did not apply a gown for EBP. There was no signage regarding EBP use and there was no PPE near the resident's room. 2. Review of Resident #4's face sheet showed the following: -admission date of 11/25/24; -Diagnoses included cognitive communication deficit, benign prostatic hyperplasia (non-cancerous enlargement of prostate (gland surrounding the tube that empties the bladder)) with lower urinary tract symptoms (pain or burning when urinating, frequent urination). Review of the resident's physician orders, active as of 02/25/25, showed the following: -An order, dated 11/25/24, for catheter care every shift; -An order, dated 11/25/24, to change catheter monthly; -An order, dated 11/25/24, to change catheter as needed; -An order, dated 11/25/24, to change catheter at physician discretion; -An order, dated 11/25/24, to flush catheter with 30 ml normal saline daily as needed. Review of the resident's care plan, last updated 12/16/24, showed the following : -Resident had a catheter related to benign prostatic hypertrophy (enlargement); -Staff will perform catheter care per physician orders; -Staff will report signs of urinary tract infection. (Staff did not care plan related to EBP.) Observation on 02/25/25, at 9:15 A.M., showed Registered Nurse (RN) A and Licensed Practical Nurse (LPN) F entered the resident's room to change the resident's catheter. The nursing staff prepared supplies and washed their hands at the sink and applied gloves. RN A opened a syringe and removed fluid from the catheter balloon. RN A removed the catheter from the resident's bladder and disposed of the catheter into the trash. RN A removed gloves and washed hands at sink. He/she applied new gloves. LPN F opened the supplies and attached the new catheter tubing to the new catheter bag. RN A attempted to put on sterile gloves and the gloves were too small and caused the gloves to tear. The nurses removed gloves and washed hands at the sink. RN A left the room to find another nurse with smaller hands. RN A returned with supplies and asked LPN F to try the catheter change. LPN F washed hands at sink and attempted to put on sterile gloves and the gloves tore. He/she removed the gloves and washed hands at sink. The staff covered the resident and left the room to find another nurse. The staff did not apply gowns for EBP. Observation on 02/25/25, at 9:55 A.M., showed RN E entered the resident's room with supplies and disinfected the bedside table, prepared supplies on the table, and then washed his/her hands at the sink. He/she opened the sterile glove package and applied the gloves. The nurse cleaned the resident's private region appropriately for catheter care, attempted to insert the catheter tubing and it would not advance. The nurse removed the catheter tubing. Covered the resident and disposed of supplies, removed gloves, and washed hands at the sink. The nurse left the room and notified the charge nurse, who notified the physician and advised to send the resident to the emergency room for catheter insertion. The nurse did not apply a gown for EBP. There was no signage regarding EBP use and there was no PPE near the resident's room. 4. During an interview on 02/25/25, at 11:10 A.M., Nurse Aide (NA) B said that when preparing a resident for catheter care he/she would wash hands and apply gloves. After completing the resident care, he/she would remove gloves and wash his/her hands. He/she said that EBP included the use of barrier creams to protect resident skin. He/she said that use of gowns was for residents that were on contact precautions, such as when a resident had an infection. The nurses notify the staff when to use PPE and sometimes there were signs and PPE carts near the residents' rooms. He/she did not wear a gown to complete catheter care or toileting hygiene with a resident that had a wound. During an interview on 02/25/25, at 12:40 P.M., CNA C said that he/she had not heard of EBP. He/she said that when working with residents he/she was required to wear a gown, gloves, and sometimes a mask if a resident had the flu. There were no signs related to EBP and no PPE near any resident rooms at this time. During an interview on 02/25/25, at 12:50 P.M., Certified Medication Tech (CMT) D said that he/she had not heard of EBP. He/she said that if a resident had flu or COVID then he/she would wear a gown and gloves in a resident room. The nurse would tell him/her when this was required. During an interview on 02/25/25, at 1:10 P.M., Registered Nurse (RN) A said he/she had not received any training about EBP. He/she only wore a gown in a resident room if the resident was on isolation or if there were specific organism present in a resident wound. During an interview on 02/25/25, at 1:20 P.M., RN E said that he/she had EBP training at a previous place of employment. He/she was aware that EBP included a resident that had any type of tube or open area. Staff should wear a gown, gloves, and sometimes masks when completing resident cares. He/she said that the staff at the facility were not using EBP. During an interview on 02/25/25, at 1:29 P.M., Licensed Practical Nurse (LPN) F said if there was a substantial wound when completing wound care then he/she would need to use EBP. Generally, he/she did not use gown when completing wound care. The PPE could be found in the supply closet, but it was not readily available at resident rooms. During an interview on 02/25/25, at 2:05 P.M., Director of Nursing (DON) said if residents that had wounds or indwelling devices that were leaking, staff should wear a gown and gloves. She was not aware that gowns should be worn any time direct resident care completed with residents with chronic wounds or indwelling devices. PPE was available in all storage room. She did not think that staff needed to wear a gown if the wound was covered when completing personal cares. During an interview on 02/25/25, at 2:25 P.M., the Administrator said that with residents with catheters, wounds, or indwelling medical devices, staff should wear gloves when completing direct cares. Gowns are used if a resident was on isolation precautions. EBP was used when residents were higher risk and usually have PPE out by the resident door at that time. The facility just got all resident off isolation precautions recently. He/she was not aware that gowns and gloves should be used for EBP with high-contact care of residents with chronic wounds and indwelling medical devices regardless of MDRO status.

Based on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they failed to ensure two residents (Residents #8 and #20) were appropriately dressed in common areas. A sample of four residents was selected for review in a facility with a census of 64. Review showed the facility did not provide a facility policy addressing residents' right to dignity and respect. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: -admission date of 01/17/22; -Diagnosis included rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), muscle wasting (thinning or loss of muscle tissue) and atrophy (gradual decline in effectiveness) multiple sites, abnormal weight loss, abnormal posture, and type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel) with mild non-proliferative diabetic retinopathy (eye condition that can cause vision loss and blindness in people who have diabetes) Review of the resident's care plan, last reviewed 07/18/23, showed the following information: -Resident had decreased activities of daily living (ADL - term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) functioning related to rheumatoid arthritis; -Required Hoyer lift (mobility tool used to help with mobility challenges get out of bed or bath) and two staff assistance for transfers; -Required one to two staff assistance with ADL's to include toileting, bathing, dressing, grooming, and eating; -Used a Broda chair (wheelchair that give patients the ability to tilt and recline and help prevent skin breakdown) for mobility and required staff to propel; -Resident had cognitive loss/dementia and had difficulty recognizing objects, people, places, or things and problems with memory, learning new things, making decisions and effectively communicating related to impaired cognition; -Staff should assist resident to maintain dignity, self-esteem, and quality of life, to the extent possible related to the disease process; -Staff should anticipate needs and observe for non-verbal cues; -Staff should explain care before beginning and as needed. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 07/20/23, showed the following: -Severe cognitive impairment; -Total dependence on one staff for bed mobility, locomotion, dressing, personal hygiene, toilet use, and bathing; -Total dependence on two staff for transfers between bed and chair; -Limited assistance with one staff physical assistance required for eating; -Required wheelchair for locomotion. Observations on 10/03/23, at 12:36 P.M., showed the resident seated in a Broda chair in dining room with black shirt and plaid colored pajama pants. The resident's incontinent brief was exposed above the top of the pants about 3 to 4 inches. The resident's shirt was not covering the incontinent brief. The resident's shirt had a large area on the top half of shirt with white specks that appear to be dried skin. The resident appeared dirty with oily appearing hair. The resident's incontinent brief remained visible throughout the meal. The resident was seated at a table with two other residents and one staff member. 2. Review of Resident #20's face sheet showed the following: -admission date of 08/30/21; -Diagnoses included autistic disorder, methicillin susceptible staphylococcus aureus infection (MRSA- bacterial infection), sepsis with shock, acute respiratory disease, seizures, abnormal glucose (blood sugar level), pneumonia, difficulty walking, muscle wasting multiple sites, anxiety, unspecified intellectual disabilities, low thyroid function, gastro-esophageal reflux disease (GERD - stomach acid backs up into the esophagus), acute kidney failure, difficulty swallowing, segmental reversible ischemia of small intestine (blocked blood flow through the intestine), colostomy status (surgically diverted colon to an artificial opening in the abdominal wall; solid stool is passed through to a collection bag outside the body), cognitive communication deficit, and other symptoms and signs involving cognitive functions and awareness. Review of the resident's care plan, last updated 09/12/23, showed convey an attitude of acceptance toward the resident. Observation on 10/05/23, at 10/37 A.M., showed the resident wheeled his/her wheelchair in the front lobby of the facility. The resident's shirt was raised causing the ileostomy (an opening in the belly (abdominal wall) that's made during surgery) bag to be fully exposed with content perceptible through the semi-opaque bag material. Three staff, the Administrator, Social Services Director (SSD), and the Business Office Manager, and two visitors were present in the lobby. 3. During an interview on 10/06/23, at 9:00 A.M., Certified Nurse Aide (CNA) C said that residents should be dressed appropriately when in the common areas of the facility, including the dining room. Residents should not have underclothing, such as incontinent briefs, exposed while in the dining room. Residents should be groomed adequately including hair brushed and clean clothing. 4. During an interview on 10/06/23, at 11:00 A.M., Licensed Practical Nurse (LPN) B said that residents should not have skin visible when out of their own room, such as their stomach, an ostomy (procedure that allows bodily waste to pass through a surgically created stoma on the abdomen), or incontinent brief. Staff should ensure residents are appropriately covered when in the dining room or common areas. Residents should be groomed adequately including hair brushed and clean clothing. 5. During an interview on 10/06/23, at 2:03 P.M., with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the DON said that residents' ostomy bags and incontinent briefs should not be visible when in the common areas. Staff should ensure residents are appropriately dressed when out of their rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident # 35's face sheet (brief resident profile) showed the following information: -admission date of 11/28/22; -Diagnoses included cerebral infarction (stroke), hypertension (high blood pressure), muscle weakness, abnormal weight loss, and depression. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Required substantial assistance of one staff for bathing. Review of the resident's care plan, revised on 09/18/23, showed the following information: -Had an ADLs deficit and required assistance with ADLs; -Resident at risk for decline in ADLs related to decreased functional status/rehabilitation potential; -Interventions included resident required standby to one person assistance. (Staff did not address the resident's shower/bathing preferences.) Review of the facility's shower schedule showed the resident was listed for a shower every Monday and Thursday. Review of the resident's July 2023 Skin Monitoring: Comprehensive CNA Shower Review sheets showed the following: -Resident received a shower on 07/03/23; -Resident received a shower on 07/08/23; -Resident received a shower on 07/12/23; -Resident received a shower on 07/18/23 (six days after the resident's last documented shower); -Resident received a shower on 07/24/23 (six days after the resident's last documented shower); -Resident received a shower on 07/31/23 (seven days after the resident's last documented shower). Review of the resident's September 2023 Skin Monitoring: Comprehensive CNA Shower Review sheets showed the following: -Resident received a shower on 09/05/23; -Resident received a shower on 09/11/23 (six days after the resident's last documented shower); -Resident received a shower on 09/18/23 (seven days after the resident's last documented shower); -Resident received a shower on 09/26/23 (eight days after the resident's last documented shower). During an interview on 10/04/23, at 9:41 A.M., the resident said he/she gets only one shower per week. He/she said that Monday is his/her shower day. He/she would like two showers per week. He/she does not feel clean getting only one shower per week and washes up in his/her bathroom during the other days because he/she does not want to stink. During an interview on 10/05/23, at 10:50 A.M., CNA D said that the resident's shower days are Mondays and Thursdays. Everyone gets a shower twice a week. He/she may not remember getting them. CNA D said residents do not ever refuse showers. 3. During an interview on 10/05/23, at 10:55 A.M., CNA P said the following: -Some of the residents get three showers a week; -Some may only want one or they may refuse; -A resident is able to decide what they want, for the number of showers they get each week; -He/she knows that the shower aide is gone today for an appointment and the other one is off today. 4. During an interview on 10/06/23, at 11:05 A.M., Licensed Practical Nurse (LPN) B said that the CNAs are responsible for showering the residents. LPN B said residents should be getting two showers per week. He/she did not know what days Resident #35 was scheduled to receive showers. 5. During an interview on 10/06/23, at 2:40 P.M., the Director of Nursing (DON) and Administrator said that it is care planned that every resident gets one shower per week. The resident may have two or three showers per week, if requested. 6. During an interview on 10/5/23, at 10:55 A.M., the Administrator said the following: -Residents should be getting at least one shower per week, but whatever they want is what is given; -Showers are documented in the kiosk and the DON keeps the shower records; -They also document if a resident refuses showers; -Hospice provides showers to their residents and the facility staff help with this if hospice is unable; -Showers at least must be offered to each resident. Based on observation, interview, and record review, the facility failed to promote and facilitate self-determination when staff failed to honor two residents' (Resident #15 and #35) reasonable shower preferences. The facility census was 64. Review of the facility's policy titled Bath (Shower), undated, showed the purpose was to maintain skin integrity, comfort, and cleanliness. 1. Review of Resident #15's face sheet (admitting demographic and payee information) showed the following: -admission date of 07/21/13; -Diagnoses included age-related cognitive decline, personal history of (healed) traumatic fracture, anxiety disorder, atrial fibrillation, and retention of urine. Review of the resident's admission Minimum Data Set (MDS - federally mandated assessment completed by facility staff), dated 7/26/23, resident required assistance of one person for showering. Review of the resident's current care plan, last revised 07/27/23, showed staff did not address the resident's shower/bathing preferences. Review of the facility's shower schedule showed the resident's showers were scheduled for every Tuesday and Friday. Record review of the resident's July 2023 Shower Sheets showed the following: -Resident received a shower on 07/21/23 (at least 21 days since the resident's last documented shower) -Resident received a shower on 07/23/23; -Resident received a shower on 07/26/23. Record review of the resident's August 2023 Shower Sheets showed the following: -Resident received a shower on 08/04/23 (nine days after the resident's last documented shower); -Resident received a shower on 08/11/23 (seven days after the resident's last documented shower); -Resident received a shower on 08/18/23 (seven days after the resident's last documented shower); -Resident received a shower on 08/23/23; -Resident received a shower on 08/30/23 (seven days after the resident's last documented shower). Record review of the resident's September 2023 Shower Sheets showed the following: -Resident received a shower on 09/01/23; -Resident received a shower on 09/08/23 (seven days after the resident's last documented shower); -Resident received a shower on 09/21/23 (13 days after the resident's last documented shower); -Resident receives a shower on 09/27/23 (six days after the resident's last documented shower). During an observation and interview on 10/03/23, at 10:50 A.M., the resident's hair appeared very unkempt. The resident's hair was messy and stood out all over his/her head. The resident said the following: -He/she was not getting many showers; -He/she was told they did not have enough help to get him/her into the shower; -He/she would like, and felt like they needed, more than one shower every couple of weeks; -The resident said the lack of showers bothered him/her; -He/she said it was embarrassing to go out to the dining room when has not received showers. During an interview on 10/05/23, at 10:55 A.M., Certified Nurse Aide (CNA) P said the following: -He/she is not sure how many showers a week the resident prefers; -The resident does most of his activities of daily living (ADL - dressing, grooming, bathing, eating and toileting) needs by himself, but does require some assistance with showering; -He/she knows that the shower aide is gone today for an appointment and the other one is off today;

Based on interview, observation, and record review, the facility failed to provide consistent and timely showers/baths for all residents to maintain good grooming and personal hygiene when one dependent resident (Resident #8) did not receive timely showers and had hair that appeared oily and unkept. The facility's census was 64. Review showed the facility did not provide a policy specific to the scheduling of and/or providing assistance with residents' showers. 1. Review of Resident #8's face sheet (gives basic profile information), showed the following information: -admission date of 01/17/22; -Diagnoses included rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), muscle wasting (thinning or loss of muscle tissue) and atrophy (gradual decline in effectiveness) multiple sites, abnormal weight loss, abnormal posture, and type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel) with mild non-proliferative diabetic retinopathy (eye condition that can cause vision loss and blindness in people who have diabetes). Review of the resident's care plan, last reviewed 07/18/23, showed the following information: -On hospice; -The facility staff will work with hospice to ensure goals and approach are appropriate and will work as a team to meet needs; -Resident had decreased activities of daily living (ADL - term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) functioning related to rheumatoid arthritis, -Required Hoyer lift (mobility tool used to help with mobility challenges get out of bed or bath) and two staff assistance for transfers; -Required one to two staff assistance with ADL's to include toileting, bathing, dressing, grooming, and eating; -Used a Broda chair (wheelchair that give patients the ability to tilt and recline and help prevent skin breakdown) for mobility and required staff to propel; -Resident had cognitive loss/dementia and had difficulty recognizing objects, people, places, or things and problems with memory, learning new things, making decisions and effectively communicating related to impaired cognition; -Staff should assist resident to maintain dignity and self-esteem and quality of life, to the extent possible related to the disease process; -Staff should anticipate needs and observe for non-verbal cues; -Staff should explain care before beginning and as needed. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/20/23, showed the following: -Severe cognitive impairment; -Total dependence of one staff for bed mobility, locomotion, dressing, personal hygiene, toilet use, and bathing; -Total dependence of two staff for transfers between bed and chair; -Required wheelchair for locomotion. (Staff did not care plan related to shower/bathing.) Review of the resident's July 2023 Shower Sheets showed the following: -The resident received a shower on 07/07/23 (at least seven days since the resident's last documented shower); -The resident received a shower on 07/18/23 (11 days after the resident's last documented shower); -The resident received a shower on 07/26/23 (12 days after the resident's last documented shower). Review of the resident's August 2023 Shower Sheets showed the following: -The resident received a shower on 08/01/23 (seven days after the resident's last documented shower); -The resident received a shower on 08/08/23 (seven days after the resident's last documented shower); -The resident received a shower on 08/15/23 (seven days after the resident's last documented shower); -The resident received a shower on 08/22/23 (seven days after the resident's last documented shower); -The resident received a shower on 08/30/23 (eight days after the resident's last documented shower). Review of the resident's September 2023 Shower Sheets showed the following: -The resident received a shower on 09/02/23; -The resident received a shower on 09/05/23; -The resident received a shower on 09/07/23; -The resident received a shower on 09/12/23; -The resident received a shower on 09/14/23; -The resident received a shower on 09/22/23 (eight days after the resident's last documented shower); -The resident received a shower on 09/28/23 (six days after the resident's last documented shower). Observation showed the following: -On 10/03/23, at 12:36 P.M., the resident was in the dining room. The resident's hair appeared oily and unbrushed; -On 10/04/23, at 11:39 A.M., the resident was in dining room. The resident's hair appeared oily. During an interview on 10/06/23, at 9:00 A.M., Certified Nurse Aide (CNA) C said that residents are scheduled for showers two times per week. Residents on hospice services are scheduled for showers by hospice providers and were not scheduled for showers by the facility. He/she said that he/she was just informed that day that residents on hospice still needed showered by the facility staff, as the showers from hospice were not always being done. During an interview on 10/06/23, at 9:15 A.M., CNA E said that she had worked at the facility for over 15 years and was the scheduled shower aide. Showers are scheduled for two times per week. He/she had been out of the facility for about one week in September and was trying to catch up on showers and get the residents two showers that week. The aide said that the residents are not happy when they do not receive two per week. If a resident asks for a shower he/she would get them in the shower. During an interview on 10/06/23, at 10:20 A.M., CNA D said that when he/she started working at the facility several weeks ago, he/she was told not to give showers to residents on hospice. During an interview on 10/06/23, at 11:00 A.M., Licensed Practical Nurse (LPN) B said that hospice residents receive showers from hospice staff. The other facility residents should receive two showers per week. During an interview on 10/06/23, at 2:03 P.M., with the Administrator, DON, and ADON, the DON said that all residents should be care planned to receive at least one shower per week. The facility tried to accommodate two showers per week. Staff should document if a resident refused an offered shower. Hospice staff had been giving their residents showers. He/she was aware it was the facility responsibility to given them showers as well. He/she said if a resident appeared dirty and was on hospice the staff would offer a shower to the resident.

2. Review of Resident #55's face sheet showed the following information: -admission date of 03/01/23; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF - long-term condition that happens when the heart cannot pump blood well enough), type 2 diabetes mellitus (problem in the way the body regulates and uses sugar as a fuel), and transient cerebral ischemic attack (stroke that lasts only a few minutes - mini stroke). Observation on 10/04/23, at 1:57 P.M., showed the resident resting in bed with a round side rail grab bar on the left side of bed. Review of the resident's POS, current as of 10/06/23, showed no order for use of grab bars. Review of the resident's care plan, last reviewed on 09/29/23, showed the following information: -Resident had decrease in activities of daily living (ADL - term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) function related to decreased mobility; -Resident had a Halo bar (Halo Safety Ring is actually a series of grab bars at just about any angle. It provides a secure handhold for getting in or out of bed. The Halo is mounted to the bed deck so that it raises and lowers with the head section) for bed mobility and transfer assistance. Review of the resident's electronic medical record (EMR) and paper chart showed staff did not document pertaining to a pre-use assessment, informed consent, or safety gap measurements for the use of bed rails. 3. During an interview on 10/06/23, at 11:15 A.M., the Social Services Director (SSD) said that side rails are not allowed due to state regulations. He/she said that residents can have a Halo or positioning bar. If a resident or family request the positioning bars, staff will notify the Director of Nursing (DON) or the therapy department. The facility did not complete any assessments for the use of positioning bars. 4. During an interview on 10/06/23, at 11:20 A.M., the Care Plan Coordinator said that positioning bars should be added to resident care plans as assistive equipment. 5. During an interview on 10/06/23, at 11:30 A.M., the Assistant Director of Nursing (ADON) said that side rails and positioning rails should have a physician's order and should be in the resident's care plan. She said that therapy can recommend or the family/resident may request bars for positioning and transfer assistance. Maintenance staff installs the grab bars, but no other paper work was completed. 6. During an interview on 10/06/23, at 11:53 A.M., the Maintenance Director said that there were no side rails in the building and they only use about one-quarter size rails. There should be a physician's order. He said that therapy or maintenance installs the rails. There was no measurements or checks completed. Everyone should ensure the bars work properly when they are in the resident's room. 7. During an interview on 10/06/23, at 2:03 P.M., with the facility Administrator, DON, ADON, and Corporate Consultant Nurse, the Administrator said the nurse should get a physician order to use bed side rails. Either the maintenance department or someone from physical therapy installs the rails. The Administrator said maintenance checks beds and side rails if there is a safety issue. She was not aware of scheduled checks on all beds/side rails. The ADON said she was not aware of any measurements that were done on side rails. The Administrator said the facility only uses side rails for mobility assistance and they do not do a risk assessment or get informed consent for the bed rail use. Based on observation, record review, and interview, the facility failed to obtain physicians orders for use, complete a pre-use assessment, obtain informed consent, and ensure measurements were within safety guidelines prior to bed rails being placed on the beds of two residents (Residents #12 and #55) of two residents sampled. Staff failed to care plan the use of bed rails for one resident (Resident #12). The facility census was 64. Review of a facility policy and procedure entitled Bed Rails, undated, showed the following: -Bed rails (also referred to as side rails, safety rails, mobility bars, etc.) are constructed of metal or plastic, and are available in various sizes (e.g., full length rails, half rails, quarter rails). Bed rails may be positioned in various locations on the bed; upper or lower, one or both sides; -The objective of the bed rail use policy is to determine if resident use is safe and appropriate; -Prior to the use of bed rails the facility should complete the Bed Rail Observation including the following: observation detail, clinical assessment, alternatives attempted prior to bed rail implementation, bed rail details, assessment of potential entrapment zones, review the risk and benefits with resident and resident representative, obtain informed consent with resident and/or resident representative signature, and obtain physician order for medical symptom assessed requiring bed rail use; -Once the Bed Rail Observation is completed, the facility will print the observation and review associated risks and benefits with the resident and resident representative. After the review is complete, the resident and/or resident representative will sign the consent line and the nurse will sign as well. Once signatures are obtained, the observation should be uploaded in electronic medical record (EMR); -Educate the resident/legal representative on the benefits and risks of bed rail use: -Develop a care plan that outlines the medical factors necessitating bed rails and an explanation of how the use a bed rail is intended to treat the specific resident's condition; -When installing or maintaining bed rails, staff should follow manufacturer's recommendations and specifications for applicable bed rails, mattresses and bed frames; -Staff will conduct regular inspection of all bed frames, mattresses, and bed rails, to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility will select equipment such as bed rails, mattresses and bed frames that are compatible. 1. Review of Resident #12's face sheet (gives basic profile information) showed the following: -admission date of 01/08/16; -Diagnoses included chronic obstructive pulmonary disease (COPD - breathing disorder), peripheral vascular disease (blood circulation disorder), dementia, low thyroid function, difficulty with swallowing, abnormal posture, acquired absence of right and left legs above the knee, phantom limb syndrome with pain, anorexia (eating disorder), left hip fracture, metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood), emotional lability (rapid changes in mood), psudobulbar affect (inappropriate and involuntary episodes of laughing or crying), nerve pain, insomnia, major depressive disorder, generalized anxiety disorder, heartburn, and muscle weakness. Observation on 10/04/23, at 11:55 A.M., showed the resident's bed had quarter length rails installed on both sides of the bed. The rails were in the raised position. Observation on 10/06/23, at 9:20 A.M., showed the resident resting in bed. He/she was awake and used the two side rails to reposition him/herself. Review of the resident's Physician Order Sheet (POS), current as of 10/06/23, showed no order for the use of bed rails. Review of the resident's care plan, last updated on 09/19/23, showed the following: -Disturbed sleep pattern related to insomnia. Staff to provide comfortable environment to promote sleep and reduce environmental disruptions. (Staff did not care plan the use of bed rails.) Review of the resident's EMR and paper chart showed staff did not document pertaining to a pre-use assessment, informed consent, or safety gap measurements for the use of bed rails.

Based on observation, interview, and record review, the facility staff failed to maintain a system that accounted for all controlled medications when staff failed to document administration of a controlled medication on the Control Substance and failed to ensure an accurate count of the controlled medication for one resident (Resident #14). The facility census was 64. Review of the facility policy titled, Controlled Substance Medication Policy, undated, showed the following: -Nurses are to count all narcotics at the beginning and end of every shift and sign the narcotic sheet prior to taking over the narcotic cart. 1. Review of Resident #14's face sheet (brief resident profile) showed the following information: -admission date of 07/06/23; -Diagnoses included weakness, anxiety, pain, hypertension (high blood pressure), and transient ischemic attack (TIA - a brief stroke-like attack). Review of the resident's care plan, revised on 10/05/23, showed the following information: -Resident was at risk for pain related to spinal fusion (surgery connecting two or more bones together) and spondylosis (abnormal wearing down of bones); -Administer medications as ordered; -Notify physician of any unrelieved pain. Review of the resident's Physician Order Sheet (POS), dated 09/22/23, showed the following information: -An order, dated 09/22/23, for lorazepam (a medication used to treat anxiety disorder) 0.5 milligrams (mg). Give one tablet by mouth at bedtime for anxiety. Review of the resident's electronic medical record (EMR) showed the following: -On 10/05/23, at 7:00 P.M., lorazepam 0.5 mg was given and charted per Licensed Practical Nurse (LPN) Q. Review of the facility's Controlled Substance Log, located in the locked medication narcotic cart, showed the following: -On 10/05/23, at 07:00 P.M., LPN Q failed to initial that lorazepam 0.5 mg was given to the resident; -On 10/06/23, at 07:00 A.M., LPN B failed to correctly count the remaining number of lorazepam 0.5 mg. During an interview on 10/06/23, at 12:40 P.M., LPN B said that the narcotic count is done upon the beginning and ending of each shift. The medication was given to the resident last night because it was charted in the electronic medical record. LPN Q forgot to sign it off in the narcotic book. LPN B said that he/she did do the narcotic count that morning with LPN Q. He/she said that they counted wrong. During an interview on 10/06/23, at 02:03 P.M., with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON), the Administrator said that the narcotic count should be done at shift change.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form to meet each resident's needs when staff staff failed to serve one resident (Resident #62) a physician ordered pureed diet. The facility had a census of 64. 1. Review of Resident #62's face sheet (a brief resident profile) showed the following information: -admission date of 08/04/23; -Diagnoses included cerebral infarction (stroke) and weight loss. Review of the resident's Physician Order Sheet (POS), current as of 10/06/23, showed the following orders: -An order, dated 08/04/23, for pureed diet; -An order, dated 08/04/23, for speech therapy to evaluate and treat as needed. Review of the resident's Speech Therapy Treatment Encounter notes showed the following: -Encounter note, dated 08/08/23, showed the resident should remain on puree diet due to lethargy (weakness) and right sided pocketing of regular hard solids; -Encounter note, dated 08/09/23, showed the resident was unable to chew fully and pocketed solid food on the left side. Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 08/10/23, showed the following: -Severely impaired cognition; -Speech unclear, sometimes understood; -One person assist with eating. Review of the resident's Speech Therapy Treatment Encounter notes showed the following: -Encounter note, dated 08/12/23, showed the resident did ok with thin liquids, however, continued to pocket solid foods. The resident to remain on pureed foods; -Encounter note, dated 08/13/23, showed the resident did ok with thin liquids, however, continued to pocket solid foods. The resident to remain on pureed foods; -Encounter note, dated 08/15/23, showed the resident continued to do ok with liquids, however, continued to pocket solid foods. The resident was disoriented and tired. The resident to remain on pureed foods; -Encounter note, dated 08/16/23, showed the resident continued to do ok with thin liquids, however, continued to pocket solid foods. The resident to remain on pureed foods; -Encounter note, dated 08/18/23, showed the resident was able to discuss and practice safe swallowing strategies (small bites, chew food on the strong side, tilting head to the right side, eat slowly and alternating between food and liquids). The resident to remain on pureed foods; -Encounter note, dated 08/21/23, showed the resident to remain on pureed foods; -Encounter note, dated 08/22/23, showed the resident to remain on pureed foods. Review of the resident's current care plan, last revised 09/29/23, showed the following: -Had a puree diet order; -Staff to notify physician of any chewing and/or swallowing problems; -Nutritional consult as needed. Review of the resident's medical record showed no signed waiver regarding diet. Observation on 10/04/23, at 12:48 P.M., showed the resident was served fried chicken, mashed potatoes with gravy, squash, pears, coffee and juice for lunch. The food was served was not pureed. Observation on 10/05/23, at 1:05 P.M., showed the resident was served ham, mashed potatoes with gravy, broccoli, carrots, cauliflower, cinnamon apples, roll, coffee and juice for lunch. The food served was not pureed. During an interview on 10/04/23, at 12:48 A.M., Certified Nurse Aide (CNA) C said that the resident did not like the pureed diet and wouldn't eat the pureed food, but he/she would eat the regular food so that is what staff give him/her. Speech Therapy had been working with the resident and told the staff to watch him/her closely during meals. During an interview on 10/05/23, at 2:05 P.M., Licensed Practical Nurse (LPN) B said that the resident has an order for a pureed diet and should be receiving a pureed diet. LPN B said that Speech Therapy would notify the physician and obtain an order when and if a change to his/her diet is needed. During an interview on 10/06/23, at 9:45 A.M., Speech Therapist (ST) K said that a pureed diet is advanced only after completing an evaluation of the resident chewing and swallowing food, and assessing the mouth, including how well the dentures fit. If there are no concerns, then ST K would inform the charge nurse, who would notify the physician to get an order to advance the resident's diet. ST K said that he/she would not recommend advancing a diet if it was not safe for the resident. ST K did not remember the resident. During an interview on 10/06/23, at 10:05 A.M., the Dietary Manager said that the resident's diet card is for a pureed diet. A pureed diet should be given and if the resident requested a regular diet, then staff then can exchange the pureed tray for a regular tray per the resident's request. During an interview on 10/06/23, at 10:22 A.M., Speech Therapist (ST) J said that the resident was not safe to eat a regular diet due to the resident's dentures not fitting properly and the resident does not always wear them. The resident also has poor cognition (understanding). ST J said that a pureed diet is the safest diet for the resident. During an interview on 10/06/23, at 10:38 A.M., the resident's physician said he/she advances diets per Speech Therapist (ST) recommendations. If the resident wants a regular diet, but ST doesn't feel that a regular diet is safe, the resident (if cognitively intact) or resident's Durable Power of Attorney (DPOA) can sign a waiver stating that he/she understands the risks vs benefits. The physician said he/she expects staff to follow the diet ordered. During an interview on 10/06/23, at 02:03 P.M., with the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the Administrator said that in order to advance a pureed diet to a regular diet that Speech Therapy would need to do multiple evaluations to assure that a regular diet is safe for the resident. The Administrator said that he/she would expect staff to serve whatever the physician has ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #21's face sheet showed the following information: -admission date of 06/02/23; -Diagnoses included CHF, anxiety disorder, chronic kidney disease (CKD - gradual loss of kidney function over time), generalized edema (too much fluid in the tissues - swelling), and type 2 diabetes mellitus. Review of the resident's nurses' notes showed staff documented the following information: -On 07/02/23, at 11:46 P.M., nursing staff documented the resident had complaints of right leg pain starting in the groin and radiating down his/her leg and into his/her back. Staff administer medication and repositioned the resident multiple times. The resident did have slight improvement of symptoms with urination and then immediately pain returned. The resident's urine was dark colored and had a foul odor. The resident was sent to the emergency room via EMS. The Director of Nursing was notified and the resident's family was notified at 11:33 P.M. (Staff did not document providing the resident or his/her representative a written copy of discharge.) Review of the resident's medical record showed staff did not have a copy of written discharge provided to the resident or resident's representative. During an interview on 10/05/23, at 8:42 A.M., the resident said that he/she had not received any information related to going to the hospital in July. 4. During an interview on 10/06/23, at 10:26 A.M., Licensed Practical Nurse (LPN) B said he/she sent the basic resident information with EMS when transferring a resident to the hospital. He/she was not aware of the Transfer Notice being sent with the resident or to the responsible party. 5. During an interview on 10/06/23, at 10:15 A.M., the Social Services Director (SSD) said he/she does not send out Transfer Notices. The SSD said the nurses may send them with the resident on transfer. 6. During an interview on 10/06/23, at 10:20 A.M., the Director of Nursing (DON) said the charge nurse sends the Transfer Notice with EMS when transferring a resident to the hospital. The forms are not sent to the resident's responsible party, but they are notified by phone of the transfer. 7. During an interview on 10/06/23, at 10:05 A.M., the Administrator said the facility did not use the Transfer Notices. They simply keep the resident's bed available and don't charge for the bed hold. The Social Services Director (SSD) does send a monthly list of transfers and discharge to the Ombudsman. The hospital will call the facility if there is a question about a bed hold. Based on record review and interview, the facility failed to notify the resident and/or the resident's representative of a transfer or discharge to the hospital, including the reason for the transfer, in writing for three residents (Residents #23, #45, and #21) of 21 residents sampled. The facility census was 64. Review showed the facility did not provide a policy regarding written transfer notices. Review of a facility form letter Emergency Transfer Notice showed the following: -Staff should fill in the spaces for: date, resident name, responsible party/representative name and address, transferring facility name, effective date, Ombudsman information, hospital/facility name and address, facility contact phone number, and name of Administrator. 1. Review of Resident #23's face sheet (gives basic profile information) showed the following: -admission date 12/28/19; -Diagnoses included high blood pressure, metabolic encephalopathy (abnormal brain function caused by infection or other body organ misfunction), abnormal weight loss, constipation, fluid overload, insomnia, COVID-19 respiratory infection, fracture of left wrist, thyroid dysfunction, influenza, anxiety disorder, heartburn, shortness of breath, pain, unspecified injury of head, fracture of right shoulder, mild intermittent asthma, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 07/07/23, showed the following: -Moderately to severely impaired cognition; -Required extensive assistance with bed mobility, transfers, dressing, toileting, hygiene, bathing, and eating. Review of the resident's nurses' notes showed the following: -On 08/13/23, at 8:22 A.M., the resident was extremely lethargic and hard to rouse. Staff notified the physician and the resident's family, who gave approval for resident to be sent to the hospital for evaluation. Emergency Medical Services (EMS) here at this time to transport resident to the hospital. (Staff did not document providing the resident or his/her representative a written copy of discharge.) Review of the resident's medical record showed staff did not have a copy of written discharge provided to the resident or resident's representative. 2. Review of Resident #45's face sheet showed the following: -admission date 06/22/23; -Diagnoses included atrial fibrillation (irregular heart rhythm), congestive heart failure (CHF - a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), aortic valve stenosis (narrowing of large blood vessel from the heart to the body), urinary tract infection (UTI), adult failure to thrive with encounter for palliative (comfort) care, abnormal weight loss, COVID-19 respiratory infection, dyspnea (shortness of breath), stage 3 chronic kidney disease, high blood pressure and low blood pressure, benign prostatic hyperplasia (BPH - enlarged prostate gland that causes difficulty in emptying the bladder), intracardiac thrombosis (blood clot in the heart), anemia (low red blood cell count), type 2 diabetes mellitus, hyperlipidemia (high level of fat in blood stream), obstructive sleep apnea (intermittent airflow blockage during sleep), diplopia (double vision), and hearing loss. Review of the resident's significant change MDS, dated [DATE], showed the following: -admission date of 06/22/23; -Moderately impaired cognition; -Required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing; -Required limited assistance with transfers and eating; -Indwelling catheter (a tubing which is inserted into the bladder, via the urethra and remains in to drain urine); -On hospice services. Review of the resident's nurses' notes showed the following entries: -On 07/27/23, at 2:05 P.M., the resident's catheter was changed and new one was placed in with some slight resistance while putting the catheter in. Staff will continue to monitor new catheter; -On 07/27/23, at 2:44 P.M., nurse reported resident complained of pain rated 8 of 10 after Foley insertion. Assisted resident to room and upon assessment and deflating balloon, noted that catheter was out with balloon intact. There was observed blood draining. Staff cleaned up area and bleeding had stopped. Attempted to insert second catheter and noticed immediate blood draining into catheter. Staff stopped. Bleeding was hard to stop on second attempt. Resident started on blood thinner today. Staff notified physician and emergency medical services (EMS) was called; -On 07/27/23, at 6:37 P.M., resident was sent to the hospital. Resident left facility around 2:49 P.M. (Staff did not document providing the resident or his/her representative a written copy of discharge.) Review of the resident's medical record showed staff did not have a copy of written discharge provided to the resident or resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #21's face sheet showed the following information: -admission date of 06/02/23; -Diagnoses included CHF, anxiety disorder, chronic kidney disease (CKD - gradual loss of kidney function over time), generalized edema (too much fluid in the tissues - swelling), and type 2 diabetes mellitus. Review of the resident's nurses' notes showed staff documented the following information: -On 07/02/23, at 11:46 P.M., nursing staff documented the resident had complaints of right leg pain starting in the groin and radiating down his/her leg and into his/her back. Staff administer medication and repositioned the resident multiple times. The resident did have slight improvement of symptoms with urination and then immediately pain returned. The resident's urine was dark colored and had a foul odor. The resident was sent to the emergency room via EMS. The Director of Nursing was notified and the resident's family was notified at 11:33 P.M. (Staff did not document providing the resident or his/her representative a bed hold policy.) Review of the resident's medical record showed staff did not have a copy of a bed hold policy provided to the resident or resident's representative at discharge. During an interview on 10/05/23, at 8:42 A.M., the resident said that he/she had not received any information related to going to the hospital in July. 4. During an interview on 10/06/23, at 10:26 A.M., Licensed Practical Nurse (LPN) B said he/she sent the basic resident information with EMS when transferring a resident to the hospital. The LPN was not aware of the Bed Hold policy being sent with the resident or to the responsible party. 5. During an interview on 10/06/23, at 10:15 A.M., the Social Service Director said he/she does not send out Bed Hold Guidelines. The SSD said the nurses may send them with the resident on transfer. 6. During an interview on 10/06/23, at 10:20 A.M., the Director of Nursing (DON) said the charge nurse sends the Bed Hold policy with EMS when transferring a resident to the hospital. The forms are not sent to the resident's responsible party. 7. During an interview on 10/06/23, at 10:05 A.M., the Administrator said the facility did not use the Bed Hold Guidelines. They simply keep the resident's bed available and don't charge for the bed hold. The hospital will call the facility if there is a question about a bed hold. Based on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for three residents (Residents #23, #45, and #21) who were transferred out to the hospital. A sample of 21 residents was selected for review in a facility with a census of 64. Review of the facility's form entitled Bed Hold Guidelines, undated, showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave; -Medicare does not pay for any type of bed hold. If the resident is discharged to the hospital, or goes out of the facility for overnight leave of absence, the bed may be held by paying the current room rate for bed being reserved; -Medicaid will pay for up to three hospital leave days when certain criteria are met. The criteria is that the facility must have had an average occupancy of 97% or greater during the quarter previous to the hospital stay, the hospital stay is three days or less, the resident has enough unused home leave days to use two home leave days for one hospital leave day and the resident or the resident's representative informs the facility of their intent to return to the facility following the hospital stay. If the resident is discharged to the hospital and the above criteria are not met, the bed may be held by paying the current Medicaid rate for each non-covered day; -Private pay residents discharged to the hospital or going on overnight leave of absence may reserve their bed by paying the current rate for the bed being reserved; -If a resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. Signed authorization must be received by the first business day following the discharge if it occurs on weekend or holiday; - If the resident or resident representative does not choose to hold the bed, the bed will be released and any personal belonging must be picked up within three days; -Bed holds are strictly voluntary. If the bed is not held and is not available when the resident wants to be re-admitted , the resident's name will be placed on a waiting list for the next available bed; -The resident or representative is to sign understanding of the bed hold guidelines and indicate whether or not to hold the bed at the indicated daily rate (to be filled in by facility staff). 1. Review of Resident #23's face sheet (gives basic profile information) showed the following: -admission date 12/28/19; -Diagnoses included high blood pressure, metabolic encephalopathy (abnormal brain function caused by infection or other body organ misfunction), abnormal weight loss, constipation, fluid overload, insomnia, COVID-19 respiratory infection, fracture of left wrist, thyroid dysfunction, influenza, anxiety disorder, heartburn, shortness of breath, pain, unspecified injury of head, fracture of right shoulder, mild intermittent asthma, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 07/07/23, showed the following: -Moderately to severely impaired cognition; -Required extensive assistance with bed mobility, transfers, dressing, toileting, hygiene, bathing, and eating. Review of the resident's nurses' notes showed the following: -On 08/13/23, at 8:22 A.M., the resident was extremely lethargic and hard to rouse. Staff notified the physician and the resident's family, who gave approval for resident to be sent to the hospital for evaluation. Emergency Medical Services (EMS) here at this time to transport resident to the hospital. (Staff did not document providing the resident or his/her representative a copy of the bed hold policy.) Review of the resident's medical record showed staff did not have a copy of a bed hold policy provided to the resident or resident's representative at discharge. 2. Review of Resident #45's face sheet showed the following: -admission date 06/22/23; -Diagnoses included atrial fibrillation (irregular heart rhythm), congestive heart failure (CHF - a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), aortic valve stenosis (narrowing of large blood vessel from the heart to the body), urinary tract infection (UTI), adult failure to thrive with encounter for palliative (comfort) care, abnormal weight loss, COVID-19 respiratory infection, dyspnea (shortness of breath), stage 3 chronic kidney disease, high blood pressure and low blood pressure, benign prostatic hyperplasia (BPH - enlarged prostate gland that causes difficulty in emptying the bladder), intracardiac thrombosis (blood clot in the heart), anemia (low red blood cell count), type 2 diabetes mellitus, hyperlipidemia (high level of fat in blood stream), obstructive sleep apnea (intermittent airflow blockage during sleep), diplopia (double vision), and hearing loss. Review of the resident's significant change MDS, dated [DATE], showed the following: -admission date of 06/22/23; -Moderately impaired cognition; -Required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing; -Required limited assistance with transfers and eating; -Indwelling catheter (a tubing which is inserted into the bladder, via the urethra and remains in to drain urine); -On hospice services. Review of the resident's nurses' notes showed the following entries: -On 07/27/23, at 2:05 P.M., the resident's catheter was changed and new one was placed in with some slight resistance while putting the catheter in. Staff will continue to monitor new catheter; -On 07/27/23, at 2:44 P.M., nurse reported resident complained of pain rated 8 of 10 after Foley insertion. Assisted resident to room and upon assessment and deflating balloon, noted that catheter was out with balloon intact. There was observed blood draining. Staff cleaned up area and bleeding had stopped. Attempted to insert second catheter and noticed immediate blood draining into catheter. Staff stopped. Bleeding was hard to stop on second attempt. Resident started on blood thinner today. Staff notified physician and emergency medical services (EMS) was called; -On 07/27/23, at 6:37 P.M., resident was sent to the hospital. Resident left facility around 2:49 P.M. (Staff did not document providing the resident or his/her representative a bed hold policy at discharge.) Review of the resident's medical record showed staff did not have a copy of a bed hold policy provided to the resident or resident's representative at discharge.

Based on observation, interview, and record review, the facility staff failed to store refrigerated medications at the medication's recommended temperatures and failed to have a system in place to monitor and adjust the temperature as needed. The facility census was 64. Review of the facility's policy titled Storage of Medications, undated, showed the following: -All medications are stored in a safe and secure area; -Medications requiring refrigeration are stored in a refrigerator located in the medication room located behind the nurses' station. -Medications are stored separately from food and are labeled accordingly. Review of the Centers for Disease Control and Prevention (CDC) guidelines for vaccines, dated 03/26/21, showed the following: -Never freeze refrigerated vaccines; -Ideal temperature of refrigerated vaccines is 40 degrees Fahrenheit (F); -Refrigerator temperature should be between 36 and 46 degrees F; Review of the Levemir (insulin) package insert, dated December 2022, showed the following: -Keep the Levemir pen or vial in cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the Humalog (insulin lispro) package insert, dated March 2022, showed the following: -Keep the Humalog pen or vial in a cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the Novolog (insulin aspart) package insert, dated July 2022, showed the following: -Keep the Novolog pen or vial in a cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the Trulicity (once weekly medication used to treat diabetes) package insert, dated July 2023, showed the following: -Keep the medication in a cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the Tubersol (used to test for tuberculosis) package insert, undated, showed the following: -The vial should be stored at 35 degrees to 46 degrees F; -The medication should be discarded if exposed to freezing temperatures. Review of the lorazepam oral concentrate (used to treat anxiety disorders) package insert, dated January 2023, showed the following: -Keep the medication in a cool storage at 36 degrees F to 46 degrees F; -Do not allow to freeze. Review of the acetaminophen suppository (used to treat pain and or fever) package insert, dated February 2023, showed the following: -May keep the medication in a cool storage at 36 degrees F to 46 degrees F to prevent melting; -Do not allow to freeze. 1. Observation on 10/06/23, at 1:00 P.M., of the medication refrigerator located in the medication room showed the following: -Temperature of refrigerator per thermometer read 31 degrees F; -The refrigerator contained resident insulin pens, tuberculosis testing serum, resident liquid lorazepam, and resident acetaminophen suppositories. Review of the facility's medication refrigerator logs, obtained from the refrigerator located in the medication room, showed staff initialed and completed the logs each day: -On 10/02/23, staff documented the temperature was 32 degrees F; -On 10/03/23, staff documented the temperature was 33 degrees F; -On 10/04/23, staff documented the temperature was 34 degrees F; -On 10/05/23, staff documented the temperature was 32 degrees F; -On 10/06/23, staff documented the temperature was 31 degrees F. During an interview on 10/06/23, at 1:00 P.M., Licensed Practical Nurse (LPN B) said the following: -The refrigerator temperature is to be checked nightly by the night shift nurse; -The nurse is to write the temperature on the log that is located on the refrigerator; -If the temperature is outside of the parameters (36 - 46 degrees F), the nurse should notify maintenance. During an interview on 10/06/23, at 2:03 P.M., with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON), the Administrator said that nursing is responsible for checking the medication refrigerator temperature every day and documenting on the temp log. The nurse should adjust the temperature up or down if the temperature is outside the range and notify maintenance. The DON is responsible for checking the temperature log weekly.

Based on interview and record review, the facility failed to follow their infection control policies and procedures when staff failed to ensure the first and second step of a 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 three out of ten randomly chosen employees. The facility census was 64. Review of the facility's TB policy titled Tuberculosis Control, undated, showed the following information: -If a new hire is unable to show documentation of a current TB two step and the results, then the first step PPD (Mantoux method purified protein derivative (PPD - a skin test to determine if someone has tuberculosis)) will be administered by the nursing department; -This will be documented on the employee immunization record; -The results must be read prior to or no later than the staff member's start date; -The results will be documented in millimeters; -The Director of Nursing (DON) or designee will maintain records of required chest x-ray and documented annual evaluation to rule out sign and symptoms of TB. Review of Missouri State Regulations 19 CSR 20-20.100 General Requirements for TB Testing for Employees in Long Term Care Facilities showed the following information: -Long-term care facilities shall screen their employees for TB using the Mantoux method purified protein derivative (PPD - a skin test to determine if someone has tuberculosis) two-step tuberculin test within one month prior to starting employment; -It is the responsibility of the facility to maintain documentation of each employee's tuberculin status; -If the initial test is negative, the second test should be given as soon as possible within three weeks after employment begins unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. 1. Review of Licensed Practical Nurse (LPN) L's personnel record showed the following information: -Hire/start date of 07/13/23; -The facility did not have documentation of the first step or second step TB test administered to the LPN. 2. Review of the Care Plan Coordinator's personnel record showed the following information: -Hire/start date of 08/30/23; -Staff administered the first step PPD to the Care Plan Coordinator on 04/15/23; -Staff read the TB test on 04/27/23. 3. Review of the Certified Nurse Aide (CNA) Trainer's personnel record showed the following information: -Hire/start date of 05/31/23; -The facility did not have documentation of the either the first step or second step TB test administered to the CNA Trainer. 4. During an interview on 10/06/23, at 10:45 A.M., the Assistant Director of Nursing (ADON) said the following: -The previous Director of Nursing (DON) is the one who would keep all the documentation of staff's TB records; -He/she is unsure as to why there isn't anything for the LPN or the CNA Trainer; -He/she is unsure why only the first step was done for the Care Plan Coordinator. 5. During an interview on 10/6/23, at 11:25 A.M., the DON said the following: -All three of these employees should have had both first and second steps completed; -He/she is unsure why they are not located in the employee's folder; -Thinks someone did the test and read them, but never put them in the DON's box to be filed; -This was the prior DON as he/she has not been here long. 6. During an interview on 10/6/23, at 2:00 P.M., the Administrator said the following: -They do offer a new employee to bring in a current TB test when they come; -If they do not have one, then it will be expected that they get it completed at the facility; -The ADON will be the one who is in charge of documenting or keeping the records on file.

4. Review of the facility policy titled Glove Use, dated May 2015, showed the following information: -To ensure safe and proper food handling during food preparation and service. The food code states that food items should not be handled with bare hands; -When serving, preference is not to use gloves unless only one task is being performed; -Hand washing per guidelines should occur between each task; -Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines. -Hands should be washed after disposing of trash or food, after handling dirty dishes, after picking up anything from the floor; when changing tasks; and any other time deemed necessary. Review of the 2013 FDA Food Code showed the following: -Bare hand contact with ready-to-eat foods can contribute to the transmission of foodborne illness; -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. Observation on 10/03/23 showed the following: -At 12:20 P.M., Certified Nurse Aide (CNA) D sat next to Resident #36. The aide was assisting the resident with eating and using a spoon to give the resident bites; -At 12:23 P.M., CNA D moved over to the next picked up the grill cheese sandwich off of Resident #8's plate with his/her bare hands and tore the sandwich in half. The aide put one piece of the sandwich into the resident's hand. The aide moved back to assist Resident #36. The aide did not complete hand hygiene between residents or prior to touch ready to eat food; -At 12:25 P.M., CNA D got up from the table, did not complete hand hygiene, and got gloves off the counter. The aide put one glove on his/her right hand and picked up the second half of the sandwich on Resident #8's plate and put it into the resident's hand' -CNA D returned to Resident #36, took off the glove, and put it on the dining room table; -Without completing hand hygiene, the aide returned to assisting Resident #36 with the meal with a spoon; -Without completing hand hygiene the aide picked up the same glove from the table and put it on his/her right hand and picked up Resident #36's bread and put butter and jelly on the bread with a knife. The aide then took off the glove and put on the table. The aide did not complete hand hygiene prior to gloving or touching the ready to eat food; -CNA D then picked up the bread and butter with his/her bare hand and put it into Resident #36's hand; -At 12:29 P.M., CNA D got up and threw away the gloves into the trash and picked up two new gloves and put on the . The aide did not complete hand hygiene; -At 12:30 P.M., CNA D sat down at Resident #8's table and put on one glove and picked up the remaining grilled cheese and handed it to the resident. The aide took off the glove and put on the table. The aide then removed the wrapping from the cup of peaches and opened the resident's chocolate milk. The aide then cut up the hash browns with a fork and asked the resident if he/she would like some of the hash browns. The aide completed no hand hygiene; -At 12:32 P.M., CNA D moved back to Resident #36 and picked up the bread and butter that was on the resident's lap and put the bread back into the resident's hand. The aide opened the resident's vanilla shake and put in a straw by holding the straw by the top. The aide did not complete hand hygiene; -CNA D returned to Resident #8 without completing hand hygiene and picked up the resident's tea cup by the handle and put the handle into the resident's hand. The aide then fed a bite of hash brown to the resident with the fork that resident had in his/her hand. The aide took the teacup from the resident and picked up the grilled cheese with his/her bare hand and put the sandwich into the resident's hand; -At 12:35 P.M., CNA D moved over to another table where Resident #31 was seated in a wheelchair. The aide picked up a bowl by placing his/her index finger inside the bowl and remaining hand on the edge of the bowl. The aide then put the bowl to the resident's hand. The aide did not complete hand hygiene; -Without completing hand hygiene CNA D returned to Resident #8 and handed the resident his/her drink cup to the resident's hands. The aide picked up the fork that the resident had his/her hand on and assisted the resident with a bite of peaches. The aide took the tea cup from the resident's hands and fed the resident peaches. As the aide was feeding him the peaches dripped peach juice on the resident's shirt with every bite. The aide did not complete hand hygiene; -At 12:40 P.M., CNA G was taking meal trays from kitchen window and brought a meal tray to Resident #20, the aide opened the resident's food items and took the sandwich out of the bag with his/her bare hands and put on the plate. The aide went to the counter and got the ketchup, butter, and ranch dressing packets. Without completing hand hygiene, the aide returned to the resident's table and opened the ranch dressing and poured on the resident's salad. The aide then picked up the resident's bread roll with his/her bare hand and cut in half and then added butter and put down onto the plate. The aide then picked up the resident's peanut butter sandwich with his/her bare hands and tore the sandwich in half and handed the resident half the sandwich and put the other half on the plate. The aide then moved the tator tots to the side of the resident's plate with his/her bare hands and put ketchup on the plate. The aide then removed the packets of trash and put in the trash can; -At 12:44 P.M., CNA G returned to the kitchen window and took the next tray to Resident #9 across the dining room without completing hand hygiene; -CNA D moved from Resident #8 to Resident #36 and held the resident's shake and the aide put the straw in between his/her own fingers near the mouth end to assist the resident with a drink; -CNA D moved back to Resident #8 and picked up the fork and assist the resident with a bite of food. The aide did not complete hand hygiene. Observations on 10/04/23 showed the following: -At 12:10 P.M., CNA C picked up Resident #20's hamburger bun with his/her bare hands and put on ketchup, and put the bun back on the hamburger. The aide then picked up a knife and put his/her bare hand on the hamburger bun and cut the hamburger in half. The aide went to kitchen serving window and got the next meal tray and took to Resident #62 without completing hand hygiene. The aide cut Resident #62's food with a fork and knife and handed the fork to the resident. The aide then patted the resident on the back and went back to the kitchen serving window and took the next meal tray to another resident without completing hand hygiene. During an interview on 10/06/23, at 9:00 A.M., CNA C said that staff should complete hand hygiene between each resident tray when assisting in the dining room. Staff should wash hands or use hand sanitizer before and after assisting a resident with eating and complete hand hygiene again before assisting another resident. Staff should use hand sanitizer before and after touching the resident's food with their bare hands. During an interview on 10/06/23, at 9:15 A.M., CNA E said staff should complete hand hygiene between all meal trays and should use soap and water after every three trays. He/she said that staff should wash hands between providing meal assist to each resident and staff should put gloves on to touch residents' food with their own hands. During an interview on 10/06/23, at 10:20 A.M., CNA D said staff should complete hand hygiene between every resident in the dining room and that staff should complete hand hygiene after passing the third tray. Staff should use hand sanitizer between each resident receiving meal assist. He/she said that staff should not touch other items, such as cutting up food for a resident and then touch or feed another resident without completing hand hygiene. Staff should use hand sanitizer before touching a resident's food to cut sandwich or handle bread, and should then use hand sanitizer after. During an interview on 10/06/23, at 11:00 A.M., Licensed Practical Nurse (LPN) B said hand hygiene should be done before and after every resident in the dining room. Hand sanitizer should be used after each resident and gloves should be used if touching the residents food. During an interview on 10/06/23, at 2:03 P.M., with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), the DON said that during meal service, staff are expected to be washing their hands every three trays or if they touch their face, hair, or pick up something off the floor. This includes touching the wheels or handles on wheelchair. It is not okay to touch the resident'' food unless they have gloves on. The staff should not be holding sandwiches in their bare hands to hand to the residents. Based on observation, interview, and record review, the facility failed to keep all food safe from potential contamination when staff stacked clean, wet dishes tracking water in them, when staff failed to keep food containers sealed, when staff failed to keep the walk-in freezer clean, and when failed to complete proper hand hygiene and used bare hands to touch ready to eat food while proving meal assistance to six residents (Resident #36, #31, #8, #9, #20, and #62). The facility. The facility census was 64. 1. Review of the facility's policy titled General Dish Room Sanitation, by Nutrition and Dining Services Manual, dated May 2015, showed the following information: -All items are to be air dried; -No moisture can be found on any stacked item. Review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -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. Observations on 10/03/23, beginning at 10:03 A.M., showed the following: -Twenty-two plastic coffee mugs stacked with water droplets trapped inside; -Twenty-nine plastic bowls stacked with water droplets trapped inside. Observation on 10/05/23, at 11:40 A.M., showed the following: -Sixty-two clear plastic cups stacked with water droplets trapped inside; -Fourteen coffee mugs stacked with water droplets trapped inside; -Fifty-one bowls stacked with water droplets trapped inside. During an interview on 10/05/23, at 1:30 P.M., [NAME] M said he/she was not aware that dishes had to be air dried before they could be stacked. During an interview on 10/05/23, at 1:30 P.M., [NAME] N said he/she thought the dishes needed to be air dried, but didn't say because he/she was not positive and does not do the dishes. During an interview on 10/05/23, at 1:30 P.M., Dietary Aide (DA) O said he/she did not know that dishes had to be air dried. During an interview on 10/05/23, at 1:30 P.M., the Kitchen Manager said he/she did know that the dishes are supposed to be air dried and just assumed the dish washer was doing it this way. During an interview on 10/05/23, at 2:15 P.M., the Administrator said everything should be air dried before being put away. 2. Observation on 10/03/23, beginning at 10:03 A.M., of the walk-in freezer, showed the following: -An open package of frozen pancakes was left exposed to other odors and the freezer elements; -An open package of sausage patties was left exposed to other odors and the freezer elements; -An open package of rolls was left exposed to other odors and the freezer elements. Observation on 10/03/23, that began at 10:03 A.M., of the dry storage area, showed the following: -Twelve cereal bowls that had cold cereal already in them with a drink lid covering up; -The drink lids were cracked in different areas and will not be able to keep the cereal from getting stale. Observation on 10/05/23, at 11:40 A.M., of the dry storage area, showed the following: -Seven bowls of cereal, covered with a drink lid; -The lids were cracked in several areas, so will not keep the cereal from going stale; -One open bag of cereal with tear exposing the cereal. During an interview on 10/05/23, at 1:30 P.M., [NAME] M said the following: -He/she does not usually put the food away and did not see any of the items in dry storage; -He/she was not sure what the cereal is doing already in the bowls. During an interview on 10/05/23, at 1:30 P.M., [NAME] N said the following: -He/she knows there is dry cereal on the shelves, already in bowls, but was unsure of what this is set up for; -He/she knows anything that was opened should be closed. During an interview on 10/05/23, at 1:30 P.M., DA O said the cereal that's already made up is to save them a little bit of time in the morning. During an interview on 10/05/23, at 1:30 P.M., the Kitchen Manager said the following: -He/she could not say why the cereal was already out in bowls; -He/she said staff know to close items in the freezer. 3. Record review of the facility's policy titled Developing Cleaning Schedules, by Dining Services Manual, dated May 2015, showed the following information: -To ensure sanitation is at acceptable standards list items to be cleaned within each area including walls, floors, vents, etc. Observation on 10/03/23, at 10:03 A.M., of the walk-in freezer, showed the following: -The ceiling had multiple area that appeared to be a build up grime or other substance; -Black, fuzzy material was near the fans, against the ceiling. Observation on 10/05/23, at 11:40 A.M., of the walk-in freezer, showed the following: -The ceiling had multiple area that appeared to be a build up grime or other substance; -Black, fuzzy material was near the fans, against the ceiling. During an interview on 10/05/23, at 1:30 P.M., [NAME] M said he/she did not realize the walk-in freezer was dirty. During an interview on 10/05/23, at 1:30 P.M., DA O said he/she was not sure how the walk-in freezer was able to get so dirty, so quick. During an interview on 10/05/23, at 1:30 P.M., the Kitchen Manager said he/she walked into the walk-In refrigerator and saw the fan and agreed that it was dirty with a film and grime of some sort. During an interview on 10/05/23, at 2:15 P.M., the Administrator said he/she would expect the kitchen staff to be following a cleaning schedule. The walk-in freezer should not be in this condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff reviewed and revised the resident care plan to ensure it accurately reflected the resident's condition and any interventions when staff failed to update one resident's (Resident #1) care plan regarding the resident's behaviors. The facility census was 63. Record review of the facility's Care Plan Comprehensive Policy, dated March 2012, showed the following: -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -A well-developed care plan will be oriented to managing the risk factors to the extent possible or indicating the limits of such interventions, addressing ways to try to preserve and build upon resident strengths, evaluating treatment of measurable goals, timetables, and outcomes of care, respecting the resident's right to decline treatment, offering alternative treatments, as applicable, and involving the direct care staff with the care planning process relating to the resident's expected outcomes; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred, at least quarterly, and when changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 1. Record review of the Resident #1's face sheet showed the following: -readmission date of 4/28/2021; -Diagnoses included sepsis (a systemic infection), unspecified psychosis not due to a substance or known physiological condition, restlessness and agitation, disorientation, and dementia with behavioral disturbance. Record review of the resident's care conference report, dated 6/23/22, showed the following: -The resident's guardian had concerns that the resident's needs were not being met, since he/she was not going to activities or eating in the dining room. The guardian said prior to coming to the facility the resident was very social and walking on his/her own; -The resident has been evaluated by the psychologist and in the past seen a counselor. He/she is not on any psych meds at this time, uses as needed Ativan (a sedative/antianxiety medication) for agitation. The guardian feels the resident has been labeled a behavior issue; -The resident does intentionally urinate on the floor and cuss at staff. Could be possible depression issues. The resident does respond better to male influences. Visiting occasionally with pastor for Hospice. -Ombudsman will visit with the resident after care plan meeting to further assess his/her needs and desires. Record review of the resident's care plan issue report, dated 6/23/22, showed the following: -The nursing approach to the resident is the determination of the resident's actions. The air conditioner is not working due to the resident urinating in it, and the resident has urinated over the floor; -The resident refuses to participate in activities. (Staff did not document any new interventions to address the resident's refusals of care or behaviors.) Record review of the resident's behavioral charting nursing notes, dated 8/1/22 to 8/31/22, showed the following: -Repeated documentation that the resident refused cares, refused to change clothing, and that he/she cussed and was rude with, yelled at, and threatened staff. On multiple times the resident also became upset with staff when his/her bedding was changed. Record review of the resident's care plan, for the month of August 2022, showed staff did not document these behaviors on the care plan or implement any new interventions to address the resident behaviors and refusals of care. Record review of the resident's behavioral charting nursing notes, dated 9/1/22 to 9/30/22, showed the following: -Repeated documentation that the resident continued to refuse care, refused to change clothing, and that he/she cussed and was rude with, yelled at, and cursed at staff. On multiple times the resident also became upset with staff when his/her bedding was changed, and on one occasion the resident exposed his privates in a public area. (Staff did not document any new interventions to address the resident's refusals of care or behaviors.) Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 9/15/22, showed the following: -The resident was moderately cognitively impaired; -The resident had behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred daily; -The resident had verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) that occurred daily; -The resident had other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming/disruptive sounds; -The resident rejected evaluation or care (e.g. bloodwork, taking medications, assistance) that was necessary to achieve the resident's goals for health and well-being. Behavior of this type occurred daily; -The resident had the behavior of wandering that occurred daily. Record review of the resident's care plan issue report, dated 9/27/22, showed the following: -The resident refused nursing cares and continued to urinate on the floor; -The resident did not participate in group activities, and preferred to stay in his/her room watching television, minimal socialization with others; -The resident refused to be present at the care plan meeting. (Staff did not document any new interventions to address the resident's refusals of care or behaviors.) Record review of the resident's care plan, for the month of September 2022, showed staff did not document these behaviors on the care plan or implement any new interventions to address the resident behaviors and refusals of care. Record review of the resident's behavioral charting nursing notes, dated 10/1/22 to 10/31/22, showed the following: -Repeated documentation that the resident continued to refuse care, refuse to change clothing, and that he/she cussed and was rude with, yelled at, and cursed at staff. On one occasion the resident urinated on the floor. The resident also attempted to hit and kick staff and tried to throw his/her wheelchair at staff. -Documentation noted a new order for a one-time Ativan dose be given; (Staff did not document any new nonpharmalogical interventions to address the resident's refusals of care or behaviors.) Record review of the resident's care plan, for the month of October 2022, showed staff did not document these behaviors on the care plan or implement any new interventions to address the resident behaviors and refusals of care. Record review of the resident's behavioral nursing notes, dated 11/1/22 to 11/25/22, showed the following: -Repeated documentation that the resident continued to refuse care, refuse change of clothing, and that he/she cussed and was rude with, yelled at, and cursed at staff. The resident also was spitting, hitting, and kicking at staff, and on one occasion came out of his/her room with his/her pants pulled down. On another occasion the resident kicked a wet floor sign across the floor while cursing. Record review of the resident's care plan, revised on revised 11/25/22, showed the following: -The resident sometimes urinates in not appropriate places and times. He/she sometimes tries to drink out of his/her urinal as well. Please redirect the resident when he/she does these things; -An approach, dated 11/25/22, to provide the resident with medications as ordered, see physician order sheet for current routine and or as needed medication orders. Monitor the resident for effectiveness; -At times the resident has problems performing learned motor tasks and communicating his/her needs effectively; -An approach, dated 11/25/22, to anticipate the resident's needs and observe him/her for non-verbal cues, knock before entering his/her room and introduce oneself and approach the resident in a calm and friendly manner, knock on the resident's door before entering his/her room and explain care before attempting, observe and report a decline in the resident's cognitive stats and notify the physician as needed, orient the resident to person, place, and time if needed, and support and reassure the resident in new situations. (Staff did not care plan address and show new interventions with the resident regarding his/her refusals of care or aggressive behaviors. The care plan did not address the resident's specific psychotropic drug use.) During an interview on 1/26/23, at 1:38 P.M., Certified Nurse Aide (CNA) A said the resident often threatened staff, threw urine at staff, hit, and yelled at staff. With those behaviors staff notified the nurse, and then the nurse charted on them. He/she was unsure what the nurse did after that regarding the resident's behaviors. The facility staff tried to give increased care to minimize his/her behaviors. He/she was unsure if the resident's behaviors were care planned. He/she said he/she is not involved with care plans. Management and the Social Service Director (SSD) did care plans. Behaviors should be addressed and updated on a care plan. CNA A said he/she did not go to care plan meetings. During an interview on 1/26/23, Registered Nurse (RN) B said the resident refused a lot of cares. The resident was aggressive and belligerent. With behaviors, the doctor is notified, and staff continue to try to provide care. This was done for the resident. Staff would offer the resident persistent care, offer shakes and candy to get the resident to participate in cares. He/she is not involved with care plans. The MDS Coordinator does this. A care plan should be updated with a resident's refusals of care and aggressive behaviors. RN D was unsure if this was done for the resident. During an interview on 1/26/23, at 2:20 P.M., the MDS Coordinator said the following: -The resident had aggressive behaviors, so the facility tried one time Ativan, but nothing worked; -Haldol (an antipsychotic medication) was ordered at the end of the resident's stay due to behaviors; -The resident refused cares. He/she urinated and then dumped the urinal on the floor; -With combative behaviors, staff redirect residents, and if that doesn't work then they call the doctor for intramuscular mood stabilizer medications. This was done for the resident and Haldol was ordered; -Behaviors are care planned. He/she creates care plans and updates them; -The resident's behaviors should have already been in his/her care plan, but the MDS Coordinator didn't take the MDS Coordinator role till late October or early November 2022. The facility has had several care plan conferences with the resident and family was always made aware of his behaviors, but the resident's family would say staff just didn't know how to handle the resident; -The resident's care plan was updated regarding his behaviors, but the MDS Coordinator was unsure what date it was updated; -The resident had baseline behaviors. The resident was always very hostile. The resident sometimes drank his own urine and then would laugh. The resident refused most cares. This should be care planned; -Staff tried to approach the resident in a calm, happy manner, but it did not work. When the resident became combative staff would separate him/her from other residents to protect them. The resident had his own room. During an interview on 1/26/22, at 2:58 P.M., the SSD said the following: -He/she is involved with care plan meetings, but he/she does not update care plans. The MDS Coordinator updates care plans; -Combative behaviors and repeated refusals of care should be care planned. If a resident has combative behaviors, the SSD enters a progress note and enters what he/she did in response to that, and he/she documents that the nurse was notified of the behaviors. The SSD assumes care plans should be updated, but he/she does not know since he/she does not do this; -The facility has care plan meetings on admission, quarterly, and annually, and with significant changes in status. The SSD was involved in the resident's care plan meetings. The facility staff never got far in these meetings. They tried to discuss the resident care and resolutions that family wanted, but staff didn't get far in the meetings, because the family would point fingers at staff and the facility; -The resident would curse and say he just wanted out of the facility, and that people were idiots. The resident's guardian said staff should not make demands of him, but do a [NAME] dance with the resident, approach the resident, sit down with him/her. The SSD tried this approach, but it didn't work. The SSD would sit down and joke with the resident before asking him/her to get his/her toe nails trimmed, and the resident would still become belligerent towards the SSD. The SSD tried to do things the guardian's way, but it didn't work. The family said staff would just barge into the resident's room demand things. Care plan meetings for the resident were never able to go anywhere; -The ombudsman came once per the guardian's request, and even that one didn't go well. Other staff didn't have success either; -After these care plan meetings, the care plan should have been updated. The SSD was not sure if this was done, since he/she does not do care plan updates. During an interview on 1/26/23, at 4:00 P.M., the Administrator and Director of Nursing (DON) said the following: -The resident was on Haldol due to behaviors. The resident has had behaviors for five years. Interventions done were to send the resident to his/her room, send him/her out for evaluations, the police were called, no other placements were found for him/her, the psychologist got involved, but the guardian refused a psychiatric evaluation; -The resident's behaviors were documented in progress notes. The resident had a care plan, but the DON was unsure if every behavior was care planned, but the resident's medications were updated on the care plan; -The DON and Administrator said they would know how to take care of a resident based on chart notes and from just being in the facility, and from report; -The plan was for the doctor to start cutting down the dose of Haldol so the resident didn't get overmedicated, and the doctor did this. There were no interventions that would have done enough for the resident. All the things the facility staff tried for the resident everyday they put in the chart notes, but they did not put all of that in the care plan; -Agency nurses would be able to look at the resident's nursing notes to know how to care for him/her; -There were no new interventions to try for the resident, because his/her reactions were the same. With medications, the resident would ask, Are these the good drugs? The resident would not take oral pills, but he/she would take intramuscular, so that would be an intervention for the resident; -The Administrator and DON did not know why the resident's care plan was updated on his/her date of discharge. They were not aware of this update; -Care plans should be updated quarterly and annually. The staff tried to redirect the resident and get him/her involved in activities. Book readings, or watching television, things a resident likes, should be care planned; -Successful interventions should be care planned; -Injections were something the resident liked for infections, and that should have been care planned; -Unsuccessful interventions should be documented in the care plan and progress notes; -If the intervention worked, liked calling the guardian, it should have been care planned; -Most of the time the interventions listed in the care plan didn't work for the resident; -The Administrator said it seemed like staff got so busy documenting in the progress notes but the facility didn't do the documentation in the care plan. MO00212847

Based on interview and record review, the facility failed to ensure all staff were properly trained in the performance of cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions often combined with artificial ventilation to restore circulation and breathing in a person who is in cardiac arrest) and use of an AED (automated external defibrillator - a medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm.) according to professional standards of practice when assisting one resident (Resident #1). The facility had a census of 57. Record review of the facility's policy Cardiopulmonary Resuscitation (CPR), undated, showed the following: -Determine unresponsiveness by tapping or gently shaking resident and shouting, Are you okay?; -Call out for help; -Delegate a specific individual to check resident clinical record for CPR or no CPR order. Have individual call paramedics, attending physician, and administrative personnel per facility guidelines and report back as soon as possible; -Do not start CPR if resident is breathing and has a pulse. Start emergency oxygen and delegate a specific individual to stay with the resident and monitor vital signs. Notify the attending physician of the resident's condition and request further orders for care; -Determine pulselessness. Palpate the carotid (artery on each side of the neck that supplies blood to the brain) pulse gently to avoid compressing the artery on side of victim; -If resident is pulseless, make sure resident is on a hard surface like backboard or floor; -Perform 30 external chest compressions at a rate of 80 to 100 per minute; -Open the airway and deliver two rescue breaths; -Repeat cycle of 30 compressions to two breaths, performing four cycles before you evaluate the resident; -Determine breathlessness by maintaining the open airway, place ear over resident's mouth and nose; -Look for chest rise and fall; -Listen for exhalation, -Feel for exhaled air; -If resident is breathless, perform rescue breathing by gently pinching resident's nose shut with thumb and index finger. If using disposable two-way valve CPR mask or facemask, place firmly over the resident's nose and mouth to create an airtight seal; -Deliver two full breaths, each lasting one to one and one-half seconds; -Pause to inhale between breaths; -Observe the chest rise (adequate ventilation volume (a measurement of the amount of air that enters the lungs per minute)); -Allow deflation between breaths; -Reassessment: Evaluate resident by checking carotid pulse; -If pulse is present, but resident has no respirations, continue rescue breathing at approximately 12 ventilations per minute; -If pulse and respirations are absent, continue cardiopulmonary resuscitation and evaluate resident periodically; -Ventilate twice, observe chest rise; -Resume compression/ventilation cycles; -Feel for carotid pulse very few minutes; -Once CPR is started do not discontinue until qualified help arrives (paramedics). Record review of the facility information provided for the AED by the American Red Cross, showed the following: -Automated external defibrillators can help save lives during sudden cardiac arrest, however, even after training, remembering the steps to use an AED the right way can be difficult; -How to Use An AED: Should be used when caring for a non-breathing adult; -As soon as an AED is available, turn it on and follow the voice prompts; -If the pads may touch, place one pad in the middle of the chest and the other pad on the back, between the shoulder blades; -Plug the pad connector cable into the AED, if necessary; -Prepare to let the AED analyze the heart's rhythm: make sure no one is touching the person. Say CLEAR in a loud, commanding voice, and push the Shock button to deliver the shock; -After the AED delivers the shock, or if no shock is advised, immediately start CPR, beginning with compressions. Record review of the Nutritional Heart, Lung, and Blood Institute web-site at the www.nhlbi.nih.gov, updated 3/24/22, showed the following: -Automated external defibrillators (AEDs) which are now found in many public spaces, are used to save the lives of people experiencing cardiac arrest. Even untrained bystanders can use these devices in an emergency; -An Automated External Defibrillator is a lightweight, battery-operated portable device that checks the heart's rhythm and sends a shock to the heart to restore normal rhythm. The device is used to help people having cardiac arrest; -Sticky pads with sensors, called electrodes, are attached to the chest of someone who is having cardiac arrest; -The electrodes send information about the person's heart rhythm to a computer in the AED; -The computer analyzes the heart rhythm to find out whether an electric shock is needed. If it is needed, the electrodes deliver the shock; -Step by step instructions and voice prompts to help untrained bystanders to use the machine correctly; -Check the person ' s breathing and pulse. If the person is not breathing and has no pulse or has an irregular heartbeat, prepare to use the AED as soon as possible. 1. Record review of Resident #1's physician's orders, dated 11/1/22 to 12/6/22, showed the following: -admission date of 8/17/22; -Diagnoses included hypotension (low blood pressure), hypoglycemia (low blood sugar), and type II diabetes mellitus (chronic health condition that affects how your body turns food into energy); -The resident was a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive included CPR). Record review of the resident's progress notes dated 12/5/22, at 7:02 A.M., showed Licensed Practical Nurse (LPN) A entered the resident's room to check the resident's blood sugar. The resident did not respond when the nurse said his/her name. The resident was cool to touch. The nurse attempted to arouse the patient by doing a sternum rub and saying his/her name. The resident did not respond. The resident's eyes were open and glassy. Certified Medication Technician (CMT) B said he/she checked the resident at 6:30 A.M. and the resident was sleeping and appeared to be okay. LPN A requested help from other nurses in the facility. Staff moved the resident from the bed to the floor, called 911 at 7:04 A.M., and applied the AED and started CPR at 7:08 A.M. Staff applied oxygen at this time. The resident was making gurgling sounds. EMS arrived at 7:16 A.M. and took over, stating the resident had a pulse at this time, but it was irregular. EMS transported the resident to the hospital at 7:20 A.M. During interview on 12/6/22, at 12:00 P.M., LPN C said the following: -About 7:00 A.M., while he/she was in the dining room doing the medication pass, LPN A came up and asked for him/her and said the resident was unresponsive; -They checked the resident's code status; -LPN C went to the resident's room and the resident lay on his/her back slightly turned to the wall; -The resident was cold to touch, pupils were pinpoint, had agonal (not getting enough oxygen and gasping for air) breathing; -LPN C checked the right carotid artery and there was a pulse; -LPN A called EMS; -The resident released his/her breath and both eyes rolled back into his/her head; -LPN C began CPR, but did not remember to recheck the resident's pulse then; -LPN C did one round of compressions on the bed and then a CNA and he/she took the resident to the floor; LPN C did check for a pulse, did not find a pulse, and began chest compressions until staff brought the crash cart to the room with the AED on it; -LPN C placed the pads on the resident's chest and waited for the AED to analyze the resident; -The AED said to continue CPR and there was three staff who did compressions and put oxygen on at 10 liters with the mask; -LPN C said he/she did check for a pulse when put on the AED and followed with the AED which said to do compressions. The AED never gave shock advisory, but did say, Push harder or Good compressions; -They did a couple rounds of mouth to mouth breathing until mask on and maintained the resident's airway; -They worked on the resident for 15 minutes until paramedics arrived; -LPN C said he/she did compressions until paramedics came. The paramedics checked the resident's pulse and said the resident had a pulse. Then they left with the resident; -This was his/her first time to use the AED. The AED never gave a shock advisory or heart rhythm; -The AED would say Clear the patient and the AED would analyze the resident. AED would then say Continue CPR. The AED never said Check pulse; -LPN C did not check the resident's pulse after they hooked the resident up to the AED; -LPN C was told to follow what the AED said to do; -Normally, he/she would do four rounds of CPR and check the resident's pulse. They did approximately 8 to 10 rounds of chest compressions on the resident. During interview on 12/6/22, at 1:00 P.M., LPN A said the following: -On 12/5/22, about 7:00 A.M., he/she went to check the resident's blood sugar; -The resident did not respond to him/her, but that was normal for the resident; -He/she pricked his/her finger and the resident did not move or growl at him/her like normal; -LPN A said his/her name several times and did a sternal (chest) rub; -The resident's eyes were wide open; -LPN A checked the resident's carotid pulse and upper wrist and there was no pulse; -The resident was gurgling and there were long periods of time between each breath; -LPN A went to call 911 and asked LPN C and CMT B to assist. LPN A grabbed the crash cart and dialed 911; -LPN C had assessed the resident and had began CPR when he/she returned with the crash cart; -LPN C did one round of compressions on bed and then moved the resident to the floor; -LPN A was not sure if the resident was still breathing when LPN C was doing compressions since it was hard to see; -LPN C hooked up the AED and he/she does not remember if LPN C checked the resident's pulse between rounds of compressions; -The AED continued to say Pulse detected and then Continue compressions after it analyzed the resident; -LPN A said he/she was taught to do what the AED told you to do; -EMS came and took over and left with the resident. During interview on 12/6/22, at 3:15 P.M., Certified Nurse Aide (CNA) D said the following: -The resident was laying outside the covers with his eyes and mouth slightly open and could hear gurgling breathing noises; -LPN C came into room, assessed the resident, checked for a pulse, checked the resident's airway, did a sternal rub and the resident did not respond; -LPN C said he/she did get a faint carotid pulse and hollered for the crash cart, call 911, and then yelled starting CPR; -The resident was on the bed and LPN C did chest compressions, gave two breaths and another round of compressions; -They put the resident on the floor and LPN C did chest compressions; -They got the AED and let it analyze and AED said Resume chest compressions; -Three staff switched places to do chest compressions of 32 compressions to two breaths and LPN C checked for a carotid pulse; -LPN C did get a pulse, but not sure if he/she did compressions, but it was a faint pulse and the resident was not breathing on his/her own and continued with chest compressions; -When medics got there, the resident took deep breaths and struggled to let the air back out. It was not normal breathing; -They did chest compressions the whole time; -CNA D thought if you get a pulse, he/she didn't believe you were to keep doing chest compressions; -The AED told them to Stop and Clear to analyze which took about ten seconds, then AED said Resume Resume Compressions, Press Harder. During interview on 12/6/22, at 2:40 P.M., CMT B said the following: -On 12/5/22, he/she went into the resident's room about 6:30 A.M. to administer medications to the roommate; -The resident's eyes were closed and appeared to be sleeping. He/she was breathing and he/she knew the resident did not like to be awakened; -He/she was passing medication about 7:00 A.M. when LPN A hollered for LPN C. CMT locked cart and went into the resident's room where they tried to rouse the resident who was breathing; -Within a few minutes, LPN C said they needed to put the resident on the floor to start CPR; -CMT B said he/she was moving the wheelchair and the bedside table and did not see if the resident had stopped breathing, but when the resident was on the floor, his/her eyes were open and it was like he/she had raspy breaths or trying to catch his breath; -CMT B said he/she documented all this on scrap paper while in the room. He/she did not write down that staff checked the resident's pulse, but the AED machine kept saying Do Compressions, Press Harder but never heard the machine say Give Breaths, but saw LPN C give breaths to the resident; -They did put oxygen on the resident; -Right before EMS arrived, the resident began breathing on his/her own and had a pulse; -The EMT said the resident was breathing and had a pulse right before they took the resident to the hospital; -If a resident gets a pulse, they were not to do chest compressions. During interview on 12/6/22, at 5:41 P.M., CNA G said the following: -There was an AED on the crash cart, but never had to use one; -AED to use if resident had no pulse; -Staff were not to use the AED if the resident had a pulse; -If a resident was not responsive and had no pulse, yell for the nurse and begin CPR with compressions and breaths, until the nurse gets there; -If the resident had a faint pulse and unresponsive, yell for the nurse and start CPR. During interview on 12/6/22, at 5:43 P.M., CNA H said the following: -An AED was a defibrillator and to use when CPR was unsuccessful; -Staff to check the resident's pulse first, and if no pulse, holler for the nurse and start CPR; -If doing CPR for a few minutes and not successful, get the crash cart with the AED, but not sure about this because it depends on the nurse; -If the resident had a faint pulse, he/she would do a sternal rub and if no reaction, would start compressions. During interview on 12/6/22, at 1:30 P.M., LPN J said the following: -Before staff initiate CPR, staff were to check for a pulse and respirations. For every 32 chest compressions, staff give two breaths then check the pulse; -If someone had a pulse, they were not to do chest compressions because the heart was pumping; -Not sure off hand about the AED for checking the pulse; -They were to follow the AED instructions. During interview on 12/6/22, at 3:42 P.M., LPN E night charge nurse said the following: -He/she was CPR certified and familiar with the AED, but not this AED at the facility; -The AED was not to replace CPR; -If the resident had a good steady pulse, they were to hold off on chest compressions; -If the resident did not have a good pulse, they would continue with chest compressions. During interview on 12/6/22, at 5:30 P.M., LPN F said the following: -If a resident had no pulse or heartbeat, he/she would assess for; -If the resident had a heart beat, and he/she felt any movement like breathing, they do not use the AED; -If the resident had no pulse, they would initiate chest compressions and call 911; -If the resident had a faint pulse, they would not initiate chest compressions. During interview on 12/6/22, at 5:45 P.M., LPN A said the following: -If staff don't get a pulse, start CPR; -Can use the AED when a resident does not have a pulse; -When the resident has a heart beat, they can stop chest compressions; -If the resident had a faint pulse and may not be breathing, bag them or do rescue breaths; -The AED machine never said Check pulse only said Do Compressions. During interview on 12/6/22, at 5:50 P.M., LPN I said the following: -If you find someone unresponsive, with no pulse, or breathing, know the code status first; -Call 911, get crash cart and AED; -Someone starts chest compressions and someone can hook up AED to analyze; -An AED is to shock a resident for the heart to beat. Chest compressions are the standard thing to do; -If resident has a faint pulse, call 911 and monitor the resident. Do not do chest compressions; -If the resident was not breathing well, do rescue breathing or give them oxygen. During interviews on 12/6/22, at 3:52 P.M. and 6:03 P.M., the Director of Nursing (DON) said the following: -If a resident was found unresponsive, check for a pulse and if no pulse, yell for someone to call 911; -Start CPR immediately; -Get crash cart; -Do chest compressions 30 compressions to two breaths for two rounds, then check for a pulse (carotid); -Hook up the AED and do chest compressions. Chest compressions get heart going; -Let AED read and it will tell you to continue compressions or if will give a shock; -Did not know if a shock was indicated for the resident; -The resident had a pulse when they left; -The AED will tell staff to stop, check pulse, and resume compressions; -If having trouble breathing, would continue with rescue breathing, but not compressions; -If staff felt a pulse, even a faint pulse, they were not to do chest compressions, but would continue with breathing; -Even with AED, they were to stop compressions if felt a pulse; -If there was a faint pulse, keep monitoring and maybe give rescue breaths. If not breathing, put on oxygen and check vital signs; -Does expect staff to use the AED with CPR. During interview on 12/6/22, at 2:24 P.M., the Administrator said the following: -Would expect staff to check for a pulse first, and if no pulse, call for help right away; -Staff were to get the resident on a hard flat surface, elevate their head and initiate CPR; -They were to give a round of 30 chest compressions, and do breaths. If the resident had a pulse, they would not give chest compressions, but do rescue breathing; -If the resident had irregular pulse, they would stop chest compressions; -She had never used an AED before even though they have had one here at the facility for several years; -They do encourage CPR classes and refresher classes for all staff. MO00210796

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** MO00167350, MO00169726, MO00181554, and MO00180853. 2. Record review of Resident #31's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease, multiple sclerosis (a potentially disabling disease of the brain and spinal cord), history of diarrhea, history or urinary tract infections (UTIs), rash, and other nonspecific skin eruption. Record review of the resident's quarterly MDS, dated [DATE],showed the following: -Resident is always incontinent of both bowel and bladder; -Toileting requires extensive one person assist; -Personal hygiene requires limited one person assist. Record review of the resident's care plan, last updated 2/16/21, showed the following: -The resident has urinary incontinence and wears incontinence briefs; -The resident has dementia, with a goal of preserving self-esteem, quality of life, and unmet needs; -The resident requires assistance with bathing, hygiene, dressing, grooming, and toileting. Observation on 3/30/21, at 10:33 P.M., showed the following: -CNA C and CNA E entered the resident's room; -The resident's bed linens were smeared with feces and the resident had visible feces under his/her fingernails; -Staff pulled the resident's covers down to reveal the resident wore no incontinent brief, the resident's bed pad was urine soaked and smeared with feces, the fitted sheet underneath was visibly wet and the resident's mattress had a visible wet circle the approximate size of a softball; -The resident's gown was urine soaked and smeared with feces; -CNA C and CNA E assisted the resident with incontinent care using a wet wash cloth; -The CNAs changed the bed linens, turned off the resident's lights, and left the room; -The CNAs did not attempt to clean the resident's hands or fingernails before leaving the resident's room. Observations made on 03/31/21, at 9:54 A.M., showed the resident had small amounts of brown material build-up on the underside of three nails on his/her left hand and two nails on his/her right hand. 3. During an interview on 4/5/2021, at 10:15 A.M., CNA B said if a resident had a bowel movement and the resident had any on his/her fingers, staff should wash the resident's hands and get an orange stick to clean under the fingernails. 4. During an interview on 4/5/2021, at 3:22 P.M., the administrator said staff should soak the resident's hands for any visible soiling on the resident's fingernails/hands and get them clean, soap and water should be used to soak. Based on observation, interview, and record review, the facility failed to provide adequate nail care and personal hygiene assistance for two dependent residents (Resident #31 and #152) following incontinent episodes. The facility census was 49. Record review of the facility's policy titled, Bath (Partial) (Nursing Guidelines Manual, March 2015), showed the following information: -Care of fingernails and toenails is part of the bath. Be certain nails are clean. 1. Record review of Resident #152's face sheet showed the following: -Resident admitted to the facility on [DATE]; -Diagnoses included psoas (lower back) muscle abscess (an enclosed collection of liquefied tissue) and intervertebral disc degeneration, lumbar region. Observation on 3/30/21, at 11:08 P.M., showed the following: -Certified Nurse Aide (CNA) C and CNA E entered the resident's room to answer the call light; -The resident was on the bed with feces covering his/her hands and under his/her fingernails; -The resident was incontinent of stool and had feces smeared on his/her bedding and mattress; -The CNAs provided incontinent care; -The CNAs attempted to clean the resident's hands with Bedside Care Foam (cleanser) and a wash cloth; -After completing cares, the resident continued to have feces on his/her hands and on and under his/her fingernails; -Staff left the room and the hall without thoroughly cleaning the resident's fingernails and hands. Observation and interview on 3/31/2021, at 10:20 A.M., showed the following: -CNA B and CNA D entered the resident's room to answer the call light; -The resident rested on the bed and said he/she could not wait for staff to answer the call light in order to use the toilet and had a bowel movement on the bed pad; -The resident had brown soiling on his/her fingernails of both hands; -Staff did not clean the resident's hands prior to leaving the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure staff followed physician orders regarding administration of the oxygen at the correct liters per minute (LPM - measurement of oxygen) and failed to keep water in the humidifier (bubble-type humidifier provides long-lasting moisture for utmost patient comfort during oxygen therapy) used with supplemental oxygen for one resident (Resident #48). The facility census was 49. Record review of the Journal of Respiratory Care, Volume 58, Issue 8, article titled, Humidification of Inspired Oxygen, dated August 2013, showed the following information: -Exposure to dry and undiluted oxygen may cause mucosal dryness and irritation; -Chronic exposure may cause local inflammation, bleeding of the mucosa, and possibly nasal-septal perforation; -Oxygen therapy is usually combined with a humidification device, to prevent mucosal dryness; -Because oxygen concentrator tanks deliver absolutely dry oxygen, humidification is recommended by some; -If humidification is used, the most widespread system is the bubble through humidifier. Record review showed the facility did not provide a policy regarding oxygen use. 1. Record review of Resident #48's face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), pneumonia (infection that inflames the air sacs in one or both lungs), emphysema (disorder affecting the alveoli (tiny air sacs) of the lungs), and cognitive communication deficit (disorders as difficulty with any aspect of communication that is affected by disruption of cognition). Record review of the physician order report showed the following information: -An order, dated 9/5/2018, for oxygen at 3 liters (L) per minute per nasal cannula (nc) continuous; -An order, dated 8/20/2020, for change oxygen tubing and humidifier bottle monthly. Record review of the resident's care plan, last updated 12/1/2020, showed staff did not address or provide interventions for staff related to the resident's oxygen treatment. Record review of the physician's nursing home progress note, dated 2/22/2021, showed the following information: -Resident seen at nursing home for annual nursing home visit; -Resident stated he/she is coughing a lot. This is chronic for him/her due to COPD. The oxygen tank, bubbler (humidifier), has been dry for a while now, per the resident. He/she has a lot of phlegm. He/she is not getting any breathing treatments at this time; -Diminished breath sounds bilaterally, oxygen per nasal cannula at 3 LPM; -Asked to have the nurses keep the oxygen bubbler filled with water; -Start albuterol nebulizer (device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) treatment three times daily for one week. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 3/10/2021, showed the following information: -Cognitively intact; -Received oxygen therapy while a resident at the facility; -Required two staff physical assistance for transfers to chair or bed; -Wheelchair required for mobility. Observations of the resident showed the following: -On 3/29/2021, at 11:52 A.M., the resident sat in the wheelchair with oxygen on at 4 LPM, the oxygen tubing and humidifier bottle, showed date of 3/20/2021. The humidity bottle did not have any water in it; -On 3/30/2021, at 10:07 A.M., the resident sat in the wheelchair with oxygen on at 4 LPM. The humidity bottle did not have any water in it and showed date of 3/20/2021; -On 3/31/2021, at 4:02 P.M., the resident was out of the facility with family. The oxygen concentrator was turned on and at 4 LPM. The oxygen humidity bottle laid on top of the machine with no water in the bottle; -On 4/1/2021, at 9:35 A.M., the resident sat in the wheelchair in his/her room with oxygen on per nasal cannula at 4 LPM. The oxygen humidifier bottle contained no water; -On 4/2/2021, at 2:59 P.M., the resident rested quietly with his/her eyes closed, in his/her wheelchair in the room, with oxygen on at 4 LPM. The oxygen humidifier bottle contained no water. During an interview on 4/5/2021, at 10:15 A.M., Certified Nursing Assistant (CNA) B said the nurses are responsible for oxygen tanks, tubing, and for putting water into the humidifier bottles. During an interview on 4/5/2021, at 10:05 A.M., Licensed Practical Nurse (LPN) F said the oxygen humidity bottles should have water in them for any resident with oxygen being administered above 2 LPM. During an interview on 4/5/2021, at 11:05 A.M., the Director of Nursing (DON) said nurses should fill the humidifier bottle when empty, it should not be dry. The night shift should be changing the tubing and bottle monthly per facility protocol. During an interview on 4/5/2021, at 11:06 A.M., the administrator said the nurses should be filling the oxygen humidifier bottles in the residents' rooms. They should not be empty. The night shift nurses are responsible for changing the oxygen tubing and bottles monthly and the treatment administration record (TAR) will alert the nurse to this task. The TAR does not alert staff to oxygen humidifiers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four residents (Resident #9, Resident #18, Resident #21 and Resident #28) remained free from misappropriation of property, when the business office manager (BOM) withdrew cash from residents' bank accounts and did not give the money to the residents. The facility's census was 49. Record review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, dated 11/28/16, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Record review of the facility's policy titled Facility/BOM Resident Trust Workflow, undated showed the following: -Withdrawals: -Before issuing personal spending money to a resident, first check Matrix Resident Trust to ensure the funds are available; -Cash will be issued from the cash box that is kept in the facility; -If the amount does not exceed the cap of $50.00, the resident can be paid directly from the cash box; -Resident must sign the Resident Fund Management (RFM) Cash Box Disbursement Log before personal spending cash will be released to the resident and before the facility shops for the resident; -Cash is for resident use only and is not to be used for any other purpose. The allowable uses are personal spending cash given directly to the resident and facility shopping for the resident; -The resident must sign the RFM Cash Box Disbursement Log for the amount requested. If the resident makes a mark or if the signature isn't legible, two witnesses must also sign; -BOM and administrator must sign at the bottom of the disbursement log; -If the amount exceeds the cap amount of $50.00 (applies to all residents), you must mail a completed and signed check request form to RFM corporate (and a copy of the signed receipt if the check is for reimbursement) for approval. RFM will then approve the request, set up the check, and the BOM will be able to print the prepared check directly from Matrix (computer program which shows the residents' amount of funds available); -The appropriate check request form is in documents under RFM and is also set up as a create mail merge document; -Attach a copy of the signed check and the signed receipt to the original signed request form. Record review of the facility's admission packet, undated, showed the following: -The facility agrees at the resident's request, to hold, safeguard, and manage personal funds for the resident at no additional charge to the resident, subject to the terms and conditions set forth in the agreement concerning management of personal funds contained in the admissions package and incorporated by reference in this agreement; -The facility shall furnish the resident with a written receipt for all expenditures and deposits regarding any of the resident funds deposited with the facility; -A record of all transactions regarding the resident's funds shall be maintained by the facility in accordance with the generally accepted accounting principles; -The resident shall have reasonable access, upon request, to the above record and shall receive an itemized quarterly statement of his or her account; -The facility will maintain resident personal funds that do not exceed $50.00 in a non-interest bearing account. As a means of safeguarding resident funds, facility access to resident funds is limited to screened, approved, and authorized facility staff. Resident requests for access to their funds will be honored by authorized staff as soon as possible and in accordance to the Federal regulations as outlined in 483.10 (f)(10)(i)-(ii). Resident can withdraw or deposit these funds by contacting the office manager during normal business/banking hours and funds will be made available the same day. As additional means of safeguarding resident funds, the facility does not hold resident cash on site. If funds will be needed for the weekend, they should be withdrawn during normal business hours the Friday before or if outside of regular business/banking hours, facility staff may contact a member of facility management for emergency access. Record review of the facility's policy titled, Guidelines for Maintaining the Resident Trust Fund Account, revised on 8/20/19, showed the following: -This facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf; -A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf; -The Matrix accounting system is to be used to record resident trust deposits, disbursements, distribute interest and print quarterly statements; -Disbursements from the resident's trust account will not be made without a signed Resident Trust Disbursement/Check request from the resident or the resident's legal representative; -Before any amounts are paid from a resident's personal funds, the facility will verify that the resident has enough money in their account to cover the withdrawal so that the resident's account will not be overdrawn; -The administrator and the BOM shall be the signatories to any check written on the resident trust account. However, in the event that either, the administrator or the BOM are unavailable, the social service designee shall be an authorized signatory; -The facility will send a copy of the signed check to system services to be kept on file with the check approval. If the disbursement falls under the one of the items listed on agreement concerning management of personal funds, a copy of the signed agreement will take the place of a resident trust disbursement/check request; -The resident or responsible party will receive a copy of the resident's trust statement showing all transactions to resident's trust fund account on a quarterly basis; -This will be done each month in January, April, July and October by the 15th of the month; -The facility will have a surety bond equal to or greater than one and 1/2 times the average annual trust fund balance. Record review of the administrator's acknowledgment (of the resident trust account statements), revised on 8/20/19, showed the following: -I, administrator for facility name hereby acknowledge that I have reviewed all quarterly resident trust account statements for the first, second, third or fourth quarter of ---- date and that they were true and accurate to the best of my knowledge and information. All resident trust account statements were completed in compliance with all applicable guidelines and procedures. In addition, I hereby certify that all resident trust account statements were mailed on ----. ; -Line for administrator signature and date; -This acknowledgement is to be completed and submitted as part of the month-end process including resident trust checkbook and bank reconciliation in January, April, July and October after the resident trust account statements are mailed for quarters ending December, March, June and September. 1. During an interview on 3/30/21, at 1:11 P.M., the Corporate Financial Consultant (CFC) said the following: -On 3/3/21, 3/4/21, 3/5/21, 3/8/21, and 3/9/21, the financial consultant helped out in the facility's business office while the BOM was on extended leave (3/2/21 to 3/24/21); -On 3/8/21, a resident wanted $20.00 for pizza out of his/her resident account. When the CFC reviewed the RFM cash box disbursement log and the available cash in the box, it was $113.77 short. The CFC emailed the cash box reconciliation log to corporate, which was due every day before 4:00 P.M. The CFC thought corporate knew of the discrepancy and could tell her the totals of the withdrawals since the BOM was on leave; -On 3/8/21, the RFM corporate emailed the CFC and agreed the cash box total did not balance; -On 3/8/21, she and the administrator called the BOM (who was on leave until 3/24/21) and asked her about the cash box reconciliation; -On 3/8/21, the BOM named residents who requested and received money on 3/1/21, but she (the BOM) did not write their names and amounts on the RFM cash box disbursement log; -On 3/8/21, the CFC asked residents, who the BOM named, if they requested and received money on 3/1/21. Resident #18, Resident #21, and Resident #28 said they did not request or receive money from the BOM; -On 3/10/21, the administrator issued a written warning to the BOM for not documenting residents' names and their received cash amounts on the RFM cash box disbursement log; -On 3/24/21, the BOM returned to the facility from leave; -On 3/25/21, the CFC re-trained the BOM on the resident trust process; -On 3/25/21, the BOM told the CFC that Resident #18 sent cash to a family member. The resident's family mailed envelopes and stamps for the resident to send him/her money. The BOM said she had called the RFM corporate who said it was the resident's money and he/she could do with it as he/she wished; -On 3/25/21, she (the CFC) took Resident #18's account statement with her to review it. The BOM asked if she wanted the statement to be shredded. She told the BOM she was going to review the resident's trust statement; -On 3/26/21, she (the CFC) called Resident #18's family member who did not know the resident had a trust account (with the facility). The family member said the resident did not send him/her any money; -On 3/26/21, she emailed the administrator regarding this discovery. The administrator called corporate, suspended the BOM and notified DHSS; -On 3/26/21, she started an investigation and ran a current balance report, which was a summary of every resident who had a resident trust account. She saw a pattern of withdrawals for residents who were their own responsible party and most of those residents, received their statements at the facility. Record review of the CFC's written statement, dated 3/30/21, showed the following: -The BOM was out on leave. While the BOM was gone, she (the CFC) went to the facility to help; -On 3/9/21, there were withdrawals from the resident trust account. When it was time to balance, the administrator said the BOM had already done the cash box reconciliations for the weeks she was gone. He/she explained that the BOM should not have done that. The administrator said the RFM gave permission and there was an email that verified this. He/she checked the emails and the RFM had agreed to this' -When the CFC was reconciling the account it did not balance. The administrator and CFC called the BOM to question it. The BOM said there were several residents who took out cash that she did not write down, put in matrix, or have them sign. The CFC explained that she should never do this and that she can never complete the resident trust reconciliations early. The BOM said that the RFM told her to; -At this time, the CFC went and visited with a few of the residents. Two of the residents (Resident #21 and Resident #28) denied receiving any money. The CFC immediately told the administrator about this; -During a conversation with the BOM, she told the CFC that there were residents who would sign out cash and then mail it to family members. The administrator said that she had never seen residents mailing money. The BOM also said that she called the corporate office to question this and was told that it was the resident's money and he/she could do whatever he/she wanted with the money. She claimed one of the residents who mailed a lot of cash was Resident #18. During conversation the BOM said the resident did it (mail money) himself/herself. The CFC told the administrator that he/she was not comfortable with this practice and that the CFC would come back to the facility to go over the trust policies and procedures with the BOM; -The BOM returned to work on 3/24/21. The CFC came in on 3/25/21 and went through training with the BOM. At that time, the BOM denied being trained in this way; -The CFC took Resident #18's statement when she left the facility. She told the BOM that she needed to check into this activity. On the morning of 3/26/21, the CFC called Resident #18's family member who the BOM claimed the money was going to. During this conversation, it was made clear that Resident #18 had never sent him/her any money. -At approximately 10:00 A.M., on 3/26/21, the CFC called the administrator to tell her the findings. The CFC immediately printed the current balance report and statements for each resident. Reviewed statements showed many transactions (mostly 2020) that looked suspicious. The CFC came back to the facility on 3/29/21 and started an investigation. Most residents denied receiving cash. Most of them only signed for the facility to do shopping (for them) once a month. Those amounts were easily identified. During the investigation, the CFC found that staff at the facility had not been educated on the resident trust process and procedure (an in-service will be done before leaving). Because of the lack of training, staff signed stating they witnessed transactions, but did not really witness the residents' signatures or see the cash placed in their (the residents') hands. 2. During interviews on 3/30/21, at 1:11 P.M., and 3/30/21, at 2:30 P.M., the administrator said the following: -When residents wanted money, they requested it from the BOM; -The resident trust cash box held up to $500. Every day, the administrator, BOM and a third person, was supposed to count the cash in the box, then the administrator and BOM signed the bottom of the RFM cash box disbursement log verifying the amount. The BOM sent the cash disbursement log to corporate by 4:00 P.M.; -If a resident requested money greater than $50, the BOM completed a check request form. After the resident signed the form, the BOM emailed the form to corporate who assigned a check number. The facility had blank checks and the BOM would print the check made out to the resident and for amount requested; -Although she and the BOM were authorized to take checks to the bank to cash, only the BOM cashed checks. -On 3/10/21, she called the BOM to the facility because the RFM cash disbursement log did not equal the amount of money in the cash box. The administrator issued a written warning to the BOM and said she would be terminated if this issue happened again (not writing down the names of the residents and the cash they received); -On 3/26/21, the CFC conducted an in-service with the BOM regarding the resident trust process; -The BOM told the administrator he/she called corporate staff who said if a resident requested money, then give it to him/her. The administrator told the BOM the facility had protective oversight over the residents and they should not have large amounts of money in their room; -The BOM never admitted to taking the money. Record review of the administrator's statement, dated 3/30/21 showed the following: -On 3/2/21, the BOM went on leave; -The CFC came (to the facility) on 3/4/21 and 3/5/21; -On 3/1/21, the BOM told the administrator she had completed the cash box reconciliations so she (the administrator) did not need to worry about that duty. The BOM also said she had already sent them (the reconciliations) to the RFM at corporate office. The administrator asked what if residents wanted cash, she said to just give it to them and keep a list with signatures, and she would catch up when she got back; -The CFC arrived at the facility and asked where the key to the cash box was. Staff could not find it anywhere in the business office. On 3/8/21, the CFC caught that the cash box did not reconcile and that it was (short money); -The administrator called the BOM and had her on speakerphone with the CFC, and asked where that money was. The BOM said she had given money to several residents on 3/1/21, the day before her surgery. She did not write it (the amount of cash withdrawn) down or get signatures from residents, she was scattered due to having surgery on 3/2/21. The BOM proceeded to come up with resident names who she gave it (money) to and the amounts. The administrator said to the BOM you didn't write it all down and get them to sign for it? The BOM said she just forgot. The BOM also said she had gotten permission from the RFM at corporate to send in the upcoming cash box reconciliations while she was off. We (the administrator and CFC) found the emails stating that and printed them off; -Two residents said they did not get it (money). The administrator called the BOM to the facility on 3/10/21 and issued a written warning with a consequence of termination if it happened again. The BOM agreed and signed the warning; -The administrator completed the cash box reconciliation each business day and counted with two people as required; -The administrator told the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Social Services Designee (SSD), in the future, they should not sign as a witness unless they counted/verified; -On 3/24/21, the BOM returned to work. -On 3/26/21, the CFC sent the administrator an email asking her to shut the door (to her office) and call her. The CFC said she had been looking at the resident trust and things were not making sense. The CFC had the administrator look at the resident accounts with her and there were a couple of issues that did not look appropriate. The administrator called the DON into the office, explained the situation, and stated an investigation would begin. At that time, with the DON, the administrator suspended the BOM, pending investigation. The BOM turned her keys in to the DON and left without incident. 3. Record review of Resident #9's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included muscle weakness, anxiety disorder, major depressive disorder, and high blood pressure; -The resident was his/her own responsible party and primary financial contact; -A family member was listed as an emergency contact and received the resident's accounts/receivable (A/R) statement. Record review of the resident's agreement concerning management of personal funds, dated and signed by the resident and BOM on 12/11/20, showed the following: -I hereby acknowledge that I have been advised of the right to manage my financial affairs and that I am not required to deposit personal funds with the facility; -I do, authorize this facility to manage personal funds in accordance with the facility's guideline regarding protection of resident funds. Record review of the resident's quarterly minimum data set (MDS - a federally mandated assessment tool completed by facility staff), dated 1/2/21, showed the resident was cognitively intact. Record review of the Resident's Trust Fund Statement, dated 10/1/20 through 12/31/20, showed the following: -On 12/23/20, check #1292 to the resident for $200.00; -On 12/23/20, cash ticket-personal spending with a withdrawal of $50.00. Record review of the resident's Resident Trust Disbursement Check Request Form, dated 12/23/20, showed the following: -No check number documented; -Amount of $200.00; -Payee: Resident #9; -For: Personal Christmas; -Resident #9's signature. Record review of a copy of check #1292 showed the following: -Payee: Resident #9; -Amount of $200.00 on 12/23/20; -BOM and Licensed Practical Nurse (LPN) K's signature the front of the check; -Resident #9 and the BOM signed the back of the check. Record review of the facility's records showed no documentation or verification the resident received the money after the BOM cashed the resident's check #1292. Record review of the resident's answers to the facility investigation, dated 3/29/21, showed the following: -Do you receive quarterly statements for your trust account? No; -How often do you request cash? I don't request cash; -Do you sign every time you receive cash? Yes, when they go shopping. During an interview on 4/1/21, at 9:30 A.M., the resident said the following: -He/she did not receive the October 2020 through December 2020 quarterly statement. -He/she did not request $50.00 or $200.00 on 12/23/20. He/she would not ask for that much in cash and could not use it anyway. -He/she never kept money in his/her room except $2.00. 4. Record review of Resident #18's face sheet showed the following: -admitted to the facility on [DATE]; -re-admitted to the facility from the hospital on [DATE]; -Diagnoses included acute (short-term) respiratory disease-Coronavirus, low blood pressure, and anxiety disorder; -The resident was his/her own responsible party and primary financial contact. Record review of the resident's agreement concerning management of personal funds, dated and signed by the resident and BOM on 1/1/19, showed the following: -I hereby acknowledge that I have been advised of the right to manage my financial affairs and that I am not required to deposit personal funds with the facility; -I do, authorize this facility to manage personal funds in accordance with the facility's guideline regarding protection of resident funds. Record review of the resident's quarterly MDS, dated [DATE], showed the resident is cognitively intact. Record review of the resident's trust fund statement, dated 10/1/20 through 12/31/20, showed the following withdrawals: -On 10/19/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 10/20/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 10/23/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 10/27/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 10/27/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 10/28/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 10/30/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/2/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/5/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/9/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/11/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/13/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/16/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/17/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/19/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/20/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/23/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/24/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 11/25/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/1/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/2/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -on 12/3/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/4/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/8/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/9/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/10/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/11/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/14/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/15/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/16/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/17/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/18/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/21/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00; -On 12/22/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00. -On 12/23/20, check #1289 to the resident for $200.00; -On 12/23/20, cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00. Record review of the resident's Resident Trust Disbursement Check Request Form, dated 12/23/20, showed the following: -Check number not documented; -Payee: Resident #18; -Amount of $200.00; -For: Personal; -Resident #18's signature. Record review of a copy of check #1289 showed the following: -Payee: Resident #18; -Amount of $200.00 on 12/23/20; -BOM and LPN K's signatures on the front of the check; -Resident #18 and the BOM's signatures on the back of the check. Record review of the facility's records showed no documentation or verification the resident received the money after the BOM cashed the resident's check #1289. Record review of the resident's trust fund statement, dated 10/1/20 through 12/31/20, showed on 12/28/20 check #1296, to the resident for $300.00. Record review of the resident's Resident Trust Disbursement Check Request Form, dated 12/28/20, showed the following: -Check number not documented; -Payee: Resident #18; -Amount of $300.00; -For: Personal; -Resident #18's signature. Record review of a copy of check #1296 showed the following: -Payee: Resident #18; -Amount of $300.00 on 12/28/20; -The BOM and DON's signatures on the front of the check; -Resident #18 and the BOM's signatures on the back of the check. Record review of the facility's records showed no documentation or verification the resident received the money after the BOM cashed the resident's check #1296. During an interview on 3/30/21, at 2:35 P.M., the BOM said the following: -Resident #18 tried to make out a check to his/her family member. The BOM emailed corporate who said unless the facility had receipts to show purchases, the check (for cash) would have to be made out to the resident; -On 12/28/20, she cashed a $300.00 check for the resident. The resident told the BOM, he/she was going to mail the money to a family member. The BOM did not call the resident's family member to ensure he/she received the money the resident mailed. Resident #18 said he/she is going to mail the money. During an interview on 3/31/21, at 1:25 P.M., and 4/1/21, at 10:59 A.M., the activity director said she never saw Resident #18 with large amounts of cash or mailing cash in an envelope. During an interview on 3/31/21, at 11:10 A.M., the resident said the following: -He/she never gave his/her family member any money; -He/she did not buy envelopes or stamps to send cash in the mail. If he/she wanted to mail money, he/she would purchase a money order and get the receipt. During a phone interview on 3/31/21, at 11:43 A.M., the resident's family member said the following: -The resident never mailed him/her money; -The family member sent the resident envelopes and stamps, but not to mail money; -The resident had not been able to go shopping; -The resident would know if he/she gave anyone cash. During interviews on 3/30/21, at 1:11 P.M., and 3/30/21, at 2:30 P.M., the administrator said she did not know anything about the BOM mailing cash for residents. Record review of the resident's trust fund statement, dated 10/1/20 through 12/31/20, showed on 12/30/20 check #1297 to the resident for $400.00. Record review of the resident's Resident Trust Disbursement Check Request Form, dated 12/30/20, showed the following: -Check number not documented; -Payee: Resident #18; -Amount: $400.00; -For: Personal spending; -Resident #18's signature. Record review of a copy of check #1297 showed the following: -Amount of $400.00 on 12/30/20; -Payee: Resident #18; -The BOM and SSD's signatures on the front of the check; -Resident #18 and the BOM's signatures on the back of the check. Record review of the facility's records showed no documentation or verification the resident received the money after the BOM cashed the resident's check #1297. During an interview on 3/30/21, at 2:35 P.M., the BOM said on 12/30/20, the BOM cashed a $400.00 check and gave the resident the money. Record review of the resident's trust fund statement, dated 1/1/21 through 3/31/21, showed on 1/4/21 check #1302 to the resident for $700.00. Record review of the resident's Resident Trust Disbursement Check Request Form, dated 1/4/21, showed the following: -Check number not documented; -Payee: Resident #18; -Amount: $700.00; -For: Personal gift to self for room; -Resident #18's signature. Record review of a copy of check #1302 showed the following: -Amount of $700.00 on 1/4/21; -Payee: Resident #18; -The BOM and LPN K's signatures on the front of the check. -Resident #18 and the BOM's signature the back of the check. Record review of the facility's records showed no documentation or verification the resident received the money after the BOM cashed the resident's check #1302. During an interview on 3/30/21, at 2:35 P.M., the BOM said on 1/4/21, she cashed a $700.00 check for the resident. The resident said he/she was going to purchase clothes and get his/her hair done. Record review of the resident trust fund statement, dated 1/1/21 through 3/31/21, showed on 1/7/21 check #1303 to the resident for $700.00. Record review of the resident's Resident Trust Disbursement Check Request Form, dated 1/7/21, showed the following: -Check number not documented; -Payee: Resident #18; -Amount: $700.00; -For: Purchase items/personal for room (chest-type dresser and small nightstand); -Resident #18's signature. Record review of a copy of check #1303 showed the following: -Payee: Resident #18; -Amount of $700.00 on 1/7/21; -The BOM and SSD's signatures on the front of the check; -Resident #18 and the BOM's signatures the back of the check. Record review of the facility's records showed no documentation or verification the resident received the money after the BOM cashed the resident's check #1303. Record review of the resident trust fund statement, dated 1/1/21 through 3/31/21, showed on 1/7/21 cash ticket #cash cash to cash-personal spending with a withdrawal of $50.00. Record review of the resident's trust fund statement, dated 1/1/21 through 3/31/21, showed on 1/12/21 check #1307 to the resident for $800.00. Record review of the resident's Resident Trust Disbursement Check Request Form, dated 1/12/21, showed the following: -No check number listed on the form; -Payee: Resident #18; -Amount: $800.00; -For: Personal bank account to shop; -Resident #18's signature. Record review of a copy of check #1307 showed the following: -Payee: Resident #18; -Amount of $800.00 on 1/12/21; -The BOM and LPN K's signatures on the front of the check; -Resident #18 and the BOM's signatures on the back of the check. Record review of the facility's records showed no documentation or verification the resident received the money after the BOM cashed the resident's check #1307. Record review of the trust fund statement dated 1/1/21 through 3/31/21, showed on 1/14/2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to maintain sufficient staff to provide timely monitoring of two residents (Resident #26 and #31) for needed incontinent care; to provide bath/showers as preferred/needed for two residents (Resident #31 and #46); to provide adequate staff to assist four residents (Resident #7, #20, #26, and #41) with meals; and to answer call lights timely. The facility census was 49. Record review showed the facility did not provide a policy regarding frequency of showers or how often staff should make rounds/observations on residents. 1. Record review of the Resident Census and Conditions form, (form staff required to complete on annual survey) completed by the Director of Nursing, dated 3/29/21, showed the following information: -Census of 49 residents; -Twenty-eight residents required assistance of one to two staff for bathing; -Fifteen residents dependent on staff for bathing; -Forty-one residents required assistance of one to two staff for eating assistance; -One resident dependent on staff for eating assistance. 2. Record review of Resident #26's face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dementia (impairment of at least two brain functions, such as memory loss and judgment) with behavioral disturbance (agitation including verbal and physical aggression, wandering), history of falling, and excoriation (skin-picking) disorder. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 1/27/21, showed the following information: -Severe cognitive deficit; -Required extensive assistance of one to two staff with bed mobility, dressing, toileting, and personal hygiene; -Always incontinent of bladder and bowel. Record review of the resident's care plan, last reviewed 3/23/21, showed the following information: -Incontinent of bladder and wears briefs; -Provide incontinence care after each incontinent episode; -Apply moisture barrier to skin as needed. Observation on 3/30/21, showed the following -At 10:02 P.M., the resident rested in bed with his/her eyes open. The resident's bed was in low position with the fall mat on the floor. The resident's sheet and blanket lay on the floor next to the bed. The resident held his/her gown. The resident did not have on an incontinent brief. The bed pad showed a large visible wet area with yellow coloring visible to the edges of the pad. The room had a urine odor that permeated out to the hallway. The resident said, it is all wet; -At 10:15 P.M., the resident remained in bed with his/her eyes open and holding his/her gown, singing softly to self; -At 10:26 P.M., the resident's room had a strong urine odor that permeated out to the hallway, the resident was quiet with eyes open and holding onto his/her gown; -At 10:45 P.M., the resident lay on the bed with no clothing on, the pillow covering his/her upper legs, his/her left arm across his/her chest. The resident said, hey, do you have anything? It is all wet here; -At 11:00 P.M., the resident remained unclothed, a pillow across his/her private area, and left arm across his/her chest. The resident said, I have nothing here, it is all wet; -At 11:05 P.M., Licensed Practical Nurse (LPN) G passed the resident's room and went to the room next door to administer medications; -At 11:06 P.M., the resident remained unclothed in bed, with sheets and gown on the floor next to the bed, the resident sang quietly to self in bed; -At 11:08 P.M., LPN G left the room next door and passed the resident's room without entering and returned to the nurses' desk; -At 11:15 P.M., the resident lay in bed with eyes open, singing to self. The resident had the pillow covering from his/her chest to upper thighs. The gown and sheets lay on the floor. The room had a strong urine odor that permeated out to the hallway. The bed pad had a yellow ring that extended to the edges of the pad; -At 11:25 P.M., LPN G sat at the nurses' desk for the resident's hall. Certified Nurse Aide (CNA) C and CNA D provided resident care on a different hall. No CNA entered the resident's hall; - At 11:32 P.M., the resident remained in bed unclothed, pillow covering chest, abdomen, and private region. The room continued with a strong urine odor. The resident's gown and sheets lay on the fall mat on the floor; -At 11:49 P.M., CNA C entered the hall and passed the resident's room to get the clean linen cart from the end of the hall. The aide saw the resident with no clothing on while passing the room; -At 11:53 P.M., CNA C entered the resident's room and put on gloves. The CNA moved the wet bed linens and resident gown off the floor mat and moved them to the tile floor near the door. He/she provided incontinent care to the resident and a complete clothing change. The CNA completed a change of the full set of bed linens. During an interview on 3/30/21, at 10:21 P.M., Licensed Practical Nurse (LPN) G said he/she was the charge nurse for this shift and will complete any scheduled treatments and narcotics, LPN H will pass all resident medications. They did not have enough staff to get all care done timely and some nights there would be only one nurse's aide for the floor. LPN G said having two certified nursing assistants (CNAs) at night is rare. He/she had requested supplemental staffing. During an interview on 4/5/21, at 10:15 A.M., CNA B said staff should complete incontinent care on residents every two hours or sooner as needed. During an interview on 4/5/21, at 10:05 A.M., LPN F said residents are not put into bed with incontinent briefs on, the skin is left open to air to breathe. Staff should put an incontinent brief on if it is in the resident's care plan. The CNAs should be checking the residents every two hours and sooner as needed. 3. Record review of Resident #31's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease, multiple sclerosis (a potentially disabling disease of the brain and spinal cord), history of diarrhea, history or urinary tract infections (UTIs), rash, and other nonspecific skin eruption. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident is always incontinent of both bowel and bladder; -Toileting requires extensive one person assist; -Personal hygiene requires limited one person assist. Record review of the resident's care plan, last updated 2/16/21, showed the following: -The resident has urinary incontinence and wears incontinence briefs; -The resident has dementia, with a goal of preserving self-esteem, quality of life, and unmet needs; -The resident requires assistance with bathing, hygiene, dressing, grooming, and toileting. Observation and interview on 3/30/21, at 10:30 P.M., showed the following: -LPN H informed CNA C and CNA E that the resident was dirty and needed changed; -CNA E said he/she last checked the resident for incontinence at 7:00 P.M. (three and one-half hours prior) during rounds with the day shift CNA. Observation on 3/30/21, at 10:33 P.M., showed the following: -CNA C and CNA E entered the resident's room; -A pungent odor of feces and urine permeated the entire room; -The resident's bed linens were smeared with feces and the resident had visible feces under his/her fingernails; -Staff pulled the resident's covers down to reveal the resident wore no incontinent brief, the resident's bed pad was urine soaked and smeared with feces. The fitted sheet underneath was visibly wet and the resident's mattress had a visible wet circle the approximate size of a softball; -The resident's gown was urine soaked and smeared with feces. 4. Observation on 4/1/21, at 2:40 P.M., showed call lights alarmed for rooms 108, 305, 410, and 413. During an interview on 4/1/2021, at 2:57 P.M., CNA B said he/she was the only CNA on duty for today's day shift for all four resident halls. The second scheduled CNA had called in. LPN M (scheduled as the certified medication technician (CMT) for the shift) tried to help with resident care in between medications as he/she could. Observation on 4/1/2021, at 3:05 P.M., (25 minutes later) showed call lights continued alarming for room [ROOM NUMBER], 410, and 413. The nurse overhead paged for CNA to come to the nurses' station to put Resident #26 to bed. The resident sat in a Broda chair in the common area near the nurses' desk. During an interview on 4/5/2021, at 10:15 A.M., CNA B said call lights are answered the best staff can with only two aides working the four halls. 5. During an interview on 3/30/21, at 11:30 P.M., CNA E said the following: -Residents must wait longer for care due to CNA staffing shortages; -Residents frequently must wait 15-20 minutes for assistance resulting in increased incontinence of bowel and bladder; -Part of the time, the facility has no designated staff working in the COVID observation unit (a designated hall located behind closed doors). 6. During an interview on 3/31/21 at 12:17 A.M., LPN H said the following: -On the current shift (7:00 P.M. to 7:00 A.M.), he/she does not have sufficient CNAs to assign a designated staff member to stay in the COVID observation unit at all times (currently housing four residents); -Staff float from other halls to make rounds on the residents in the the observation hall; -The facility typically has two staff working as aides on the night shift for the entire facility; -Staff try to make rounds on all residents to check for incontinence and assist with toileting and repositioning every two hours; -The process of making rounds on the residents takes staff longer than two hours with current staffing numbers; -It typically takes the aides, three to four hours to complete a round on all residents needing assistance, depending on how many resident call lights the staff must answer; -The nurses do not have time to make rounds on all the residents; -The nurse said he/she spoke with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) about staffing concerns, but was told the facility is within minimum fire safety code requirements for staffing; -The DON and ADON said they were trying to hire more staff. 7. During an interview on 4/5/2021, at 3:22 P.M., the administrator said staff should check residents for incontinent care needs at the minimum every two hours and as needed. The nurses should round every two hours at the minimum to check resident conditions and to make sure they are okay, the nurses and aides should round on separate times so that the residents are being checked every hour. The nurses should be checking the new residents more frequently. He/she did not feel the facility had adequate staffing to complete resident cares and every two hour rounds. 8. Record review of Resident #46's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admitted to the facility on [DATE] from the hospital; -Own responsible party; -Diagnoses included Parkinson's disease (progressive nervous system disorder that affects movement), chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)). Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance of one staff with bed mobility, dressing, toileting, and personal hygiene; -Required physical assistance of one staff for part of the bathing activity. Record review of the resident's care plan, last reviewed 10/20/20, showed the following information: -Required assistance of one staff for activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Bathing/hygiene with assist of one staff as needed; -Dressing/grooming assist of one staff as needed. During interviews on 3/29/21, at 10:53 A.M., and on 4/01/2021, at 9:36 A.M., the resident said the following: -He/she would like to receive more than one shower per week; -I am an adult (male/female), I stink and feel dirty if I don't get more baths; -At home, the resident took a shower daily, but understood that could not happen here. He/she would like at least two times per week or preferably three; -Resident had been told there is not enough staffing for further baths. Record review of the resident's skin inspection sheets used by the shower aides, dated 1/1/2021 through 1/31/2021, showed the following information: -Resident received a shower on 1/4/2021; -Resident received a shower on 1/11/2021; -Resident received a shower on 1/18/2021; -Resident received a shower on 1/26/2021. Record review of the resident's skin inspection sheets used by the shower aides, dated 2/1/2021 through 2/28/2021, showed the following information: -Resident received a shower on 2/1/2021; -Resident received a shower on 2/8/2021; -Resident received a shower on 2/16/2021; -Resident received a shower on 2/22/2021; -Resident received a shower on 2/25/2021. Record review of the resident's skin inspection sheets used by the shower aides, dated 3/1/2021 through 3/31/2021, showed the following information: -Resident received a shower on 3/2/2021; -Resident received a shower on 3/8/2021; -Resident received a shower on 3/18/2021; -Resident received a shower on 3/24/2021; -Resident received a shower on 3/30/2021. 9. Record review of Resident #31's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease, multiple sclerosis (a potentially disabling disease of the brain and spinal cord), history of diarrhea, history or urinary tract infections (UTIs), rash, and other nonspecific skin eruption. Record review of the resident's quarterly MDS, dated [DATE] showed the following: -Resident is always incontinent of both bowel and bladder; -Toileting requires extensive one person assist; -Personal hygiene requires limited one person assist. Record review of the resident's care plan, last updated 2/16/21, showed the following: -The resident has urinary incontinence and wears incontinence briefs; -The resident has dementia, with a goal of preserving self-esteem, quality of life, and unmet needs; -The resident requires assistance with bathing, hygiene, dressing, grooming, and toileting. Record review of the staff completed the resident bath/shower sheets (indicating staff assisted with a shower on that occasion) showed showers were completed on the following day: -01/21/21; -01/28/21; -02/03/21; -02/19/21 -03/16/21 -03/24/21 -03/30/21. Record review of the residents nurse progress notes for January 2021 through March 2021 show the following: -Staff consistently recorded the resident was incontinent of bowel and bladder and wears incontinence briefs; -Staff did not document any addition baths given to the resident. 10. During an interview on 3/31/21, at 3:33 P.M., LPN I said due to staffing shortages, the staff cannot give adequate assistance to residents with scheduled showers. 11. During interviews on 4/1/2021, at 1:15 P.M. and 1:51 P.M., CNA A (a shower aide) said the facility had two shower aides, the second shower aide had been away for approximately three weeks due to an emergency. Even with two shower aides, the residents had only been getting one shower a week recently. CNA A had been pulled to the floor to help with cares and then unable to give showers. With only one shower aide, it is not possible to shower every resident. Each resident is supposed to get two showers a week. However, recently residents have only been getting one shower a week, even when both shower aides are working. One of the shower aides is pulled from shower duty to work the floor as a CNA quite often, and this has been occurring since about October, 2020. The CNA did not give every resident on schedule a shower today, and he/she will be working as a CNA tomorrow, so no resident showers will be completed. The CNA said staff complete shower sheets for each time a shower is given. If no shower sheet is completed, it is assumed the resident did not receive a shower. 12. During an interview on 4/1/21, at 2:33 P.M., LPN F said said residents should be getting two showers a week, but one shower aide was out last week. 13. During an interview on 4/5/2021, at 10:15 A.M., CNA B said CNA A had been doing his/her best to get all showers done each week, now the second shower aide had returned from time off. 14. During interviews on 4/1/21, at 3:22 P.M., and 4/5/2021, at 1:15 P.M., the Director of Nursing (DON) said he/she would like for the resident to have showers at least two times per week. The facility had one shower aide out for the past three weeks due to an emergency. The residents should be in the shower at least one time per week and should be at least freshened up daily in their room. The shower aides complete shower sheets for each time a resident is bathed. Staff should also be recording the baths in the nurse progress notes. If no bath is recorded on the shower sheets or in progress notes, it must be assumed that the resident did not receive a bath. 15. During an interview on 4/5/2021, at 3:22 P.M., the administrator said resident showers have suffered the last couple weeks because of a shower aide being gone due to a family emergency. 16. Record review of Resident #7's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included anxiety disorder (intense, excessive and persistent worry and fear about everyday situations) due to known physiological condition (interferes with the way that the functions of the body are carried out), epilepsy (seizure disorder), dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and cognitive communication deficit (using spoken language and gestures, inability to initiate and sustain appropriate conversation). Record review of the resident's annual MDS, dated [DATE], showed the following information: -Severe cognitive deficit; -Required limited assistance of one staff to provide guidance for eating. Record review of the resident's care plan, last reviewed on 3/23/21, showed the following information: -Resident required meal tray set up and supervision and assistance with eating as needed; -Unable to use call light, check resident every 30 to 60 minutes for safety. 17. Record review of Resident #26's face sheet (basic information sheet) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dementia (impairment of at least two brain functions, such as memory loss and judgment) with behavioral disturbance (agitation including verbal and physical aggression, wandering), history of falling, and excoriation (skin-picking) disorder. Record review of the resident's admission MDS, a federally mandated comprehensive assessment instrument, completed by facility staff, dated 1/27/21 showed the following information: -Severe cognitive deficit; -Required extensive assistance of one staff for eating. Record review of the resident's care plan, last reviewed on 2/24/21, showed the following information: -Interventions will be in place to prevent nutritional decline; -Allow ample time to consume meals; -Encourage to eat meals in the main dining room; -Open cartons and plastic; -Offer condiments and assist as needed to meet taste for resident; -Monitor meal percentage consumption and encourage 75% intake. Notify charge nurse of less than 25% intake. 18. Record review of Resident #20's face sheet showed the following information: -re-admitted on [DATE]; -Diagnoses included multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves) with cognitive defects (impairment in an individual's mental processes that lead to the acquisition of information and knowledge), metabolic encephalopathy (brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and pseudobulbar affect (condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying) Record review of the resident's care plan, last reviewed 1/7/21, showed the following information: -Will maintain stable weight; -At times, resident will refuse to eat and/or not eat very well; -Open cartons and plastic for resident; -Offer resident condiments and assist as needed to meet resident tastes. Record review of the the resident's quarterly MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive assistance of one staff for eating. 19. Record review of the Resident #41's admission MDS, dated [DATE], showed the following information: -admitted [DATE]; -Cognitively intact; -Required extensive assistance with transfers and mobility; -Required limited assistance of one staff with meals. 20. Observation on 3/29/2021 showed the following: -At 11:56 A.M., there were 16 residents in the dining room; -At 12:04 P.M., Resident #7 sat in the Broda chair (a specialized type of wheelchair that assists in positioning and helps resolve seating issues such as slumping, sliding, poor lateral support and falls). CNA D assisted the resident with bites of food; -At 12:07 P.M., a randomly observed resident sat in a wheelchair at a table by him/her self. The resident had food and drink in front of him/her. The resident had not taken any bites of food or drank any of the drink that sat in front of him/her; -At 12:08 P.M., Resident #26 sat in the wheelchair at the table. Milk and juice remained sealed with plastic wrap. Resident drank a shake; -At 12:09 P.M., CNA D encouraged Resident #7 to take bites of food. The resident's water and juice drinks remained full; -At 12:10 P.M., CNA D took off the plastic wrap on the juice cup for Resident #26 and encouraged the resident to drink. The resident had mashed potatoes, carrot, and beef each in a separate bowl. The CNA did not offer a bite of food; -At 12:11 P.M., Resident #41 drank some of his/her juice, the water and milk cup remained full. Staff did not offer the resident assistance or cueing; -At 12:13 P.M., CNA D provided bites of potato to Resident #20. The resident's water and juice cups remained full; -At 12:23 P.M., staff pushed another resident in a wheelchair out of the dining room. The resident had drank the water and about 2/3 of his/her juice and the shake. The resident did not eat any pears or carrots and had taken a few bites from the meat and potato. Staff did not ask the resident if he/she was done with the meal and did not offer any further meal assistance; -At 12:25 P.M., CNA D helped Resident #7 with bites of meat and potato, the resident had not drank any water or juice and did not eat any carrots. The CNA did not offer a drink to the resident; -CNA D was the only staff present assisting resident with eating their meals. During an interview on 3/29/2021, at 12:13 P.M., CNA D said there is usually more staff assisting in the dining room, but there are no shower aides on the schedule today. Observation on 3/30/2021, in the dining room, showed the following: -At 12:08 P.M., CNA A sat next to Resident #7, assisted the resident to eat bites of food with silverware and assisted with drink cups; -At 12:16 P.M., he/she moved over to Resident #41, took the spoon the resident had been holding and assisted with bites of the meal; -At 12:17 P.M., he/she got up and adjusted Resident #20's clothing protector at the resident's hairline; -At 12:18 P.M., he/she returned to Resident #7 and picked up the spoon and offered the resident bites; -At 12:18 P.M., he/she moved over to Resident #20 and opened the pudding container and handed the pudding to the resident; -At 12:19 P.M., he/she moved over to Resident #41 and picked up the spoon and offered bites of pudding; -At 12:20 P.M., he/she returned to Resident #7. He/she picked up the resident's cup and assisted with drink of juice, picked up the fork and assisted with bites of cake; -At 12:22 P.M., he/she put a napkin into the resident's hand and encouraged the resident to wipe his/her mouth; -At 12:24 P.M., CNA A asked other staff to bring a glove to him/her; -At 12:25 P.M., CNA A put a glove on his/her right hand and wiped Resident #7's face and lips; -At 12:26 P.M., CNA A disposed of the glove and washed hands at sink; -At 12:26 P.M., CNA A returned to Resident #7 and assisted with drink of juice; -At 12:29 P.M., CNA A moved to Resident #20 and picked up the resident's fork that resident had been using and assisted with bites of cake; -Seventeen residents in the dining room with approximately five to eight residents that needed assistance and/or cueing. -Once trays and drinks served, CNA A was the only staff member in the dining room assisting and/or cueing residents to eat. 21. During an interview 4/1/21 at 1:50 P.M., CNA A said there is not enough staff available for meal assistance. I wouldn't want to eat cold food. Since residents have returned to eating in the dining room, for about two months, it has just been him/her assisting resdients with eating. For breakfast time in the dining room, there are no other staff. He/she has to pass trays and food, and also assist residents with eating. For all meals there are about 20 residents who eat in the dining room. He/she added that when there are two staff in the dining room, it runs pretty smooth 22. During an interview on 4/05/21, at 3:22 P.M., the administrator said that before COVID there was a meal calendar for all department supervisors to be in the dining room. There was to be one nurse during meal time, the CMT is supposed to go in there to help, and at least one to two CNA's. The shower aides are to go in the dining room for feeding assistance. Staffing is not usually this sparse. There are four to five residents that need staff assistance and several that need encouragement or to be cued. MO00174712, MO00174790, MO00179984, MO00180760, MO00180853, and MO00181554.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #33's admission MDS, dated [DATE], showed the following: -admitted to the facility from the hospital on 8/16/18; -Cognitively intact; -Diagnoses of diabetes mellitus, diabetes mellitus with diabetic neuropathy (nerve damage caused by diabetes), and unspecified dementia without behavioral disturbance. Record review of the resident's care plan, dated 2/23/21, showed the following: -Staff to provide resident with medications as ordered -See physician orders for current routine or as needed medication order; -Monitor me for effectiveness. Record review of the resident's physician order sheet, dated 1/1/21-3/1/21, showed the following: -Diagnoses of Type 2 diabetes mellitus without complications and Type 2 diabetes mellitus with diabetic neuropathy unspecified; -A current order for Novolog (quick acting insulin) U-100 Insulin aspart (insulin aspart u-100) solution, 100 unit/ml, one unit every 10 mg/dL above 150 mg/dL blood glucose level, three times a day before each meal (7:30 A.M., 12:00 P.M., 4:30 P.M.). Record review of the resident's nurse MAR, dated 1/01/21-3/31/21, showed the following for administration of the Novolog order:. -On 01/05/21, at 7:30 A.M., staff noted an accucheck of 435 mg/dL and administration of 16 units of insulin. (The ordered dose was 28 units.); - On 01/05/21, at 12:00 P.M., staff noted an accucheck of 435 mg/dL and administration of 34 units of insulin (The ordered dose was 28 units.); - On 01/07/21, at 7:30 A.M., staff noted a blood sugar result of 261 mg/dL and administration of 10 units of insulin. (The ordered dose was ordered dose of 11 units.); - On 01/10/21, at 4:30 P.M., staff noted a blood sugar result of 498 mg/dL and administration of 35 units of insulin (The ordered dose was 34 units.); - On 01/14/21, at 4:30 P.M., staff noted a blood sugar result of 226 mg/dL and administration of eight units of insulin. (The ordered dose was seven units); - On 01/15/21, at 12:00 P.M., staff noted a blood sugar result of 307 mg/dL and administration of 16 units of insulin.(The ordered dose was 15 units.); -On 01/15/21, at 4:30 P.M., staff noted a blood sugar result of 245 mg/dL and administration of 10 units of insulin. (The ordered dose was nine units.); -On 01/19/21, at 7:30 A.M., staff noted a blood sugar result of 237 mg/dL and administration of nine units of insulin. (The ordered dose was eight units.); -On 2/11/21, at 7:30 A.M., staff noted a blood sugar result of 198 mg/dL and administration of five units of insulin. (The ordered dose was four units.); -On 2/11/21, at 4:30 P.M., staff noted a blood sugar result of 219 mg/dL and administration of seven units of insulin. (The ordered dose was six units.); -On 2/12/21, at 7:30 A.M., staff noted a blood sugar result of 188 mg/dL and administration of four units of insulin. (The ordered dose was three units.); -On 2/12/21 at 12:00 P.M., a blood sugar result of 265 mg/dl, and administration of 12 unit of insulin (instead of the ordered dose of 11 units.); -On 2/12/21, at 4:30 P.M., staff noted a blood sugar result of 229 mg/dL and administration of eight unit of insulin. (The ordered dose was seven units.); -On 2/16/21, at 12:00 P.M., staff noted a blood sugar result of 236 mg/dL and administration of six units of insulin. (The ordered dose was eight units.); -On 2/21/21, at 4:30 P.M., staff noted a blood sugar result of 256 mg/dL and administration of eight units of insulin. (The ordered dose was ten units.); -On 2/28/21, at 4:30 P.M., staff noted a blood sugar result of 506 mg/dL and administration of five units of insulin. (The ordered dose was 35 units.); -On 3/11/21, at 7:30 A.M., staff noted a blood sugar result of 264 mg/dL and administration of 10 units of insulin. (The ordered dose was 11 units.); -On 3/15/21, at 12:00 P.M., staff noted a blood sugar result of 268 mg/dL and administration of 12 units of insulin. (The ordered dose was 11 units.); -On 3/16/21, at 7:30 A.M., staff noted a blood sugar result of 187 mg/dL and administration of four units of insulin. (The ordered dose was three units.); -On 3/15/21, at 12:00 P.M., staff noted a blood sugar result of 268 mg/dL and administration of 12 unit of insulin. (The ordered dose was 11 units.); -On 3/18/21, at 7:30 A M., staff noted a blood sugar result of 176 mg/dL and administration of three units of insulin. (The ordered dose was two units.); -On 3/25/21, at 4:30 P.M., staff noted a blood sugar result of 208 mg/dL and administration of three units of insulin. (The ordered dose was five units.); During an interview on 04/01/21, at 10:00 A.M., Certified Nurse Aide (CNA) B said the following: -The resident is on a diabetic diet; -The resident sometimes follows the diet. During an interview on 04/01/21, at 10:08 A.M., LPN F said the following: -The resident is on diabetic order; -The facility had a sliding scale and added set insulin because the blood sugar was running in the 500's and 600's, but it is down now. 4. During an interview on 4/5/21, at 10:00 A.M. CNA J said the following: -The nurses should know what residents take insulin because they do the accuchecks; -Symptoms of low blood sugar include sweating, unresponsive or slow with communication; -Symptoms of high blood sugar include delusions, irritability, increase in urine; -Staff should notify the nurse if they notice signs of low or high blood sugar. 5. During on 4/05/21, at 10:26 A.M., LPN I said the following: -Some residents have standing orders or a sliding scale; -The physician orders the sliding scale; -The sliding scale orders can be confusing at times and staff have to pay attention when they calculate the amount of insulin needed; -Staff should calculate the sliding scale with a calculator. 6. During an interview on 4/05/21, at 11:06 A.M., the DON said the following: -Nurses should view the MAR on the computer system for residents who receive insulin. The MAR will show up as a green color when the insulin is due; -Nurses should look at the insulin order for how many units to administer and if there is a sliding scale; -There are insulin orders for one unit for each 10 over 150 and one unit for every five over an amount; -The physician gives the order for the amount of the sliding scale; -Staff should calculate the sliding scales with a calculator or on paper; -Nurses should not round up the blood sugar amounts; -Nurses administer the insulin and provide the accuchecks; -The nurse practitioner comes to the facility once a week and reviews the insulin amounts given and determines if the insulin needs to be increased or decreased; -Nurses should give the correct dose of insulin due to the physician order -She expects the nurses to calculate and administer the insulin as ordered and correctly; -The physician sets the baseline of the resident's sugar level. 7. During an interview on 4/5/21, at 3:29 P.M., the administrator said the following: -Staff should document the insulin amount administered; -She would expect the staff to give the insulin dose that is ordered by the physician; -The physician is specific with the insulin orders and expects the staff to follow the insulin dose ordered. 2. Record review of Resident #39's admission MDS, dated [DATE], showed the following: -admitted to the facility from the hospital on 2/16/21; -Cognitively intact; -Diagnoses of nephrotic syndrome (a collection of symptoms due to kidney damage), diabetes mellitus, congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), high blood pressure, and edema (swelling). Record review of the resident's current care plan, revised on 3/7/21, showed staff did not address the resident's diabetes diagnosis for need for insulin. Record review of the resident's nurse MAR, dated 2/16/21-3/16/21, showed the following: -An order, dated 2/16/21, for Humalog KwikPen insulin (insulin lispro) 100 units/milliliter (ml), administer one unit for every 20 mg/dL over 150 mg/dL, subcutaneously; -On 2/18/21, at 4:30 P.M., staff noted a blood sugar result of 205 mg/dL and administration of three units of insulin. (The ordered dose was two units.); -On 2/19/21, at 7:30 A.M., staff noted a blood sugar result of 233 mg/dL and administration of three units of insulin. (The ordered dose was four units.); -On 2/21/21, at 11:30 A.M., staff noted a blood sugar result of 240 mg/dL and administration of five units of insulin. (The ordered dose was four units.); -On 2/21/21, at 4:30 P.M., staff noted a blood sugar result of 166 mg/dL and administration of one unit of insulin. (The ordered did not direct administration of insulin.); -On 2/24/21, at 7:30 A.M., staff noted a blood sugar result of 229 mg/dL and administration of four units of insulin. (The ordered dose was three units.); -On 2/24/21, at 11:30 A.M., staff noted a blood sugar result of 267 mg/dL and administration of six units of insulin. (The ordered dose was five units.); -On 2/25/21, at 7:30 A.M., staff noted a blood sugar result of 192 mg/dL and administration of four units of insulin. The ordered dose was two units); -On 2/25/21, at 11:30 A.M., staff noted a blood sugar result of 204 mg/dL and administration of three units of insulin. (The ordered dose was two units.); -On 2/26/21, at 11:30 A.M., staff noted a blood sugar result of 165 mg/dL and administration of one unit of insulin. (The order did not direct administration of insulin.); -On 2/26/21, at 4:30 P.M., staff noted a blood sugar result of 164 mg/dL and administration of one unit of insulin. (The order did not direct administration of insulin.); -On 3/2/21, at 11:30 A.M., staff noted a blood sugar result of 202 mg/dL and administration of three units of insulin. (The ordered dose was two units.); -On 3/2/21, at 4:30 P.M., staff noted a blood sugar result of 169 mg/dL and administration of one unit of insulin. (The order did not direct administration of insulin.); -On 3/6/21, at 11:30 A.M., staff noted a blood sugar result of 300 mg/dL and administration of eight units of insulin. (The ordered dose was seven units.); -On 3/7/21, at 11:30 A.M., staff noted a blood sugar result of 245 mg/dL and administration of five units of insulin. (The ordered dose was four units.); -On 3/7/21, at 4:30 P.M., staff noted a blood sugar result of 209 mg/dL and administration of three units of insulin. (The ordered dose was two units.); -On 3/12/21, at 7:30 A.M., staff noted a blood sugar result of 226 mg/dL and administration of four units of insulin. (The ordered does was three units). Record review of resident's nurse MAR, dated 3/17/21- 4/02/21, showed the following: -An order, dated 2/16/21, for Humalog KwikPen insulin (insulin lispro) 100 units/ml, administer one unit for every 20 mg/dL over 150 mg/dL, subcutaneously; -On 3/19/21, at 4:30 P.M., staff noted a blood sugar result of 215 mg/dL and administration of four units of insulin. (The ordered dose was three units.); -On 3/20/21, at 7:30 A.M., staff noted a blood sugar result of 267 mg/dL and administration of six units of insulin. (The ordered dose was five units.); -On 3/21/21, at 11:30 A.M., staff noted a blood sugar result of 367 mg/dL and administration of 11 units of insulin. (The ordered dose was ten units.); -On 3/24/21, at 7:30 A.M., staff noted a blood sugar result of 326 mg/dL and administration of nine units of insulin. (The ordered dose was eight units). Observation and interview on 3/29/21, at 11:30 A.M., showed the following: -The resident said he/she had a diagnosis of diabetes; -The resident said his/her blood sugars were running higher recently due to steroid use; -The resident voiced no concerns over his/her insulin dosage. Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to administer the correct dose of insulin per the physician's order for three residents (Resident #33, Resident #34 and Resident #39). The facility census was 49. Record review showed the facility did not provide a policy regarding administration of sliding scale insulin 1. Record review of Resident #34's face sheet showed the following: -Resident admitted to the facility on [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), hypertension (high blood pressure), and Type 2 diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 2/13/21, showed the following information: -Cognitively intact; -Diagnoses included diabetes; -Received insulin injections seven of the seven days in the assessment lookback period. Record review of the resident's current care plan showed staff did not address the resident's diabetes or insulin administration. Record review of the resident's active physician orders, dated 1/1/2021 through 4/5/21, showed the following: -An order, start date 4/22/20, for Humalog U-100 Insulin (insulin lispro - a fast acting insulin) solution, 100 unit/milliliters (ml) per sliding scale, subcutaneous (under the skin), one unit of insulin for every 20 milligram/deciliter (mg/dL) of blood glucose reading over blood glucose of 150 mg/dL before meals (8:00 A.M., 12:00 P.M. and 5:00 P.M.). Record review of the resident's January 2021 Medication Administration Record (MAR) showed an order, start date 4/22/20, for the following: -Humalog U-100 Insulin (insulin lispro) solution 100 unit/ml, administer, per sliding scale, subcutaneous, administer one unit of insulin for every 20 mg/dL over blood glucose of 150 mg/dL: -On 1/5/21, at 5:00 P.M., staff noted the resident's accucheck (blood sugar level) as 184 mg/dL. The nurse administered two units of insulin.(The ordered dose was one unit.); -On 1/8/21, at 5:00 P.M., staff noted the resident's accucheck as 243 mg/dL. The nurse administered five units of insulin.(The ordered does was four units.); -On 1/10/21, at 5:00 P.M., staff noted the resident's accucheck as 224 mg/dL. The nurse administered four units of insulin.(The ordered dose was three units.); -On 1/14//21, at 5:00 P.M., staff noted the resident's accucheck as 225 mg/dL. The nurse administered four units of insulin.(The ordered dose was three units.); -On 1/17/21, at 5:00 P.M., staff noted the resident's accucheck as 215 mg/dL. The nurse administered four units of insulin.(The ordered dose was three units.); -On 1/21/21, at 12:00 P.M., staff noted the resident's accucheck as 280 mg/dL. The nurse administered seven units of insulin.(The ordered dose was six units.); -On 1/27/21 at 5:00 P.M., staff noted the resident's accucheck was 266 mg/dL. The nurse administered three units of insulin.(The ordered does was five units). Record review of the resident's February 2021 MAR, showed an order, start date 4/22/20, for the following: -Humalog U-100 Insulin (insulin lispro) solution, 100 unit/ml, per sliding scale, subcutaneous, before meals, administer one unit of insulin for every 20 mg/dL over blood glucose of 150 mg/dL: -On 2/4/21, at 5:00 P.M., staff noted the resident's accucheck as 225 mg/dL. The nurse administered four units of insulin.(The ordered dose was three units.); -On 2/6/21, at 12:00 P.M., staff noted the resident's accucheck as 183 mg/dL. The nurse administered two units of insulin.(The ordered dose was one unit.); -On 2/16/21, at 5:00 P.M., staff noted the resident's accucheck as 233 mg/dL. The nurse administered six units of insulin.(The ordered dose was four units.); -On 2/21/21, at 12:00 P.M., staff noted the resident's accucheck as 243 mg/dL. The nurse administered five units of insulin.(The ordered dose was four units.); -On 2/24/21, at 12:00 P.M., staff noted the resident's accucheck as 265 mg/dL. The nurse administered four units of insulin.(The ordered dose was five units.); -On 2/25/21, at 12:00 P.M., staff noted the resident's accucheck as 226 mg/dL. The nurse administered four units of insulin.(The ordered dose was three units.); -On 2/25/21, at 5:00 P.M., staff noted the resident's accucheck was 240 mg/dL. The nurse administered five units of insulin. (The ordered dose was four units.); -On 2/26/21, at 5:00 P.M., staff noted the resident's accucheck was 167 mg/dL. The nurse administered one unit of insulin.(The order did not instruct insulin to be given.); -On 2/27/21, at 8:00 A.M., staff noted the resident's accucheck was 174 mg/dL. The nurse administered two units of insulin.(The ordered does was one unit.); -On 2/28/21, at 12:00 P.M., staff noted the resident's accucheck was 289 mg/dL. The nurse administered five units of insulin.(The ordered dose was six units). Record review of the resident's March 2021 MAR showed an order, start date of 4/22/20, for the following: -Humalog U-100 Insulin (insulin lispro) solution, 100 unit/ml, per sliding scale, subcutaneous, before meals, administer one unit of insulin for every 20 mg/dL over blood glucose of 150 mg/dL: -On 3/2/21, at 12:00 P.M., staff noted the resident's accucheck was 248 mg/dL. The nurse administered three units of insulin.(The ordered dose was four units.); -On 3/5/21, at 12:00 P.M., staff noted the resident's accucheck was 183 mg/dL. The nurse administered two units of insulin.(The ordered dose was one unit.); -On 3/12/21, at 5:00 P.M., staff noted the resident's accucheck was 183 mg/dL. The nurse administered two units of insulin.(The ordered dose was one unit.); -On 3/23/21 at 12:00 P.M., staff noted the resident's accucheck was 177 mg/dL. The nurse administered two units of insulin.(The ordered does was one one unit.); -On 3/26/21 at 12:00 P.M., staff noted the resident's accucheck was 240 mg/dL. The nurse administered five units of insulin.(The ordered dose was four units). During on 4/05/21 at 10:26 A.M. Licensed Practical Nurse (LPN) I said the resident had incorrect units of insulin administered for the dates shown (above). During an interview on 4/05/21, at 11:06 A.M. the Director of Nursing (DON) said the following: -The resident's insulin amounts on the January, February, and March 2021 MAR noted were incorrect insulin amounts (noted above); -She said it looks like the nurses are rounding up the blood sugar amounts.

Based on observation, interview, and record review, the facility failed to wash or sanitize hands per nursing standards for infection control when providing incontinent care and/or grooming for six residents (Resident #7, #20, #26, #31, #41 and #152). The facility had a census of 49. Record review of the facility's policy titled, Nursing Guidelines Manual, Handwashing, dated March 2015, showed the following information: -Turn on the water and adjust temperature; -Soap hands well; -Rub hands briskly, paying special attention to area between fingers; -Use brush to clean under nails as necessary; -Rinse with hands lowered to allow soiled water to drain directly into sink; -Do not splash water onto clothing; -Do not allow hands to touch sink; -Use disposable hand towel to turn off faucet and dry hands well, especially between fingers; -Apply moisture barrier if desired. Record review of the facility's policy titled, Nursing Guidelines Manual, Hand Cleanser (Antiseptic), dated March 2015, showed the following information: -Place the container of antiseptic solution on the medication cart or in a secure area not accessible to residents; -Wash and dry hands thoroughly in preparation for resident care; -Administer medication or provide care to resident as indicated; -Apply recommended amount of antiseptic cleanser into the palm of the hand; -Rub hands briskly until cleanser has evaporated. Record review of Centers for Disease Control and Prevention (CDC) guidance titled, Hand Hygiene in Healthcare Settings, dated January 30, 2020, showed the following information: -Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient; -Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices; -Before moving from work on a soiled body site to a clean body site on the same patient; -After touching a patient or the patient's immediate environment; -After contact with blood, body fluids, or contaminated surfaces; -Immediately after glove removal. 1. Observation on 3/30/2021, at 2:37 P.M., showed the following: -Certified Nursing Assistant (CNA) B assisted Resident #7 from the broda chair (a specialized type of wheelchair that assists in positioning and helps resolve seating issues such as slumping, sliding, poor lateral support and falls) to sit on the bed. He/she laid the resident down; -CNA B rolled the resident towards the wall, pulled down the resident's pants, removed his/her socks and pants, and rolled the resident to his/her back. The CNA applied gloves without washing hands or using hand sanitizer, and picked up wash cloths and peri-care spray; -The CNA unhooked the resident's incontinent brief and rolled the resident to the left side, he/she removed the wet brief and sprayed the resident's buttock. He/she rolled the resident to his/her back and sprayed the resident's front private area and wiped the area with the cloth. The CNA placed the soiled cloth into a trash liner that was on the bed until cares were completed; -With the same gloved hands, the CNA pulled down the resident's gown, pulled the resident's blanket up, lowered the resident's bed, and applied the top blanket; -With the same gloved hands, the CNA moved the broda chair and put the fall mat on the floor; -The CNA removed the gloves and washed hands at the sink. 2. Observation on 3/30/2021, at 11:45 P.M., showed the following: -CNA C entered Resident #26's room and put on gloves, without using hand sanitizer or washing his/her hands; -CNA C moved wet bed linen and a gown off the floor mat and put them onto the tile floor near the door: -The CNA said, going to change you, you are dirty; -The CNA grabbed the bed pad, pulled the resident up in the bed, and untucked the corners of the sheet from the bed; -The CNA removed his/her gloves, without washing or sanitizing his/her hands, left the room, went to the hallway and obtained clean linens from the linen cart; -The CNA put on new gloves without washing hands or using hand sanitizer. The CNA picked up the resident's pillow off the top of the resident and set it onto the bedside chair; -The CNA took the wet wipes container out of the bedside table drawer and wiped the front of the resident's private area, then rolled the resident to his/her right side. CNA C then wiped the back of the thighs and buttock with a wet wipe and then wiped a spot on the bed with the same wipe. CNA C applied cream to the resident's buttock with the same gloved hands and then rolled the resident to his/her back and applied cream to the inner upper thighs with the same gloved hands; -The CNA removed the gloves and applied new gloves, without washing hands or using hand sanitize; -The CNA picked up the clean sheet and bed pad and put it on the left side of the bed, then rolled the resident to the left. The resident held onto the wet linens and the CNA assisted and encouraged the resident to release the dirty linen. The CNA removed the wet linens and placed the wet linens onto the end of the bed. The dirty linen rested on top of the resident's right foot. -The CNA pulled the clean linens through to the right side of the bed and rolled the resident to his/her back and put the sheet bed corners into place. The CNA then applied a clean gown onto the resident; -CNA C removed the wet linens and gown from the floor and put them into a bag. The CNA sat the bag back on the foot of the bed at the resident's feet; -Without changing gloves or washing/sanitizing his/her hands, the CNA put on a clean top sheet, picked up the pillow from the bedside chair, removed the pillow case, and placed the pillow to the resident's right side and the pillow case into the linen bag; -With the same gloved hands, the CNA picked up the resident's two dolls from the chair and placed them into the resident's right arm on the bed. The CNA then removed his/her gloves removed the trash can liner containing the soiled brief and wet wipes from from the trash can and placed them on top of the laundry bag at the foot of the resident's bed; -Without washing hands or using hand sanitizer, the CNA opened the room door and got a blanket and pillow case from the clean linen cart. The CNA put the pillow case on the pillow and put the blanket onto the resident's bed; -The CNA then picked up the laundry and trash bags, put the wet wipes in the resident's bedside table drawer and left the room; -Without washing or sanitizing his/her hands, the CNA walked down the hall to the soiled utility room. The CNA did not wash hands or use hand sanitizer in the soiled utility room. The CNA returned to the same hall and moved the clean linen cart to the next resident room (Resident #20 and #7) and entered the room without washing hands or using hand sanitizer. Observation on 3/31/2021, at 12:01 A.M. showed the following: -CNA C entered Resident #20's room and put on gloves, without washing hands or using hand sanitizer; -The CNA took wash cloths into the bathroom, wet the washcloths, rolled the resident to the left side, wiped the resident's buttocks with the wet cloth, rolled the dirty bed pad under the resident, and placed the clean pad under the right side. The CNA rolled the resident to the right side and pulled the bed pad through; -The CNA touched the resident's gown, with the same gloved hands, to ensure the gown was not wet; -The CNA rolled the resident to his/her back and pulled up the bed sheet and blanket; -The CNA removed his/her gloves, without washing hands or using hand sanitizer, and walked over to the roommate, Resident #7. Observations, on 3/31/2021, showed the following: -At 12:06 A.M., CNA C picked up the call lights from the floor and untangled the cords. He/she attached one call light cord on to Resident #7's bed and one call light to Resident #20's bed; -At 12:08 A.M., the CNA moved Resident #7's bed covers and gown to check for incontinence. Without completing hand hygiene, the CNA moved to the hallway and obtained clean linens and gown, re-entered the resident's room with clean supplies and put on gloves, without washing hands or using hand sanitizer. The CNA looked through the resident's bedside table for wet wipes and could not locate any. The CNA removed the gloves, and without completing hand hygiene, left the room and obtained clean wash cloths from the linen cart, took the cloths to the bathroom, and wet the cloths. The CNA applied new gloves and began personal cares with the resident. The CNA did not wash hands or use hand sanitizer between glove changes or between residents. 3. Observation on 3/31/21, in Resident #152's room, showed the following: -At 10:20 A.M., CNA B and CNA D applied face masks and goggles to enter the resident's room (new admission on isolation). The resident said he/she could not wait for the toilet and had a bowel movement on the bed pad. CNA D applied gloves and emptied the urinal from the bedside table. He/she then removed his/her gloves, and without washing hands or using hand sanitizer, applied new gloves; -At 10:21 A.M., CNA B applied gloves without sanitizing his/her hands or using hand sanitizer. The CNA took the wash cloths to the sink and wet the wash cloths. CNA D removed the dirty linens from the bed; -At 10:23 A.M., CNA B removed his/her gloves, without washing hands or using hand sanitizer, left the room and obtained a clean gown from the linen cart in the hall; -At 10:24 A.M., CNA B re-entered the resident's room with the clean gown, and without washing hands or using hand sanitizer, applied new gloves. The CNA removed the resident's soiled gown and the resident rolled to his/her left side. CNA B wiped bowel movement off the resident's buttock. CNA B rolled the dirty pad under the resident and placed the clean bed pad under the resident. The CNA applied cream to the resident's buttock area with the same soiled gloves; -At 10:27 A.M., the resident rolled to his/her right side. CNA D removed the dirty bed pad and pulled the clean bed pad through. CNA B wiped the resident's front private area with cloth, applied cream, and removed gloves while wearing the same soiled gloves; -At 10:28 A.M., CNA B applied new gloves, without washing his/her hands or using hand sanitizer. CNA B and CNA D repositioned the resident in bed and applied a clean top sheet. 4. Observation on 3/30/2021, at 10:22 P.M., showed the following: -CNA C and CNA E assisted Resident #41 with incontinent care; -Both CNAs had gloves on; -The CNAs pulled down the resident's blankets to reveal a wet gown and urine soaked incontinent bed pad under the resident; -Both CNAs cleaned the urine off the resident's skin using wet washcloths; -Wearing the same gloves, the CNAs rolled the resident side-to-side and placed a clean incontinent bed pad under the resident; -After completing peri-care, the CNAs changed their gloves, without performing hand hygiene; -The CNAs pulled the bedding up over the resident and placed the resident's call light in reach. 5. Observation on 3/30/2021, at 10:33 P.M., showed the following: -CNA C and CNA E were assisting Resident #31 with incontinent care; -The resident had feces and urine on his/her skin and bedding; -While wearing gloves, CNA E used a wet wash cloth to wipe the resident's skin; -CNA E then rolled the dirty bedding up under the resident; -CNA E changed his/her gloves without washing or sanitizing his/her hands; -CNA E placed clean bedding on the resident's bed and covered the resident with a sheet; -CNA E adjusted the resident's head pillow and picked up the resident's call light and fastened it to his/her sheet; -While wearing gloves, CNA C assisted with rolling the resident side to side and handling and bagging the dirty bedding; -CNA C handed the resident a toy doll, wearing the same gloves; -CNA C then removed his/her gloves, without washing his/her hands, and exited the room; -CNA C walked to the clean linen cart in the hallway and touched the cart and other clean bedding; -CNA C picked up a clean blanket and brought it to the resident's room; -Without washing or sanitizing his/her hands, CNA C then covered the resident with the blanket. 6. During an interview on 3/31/21, at 10:27 A.M., CNA D said that staff should wash hands after completing any resident cares. (The CNA did not say hand hygiene should be completed between glove changes.) 7. During an interview on 4/5/2021, at 10:15 A.M., CNA B said hand hygiene should be completed before and after any resident care. When completing incontinent care, staff should change gloves after cleaning up the resident and before putting on clean clothing. (The CNA did not say hand hygiene needed completed between glove changes.) 8. During an interview on 4/5/2021, at 10:05 A.M., Licensed Practical Nurse (LPN) F said staff should complete hand hygiene before and after each resident interaction. Hand hygiene should be completed before resident incontinent care and before putting on residents' clean clothing. He/she said during incontinent care, staff should complete hand hygiene after touching anything dirty and before starting the clean task. Staff should wash hands after taking off dirty gloves and before putting on clean gloves. 9. During an interview on 4/5/2021, at 1:15 P.M., the Director of Nursing (DON) said hand hygiene should be completed before and after every resident interaction. Staff should wash or sanitize their hands each time they change gloves. At least annually and at orientation staff are educated on hand hygiene. 10. During an interview on 4/5/2021, at 3:22 P.M., the administrator said staff should complete hand hygiene every time they put clean gloves on and every time they go into the resident room. Hands should be washed before putting on new gloves to do the next task. The staff should stop and wash hands between any dirty to clean contact. MO00174790

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for three residents (Residents #15, #31, and #52). The facility census was 89. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. 1. Record review of Resident #15's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services started 12/20/18; -Last covered day of Medicare Part A service as 1/30/19; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS-10055 or alternative denial letter. 2. Record review of Resident #31's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services episode start date 1/07/19; -Last covered day of Medicare Part A service as 2/14/19; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS-10055 or alternative denial letter. 3. Record review of Resident #52's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services episode start date 2/07/19; -Last covered day of Medicare Part A service as 3/22/19; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS-10055 or alternative denial letter. 4. During an interview on 4/3/19, at 9:50 A.M., the Assistant Director of Nursing (ADON) said she did not know anything about the SNF ABN CMS-10055 form or that it was required to be completed and if the notification was not required to complete an explanation of why the form was not issued. The ADON said she was only trained to complete and issue the NOMNC CMS-10123 form. 5. During an interview on 4/08/19, at 3:45 P.M., the administrator said she expected both notices to be given to residents going off Medicare Part A services.

Based on interview and record review, the facility failed to provide prompt (within 24 hours) mail delivery when staff failed to deliver mail to residents on Saturdays. The facility census was 89. 1. During the group interview on 4/02/19, at 11:03 A.M., Residents #10, #13, #20, #24, #56, #59, #65 and #68 said the following: -They do not receive any mail on Saturdays; -The mail they would receive on Saturdays is given to them on Mondays; -The Activity Director passes the mail Monday through Friday; -There are no staff who deliver the mail scheduled to work on Saturdays; -They would like to receive mail on Saturdays just like they did when they were at home. During an interview on 4/05/19, at 1:00 P.M., the Activities Director said the following: -She picks up the mail from the mailbox and deliver it Monday through Friday; -The activity staff do not work on the weekends; -She does not know who is responsible for delivering the mail to the residents on Saturday. During an interview on 4/05/19, at 2:00 P.M., the administrator said: -The mail should be delivered to residents Monday through Saturday; -She did not know the residents were not getting their mail delivered to them on Saturdays.

Based on interview and record review, the facility failed to screen all staff for prior history of possible abuse when staff failed to check the nurse aide (NA) registry for a federal indicator (indicating possible prior abuse) for four staff (Director of Nursing (DON), Assistant Business Office Manager (ABOM), Dietary Aide (DA) A, and Housekeeper (HK) B) of six sampled staff. The facility census was 89. 1. Record review on 4/05/19 of DON's personnel file showed the following information: -Date of hire 5/01/18; -Staff did not complete the NA registry check. 2. Record review on 4/05/19 of the ABOM's personnel file showed the following information: -Date of hire 3/04/19; -Staff did not complete the NA registry check. 3. Record review on 4/05/19 of DA A's personnel file showed the following information: -Date of hire 3/06/19; -Staff did not complete the NA registry check. 4. Record review on 4/05/19 of HK B's personnel file showed the following information: -Date of hire 3/13/19; -Staff did not complete the NA registry check. 5. During an interview on 4/05/19, at 10:25 A.M., the assistant business office manager said she did not know the NA registry check had to be completed on all staff. 6. During an interview on 4/05/19, at 10:40 A.M., the administrator said the NA registry should be checked on all new employees prior to hire.