Based on observation, interview, and record review, the facility failed to provide showers for one resident (Resident #1) out of four sampled residents. The facility's census was 39 Review of facility's policy titled, Bath, Shower/Tub dated 2001, showed: - The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Resident will have bath/shower per their request; - Documentation: the date, time the shower/tub bath was performed; name and title of who performed shower/tub bath; all assessment data (skin assessment) obtained during shower/tub bath; If resident refused the shower/tub bath and reasons; Notify supervisor if the resident refuses the shower/tub bath with reasons. Review of Resident #1's medical record showed: - An admission date of 02/04/25; - Diagnoses of hypertension (high blood pressure), Peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), chronic obstructive pulmonary disease (a group of lung diseases that block airflow, making it difficult to breath), chronic pain, arthritis, Stage Three Pressure Ulcers ( involves full-thickness skin loss, exposing the subcutaneous tissue) and Stage Two Pressure Ulcer (involves partial-thickness skin loss, exposing the dermis, and may present as a shallow open ulcer with a red or pink wound bed, or as an intact or open/ruptured blister. The wound bed should be viable); - Minimum Data Set (MDS) showed resident is dependent, requires partial/moderate assistance with shower/bathing and personal hygiene; - Progress notes, 04/24/25 to 5/22/25 showed no documentation related to refusal of showers or not receiving showers. Review of facility's shower assignment sheet showed resident was scheduled for showers every Wednesday and Saturday. Review of Resident #1's weekly shower sheets 05/02/25 to 05/22/2025 showed He/She received a shower on Monday, 05/02/25, and Thursday, 05/15/25 Observation of Resident #1 showed his/her hair to be greasy and a general unkempt appearance. During an interview on 05/22/25 at 1:00 P.M. Resident #1 said: - He/She has not had a shower in the past ten days; - He/She frequently went without showers for ten to fourteen days; - He/ She did want his her showers twice a week. During an interview on 05/22/25 at 1:20 P.M., Certified Nurse Assistant (CNA) A said: - Residents are scheduled for showers at least twice a week; - A shower sheet is completed for resident and the CNA signs off and turns it in to the charge nurse; - If a resident refuses a shower, the resident signs a refusal if able and it is reported to the charge nurse to follow up on; - Any abnormalities or problems are reported to the charge nurse. During an interview on 05/22/25 at 1:28 P.M., Licensed Practical Nurse (LPN) B said: - Residents are assigned showers twice a week; - Shower list is at the nurses station; - If a resident refused a shower, staff will go back later and offer shower again; - The CNAs complete shower sheets and turn in to charge nurse and charge nurse reviews them, signs them and turns them in to the Director of Nurses. During an interview on 05/22/25 at 4:00 P.M., the Director of Nurses (DON) said: - Residents are assigned showers twice a week; - Shower list is at the nurses station; - If resident refused shower, staff will go back later and offer shower again; - The CNAs complete shower sheets and turn in to charge nurse and charge nurse reviews them, signs them and turns them in to the Director of Nurses; - Resident # 1 did not complain about not getting showers twice a week so did not know there was a problem about him/her not getting showers; - Residents should receive showers at least twice a week and should have follow up to ensure they are receiving showers. Compliant #MO00254267

Based on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #191) out of one sampled resident. The facility census was 37. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed: - A baseline plan of care is developed for each resident within 48 hours of admission to meet the resident's immediate health and safety needs; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care; - The resident and/or representative are provided a written summary of the baseline care plan that includes, but not limited to: stated goals and objectives of the resident, summary of the resident's medications and dietary instructions, any services/treatments to be administered by the facility, and any updated information based on the details of the comprehensive care plan, as necessary; - Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Review of Resident #191's Physician Order Sheet (POS), dated January 2025, showed: - An admission date of 01/14/25; - Diagnoses of unspecified atrial fibrillation (rapid, irregular heartbeats), chronic kidney disease, stage 4 (severe kidney damage), heart failure (when the heart does not pump or fill adequately), hypertension (high blood pressure), and diabetes mellitus (DM - a condition that affects the way the body processes blood sugar); - An order for wound care to a Stage II (a partial-thickness of dermis presenting as a shallow open ulcer) sacral (lower back and spine) wound every day, cleanse with wound cleanser, apply MediHoney (a type of wound dressing), cover with foam boarder dressing, dated 01/14/25. Review of the resident's Baseline Care Plan, dated 01/15/25, showed: - The Stage II sacral wound with interventions not addressed. During an interview on 01/22/25 at 4:15 P.M., the Director of Nursing (DON) said a baseline care plan should include the resident's needs, such as a wound. During an interview on 01/22/25 at 4:50 P.M., the Administrator said a baseline care plan should be individualized and include the resident's immediate needs. It should be signed by the resident or representative. If the resident was unable to sign and did not have a representative, then two nurses should document it was reviewed with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Residents #4, #5, #12, and #38) out of 12 sampled residents. The facility census was 37. Review of the facility's policy titled, Care Plans - Comprehensive, revised September 2010, showed: - An individualized comprehensive care plan that includes measurable timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident; - The facility's Care Planning/Interdisciplinary Team (IDT - a group of healthcare professionals from diverse fields who work in a coordinated effort toward a common goal for a resident), in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest functioning the resident may be expected to attain; - The comprehensive care plan is based on a thorough assessment that includes, but not limited to, the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff); - Each resident's comprehensive care plan is designed to aid in preventing or reducing declines in the resident's functional status and/or functional levels; - Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools, including Care Area Assessments, before interventions are added to the care plan; - Assessments of residents are ongoing and care plans are revised as information about the resident's condition change. 1. Review of Resident #4's medical record showed: - admitted on [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure (difficulty breathing due to lungs cannot get enough oxygen), gastrointestinal esophageal reflux disease (GERD - stomach acid being forced back into the throat region), diabetes mellitus (DM - a condition that affects the way the body processes blood sugar) and tobacco use. Review of the resident's weights showed: - On 07/03/24, the resident weighed 191.9 pounds (lbs.); - On 01/02/25, the resident weighed 169.6 lbs.; - A significant weight loss of 11.62% within the last six months. Review of the resident's January 2025 Physician's Order Summary (POS), showed: - An order for mirtazapine (an antidepressant also used as an appetite stimulant) 15 milligrams (mg) by mouth one time a day, dated 01/02/25; - An order for monthly weights, dated 07/15/24; - An order for a regular texture, regular/thin consistency diet, dated 07/08/24. Review of the resident's Care Plan, dated 12/31/24, showed: - Did not address the significant weight loss with specific interventions to meet the individual's needs. 2. Review of Resident's #5 medical record showed: - admitted on [DATE]; - Diagnoses of hypertension, diabetes mellitus, depression (a mental health condition that involves a prolonged low mood or loss of interest in activities), hemiplegia (a condition that causes weakness or paralysis on one side of the body), bipolar disease (a mental illness that causes changes in a person's mood, energy, activity levels, and concentration), an unstageable (a wound that is covered by dead tissue, making it impossible to determine the stage of the wound), and tobacco use. Review of the resident's January 2025 POS showed: - An order to cleanse the left buttock with house cleanser daily, dated 12/31/24; - An order for Santyl (a wound debridement) apply to the left buttock topically one time a day for wound treatment and ABD (a thick abdominal pad used for absorbency) pad to wound daily and as needed, dated 12/31/24. Review of the resident's Care Plan, dated 11/23/24, showed: - Did not address the wound with specific interventions to meet the individual's needs. 3. Review of Resident's #12 medical record, showed: - admitted on [DATE]; - Diagnoses of diabetes mellitus, non-pressure chronic ulcer (wound) of the left heel, pulmonary embolism (a blood clot that blocks arteries in the lungs), epilepsy (recurrent, unprovoked seizures), cerebral infarction (stroke), malignant neoplasm of the bronchus or lung (lung cancer), and sepsis (systemic infection with life-threatening organ dysfunction). Review of the resident's January 2025 POS showed: - An order for hydrocodone-acetaminophen (pain medication) 5-325 mg by mouth every 6 hours as needed for pain, dated 12/12/24; - An order for apixaban (an anticoagulant medication) 5 mg by mouth two times a day, dated 11/29/24. Review of the resident's Care Plan, dated 12/2/24, showed: - Did not address the pain management with specific interventions to meet individual needs; - Did not address the anticoagulant use with specific interventions to meet individual needs. 4. Review of Resident #38's medical record, showed: - admitted on [DATE]; - Diagnoses of COPD, emphysema (difficulty breathing due to damaged airways in the lungs) and Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors). Review of the resident's weights showed: - For 12/05/24, the resident weighed 117.1 lbs.; - For 01/15/25, the resident weighed 104.9 lbs.; - A significant weight loss of 10.42% within the last 30 days. Review of the resident's January 2025 POS, showed: - An order for weekly weights, dated 12/04/24; - An order for a regular texture, regular/thin consistency diet, dated 12/04/24. Review of the resident's Care Plan, dated 12/31/24, showed: - Did not address the significant weight loss with specific interventions to meet the individual's needs. During an interview on 01/22/25 at 3:57 P.M., the Director of Nursing (DON) said she would expect the care plan to reflect the resident's individualized care needs. During an interview on 01/22/25 at 4:35 P.M., the Administrator said she would expect a resident with a weight loss, pressure ulcer, anticoagulant, or a pain concern to be addressed on the resident's care plan with specific interventions in place. This should be updated as needed to reflect the resident's current care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for oxygen (O2) for two residents (Residents #3 and #14) out of three sampled residents and wound care for one resident (Resident #5) out of three sampled residents. The facility's census was 37. Review of the facility's policy titled, Oxygen Administration, dated October 2010, showed: - The purpose of the procedure is to provide guidelines for safe oxygen administration; - Verify that there is a physician's order for this procedure; - Review the the physician's orders or facility's protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident; - While the resident is receiving oxygen therapy, assess for cyanosis (blue tone to the skin), hypoxia (low level of oxygen in the tissues), oxygen toxicity (lung damage that happens from breathing in too much extra or supplemental oxygen) and vital signs. The facility did not provide a policy on following physician orders. 1. Review of Resident #3's medical record, showed: - admitted on [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure (difficulty breathing due to lungs cannot get enough oxygen), dependence on oxygen and tobacco use. Review of the resident's January 2025 Physician Order Sheet (POS) showed: - An order for O2 at 6 liter (L) per via nasal cannula (tubing used to provide O2 to people who need extra O2) continuous two times a day, dated 07/9/24; - An order to obtain saturation and pulse O2 (SPO2 - a measurement of the amount of O2 in a person's blood) as needed, dated 07/22/24; - An order for O2 tubing and humidifier change one time a day every Monday night shift and PRN (as needed), dated 07/09/24. Review of the resident's January 2025 Medication Administration Record (MAR) showed: - Resident received O2 at 6 L between 01/01/25 - 01/22/25. Review of the resident's care plan, revised 11/10/24, showed: - Administer O2 as ordered; - Monitor SPO2 as ordered and PRN. Observation on 01/20/25 at 10:19 A.M., showed the resident lay in bed watching television with the O2 concentrator in use at 8 L per nasal cannula. Observation on 01/20/25 at 2:19 P.M., showed the resident lay in bed playing a game on his/her phone with the O2 concentrator in use at 8 L per nasal cannula. Observation on 01/21/25 at 8:19 A.M., showed the resident lay in bed with his/her eyes closed and the O2 concentrator in use at 8 L per nasal cannula. Observation on 01/22/25 at 8:31 A.M., showed the resident lay in bed listening to music with the O2 concentrator in use at 8 L per nasal cannula. During an interview on 01/22/25 at 10:23 A.M., the resident said he/she asked a staff member to turn up his/her O2 concentrator a couple of weeks ago. The increase in the O2 helped him/her breathe better. 2. Review of Resident's #5 medical record showed: - admitted on [DATE]; - Diagnoses of hypertension, diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), depression (a mental health condition that involves a prolonged low mood or loss of interest in activities), hemiplegia (a condition that causes weakness or paralysis on one side of the body), bipolar disease (a mental illness that causes changes in a person's mood, energy, activity levels, and concentration), an unstageable (a wound that is covered by dead tissue, making it impossible to determine the stage of the wound) and tobacco use. Review of the resident's January 2025 POS showed: - An order to cleanse the left buttock with house cleanser daily, dated 12/31/24; - An order for Santyl (a wound debridement) apply to the left buttock topically one time a day for wound treatment and ABD (a thick abdominal pad used for wound absorbency) pad to the wound daily and PRN, dated 12/31/24. Observation on 01/21/25 at 4:03 P.M., of the resident's wound care showed: - Licensed Practical Nurse (LPN) A cleaned the buttock with wound cleanser; - LPN A removed gloves, sanitized his/her hands, and put on gloves; - LPN A applied Santyl to a non-adherent (a non-stick dressing for wound coverage) dressing by dabbing the top of the Santyl tube on the dressing; - LPN A placed the dressing over the wound area; - LPN A secured the dressing with tape; - LPN A did not apply the Santyl to the resident's wound as ordered. During an interview on 1/23/25 at 11:40 A.M., LPN A said he/she would clean the area with wound cleanser, pat dry and apply Santyl to the non-adherent dressing. He/She had been doing this repetitively for three weeks and knew where to place the dressing after doing it so much. 3. Review of Resident #14's medical record showed: - admitted on [DATE]; - Diagnoses of hypertension, diabetes mellitus, depression, COPD, and Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors). Review of the resident's January 2025 POS showed: - An order for O2 at 6 L per via nasal cannula continuous two times a day, dated 07/11/24; - An order to obtain SPO2 PRN, dated 07/22/24; - An order for O2 tubing and humidifier change one time a day every Monday night shift and PRN, dated 07/15/24. Review of the resident's January 2025 MAR showed: - The resident received O2 at 6 L between 01/01/25 - 01/22/25. Observation on 01/21/25 at 9:25 A.M., showed the resident lay in bed with the O2 concentrator in use at 4 L per nasal cannula. Observation on 01/21/25 at 12:12 P.M., showed the resident sat in the dining room with the O2 concentrator in use at 4 L per nasal cannula. Observation on 01/22/25 at 10:40 A.M., showed the resident lay in bed with the O2 concentrator in use at 4 L per nasal cannula. During an interview on 01/21/25 at 9:26 A.M., the resident said he/she did not know what the setting on the O2 concentrator should be. During an interview on 01/23/25 at 12:02 P.M., the Director of Nursing (DON) said she would expect staff to follow the physician's orders as written. Santyl should be placed on the area of concern and never on the dressing. She would expect nursing staff to check the O2 concentrators to make sure a resident received the the prescribed O2 liter. She would expect nursing staff to check vital signs and contact the physician prior to any changes made related to the O2 level for a resident. During an interview on 01/22/25 at 4:33 P.M., the Administrator said she would expect physician's orders to be followed at all times related to wound care treatments and O2. She would expect nursing staff to check a resident with an O2 order to ensure it was at the prescribed liter of oxygen. She would expect nursing to follow up on a resident's request to increase his/her oxygen first by checking the resident's oxygen level and contacting the physician before making the change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order for a house supplement recommendation by the registered dietician (RD) and failed to ensure the RD completed a nutritional assessment due to significant weight loss for four residents (Residents #4, #24, #34 and #38) out of four sampled residents. The facility census was 37. Review of the facility's policy titled, Monthly Dietary Consultant Report, undated, showed: - A report of RD activities shall be made in writing or completed electronically and provided to the facility in hard copy or electronic format at the close of each consultation; - The monthly consultant report is to: serve as a communication tool between consultations, provide documentation that a consultation was provided according to state and federal regulations, avoid verbal misunderstanding of RD recommendations and findings, assist the consultant in planning for future consultations, assist the Dining Service Manager in correcting areas of deficiency, and assist nursing staff in follow up with RD recommendations; - The Dietary Consultation Report Form documents the following: date and time of consultation, summary of important activities, residents receiving visitation and/or consultation with RD, resident nutritional assessment and consultation, meal service observation and findings, request for diet change and/or revision of resident's diet order, inspection on all equipment, personnel, systems, and miscellaneous items in the dining service department, recommendations on future action, progress on previous recommendations, in-service education conducted and/or provided, outside activities and telephone consultations, date of next consultation, may be used to identify problems or priority, and may be used to monitor food cost. Review of the facility's policy titled, Nutritional Assessment, dated October 2017, showed: - As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident; - The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment time frames) and as indicated by a change in condition that places the resident at risk for impaired nutrition; - As part of the comprehensive assessment, the nutritional assessment will by a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Review of the facility's policy titled, Weight Assessment and Intervention, dated March 2022, showed: - Resident weights are monitored for undesirable or unintended weight loss or gain; - Residents are weighed upon admission and at intervals established by the interdisciplinary team; - Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation; - Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time; - The threshold for significant unplanned and undesired weight loss will be base on the following criteria: a. One month-5% weight loss is significant, greater than 5% is severe; b. Three months-7.6% weight loss is significant, greater than 7.5% is severe; c. Six months-10% weight loss is significant, greater than 10% is severe; - If the weight change is desirable, this is documented; - Undesirable weight change is evaluated by the treatment team whether or not the criteria for the significant weight change has been met; - The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia (reduction in appetite and food intake), weight loss or increasing the risk of weight loss. Review of the dietary department's House Supplement Resident List, dated 01/22/25, showed: - Resident #4 received a house supplement for breakfast, lunch and supper; - Resident #24, Resident #34, and Resident #38 not on the list of house supplements. 1. Review of Resident #4's medical record showed: - admitted on [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure (difficulty breathing due to lungs cannot get enough oxygen), gastrointestinal esophageal reflux disease (GERD - stomach acid being forced back into the throat region), diabetes mellitus (DM - a condition that affects the way the body processes blood sugar) and tobacco use. Review of the resident's weights showed: - On 07/03/24, 191.9 pounds (lbs.); - On 08/02/24, 187.1 lbs.; - On 09/03/24, 186.2 lbs.; - On 10/02/24, 194.5 lbs.; - On 12/25/24, 171.5 lbs.; - On 01/02/25, 169.6 lbs.; - A severe weight loss of 11.62% within the last six months. Review of the resident's RD nutrition progress notes, dated 03/12/24 - 06/13/24, showed: - A recommendation for house supplement three time a day (TID), dated 03/12/24; - A recommendation for house supplement TID, dated 06/13/24. Review of the resident's January 2025 Physician's Order Summary (POS), showed: - An order for mirtazapine (an antidepressant medication also used as an appetite stimulant) 15 milligrams (mg) by mouth one time a day, dated 01/02/25; - An order for a regular texture, regular/thin consistency diet, dated 07/18/24; - An order for monthly weights, dated 07/15/24; - No order for a house supplement TID. Review of the resident's care plan, dated 12/31/24, showed: - Unexpected/planned weight loss due to acute illness; - A goal to consume 75% of two of three meals a day; - Offer substitutes as requested or indicated. Review of the resident's dietary card showed: - Likes and dislikes; - A house supplement TID. Observations on 01/20/25 at 12:27 P.M., 01/21/25 at 12:17 P.M., and 5:27 P.M., and 01/22/25 at 12:20 P.M., showed: - Resident ate his/her meal in the main dining room with no house supplement provided. During an interview on 01/22/25 at 2:37 P.M., the resident said he/she was supposed to get a house shake every meal, but didn't always get one. 2. Review of Resident #24's medical record showed: - admitted on [DATE]; - Diagnoses of Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking and behavior), major depressive disorder (persistent feelings of sadness, hopelessness and loss of interest), anxiety (feelings of unease, worry, fear or apprehension), and paranoid personality disorder (extreme and long-term distrust of others). Review of the resident's weights showed: - On 11/08/24, 184.6 lbs.; - On 12/05/24, 173.3 lbs.; - A severe weight loss of 6.1% within the last 30 days. Review of the resident's RD progress notes, dated 12/26/24, showed: - A recommendation of a house supplement once daily, dated 12/26/24; - No documentation of nutrition assessment completed. Review of the resident's January 2025 POS showed: - An order for monthly weights, dated 07/11/24; - An order for a regular diet, regular texture, regular/thin consistency, dated 06/24/24; - No order for a house supplement daily. Observations on 01/20/25 at 12:25 P.M., 01/21/25 at 12:12 P.M., and 5:25 P.M., and 01/22/25 at 12:22 P.M. showed: - Resident ate his/her meal in the main dining room with no house supplement provided. 3. Review of Resident #34's medical record showed: - admitted on [DATE]; - Diagnoses of hypertension and GERD. Review of the resident's weights showed: - On 07/03/24, 174.2 lbs.; - On 08/02/24, 173.9 lbs.; - On 09/03/24, 180.7 lbs.; - On 10/02/24, 177.6 lbs.; - On 11/05/24, 160.4 lbs.; - On 12/09/24, 158.3 lbs.; - On 01/02/25, 157.6 lbs.; - A weight loss of 9.5% within the last six months; - A severe weight loss of 11.2% within the last three months. Review of the resident's RD progress notes, dated 11/29/24 - 12/26/24, showed: - No recommendations for the visit, dated 11/29/24; - A recommendation for house supplement once daily, dated 12/26/24; - No documentation of a nutrition assessment completed. Review of the resident's January 2025 POS showed: - An order for weekly weights, dated 11/01/24; - No order for a house supplement daily; - An order for a regular diet, regular texture, regular/thin consistency, dated 07/04/24. Observations on 01/20/25 at 12:25 P.M., 1/21/25 at 12:12 P.M., and 5:25 P.M., and 01/22/25 at 12:22 P.M. showed: - Resident ate his/her meal in the main dining room with no house supplement provided. During an interview on 01/22/25 at 12:30 P.M., the resident said he/she did not ever get a supplement. 4. Review of Resident #38's medical record showed: - admitted on [DATE]; - Diagnoses of COPD, emphysema (difficulty breathing due to damaged airways in the lungs) and Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors). Review of the resident's weights showed: - On 12/05/24, 117.1 lbs.; - On 12/09/24, 102.4 lbs.; - On 12/18/24, 101.7 lbs.; - On 12/23/24, 106.8 lbs.; - On 01/02/25, 104.6 lbs.; - On 01/09/25, 103.8 lbs.; - On 01/15/25, 104.9 lbs.; - A severe weight loss of 10.42% within the last 30 days. Review of the resident's RD nutrition progress note, dated 12/23/24, showed: - Weight down 10.3 lbs. since admission with an 8.8% significant weight loss; - A recommendation for house supplement BID. Review of the resident's January 2025 POS showed: - An order for weekly weights, dated 12/04/24; - An order for a regular texture, regular/thin consistency diet, dated 12/04/24; - No order for a house supplement BID. Review of the resident's Care Plan, dated 12/10/24, showed: - Did not address severe weight loss with specific interventions to meet the individual needs. Review of the resident's dietary card showed: - Likes and dislikes; - Did not address a house supplement BID. Observations on 01/20/25 at 12:20 P.M. and 8:16 A.M., showed: - Resident ate his/her meal in his/her room with no house supplement provided. Observations on 01/21/25 at 12:24 P.M. and 12:04 P.M., showed: - Resident ate his/her meal in the main dining room with no house supplement provided. During an interview on 01/22/25 at 3:13 P.M., the resident said he/she had never received a shake at mealtimes since admission to the facility. He/She didn't remember the RD discussing a house shake. During an interview on 01/20/25 at 9:24 A.M., the Dietary Manager (DM) said he/she had spoken with the RD on the phone but never in person. The RD came to the facility after hours when the DM was gone and also came on the weekends when he/she was not working. He/She was notified of any dietary recommendations at the morning department head meetings. During an interview on 1/22/25 at 3:40 P.M., the Director of Nursing (DON) said she would think 24-48 hours turn around time for RD recommendations would be timely. She would like to see the RD at the facility during the day shift. The RD needed to see every resident and not just the ones that had weight loss. Recommendations were done by the RD and emailed to the Social Services Designee (SSD) and the Administrator. The Administrator forwarded the RD recommendations to the DON. During an interview on 01/22/25 at 4:33 P.M., the Administrator said she would expect a dietary recommendation from the RD to be addressed in a timely manner to ensure nutritional needs were being met and followed for the resident. She would like to see the RD in the building during the day shift more and not after hours or on weekends. The RD only saw residents that had a weight loss. The Administrator said she knew the facility had a problem with the RD only seeing the residents with weight loss and the recommendations. During an interview on 01/29/25 at 2:25 P.M., the RD said he/she did not assess every resident on a monthly basis, but was in the facility once monthly. He/She observed meals, assessed residents that triggered for weight loss, assessed new admissions, and resident's with significant changes. The RD said when he/she completed the monthly report, it was emailed to the Administrator. The nutrition assessments were completed annually, upon admission, with a significant change, and re-admissions.

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two sampled medication carts. This practice had the potential to affect all residents. The facility census was 37. Review of the facility's policy, titled, Controlled Substances, revised November 2022, showed: - Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; - Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; - The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the Director of Nursing (DON) services. 1. Review of the 100 Hall Certified Medication Technician (CMT) Narcotic Count Log for Controlled Substances on 01/22/25 at 9:45 A.M., showed: - For the 5 A.M. - 11 P.M. shift on 10/02/24 - 11/11/24, the staff missed 80 out of 80 opportunities to reconcile the narcotics; - For the 11 P.M. - 5 A.M. shift on 11/18/24 - 12/16/24, the staff missed 39 out of 64 opportunities to reconcile the narcotics; - For the 11 P.M. - 8 A.M. shift on 12/16/24 - 01/15/25, the staff missed 22 out of 44 opportunities to reconcile the narcotics; - For the 5 A.M. - 5 A.M. shift on 01/06/25 - 01/19/25, the staff missed 18 out of 27 opportunities to reconcile the narcotics. 2. Review of the 200 Hall CMT Narcotic Count Log for Controlled Substances on 01/22/25 at 10:17 A.M., showed: - For the 5 A.M. - 11 P.M. shift on 10/02/24 - 11/11/24, the staff missed 80 out of 80 opportunities to reconcile the narcotics; - For the 5 A.M. - 6 A.M. shift on 11/12/24 - 12/10/24, the staff missed 24 out of 60 opportunities to reconcile the narcotics; - For the 11 P.M. - 5 A.M. shift on 12/10/24 - 01/01/25, the staff missed 11 out of 54 opportunities to reconcile the narcotics; - For the 5 A.M. - 5 A.M. shift on 01/02/25 - 01/19/25, the staff missed 26 out of 35 opportunities to reconcile the narcotics. During an interview on 01/22/25 at 9:21 A.M., Licensed Practical Nurse (LPN) A said it should be the off-going staff and the on-coming staff completing the narcotic reconciliation and signing the Narcotic Count Log. During an interview on 01/22/25 at 4:04 P.M., the DON said two staff should reconcile the narcotic count on each shift. During an interview on 01/22/25 at 4:47 P.M., the Administrator said the narcotics should be reconciled with the off-going staff and the on-coming staff on each shift.

Based on interview and record review, the facility failed to monitor the drug regimen for unnecessary medications by not ensuring the as needed (PRN) psychotropic (medications that affect a persons mental state) medication orders were limited to 14 days unless specific duration and clinical rationale were provided for one resident (Resident #18) out of five sampled residents and one resident (Resident #19) outside the sample. The facility failed to ensure a gradual dose reductions (GDR) was attempted for four residents (Residents #7, #14, #18 and #24) out of five sampled residents. The facility failed to ensure an appropriate diagnosis for the use of a psychotropic medication for one resident (Resident #24) out of five sampled residents. The facility census was 37. Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction, revised July 2022, showed: - Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs; - The physician will order appropriate tapering of medications, as indicated. Review of the facility's policy titled, Medication Regimen Review, revised May 2019, showed: - The consultant pharmacist reviews the medication regimen of each resident at least monthly; - The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication; - Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated; - Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medications irregularity. The report contains: the resident's name, the name of the medication, the identified irregularity, and the pharmacist's recommendation; - An irregularity refers to the use of a medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services; - The consultant pharmacist provides the Director of Nursing (DON) services and the Medical Director with a written, signed and dated copy of all medication regimen reports. The facility did not provide a PRN psychotropic medication policy. 1. Review of Resident #7's January 2025 Physician Order Sheet (POS) showed: - Diagnoses of depression (a mental health condition that involves a prolonged low mood or loss of interest in activities) and psychotic disorder (a mental disorder characterized by a disconnection from reality); - An order for bupropion (an antidepressant medication) 100 milligram (mg) by mouth (PO) daily for psychotic disorder, dated 10/15/24; - An order for topiramate (a seizure medication) 50 mg PO twice daily for psychotic disorder, dated 10/04/24; - An order for divalproex (a seizure medication) 500 mg PO for psychotic disorder, dated 10/04/24. Review of the resident's Pharmacy Consultant Report, dated 12/23/24, showed: - A recommendation to change bupropion to 75 mg PO daily; - A recommendation to change topiramate to 25 mg PO daily; - A recommendation to change change divalproex to 375 mg PO daily; - No physician/prescriber signature and date; - The facility failed to address the pharmacy recommendations with the physician. 2. Review of Resident #8's January 2025 POS showed: - Diagnoses of anxiety (persistent worry and fear about everyday situations), depression, post traumatic stress disorder (PTSD - psychological distress following a traumatic event), and history of falls; - An order for Valium (an antianxiety medication) 5 mg PO every 12 hours PRN for anxiety, revised 01/19/25, with no stop date; - An order for Depakote (used as a mood stabilizer) sprinkles 125 mg delayed release by mouth four times a day for mood stability, dated 11/21/24; - No standing order for labs while on chronic Depakote therapy. Review of the resident's Pharmacy Consultant Reports, dated 07/30/24, 09/28/24, 11/19/24, and 01/16/25, showed: - Recommendations to place a 14 day stop date on the medication Valium 5 mg PO every 12 hours PRN for anxiety; - Consider placing a standing order for labs while on chronic Depakote therapy if deemed to be clinically appropriate; - No documentation of a physical assessment and reason to continue or change the Valium medication; - No stop date for the Valium PRN order; - No physician/prescriber signature and date; - The facility failed to address the pharmacy recommendations with the physician. Review of the resident's medical record showed: - No documentation of a specific duration or clinical rationale provided by the physician for continuation of the PRN Valium medication order for longer than 14 days. Review of the resident's Medication Administration Record (MAR) dated July 2024 - January 2025, showed: - From 07/01/24 - 07/31/24, Valium 5 mg PO every 12 hours PRN for anxiety administered nine times; - From 08/01/24 - 08/31/24, Valium 5 mg PO every 12 hours PRN for anxiety administered 18 times; - From 09/01/24 - 09/30/24, Valium 5 mg PO every 12 hours PRN for anxiety administered 18 times; - From 10/01/24 - 10/31/24, Valium 5 mg PO every 12 hours PRN for anxiety administered 14 times; - From 11/01/24 - 11/30/24, Valium 5 mg PO every 12 hours PRN for anxiety administered eight times; - From 01/01/25 - 01/21/25, Valium 5 mg PO every 12 hours PRN for anxiety administered two times. 3. Review of Resident #14's January 2025 POS showed: - Diagnoses of depression; - An order for Abilify (an antipsychotic medication) 5 mg by mouth one time daily for depression related to major depressive disorder (persistent feelings of sadness, hopelessness and loss of interest), dated 07/17/24; - An order for duloxetine (an antidepressant medication) 60 mg by mouth once daily for depression related to major depressive disorder, dated 07/17/24. Review of the resident's Pharmacy Consultant Report, dated 07/30/24, showed: - A recommendation to change the Abilify to 2.5 mg by mouth once daily; - A recommendation to change the duloxetine to 40 mg one by mouth once daily; - No physician/prescriber signature and date; - The facility failed to address the pharmacy recommendations with the physician. 4. Review of Resident #18's January 2025 medical record showed: - Diagnoses of delusional disorder (a mental illness that makes it hard to distinguish between reality and imagination), bipolar disorder, major depressive disorder, anxiety, Alzheimer's disease (a progressive neurodegenerative disorder that affects memory, thinking and behavior), visual hallucinations (seeing things that are not present in reality), and auditory hallucinations (sensory perceptions of hearing in the absence of external stimulus); - An order for clonazepam (an antianxiety medication) 0.5 mg by mouth every 12 hours PRN for anxiety, dated 10/27/24, with no stop date. Review of the resident's Pharmacy Consultant Report, dated 9/28/24, showed: - The pharmacist did not address the clonzaepam PRN order; - No stop date for the clonzaepam PRN order recommended by the pharmacist; - No documentation of a physical assessment and reason to continue or change the clonazepam medication. Review of the resident's medical record showed: - No documentation of a specific duration or clinical rationale provided by the physician for continuation of the clonazepam longer than the 14 days. Review of the resident's MAR, dated November 2024 - January 2025, showed: - Clonazepam 0.5 mg by mouth every 12 hours PRN for anxiety, dated 10/27/24; - Clonazepam PRN not administered 11/01/24 - 01/21/25. 5. Review of Resident #19's January POS showed: - Diagnoses of anxiety, bipolar disorder (extreme mood swings or changes in energy, activity and concentration), and dementia (a group of conditions characterized by impairment of at least two brain functions); - An order for olanzapine (an antipsychotic medication) 5 mg PO every 8 hours PRN, dated 10/17/24. Review of the resident's Pharmacy Consultant Report, dated 12/23/24, showed: - A recommendation to place a 14 day stop date on the medication olanzapine 5 mg PO every 8 hours PRN or discontinue the olanzapine; - No stop date assigned; - No physician/prescriber signature and date; - The facility failed to address the pharmacy recommendations with the physician. Review of the resident's medical record showed: - No documentation of a specific duration or clinical rationale provided by the physician for the continuation of the PRN olanzapine medication for longer than 14 days. Review of the resident's MAR dated October 2024 - January 2025, showed: - An order for olanzapine 5 mg PO every 8 hours PRN, dated 10/17/24; - The olanzapine 5 mg PRN medication not administered between 10/01/24 - 12/31/24; - The olanzapine 5 mg PRN medication administered one time between 01/01/25 - 01/21/25. 6. Review of Resident #24's medical record showed: - Diagnoses of Alzheimer's disease, major depressive disorder, anxiety, and paranoid personality disorder (extreme and long-term distrust of others); - An order for Zyprexa (an antipsychotic medication) 2.5 mg PO one time a day for anxiety, dated 07/17/24; - An order for Zyprexa 5 mg PO one time a day for anxiety, dated 07/17/24; - No documentation of an appropriate diagnosis for Zyprexa. Review of the resident's Pharmacy Consultant Report, dated 08/14/24, showed: - A recommendation to change the Zyprexa to 2.5 mg PO twice a day; - No physician/prescriber signature and date; - The facility failed to address the pharmacy recommendations with the physician. During an interview on 01/22/25 at 4:35 P.M., the DON said the pharmacist reviewed the residents' medical records, made recommendations, the reports of irregularities were emailed to the DON and the Administrator, and they were given to the physicians when they were in the facility. She thought there was a system failure, due to these recommendations not getting completed as they should be. During an interview on 01/21/25 at 11:55 A.M., the DON said she would expect a 14 stop date to be ordered for PRN psychotropic medications. During an interview on 01/22/25 at 4:33 P.M., the Administrator said she would expect pharmacy recommendations to be addressed in a timely manner. She would expect a pharmacy recommendation be given to the physician for review, signed and dated within a reasonable time frame to ensure compliance, and follow up with GDR recommendations and PRN medications with the physicians.

Based on observation, interview, and record review, the facility failed to implement Enhance Barrier Precautions (EBP) during wound care for two residents (Resident #5 and #191) out of three sampled residents and one resident (Resident #12) outside the sample. The facility census was 37. Review of the facility's policy titled, Enhanced Barrier Precautions, reviewed March 2024, showed: - Enhanced barrier precautions are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents; - EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply; - Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); h. wound care (any skin opening requiring a dressing); - EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous statis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears; - Staff are trained in caring for residents on EBPs; - Signs are posted on the door or wall outside the resident room indicating the type of precautions and Personal Protective Equipment (PPE) required; - PPE is available outside of the resident rooms. 1. Observation on 01/21/25 at 4:03 P.M., of Resident #5's wound care showed: - EBP signage not posted outside of the resident's room; - Licensed Practical Nurse (LPN) A did not put on an isolation gown, entered the resident's room, performed hand hygiene, and put on gloves; - LPN A cleaned the wound with wound cleanser; - LPN A removed the gloves, performed hand hygiene, and put on gloves; - LPN A applied Santyl (a wound debridement medication) to a non-adherent (a non-stick dressing for wound coverage) dressing by dabbing the top of the Santyl tube on the dressing; - LPN A placed the dressing over the wound area; - LPN A secured the dressing with tape; - LPN A removed the gloves, performed hand hygiene, and left the room. During an interview on 01/23/24 at 11:40 A.M., LPN A said he/she should have put a gown on before entering the resident's room. He/She was not aware PPE was needed for this resident while doing care until after the care had been completed. 2. Observation on 01/22/25 at 4:07 P.M., of Resident #12's wound care showed: - EBP signage posted outside of the resident's room; - Registered Nurse (RN) L put on an isolation gown, entered the resident's room, performed hand hygiene, and put on gloves; - RN L performed wound care to the right and left heels; - RN L paused the wound care; didn't remove the isolation gown, gloves, or perform hand hygiene; and stepped out into the hallway with the isolation gown on to get help from another staff; - RN L entered the resident room with the same isolation gown and gloves, did not perform hand hygiene, and continued to complete the wound care; - RN L removed the isolation gown and the gloves, performed hand hygiene, and exited the resident's room. During an interview on 01/22/25 at 4: 39 P.M., RN L said he/she should've removed the gloves and gown and performed hand hygiene prior to walking out into the hallway. 3. Observation on 01/22/25 at 4:40 P.M., of Resident #191's wound care showed: - EBP signage not posted outside the resident's room; - RN L did not put on an isolation gown, entered the room, performed hand hygiene, and put on gloves; - RN L removed the saturated dressing from the resident's buttocks; - RN L performed hand hygiene and changed gloves; - RN L cleaned the bloody wound with wound cleanser, did not change gloves, and did not perform hand hygiene; - RN L applied MediHoney (topical wound ointment made from medical grade honey) to the foam border dressing, did not change gloves, and did not perform hand hygiene; - RN L applied the foam border dressing to the resident's wound; - RN L removed the gloves, performed hand hygiene, and exited the resident's room. During an interview on 01/22/24 at 5:00 P.M., RN L said he/she was not aware a gown was needed for this resident while doing care. Glove changes with hand hygiene should be done anytime the gloves get visibly soiled. During an interview on 01/22/25 at 3:57 P.M., the Director of Nursing (DON) said she was not aware Resident #5 and #191 did not have EBP signage posted. Residents with wounds that were open and draining should have EBP implemented. Staff should be using gowns and gloves any time they were providing care to any resident on EBP. Staff should remove gowns and gloves prior to exiting the resident room if on EBP.

Based on interview and record review, the facility failed to follow their policy and procedure to complete Criminal Background Checks (CBC) for four of the ten sampled staff prior to hire and to check the Nurses Aide (NA) Registry for all new staff before the employment date to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect) for seven of the ten sampled staff. The facility census was 37. Review of the facility's policy titled, Abuse Prevention, dated September 2021, showed: - Background checks will be done at the time of hire in accordance with the facility background check policy. Staff will not be hired who have been found guilty, or plead nolo contendere (a plea of no contest) of abuse, neglect, mistreatment of residents, or misappropriation of resident property by a court of law. Such determination will not be limited to residents but shall include any known abusive acts against others; - The nurse aide registry will be checked prior to employment, nurse aides will not be hired whose name is on any state abuse registry; - Verification of background checks and nurse aide registry checks will be maintained in the personnel file of each employee. Review of the facility's policy titled, Criminal Background Checks Policy and Procedure, dated February 2022, showed: - The facility shall perform criminal background checks on all employees hired after August 28, 1997; - After an employment application has been received by Administrations and it is determined the applicant will be offered employment, the designated facility employee will complete an online Criminal Background Request; - Print the request for the employee record. In addition, a copy of the disclosure of the applicant's rights under the Fair Credit Reporting Act shall be given to the applicant. Both requirements shall be completed the same day as the decision to hire, and prior to allowing any person contact with a resident. The responsibility for completing this requirement shall remain with the Administrator even if the task shall be delegated to a designee; - The reply for Criminal Background Request will be emailed with a notice that there is no match or that a follow-up is being mailed, which will indicate a criminal history and this applicant shall not be started to work until such time as the Administrator, or designee, shall receive the response and determine whether or not the applicant is to be disqualified; - There will be no exceptions to this policy. 1. Review of Employee B's personnel file showed: - A hire date of 09/26/23; - No documentation the CBC and the NA Registry was completed before the employee's hire date. 2. Review of Employee C's personnel file showed: - A hire date of 12/12/23; - No documentation the CBC and the NA Registry was completed before the employee's hire date. 3. Review of Employee D's personnel file showed: - A hire date of 12/29/24; - No documentation the CBC and the NA Registry was completed before the employee's hire date. 4. Review of Employee E's personnel file showed: - A hired date of 12/12/22; - No documentation the NA Registry was was completed before the employee's hire date. 5. Review of Employee F's personnel file showed: - A hire date of 01/02/24; - No documentation the NA Registry was completed before the employee's hire date. 6. Record review of Employee G's personnel file showed: - A hire date of 2/1/24; - No documentation the NA Registry was completed before the employee's hire date. 7. Review of Employee I's personnel file showed: - A hire date of 02/01/24; - No documentation the CBC and the NA Registry was completed before the employee's hire date During an interview on 01/23/25 at 9:20 A.M., the Administrator said she would expect all new hires to be properly screened for the CBC. However she was unaware all staff needed the NA Registry completed. She thought only the nursing department staff needed the NA Registry checked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement comprehensive care plans in seven days after completion of the comprehensive assessment and no more than 21 days after admission to properly care for two residents (Residents #1 and #2) out of five sampled residents. The facility census was 36. Review of the facility policy, Care Plans; Comprehensive Person Centered, dated March 2022, showed: - A comprehensive person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The comprehensive person centered care plan is developed within seven days after completion of the required Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff), and no more than 21 days after admission; - The comprehensive, person-centered care plan includes measurable objectives and time frames, describes the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well being, professional services which are responsible for each element of care, and reflects currently recognized standards of practice for problem areas and conditions; - The care plan is the blue print for the resident's entire care needs and directs the actions of all healthcare team members. A new staff member should be able to know everything essential about the resident by reading the care plan. 1. Record review of Resident #1's admission MDS, dated [DATE], showed: - admitted to the facility on [DATE]; - Diagnoses of Coronary Artery Disease, Gastroesophageal Reflux Disease (GERD)(stomach acid being forced back into throat region causing irritation), Cardiovascular Accident (CVA)(damage to the brain from interrupted blood supply), Dementia (a group of thinking and social symptoms that interferes with daily functioning), and arthritis; - Brief Interview for Mental Status (BIMS)(assessment tool to evaluate resident cognitive abilities) score of three of fifteen. Required supervision with care. He/she is delusional (an unshakable belief in something that's untrue). He/she has verbal and physical behaviors. He/she exhibited wandering behaviors that places resident at significant risk of getting to potentially dangerous place. Review of Resident #1's medical record on 09/24/24 showed no care plan. 2. Record review of Resident #2's admission MDS, dated [DATE], showed - admitted to the facility on [DATE]; - Diagnoses of Anemia (a condition where the body doesn't produce enough healthy red blood cells), Dementia (a group of thinking and social symptoms that interferes with daily functioning), Depression (a serious mental health condition that involves a persistent low mood or loss of interest in activities), Hypertension (high blood pressure); - BIMS score of 12 out of 15. Required supervision with care. He/she is delusional (an unshakable belief in something that's untrue). He/she has verbal and physical behaviors. He/she exhibited wandering behaviors that places resident at significant risk of getting to potentially dangerous place. Review of Resident #2's medical record on 09/24/24, showed no care plan. During a interview on 09/24/24 at 2:30 P.M., the Director of Nurses said residents should have a care plan within seven days of the completion of the MDS or within 21 days of admission. He/she said the the MDS coordinator was responsible for doing care plans. He/she knew the care plans were behind due to the transition of going to electronic medical records (EMR). During an interview on 09/24/24 at 3:30 P.M., Licensed Practical Nurse (LPN) said he/she was the MDS and care plan coordinator. He/she said that the facility was in process of going to EMR which was put in place 07/01/24. Residents' care plans were to be entered into the EMR as they became due. He/she said the care plans were behind or had not been completed. He/she said all residents should have a care plan with in seven days of completion of MDS or within 21 days of admission. During an interview on 09/24/24 at 3:45 P.M., the Administrator said the care plans were behind due to transition to EMR 07/01/24. He/she said all residents should have a care plan with in seven days of completion of MDS or within 21 days of admission. Complaint #MO241812

Based on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Resident #1, #2, #3, and #5) out of five sampled residents. The facility census was 39. The facility did not provide a policy. 1. Review of Resident #1's medical record showed: - An admission date of 11/16/23; - Diagnoses of weakness, confusion, cerebral vascular accident (CVA (stroke), damage to the brain from interrupted blood supply), arteriosclerotic heart disease (ASHD, a thickening and hardening of the walls of the coronary arteries), congestive heart failure (CHF, an inability of the heart to pump sufficient blood flow to meet the body's needs), orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), right abdomen mass, anxiety (persistent worry and fear about everyday situations), hypertension (HTN, high blood pressure), gastroesophageal reflux disease (GERD, stomach acid being forced back into the throat region), pain, and atrial fibrillation (a-fib, heart dysrhythmia); - An order, dated 05/28/24, for Medihoney (an ointment used for wound care) and bordered foam to coccyx (a small triangular bone at the base of the spinal column) daily; - An undated order for weekly skin assessments on Monday. Review of the resident's Treatment Administration Record (TAR), dated May 2024, showed: - Medihoney and bordered foam to coccyx daily, not signed for three out of four opportunities; - Weekly skin assessment on Mondays, not signed for four out of four opportunities. 2. Review of Resident #2's medical record showed: - An admission date of 03/09/23; - Diagnoses of vagal response (a series of unpleasant symptoms that occur when the vagus nerve is stimulated), weakness, a-fib, atherosclerotic heart disease, percutaneous coronary intervention (PCI, a procedure where a blocked or narrowed coronary is opened or widened with balloons or stents), HTN, chronic kidney disease stage III, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety, and osteoarthritis (a type of arthritis marked by cartilage deterioration of joints and vertebrae); - An order, dated 03/09/23, for UAD (a central venous line (CVL), a large-bore central venous catheter placed) to be flushed monthly per protocol 1st Saturday of month in right upper chest, Registered Nurse (RN) only; - An order, dated 05/14/24, for Triad (ointment used for wound care) to right and left ischium (the paired bone of the pelvis) daily; - An order, undated, for weekly skin assessment. Review of the May 2024 TAR showed: - Triad to right and left ischium daily shows seven opportunities out of 17 missed; - UAD flush monthly 1st Saturday of month not signed off or indicated when due; - Weekly skin assessments with four out of five opportunities missed. Review of the April 2024 TAR showed: - Weekly skin assessments with one out of four opportunities missed; - UAD flush monthly 1st Saturday of month indicated due on April 6th, not signed off but signed off on April 21. 3. Review of Resident # 3's medical record showed: - An admission date of 05/17/24; - Diagnoses of stroke, chronic anti-coagulation (long-term anticoagulant therapy to prevent venous and arterial thromboembolism, a circulating blood clot that gets stuck and causes an obstruction), GERD, Stasis dermatitis ulcerations (a change in the skin that results from the pooling of blood in the veins of the lower leg. Ulcers are open sores that can result from untreated stasis dermatitis), cellulitis (a deep bacterial infection of the skin) , necrosis (death of body tissue) bilateral extremities, concussion (a mild traumatic brain injury that affects brain function), altered mental status (AMS) (Certain illnesses, chronic disorders and injuries that affect brain function can lead to an altered mental status, and hypercholesterolemia (high levels of cholesterol in the blood); - An order, dated 05/20/24, for Lanolin (waxy substance used as moisturizer for skin) 1.41 ounce (oz.) ointment, apply to bilateral legs and feet three times a day, for cellulitis; - An order, dated 05/20/24, for weekly weights; - An order, dated 05/20/24, for pressure ulcer risk assessment weekly for four weeks; - An order, dated 05/20/24, may use facility skin and wound protocol, PRN (as needed); - An order, dated 05/22/24, for Cholecalciferol (Vitamin D3) 50,000 units by mouth for 12 weeks. Review of Resident #3's TAR, dated May 2024, showed: - Pressure ulcer risk assessment weekly x4, not signed for two out of two opportunities; - Did not address weekly weights. Review of Resident #3's MAR, dated May 2024, showed: - Cholecalciferol 50,000 unit, 1 capsule by mouth weekly for 12 weeks, showed one out of two missed opportunities; - Lanolin 1.41 oz ointment, apply to bilateral legs and feet, three times daily, for cellulitis, showed 32 out of 33 missed opportunities. Review of Resident #3's TAR, dated June 2024, showed: - Lanolin ointment, apply to bilateral legs and feet three times daily for cellulitis, showed 10 out of 10 missed opportunities; - May use facility skin and wound protocol PRN, showed none documented; - Weekly weights, none documented; - Did not address pressure ulcer risk assessment. Review of Resident #3's MAR, dated June 2024, showed: - Vitamin D 50,000 units PO weekly for 12 weeks, not signed off. Review of Resident #3's Weekly Skin Integrity Review, dated June 2024, showed: - On 06/03/24, dry areas of skin with bilateral lower legs and feet indicated. Review of Resident #3's Weekly Weights showed: - On 05/20/24, Admit, 173.6; two out of three missed opportunities. Review of Resident #3's Braden Scale for Predicting Pressure Sore Risk, dated 5/20/24, showed one out of two opportunities missed. Review of Resident #3's Nurses Progress Notes, dated 05/20/24 through 06/02/24, showed: - On 05/20/24, resident arrived to facility, via Emergency Medical Services (EMS). Resident has wounds noted to right foot, resident has wounds noted to top part of right foot and anterior and posterior of foot. Resident has wound noted to right heel and dry skin noted to bilateral lower legs; - On 05/25/24, Resident receiving wound care for wound to right foot; - On 05/29/24, Resident continues Medicare A skilled service with therapy due to wound; - On 05/30/24, open area improving, applying lotion to help reduce the skin dryness and flaking; - On 06/02/24, redness to bilateral lower legs, no drainage. Observation on 06/04/24 at 10:56 A.M. showed Resident #3's 2-inch x 2-inch bordered foam dressing top of right foot, undated, dried blood on bottom and sides of right foot. Dry, flaky skin with scattered scabs, with redness to bilateral lower legs. Dry flaky skin to bottom of right foot. Observation on 06/04/24 at 11:40 A.M. showed Licensed Practical Nurse (LPN) A provided care to Resident #3, cleaned dried blood off right foot with gauze and facility wound cleanser, 2-inch x 2 inch bordered foam dressing removed prior, scab noted to top of foot. LPN A said they (Staff) had been using skin prep (protective barrier wipes) on Resident #3's feet where they are flaky, to keep the dry skin from tearing off. LPN A applied skin prep to area on bottom of right foot, heel and toes, applied Triad paste (a hydrocolloid dressing) to bilateral lower legs, applied skin prep to scabbed area on top of right foot. LPN A said the wound Nurse Practitioner (NP) just came in and rounded with Resident #3, the NP said there wasn't anything to see, Resident #3 had no open wounds at this time. LPN A said it was the NP's first time rounding with the resident. LPN A said the NP told him/her to just put moisturizing lotion like Eucerin on Resident #3's legs and feet. 4. Review of Resident #5's medical record showed: - An admission date of 04/16/24; - Diagnosis of left unstable Tri malleolar ankle fracture (when the ankle breaks in three separate places; unstable: the restraining structures on the inside of the ankle are disrupted) , HTN, hypothyroidism (a decreased level of thyroid hormone), and gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints); - An order, dated 04/17/24, for Toprol XL (a blood pressure medication) 25 milligrams (mg), one tablet by mouth daily, for hypertension; - An order, dated 05/2024, change oxygen (O2) tubing weekly on Monday nights and as needed (PRN); - An order, dated 05/2024, change distilled water in concentrator weekly on Monday nights and PRN. Review of Resident #5's MAR, dated May 2024, showed: -Toprol XL 25 mg, one tab by mouth daily for hypertension not addressed. Review of Resident #5's TAR, dated May 2024, showed: -O2 tubing change weekly on Mondays, not signed off for two out of four missed opportunities; -Change distilled water in concentrator weekly on Monday nights and PRN, not signed off for two out of four missed opportunities. Review of Resident #5's Medication Error Report, dated 5/21/24, showed: - Toprol XL 25 mg, one tablet by mouth daily ordered on 04/17/24, was put on MAR for April, not placed on Physician's Order Sheet (POS), and not placed on MAR for May; - Corrective action taken: Chart audit - medication put on May MAR on date discovered (05/21/24); - Measures taken to prevent the recurrence of similar errors: education of staff. During an interview on 06/04/24 at 10:56 A.M., Resident #3 said no one has done anything to his/her legs or feet in a while, no lotion or creams have been put on. He/she said they (legs and feet) itch all the time. During an interview on 06/04/24 at 11:05 A.M., LPN A said we (staff) follow protocol for wounds, put in wound consult with wound care company, then the NP comes in and sees the resident and does wound care. The NP emails the reports with measurements and orders to the Director of Nursing (DON). The order gets added to the TAR. During an interview on 06/04/24 at 12:00 P.M., the Interim DON said she would expect any order to be followed and documented. She would expect residents to receive medications and treatments per order, and for pressure ulcer assessments to be completed as ordered. During an interview on 06/04/24 at 12:00 P.M., the Administrator said Resident #3 had wounds in the hospital that had healed while in the hospital. She said she would expect physician orders to be followed and to be documented when done. She said hospital discharge orders should be updated in the residents medical record, and chart audits should be completed by the DON. Cmp #MO00236609

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS, a federally mandated assessment to be completed by the facility) for two residents (Resident #3, and #18) out of 12 sampled residents. The facility's census was 35. Review of the facility's Resident Assessment policy, revised March, 2022, showed: - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews; - A comprehensive assessment includes a completion of the MDS. 1. Review of Resident #3's medical record showed: - An admission date on 07/17/23; - Diagnoses of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), and benign prostatic hyperplasia (BPH) (an enlargement of the prostate causing difficulty in urination); - No documentation of a psychotic (a mental disorder characterized by a disconnection from reality) disorder. Review of the resident's quarterly MDS, dated [DATE], showed: - Psychotic disorder documented; - No documentation of BPH. 2. Review of Resident #18's medical record showed: - An admission date of 07/21/22; - Diagnoses of heart failure (chronic condition where heart does not pump blood as well it should), anxiety (persistent worry and fear about everyday situations), depression (a serious medical illness that negatively affects how you feel, the way you think, and how you act), hearing loss, dementia, BPH, Alzheimer's Disease (progressive mental deterioration), dyspnea (difficulty breathing), transient cerebral ischemic attack (TIA) (a neurologic deficit that produces stroke symptoms that resolve within 24 hours), and seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness). Review of the resident's quarterly MDS, dated [DATE], showed no documentation of dementia or Alzheimer's, TIA, anxiety, and heart failure. During an interview on 01/11/23 at 11:10 A.M., the MDS Coordinator said the MDS should accurately reflect the condition of the resident. The Resident Assessment Instrument (RAI) manual should be followed regarding MDS assessments. During an interview on 01/11/23 at 12:30 P.M., the Administrator said the RAI manual should be followed regarding MDS assessments and expectations were for the MDS to accurately reflect the condition of the resident. During an interview on 01/11/23 at 2:18 P.M., the Director of Nursing (DON) said the RAI manual should be followed regarding MDS assessments. The MDS should accurately reflect the condition of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement care plans with specific interventions tailored to meet individual needs for three residents (Resident #2, #9, and #28) out of 12 sampled residents. The facility census was 35. Review of the facility's policy titled, Care Plan, revised 03/2022, showed: - A comprehensive, person centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and is developed and implemented for each resident; - Builds on the resident's strength; - Reflects currently recognized standards of practice for problem areas and conditions. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnoses of dementia (progressive or persistent loss of intellectual functioning), Parkinson's (a disorder of the central nervous system that affects movement), aggression, and agitation; - An order for haloperidol (an antipsychotic medication) 2 milligram (mg) by mouth every 12 hours as needed (PRN) for agitation, dated 10/07/23; - An order for Ativan (an antianxiety medication) 0.5 mg every eight hours PRN for agitation, dated ?; - An order for quetiapine (an antipsychotic medication) 25 mg by mouth one time a day for aggression/agitation, dated 09/28/23; - An order for quetiapine 50 mg by mouth every evening for aggression/agitation, dated 09/28/23. Review of the resident's care plan, dated 10/17/23, showed: - Received psychotropic (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) medication; - No targeted behaviors for haloperidol, Ativan, and quetiapine use; - No interventions for monitoring the side effects or the effectiveness; - No specific non-pharmalogical interventions; - No individualized interventions for the behaviors. 2. Review of Resident #9's medical record showed: - admitted on [DATE]; - Diagnoses of dementia, anxiety, agitation, and depression (feelings of severe despondency and dejection); - An order for Zyprexa (an antipsychotic medication) 10 mg by mouth daily at 2:00 P.M., for agitation/anxiety, dated 04/19/23; - An order for quetiapine 25 mg by mouth three times a day for anxiety, dated 02/23/23. Review of the resident's care plan, dated 10/17/23, showed: - Received psychotropic medications; - No targeted behaviors for Zyprexa or quentiapine use; - No interventions for monitoring the side effects or the effectiveness; - No specific non-pharmalogical interventions; - No individualized interventions for the behaviors. 3. Review of Resident #25's medical record showed: - admitted on [DATE]; - Diagnosis of anxiety; - An order for Xanax (an antianxiety medication) 0.5 mg one tablet by mouth twice a day PRN for anxiety, dated 10/21/23. Review of the resident's care plan, dated 02/22/23, showed: - Received psychotropic medications; - No targeted behaviors for Xanax use; - No interventions for monitoring the side effects or the effectiveness of the medications; - No specific non-pharmalogical interventions; - No individualized interventions for the behaviors. During an interview on 01/11/24 at 02:15 P.M., the Director of Nursing (DON) said there should be a care plan addressing the use of the psychotropic medication, why the resident was receiving it, and the possible side effects for the staff to assess for.

Based on observation, interview, and record review, the facility failed to obtain a physician's order and failed to complete a resident assessment and safety evaluation for the use of a trapeze (a device designed to assist residents in changing positions) for one resident (Resident #27) out of one sampled resident. The facility census was 35. The facility did not provide a policy regarding trapeze use. 1. Review of Resident #27's Physician's Order Sheet (POS), dated January 2024, showed: - admission date of 08/31/22; - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), high blood pressure, diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), anxiety (persistent worry and fear about everyday situations), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), bipolar disorder (a mental disorder that causes unusual shifts in mood) and morbid obesity; - No order for a trapeze. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 11/07/23, showed: - Cognition intact; - Required no assistance for mobility, transfers or dressing; - Require total assistance for toileting. Review of the resident's medical record showed no documentation of a Safety Evaluation Assessment for the use of a trapeze. Review of the resident's care plan, revised on 11/7/23, showed: - The resident transferred him/herself with assistance as needed; - No documentation of the use of a trapeze. Observations of Resident #27 showed: - On 01/08/24 at 2:30 P.M., and 01/09/24 at 8:40 A.M.,the resident lay in bed with a trapeze hanging over the bed; - On 01/20/24 at 10:20 A.M., the resident lay in bed with a trapeze hanging over the bed. The resident used the trapeze to pull him/herself higher up in the bed. During an interview on 1/10/24 at 10:20 A.M., Resident #27 said he/she used the trapeze for mobility. It helped him/her to move in bed and get out of bed independently. During an interview on 01/11/24 at 2:15 P.M., the Director of Nursing (DON) said therapy should assess for the use of a trapeze. There should be an order and assessment. During an interview on 1/11/24 at 2:45 P.M., the Administrator said the trapeze should have been assessed.

Based on observation, interview, and record review, the facility failed to follow physician's orders for two residents (Resident #18 and #27) out of 12 sampled residents. The facility census was 35. The facility did not provide a policy related to following physician's orders. 1. Review of Resident #18's Physician Order Sheet (POS), dated January 2024, showed: - Diagnoses of benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), hearing loss, and obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow); - An order to change the Foley catheter (a tube inserted into the bladder to drain urine) size 16 french with 10 milliliter (ml) balloon monthly (on the 19th) and as needed for obstructive uropathy, dated 09/23/22; - An order to change hearing aid batteries every Friday, dated 03/24/23. Review of the resident's Treatment Administration Record (TAR), dated December 2023, showed: - No documentation of the Foley catheter changed with one out of one opportunity missed; - No documentation of the hearing aids batteries changed with four out of four opportunities missed. Observation on 01/08/24 at 01:42 P.M., 01/09/24 at 10:26 A.M., 01/10/24 at 10:10 A.M., and 01/11/24 at 10:20 A.M., showed: - The resident 's Foley catheter bag not dated; - The resident with hearing aides in his/her ears and difficulty hearing others. During an interview on 01/08/24 at 01:42 P.M., Resident #18 said he/she did not know when the Foley catheter or hearing aids were last changed. The staff kept track of that. During an interview on 01/10/24 at 10:20 A.M., Registered Nurse (RN) H said that he/she knew the Foley catheter was to be changed every month and the hearing aid batteries changed weekly. The staff was to document it in the resident's medical record when it was completed. 2. Review of Resident #27's POS, dated January 2024, showed: - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - An order for oxygen tubing (the tube delivering oxygen from the oxygen container to the person) and humidifier to be changed weekly on Monday night and as needed (PRN), dated 08/21/22; - An order for oxygen 4 liters per minute (LPM), per nasal cannula (a tube delivering oxygen to a person's nose) (NC) continuously, dated 08/31/22. Review of the resident's TARs, dated December 2023, showed: - The resident received oxygen 4 LPM daily; - No documentation of the oxygen tubing and humidifier changed with four out of four opportunities missed. Observations on 01/08/24 at 1:27 P.M., 01/09/24 at 10:30 A.M., and at 2:00 P.M., and 01/10/24 at 10:30 A.M., showed the resident sat in his/her wheelchair with oxygen on at 2 LPM via NC. The oxygen tubing, dated 01/01/24, and the humidifier bottle not dated. During an interview on 01/10/24 at 10:30 A.M., Resident #27 said his/her oxygen should be at 4 LPM and staff should change the oxygen tubing but did not know how often. He/She could not remember the last time the oxygen tubing or humidifier had been changed. During an interview on 01/11/24 at 11:20 A.M., the Director of Nursing (DON) said staff should follow orders. Oxygen should be kept at the correct setting for the resident as ordered and the oxygen tubing and humidifier should be changed per orders. During an interview on 01/11/24 at 12:30 P.M., the Administrator said she would expect physician orders to be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess residents for the use of bed rails prior to installation and use nor did they obtain informed consent from the resident or if applicable, the resident representative for two residents (Resident #18 and #27) out of 12 sampled residents. The facility's census was 35. Review of the facility's policy titled, Bed Safety and Bed Rails, revised August 2022, showed: - The resident's sleeping environment is evaluated by the interdisciplinary team; - Bed frames, mattresses, and bed rails are checked for compatibility and size; - Bed dimensions are appropriate for resident's size; - The use of bed rails or side rails is prohibited unless the criteria for the use if bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.; - Alternatives to the use of bed or side rails that are attempted include roll guards, foam bumpers, lowering the bed, and/or use of concave mattresses to reduce rolling off the bed; - The interdisciplinary team evaluation includes the evaluation of bed rail alternatives that were used and why they failed to meet resident's needs, the resident's risk associated with use of bed rails, input from resident or representative, and consultation with attending physician; - The resident assessment determines potential risk like accident hazards, restricted mobility, and psychosocial outcomes; - Before using bed rails, staff shall inform the resident or representative about benefits and potential hazards associated with bed rails and obtain inform consent; - Maintenance staff routinely inspects all beds and related equipment to identify entrapment risks. 1. Review of Resident #18's medical record showed: - admitted on [DATE]; - Diagnoses of heart failure (chronic condition where heart does not pump blood as well it should), anxiety (persistent worry and fear about everyday situations), depression (a serious medical illness that negatively affects how you feel, the way you think, and how you act), hearing loss, dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), Alzheimer's Disease (progressive mental deterioration), dyspnea (difficulty breathing), transient cerebral ischemic attack (TIA) (a neurologic deficit that produces stroke symptoms that resolve within 24 hours), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness) - No documentation of a bed rail assessment; - No documentation of an informed consent for the use of the bed rails. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 11/14/23, showed: - Cognition severely impaired; - Required no assistance with mobility, transfers, dressing, and toileting; - Required supervision with personal hygiene and shower transfer. Observation of Resident #18 showed: - On 01/08/24 at 01:42 P.M., the resident independently laid down on the bed with the quarter side rail in the upright position on the right side of the bed; - On 01/09/24 at 09:25 A.M., the resident sat on the side of the bed and held onto the quarter side rail in the upright position on the right side of the bed to put on his/her shoes; - On 01/10/24 at 10:20 A.M., the resident lay in bed with the quarter side rail in the upright position on the right side of the bed. During an interview on 01/09/24 at 09:25 A.M., Resident #18 said he/she used the bed rail to help keep his/her balance and used it to help get out of bed. 2. Review of the Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), high blood pressure, diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), anxiety, depression, bipolar disorder (a mental disorder that causes unusual shifts in mood) and morbid obesity. - No documentation of bed rail assessment; - No documentation of informed consent for the use of the bed rails. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognition intact; - Required no assistance for mobility, transfers or dressing; - Required total assistance for toileting; - Required supervision for showers; - Required moderate assist for hygiene. Observations of the resident on 01/08/24 at 2:30 P.M., 01/09/24 at 8:40 A.M., and 01/10/24 at 10:20 A.M., showed the resident lay in bed with the half side rail in the upright position on the right side of the bed. During an interview on 01/10/24 at 10:20 A.M., Resident #27 said he/she used the half side rail for mobility and it allowed him/her to be independent. He/She couldn't remember if an assessment and a consent for the half side rail had been provided by the facility. During an interview on 01/11/24 at 2:15 P.M., the Director of Nursing (DON) said side rail assessments should be completed. A consent should be obtained as well. He/She didn't like side rails and thought the residents should only have a grab bar. During an interview on 01/11/24 at 2:45 P.M., the Administrator said siderails should have an assessment and consent.

Based on observation, interview, and record review, the facility failed to post the nurse staffing data with all the required components in a clear and readable format in a prominent place readily accessible to residents and visitors on a daily basis. The facility's census was 35. The facility did not provide a nurse staffing policy. Observations of the facility showed: - On 01/08/24 at 11:45 A.M., and 2:30 P.M., no documentation of the nurse staffing posted; - On 01/09/24 at 9:10 A.M., and 1:05 P.M., no documentation of the nurse staffing posted; - On 01/10/24 at 10:30 A.M., no documentation of the nurse staffing posted. During an interview on 01/10/24 at 10:30 A.M., Registered Nurse (RN) A said the nurse staffing sheets were completed and placed into the hanging folder on the door across from the nurse's station. The nurse staffing sheets were not visible to the residents or visitors. They were completed at the start of each shift but one had not been completed for 01/10/24. During an interview on 01/10/24 at 10:35 A.M., the Administrator said the staffing sheets should be posted and not placed in a folder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the pharmacy consultant identified an appropriate diagnosis for the use of an antipsychotic (a medication used to treat psychosis or the loss of connection to reality) medication during the pharmacist's monthly Medication Regimen Review (MRR) for three residents (Resident #2, #9, and #18) out of three sampled residents. The facility's census was 35. Review of the facility's policy titled, Antipsychotic Medication Use, revised July 2022, showed: - Residents will only receive antipsychotic medications when necessary to treat a specific condition for which they are indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; - Diagnosis of a specific condition for which antipsychotic medications will be necessary to treat, will be based on a comprehensive assessment of the resident; - Resident will not receive as needed (PRN) as needed doses of psychotropic (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; - PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for appropriateness of the medication and documented the rational for continued use. The duration of the PRN order will be indicated in the order. Review of the facility's policy titled, MRR, revised May 2019, showed the MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors, and other irregularities. 1. Review of Resident #2's medical record showed: - admitted [DATE]; - Diagnoses of dementia (progressive or persistent loss of intellectual functioning), Parkinson's (a disorder of the central nervous system that affects movement), aggression, and agitation; - An order for haloperidol (an antipsychotic medication) 2 milligram (mg) by mouth every 12 hours PRN for agitation, dated 10/07/23; - An order for quetiapine (an antipsychotic medication) 25 mg by mouth one time a day for aggression/agitation, dated 09/28/23; - An order for quetiapine 50 mg by mouth every evening for aggression/agitation, dated 09/28/23; - No documentation of behavior monitoring and identifying specific symptoms with risks to the resident and others. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/09/24, showed: - Severe cognitive impairment; - No physical, verbal or other behavioral symptoms directed toward others. Review of the resident's MRR, dated 11/18/23 and 12/08/23, showed no documentation of requests made by the pharmacist to the physician for an appropriate diagnosis for the quetiapine or haloperidol medications. 2. Review of Resident #9's medical record showed: - admitted on [DATE]; - Diagnoses of dementia, anxiety (persistent worry and fear about everyday situations), agitation, and depression (feelings of severe despondency and dejection); - An order for Zyprexa (an antipsychotic medication) 10 mg by mouth daily at 2:00 P.M., for agitation/anxiety, dated 04/19/23; - An order for quetiapine 25 mg by mouth three times a day for anxiety, dated 02/23/23; - No documentation of behaviors with specific symptoms, and risks to the resident and others. Review of the resident's significant change MDS, dated [DATE], showed: - Severe cognitive impairment; - No physical, verbal or other behavioral symptoms directed toward others. Review of the resident's monthly Behavior Monitoring Flowsheets showed: - Identified behavioral symptom of exit seeking; - Zero episodes documented for October 1, 2023 through December 31, 2023. Review of the resident's MRR, dated 03/04/23, 04/19/23, 05/12/23, 06/10/23, 07/14/23, 09/09/23, 10/14/23, 11/18/23, and 12/08/23 showed no documentation of requests made by the pharmacist to the physician for an appropriate diagnosis for the quetiapine and Zyprexa. 3. Review of Resident #18's medical record showed: - admitted on [DATE]; - Diagnoses of dementia, Alzheimer's disease (progressive mental deterioration), anxiety, and depression; - An order for quetiapine 50 mg by mouth two times a day for behaviors, dated 09/23/22; - An order for quetiapine 100 mg by mouth one time a day at night for behaviors, dated 09/23/22; - No documentation of behavior monitoring and identifying specific symptoms with risks to the resident and others. Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - No physical, verbal or other behavioral symptoms directed toward others. The facility failed to provide the resident's monthly Behavior Monitoring Flowsheets for August 2023 through December 2023. Review of the resident's MRR, dated 03/04/23, 04/19/23, 05/12/23, 06/10/23, 07/14/23, 09/09/23, 10/14/23, 11/18/23, and 12/08/23, showed no documentation of requests made by the pharmacist to the physician for an appropriate diagnosis for the quetiapine. During an interview on 01/11/24 at 02:15 P.M., the Director of Nursing (DON) said she would expect medications to have an appropriate diagnoses and if they didn't, the expectation was that the pharmacist will request an appropriate diagnoses from the resident's physician. During an interview on 01/11/23 at 11:03 A.M., the Pharmacist said he had just started at the facility and was not yet familiar with the residents, but he would expect the MRR to address the need for an appropriate diagnoses of the prescribed medications to the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the appropriate diagnosis for the use of an antipsychotic (a medication used to treat psychosis or the loss of connection to reality) medication for three residents (Resident #2, #9, and #18) out of three sampled residents and failed to limit the use of an as needed (PRN) psychotropic (a psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) medication to 14 days or to document the rationale for extending the order for three residents (Resident #2, #14, #25) out of 12 sampled residents during the pharmacist's monthly Medication Regimen Review (MRR). The facility's census was 35. Review of the facility's policy titled, Antipsychotic Medication Use, revised July 2022, showed: - Residents will only receive antipsychotic medications when necessary to treat a specific condition for which they are indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; - Diagnosis of a specific condition for which antipsychotic medications will be necessary to treat, will be based on a comprehensive assessment of the resident; - Resident will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; - PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for appropriateness of the medication and documented the rational for continued use. The duration of the PRN order will be indicated in the order. Review of the facility's policy titled, MRR, revised May 2019, showed the MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors, and other irregularities. 1. Review of Resident #2's January 2024 Physician Order Sheet (POS) showed: - admitted on [DATE]; - Diagnoses of dementia (progressive or persistent loss of intellectual functioning), Parkinson's (a disorder of the central nervous system that affects movement), aggression, and agitation; - An order for Ativan (an antianxiety medication) 0.5 milligram (mg) every eight hours PRN for agitation, with an order date of 09/28/23 and no stop date; - An order for haloperidol (an antipsychotic medication) 2 mg by mouth every 12 hours PRN for agitation, dated 10/07/23 and no stop date; - An order for quetiapine (an antipsychotic medication) 25 mg by mouth one time a day for aggression/agitation, dated 09/28/23; - An order for quetiapine 50 mg by mouth every evening for aggression/agitation, dated 09/28/23. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/09/24, showed: - Severe cognitive impairment; - No physical, verbal or other behavioral symptoms directed toward others. Review of the resident's Medication Administration Record (MAR), dated October 2023, showed: - Ativan administered one dose on 10/06/23, 10/07/23 10/22/23, and 10/28/23. Two doses administered on 10/05/23, and 10/26/23; - Haloperidol administered one dose on 10/10/23, 10/12/23, 10/13/23, 10/14/23, 10/20/23, 10/22/23, 10/25/23, 10/26/23 and 10/27/23. Two doses administered on 10/11/23, 10/17/23, 10/18/23, 10/19/23, 10/24/23, 10/28/23, and 10/29/23.; Review of the resident's MAR, dated November 2023, showed: - Ativan administered one dose on November 24; - Haloperidol administered one dose on 11/01/23, 11/02/23, 11/03/23, 11/17/23, 11/20/23, 11/21/23, 11/22/23, 11/23/23, 11/24/23, 11/28/23, and 11/29/23. Two doses administered on 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, and 11/09/23. Review of the resident's MAR, dated December 2023, showed: - Ativan administered one dose on 12/01/23, 12/02/23, 12/04/23, 12/05/23, 12/06/23, 12/09/23, 12/14/23, 12/18/23, and 12/26/23. Two doses administered on 12/07/23, 12/16/23, and 12/17/23; - Haloperidol administered one dose on 12/14/23, 12/26/23, and 12/30/23. Review of the resident's MAR, dated January 1 -11, 2024, showed haloperidol administered one dose on 01/08/24 and 01/09/24. Review of the resident's MRR, dated 11/18/23 and 12/08/23, showed no pharmacist recommendations related to the PRN Ativan or haloperidol orders and no recommendations to the physician for an appropriate diagnosis for the quetiapine or haloperidol medications. Review of the resident's medical record showed: - No documentation of behavior monitoring and identifying specific symptoms with risks to the resident and others; - No documentation of the attending physician's rationale to continue the current Ativan order beyond 14 days or any indication of the duration for the PRN order; - No documentation of the physician or prescribing practitioner evaluated the resident for the appropriateness with indications of use for a new order for haloperidol after 14 days. Observations of the resident showed: - On 01/08/24 at 12:15 P.M., and on 01/09/24 at 8:05 A.M., the resident sat quietly and calmly in the dining room in a high back wheelchair at an assist table feeding him/herself; - On 01/09/24 at 1:48 P.M., the staff assisted the resident with transferring from the wheelchair to the bed and with incontinent care. The resident quietly and calmly cooperated with staff. During an interview on 01/10/24 at 02:40 P.M., Certified Medication Technician (CMT) B said the resident did have an order for PRN haloperidol and that he/she got real anxious sometimes and yelled out. The resident yelled out a family member's name a lot of the time. The resident had not gotten the medication as often recently. 2. Review of Resident #9's January 2024 POS showed: - admitted on [DATE]; - Diagnoses of dementia, anxiety, agitation, and depression (feelings of severe despondency and dejection); - An order for Zyprexa (an antipsychotic medication) 10 mg by mouth daily at 2:00 P.M., for agitation/anxiety, dated 04/19/23; - An order for quetiapine (an antipsychotic medication) 25 mg by mouth three times a day for anxiety, dated 02/23/23; Review of the resident's significant change MDS, dated [DATE], showed: - Severe cognitive impairment; - No physical, verbal or other behavioral symptoms directed toward others. Review of the resident's monthly Behavior Monitoring Flowsheets showed: - Identified behavioral symptom of exit seeking; - Zero episodes documented for October 1, 2023 through December 31, 2023. Review of the resident's MRR, dated 03/04/23, 04/19/23, 05/12/23, 06/10/23, 07/14/23, 09/09/23, 10/14/23, 11/18/23, and 12/08/23 showed no documentation of requests made by the pharmacist to the physician for an appropriate diagnosis for the quetiapine and Zyprexa. Review of the resident's medical record showed no documentation of appropriate behaviors with specific symptoms and risks to the resident and others. Observations of the resident showed: - On 01/08/24 at 12:19 P.M., the resident sat quietly and calmly in the wheelchair in the dining room and fed him/herself; - On 01/09/24 at 10:13 A.M., the resident sat quietly and calmly on the side of the bed; - On 01/09/24 at 01:47 P.M., the resident sat quietly and calmly in the wheelchair at the end of the 100 Hall; - On 01/10/24 at 08:20 A.M., the resident lay quietly and calmly in bed with his/her eyes closed; - On 01/10/24 at 09:15 A.M., the resident sat quietly and calmly in the wheelchair in his/her room at the bedside table and fed him/herself breakfast; - On 01/11/24 at 9:35 A.M., the resident lay in bed as staff completed incontinent care. The resident quietly and calmly cooperated with staff. 3. Review of Resident #14's January 2024 POS showed: - An admit date of 07/21/23; - A diagnoses of insomnia (difficulty sleeping) and anxiety (persistent worry and fear about everyday situations); - An order for Xanax (an antianxiety medication) 0.25 mg one tablet by mouth every eight hours PRN for anxiety with an order date of 07/21/23 and no stop date. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognition intact; - No physical, verbal or other behavioral symptoms directed toward others; - Inattention that fluctuated. Review of the resident's MAR, dated October 2023, showed Xanax administered one dose on 10/03/23, 10/04/23, 10/05/23, 10/22/23, 10/23/23 and 10/30/23. Review of the resident's MAR, dated November 2023, showed Xanax administered one dose on 11/07/23, 11/12/23, 11/13/23, 11/14/23, 11/15/23, 11/16/23, and 11/17/23. Three doses administered on 11/18/23, 11/19/23, 11/20/23, 11/23/23, 11/26/23, and 11/27/23. Review of the resident's MAR, dated December 2023, showed Xanax administered one dose on 12/28/23. Review of the resident's MAR, dated January 2024, showed Xanax administered one dose on 01/04/24 and 01/07/24. Review of the resident's MRRs, dated 11/18/23 and 12/08/23, showed no pharmacist recommendations related to the PRN Xanax order. Review of the resident's medical record showed no documentation of the attending physician's rationale to continue the current Xanax order beyond 14 days or any indication of the duration for the PRN order. Observations of the resident showed: - On 01/08/24 at 12:15 P.M., the resident sat quietly and calmly in the dining room and fed him/herself; - On 01/09/24 at 10:45 A.M., and on 01/10/24 at 09:11 A.M., the resident sat quietly and calmly in a chair in his/her room. 4. Review of Resident #18's medical record showed: - admitted on [DATE] - Diagnoses of dementia, Alzheimer's disease (progressive mental deterioration), anxiety, and depression; - An order for quetiapine 50 mg by mouth two times a day for behaviors, dated 09/23/22; - An order for quetiapine 100 mg by mouth one time a day at night for behaviors, dated 09/23/22; - No documentation of behavior monitoring and identifying specific symptoms with risks to the resident and others. Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment - No physical, verbal or other behavioral symptoms directed toward others. The facility failed to provide the resident's monthly Behavior Monitoring Flowsheets for August 2023 through December 2023. Review of the resident's MRR, dated 03/04/23, 04/19/23, 05/12/23, 06/10/23, 07/14/23, 09/09/23, 10/14/23, 11/18/23, and 12/08/23 showed no documentation of requests made by the pharmacist to the physician for an appropriate diagnosis for the quetiapine. Observations of the resident showed: - On 01/08/24 at 01:42 P.M., the resident sat in a chair quietly and calmly in the dining area; - On 01/09/24 at 09:25 A.M., the resident quietly and calmly sat on the side of the bed; - On 01/10/24 at 10:20 A.M., the resident lay quietly and calmly in bed; - On 01/11/24 at 10:20 A.M., the resident lay in bed as staff performed catheter (a tube inserted into the bladder to drain urine). The resident quietly and calmly cooperated with staff. 5. Review of Resident #25's January 2024 POS showed: - admitted on [DATE]; - Diagnosis of anxiety; - An order for Xanax 0.5 mg one tablet by mouth twice a day PRN for anxiety with an order date of 10/21/23 and no stop date. Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - No physical, verbal or other behavioral symptoms directed toward others; - Inattention that fluctuated. Review of the resident's MAR, dated October 2023, showed Xanax administered one dose on 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/29/23 and 10/30/23. Two doses administered on 10/21/23. Review of the resident's MAR, dated November 2023, showed Xanax administered one dose daily 11/01/23 through 11/30/23. Review of the resident's MAR, dated December 2023, showed Xanax administered one dose on 12/02/23,12/04/23 through 12/21/23, 12/24/23 through 12/26/23, and 12/31/23. Two doses administered on 12/03/23. Review of the resident's MAR, dated January 2024, showed Xanax administered one dose on 01/02/24, 01/03/24, and 01/09/24. Review of the resident's MRRs, dated 11/18/23 and 12/08/23, showed no pharmacist recommendations related to the PRN Xanax order. Review of the resident's medical record showed no documentation of the attending physician's rationale to continue the current Xanax order beyond 14 days or any indication of the duration for the PRN order. During an interview on 01/14/24 at 12:30 P.M., the Director of Nursing (DON) said she would expect a medication prescribed PRN not to be utilized for longer than 14 days unless advised by the physician to continue and an antipsychotic medication should have an appropriate diagnosis for the indication of usage. During an interview on 01/11/24 at 11:03 A.M., the Pharmacist said a PRN psychotropic order required a 14 day stop date unless there was documentation of the clinical reasoning along with a required stop date. However, a PRN antipsychotic medication required the resident first be evaluated by the physician before a new order was given to continue for a longer period. He/She just started at the facility and was not yet familiar with the residents, but would expect the MRR to address PRN psychotropic medication orders and the appropriate diagnoses of the prescribed medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide information and education to the resident or the resident's representative of the pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus) and influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) vaccines, and offer the pneumococcal and influenza vaccines to four residents (Resident #2, #3, #18, and #22) out of five sampled residents. The facility census was 35. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, revised on 09/22/23, showed the CDC recommends pneumococcal vaccination for adults [AGE] years old and older and adults 19 through [AGE] years old with certain underlying medical or risk conditions. Review of the United States Department of Health and Human Services Centers for Disease Control (CDC) Pneumococcal Vaccine Timing for Adults, dated 03/15/23, showed the following: -CDC recommends adults greater than or equal to the age of 65 with no previous pneumococcal vaccine receive 20-valent pneumococcal conjugate vaccine (PCV20) or 15-valent pneumococcal conjugate vaccine (PCV 15) followed by pneumococcal polysaccharide vaccine (PPSV 23) after one year; -CDC recommends receive PCV 20 or PCV 15 if received PPSV 20 greater than or equal to a year prior; -CDC recommends receive PCV 20 or PPSV 23 if received 13-valent pneumococcal conjugate vaccine (PCV 13) greater than or equal to a year prior; -CDC recommends if received PCV 13 at any age or PPSV before [AGE] years old, then after five years from previous vaccine the residents are eligible to receive PCV 20 or PPSV 23. Review of the facility's policy titled, Pneumococcal Vaccine, revised March 2022, showed: - Prior or upon admission, residents are assessed for eligibility to receive the pneumococcal series, and offered the vaccine series within 30 days of admission unless medically contraindicated or resident has already been vaccinated; - Assessments of the resident's pneumococcal vaccination status are conducted within five working days of the resident's admission; - The resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of education is documented in the resident's medical record; - For each resident who receives the vaccine, the date of vaccine, lot number, expiration date, person administering, and the site of vaccination are documented in the resident's medical record; - If refused, information is documented in the medical record indicating the date of the refusal; -Administration of the pneumococcal vaccines are made in accordance with current CDC recommendations at the time of vaccination. Review of the facility's policy titled, Influenza Vaccine, revised March 2022, showed: - The influenza vaccine shall be offered to all residents and employees between October 1 and March 31 annually; - Employees hired or residents admitted to the facility between October 1 and March 31 shall be offered the vaccine within five working days with no charge at a location site; - The resident or legal representative or employee will be provided information and education regarding the benefits and potential side effects with the education documented in resident's/employee's medical record; - For each resident who receives the vaccine, the date of vaccine, lot number, expiration date, person administering, and the site of vaccination are documented in the resident's/employee's medical record; - If refused, information is documented on the informed consent for influenza vaccine in the resident's medical record; -Administration of the influenza vaccine will be made in accordance with CDC recommendations at the time of vaccination. 1. Review of Resident #2's medical record showed: - The resident admitted on [DATE]; - The resident older than [AGE] years of age; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and heart failure (an inability of the heart to pump sufficient blood flow to meet the body's needs); - No documentation of the resident's pneumococcal and influenza vaccine history; - No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal and influenza vaccines; - No documentation of a signed consent/refusal form. 2. Review of Resident #3's medical record showed: - The resident admitted on [DATE]; - The resident older than [AGE] years of age; - Diagnoses of pneumonia (infection in lungs), diabetes mellitus (DM) (abnormal blood sugar in blood), and stroke (damage to the brain from interrupted blood supply); - No documentation of the resident's pneumococcal and influenza vaccine history; - No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal and influenza vaccines; - No documentation of a signed consent/refusal form. 3. Review of Resident #18's medical record showed: - The resident admitted on [DATE]; - The resident older than [AGE] years of age; - Diagnoses of dementia, obstructive uropathy (disorder of urinary tract due to obstructed urinary flow), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), frequent urinary tract infections (UTIs), stroke, heart failure, and pneumonia; - No documentation of the resident's pneumococcal and influenza vaccine history; - No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal and influenza vaccines; - No documentation of a signed consent/refusal form. 4. Review of Resident #22's medical record showed: - The resident admitted on [DATE]; - The resident older than [AGE] years of age; - Diagnoses of heart failure, deep vein thrombosis (DVT) (blood clot), UTI, and chronic obstructive pulmonary disease (COPD) (chronic inflammation of lung that causes obstructed airflow); - No documentation of the resident's pneumococcal and influenza vaccine history; - No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal and influenza vaccines; - No documentation of a signed consent/refusal form. During an interview on 01/11/24 at 02:10 P.M., the Director of Nursing (DON) was not aware of the residents who did not have up-to-date influenza or pneumonia vaccines During an interview on 01/11/24 at 11:35 A.M., the Administrator said the influenza and pneumococcal vaccines were available to give. The process was the Social Worker did the admission screening questions and if the resident wanted the vaccines, then the Social Worker sent the request to the DON. The consent then got signed after the risks and benefits of the vaccines were discussed with the resident and/or resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure COVID-19 resident vaccinations were offered, administered, or refused by the resident and/or the resident representative for four residents (Residents #2, #3, #18, and #22) out of five sampled residents. The facility census was 35. Review of the facility policy titled, COVID-19 Vaccination of Residents, revised June 2022, showed: - Residents eligible to receive the COVID-19 vaccine are strongly encouraged to do so; - Resident or representative has the right to accept, refuse, and change his/her decision about taking the COVID-19 vaccine; - Resident is provided with education regarding the benefits, risks, and potential side effects associated with the each vaccine and booster; - Residents are screened for contraindications to the vaccine; - Residents must sign a consent to vaccinate form prior to receiving the vaccine; - When COVID-19 vaccines are administered in two does, the second dose is automatically scheduled if first dose is received; - A vaccination administration record is provided to the resident and a copy is filed in resident's medical record; - The resident's medical record includes documentation that the resident or representative was provided education of risks and benefits of vaccine, samples of educational materials used, date education took place, name of individual receiving education, signed consent, and each dose of COVID-19 vaccine that was administered to the resident. 1. Review of Resident #2's medical record showed: - The resident admitted on [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and heart failure (an inability of the heart to pump sufficient blood flow to meet the body's needs); - No documentation of the resident's COVID-19 vaccine history; - No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the COVID-19 vaccines; - No documentation of a signed consent/refusal form. 2. Review of Resident #3's medical record showed: - The resident admitted on [DATE]; - Diagnoses of pneumonia (infection in lungs), diabetes mellitus (DM) (abnormal blood sugar in blood), and stroke (damage to the brain from interrupted blood supply); - No documentation of the resident's COVID-19 vaccine history; - No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the COVID-19 vaccines; - No documentation of a signed consent/refusal form. 3. Review of Resident #18's medical record showed: - The resident admitted on [DATE]; - Diagnoses of dementia, obstructive uropathy (disorder of urinary tract due to obstructed urinary flow), benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), frequent urinary tract infections (UTIs), stroke, heart failure, and pneumonia; - No documentation of the resident's COVID-19 vaccine history; - No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the COVID-19 vaccines; - No documentation of a signed consent/refusal form. 4. Review of Resident #22's medical record showed: - The resident admitted on [DATE]; - Diagnoses of heart failure, deep vein thrombosis (DVT) (blood clot), UTI, chronic obstructive pulmonary disease, and (COPD) (chronic inflammation of lung that causes obstructed airflow); - No documentation of the resident's COVID-19 vaccine history; - No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the COVID-19 vaccines; - No documentation of a signed consent/refusal form. During an interview on 01/11/24 at 02:10 P.M., the Director of Nursing (DON) said she was new and was finding and organizing the resident's information to know who needed what vaccine. During an interview on 01/11/24 at 11:35 A.M., the Administrator said she was working on getting everything up-to-date since there were a lot of new staff.

Based on interview and record review, the facility failed to provide the required annual competencies of dementia care (care of a resident with an impaired ability to remember, think, or make decisions) or the abuse and neglect training and 12 hours of training for two Certified Nurse Aides (CNA) (CNA B and CNA C) out of two sampled CNAs, which had the potential to affect all residents. The facility's census was 35. The facility failed to provide a policy regarding the required annual nurse aide training. 1. Review of CNA B's in-service record showed: - A hire date of 03/30/20; - No documentation of the annual dementia care training provided for March 2022 through March 2023; - No documentation of 12 hours of training provided for March 2022 through March 2023. 2. Review of CNA C's in-service record showed: - A hire date of 12/12/22; - No documentation of the annual abuse and neglect training provided for December 2022 through December 2023; - No documentation of 12 hours of training provided for December 2022 through December 2023. During an interview on 01/11/24 at 1:20 P.M., the Director of Nursing (DON) said CNAs should receive 12 hours of training annually that should include abuse and neglect and dementia care. During an interview on 01/11/24 at 1:27 P.M., CNA A said the facility used a web-based system for training. He/She wasn't sure how many hours they did annually, but he/she just do what was required on the system. Abuse and neglect was done when required on the system and if there was an abuse situation. Dementia care was done when required on the system also. During an interview on 01/11/24 at 1:30 P.M., the Administrator said CNAs should have 12 hours of training annually that included abuse and neglect and dementia care.

Based on observation, interview, and record review, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 35. Review of the facility's policy titled, Food-Related Garbage and Refuse Disposal, revised October 2017, showed the outside dumpsters provided by the garbage pickup services will be kept closed and free of surrounding litter. 1. Observations on 01/08/24 at 11:00 A.M., 01/09/24 at 10:45 A.M., 01/10/24 at 2:00 P.M., and 1:53 P.M., and 01/11/24 at 9:03 A.M., of the outside trash dumpster located near the kitchen entrance showed one 6-yard (yd.) dumpster partially filled with the one plastic lid completely opened. During an interview on 01/11/24 at 9:00 A.M., the Dietary Manager said the dietary staff removed the trash at the end of their shifts daily. Trash bags were usually tossed in the dumpster, and it was left open for the next time it needed to be filled, but it should be closed. During an interview on 01/11/24 at 9:04 A.M., Dietary Aide G said staff took the trash to the dumpster daily. The lid stayed open on the dumpster so that it was easy to throw trash in it and get back inside the facility. During an interview on 01/11/24 at 10:09 A.M., the Administrator said the trash dumpster was normally left open but it should remain closed. The area around the dumpster should be orderly. During an interview on 01/11/24 at 11:10 A.M., the Maintenance Director said the trash dumpster should be closed when it was unattended. There had been issues with staff keeping the dumpster closed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one resident's (Resident #1) responsible party after the resident fell and sustained injuries on two separate occasions, one of which resulted in the resident going to the emergency room for evaluation. The facility census was 32. Review of the facility policy titled, Change in Resident's Condition or Status, revised on February 2021, showed the following: -The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition; -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: The resident is involved in an accident or incident that results in an injury including injuries of an unknown source; there is a significant change in the resident's physical, mental, or psychosocial status; or it is necessary to transfer the resident to the hospital. 1. Review of Resident #1's face sheet showed the following: -admission date of 05/26/22; -Diagnoses included dementia with behavioral disturbances, Alzheimer's disease, and adult failure to thrive (an decline in older adults health and abilities); -The form listed a responsible party and a second contact with phone numbers. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 08/08/23, showed the following: -Short-term and long-term memory problems; -Severely impaired cognitive skills for daily decision making; -No falls since prior assessment Review of the resident's Incident/Accident Report dated 10/10/23, untimed, showed the following: -Found the resident lying in the floor between his/her bed and the chair; -Resident unable to describe the incident; -Resident assessed for injuries with none found except for bruising/swelling to right eyebrow/eye; -Vital signs were within normal limits, except temperature 100.9 degrees Fahrenheit (F). Staff will report to the day shift nurse. Resident assisted back into bed and neurological checks started; -Notification of resident representative showed notified on 10/10/23, but staff did not document time of notification. Review of the resident's change in condition form, dated 10/10/23, showed the following: -Resident had fall with injury to right eyebrow/eye bruising/hematoma (collection or pooling of blood under the skin); -Attempted to contact resident's responsibility with no answer. Review of the resident's nurse's note, dated 10/11/23, showed the Director of Nursing (DON) documented staff transferred resident to the emergency room related to head injury and and nausea per the resident's physician's order at 10:00 A.M. Review of the resident's October 2023 physician order sheet showed the following: -An order, dated 10/11/23, to send the resident to the emergency room related to a fall with injury to the right eye and complaints of nausea. Review of the resident's record showed staff did not document notifying the resident's representative regarding the fall or the transfer to the emergency room. Review of the resident's Incident/Accident Report dated 10/23/23, at 4:00 P.M., showed the following: -Thud heard from the nurses' station and then another resident yelled he/she fell; -Nurse found the resident face down in the dining room floor. Resident appeared to have fallen asleep and fell forward out of his/her wheelchair; -Quarter-sized bruise noted to the right side of the resident's forehead extending into his/her hairline with no other apparent injuries; -Staff notified physician; -Staff attempted to contact the resident's responsibility party, but no answer; -The nurse did not document any attempt to contact the secondary emergency contact. Review of the resident's record showed staff did not document notifying the resident's representative regarding the fall. During an interview on 10/27/23, at 3:27 P.M., Licensed Practical Nurse (LPN) A said the following: -The nurse should notify the resident's responsible party of a change in condition, such as a fall; -The nurse should notify the resident's responsible party, if the resident's physician gave an order for the resident's to go to the emergency room for evaluation; -The nurse should document the notifications in the nurse notes in the resident's medical record. During an interview on 10/30/23, at 10:45 A.M., Registered Nurse (RN) B said the following: -On 10/23/23, the nurse attempted to contact the resident's responsible party four times to notify of the fall, but the responsible party did not answer and did not return the call; -The nurse did not attempt to contact the secondary emergency contact; -The nurse should document his/her attempted notification of the responsible party in the nurse notes or on the change in condition form along with the date and time. During an interview on 10/30/23, at 10:40 A.M., the Director of Nursing (DON) said the following: -The resident fell on [DATE], but the DON did not recall what time the resident fell and failed to document the time of the fall; -On 10/11/23, the physician gave an order for the resident to go to the emergency room to be evaluated from a fall on 10/10/23; -He/she sent the resident to the emergency room via ambulance; -The DON did not recall whether or not he/she notified the resident's responsible party about the resident going to the emergency room. During an interview on 10/30/23, at 12:52 P.M., the Administrative Assistant and the DON said the following: -The nurse on duty should notify the resident's responsible party of a change in condition, such as a fall with injuries; -The nurse should try at least one time and leave a message for the responsible party; -The nurse should attempt the secondary emergency contact if one is listed; -If the nurse cannot reach the resident's responsible party, the nurse should notify the next shift nurse and the DON or Administrator; -The nurse should document all attempted notifications in the resident's nurse notes or on the incident report. Complaint #MO00226392

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1), with a diagnosis of pneumonia and respiratory syncitial virus (RSV - a common contagious airborne virus of the respiratory tract), received appropriate treatment and care when staff failed to notify the physician of the resident's return from the hospital, new diagnoses, and new medication orders, and failed to administer these ordered medications to the resident. The facility census was 37. Record review of the facility policy titled, Admissions-From Other Healthcare Facilities, revised March 2017, showed the following: -Residents from other healthcare facilities may be admitted upon receipt of appropriate documentation; -A resident may be admitted to the facility on ly upon the written order of his or her attending physician; -The following information will be provided to the facility prior to or upon the resident's admission: admitting diagnosis and physician orders for immediate care. Record review of the facility policy titled, Administering Medications, revised April 2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescribers orders, including any required time frame; -Medications are administered within one hour of their prescribed time, unless otherwise specified; -As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; dosage; route of administration; any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the drug. 1. Record review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE] from the hospital. Record review of the resident's, undated, baseline care plan showed the following: -Required assistance of one staff transfers, bathing, toileting, and dressing; -Required oxygen equipment. Record review of the resident's November 2022 physician order sheets showed the following: -Diagnoses of chronic respiratory failure, bronchitis, chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs), and diabetes mellitus type 2 (a chronic health condition that affects how the body turns food into energy.). Record review of the resident's nurse progress notes, dated 11/5/22, showed the following: -At 6:15 A.M., a nurse documented the resident complained of discomfort all over, lungs with wheezing throughout, oxygen saturation 82% (normal pulse oximeter readings usually range from 95% to 100%, values under 90% are considered low), oxygen at 2 liters/minute per nasal cannula (L/min/NC), albuterol (a bronchodilator used to treat airways) solution per nebulizer (a mist treatment inhaled into the lungs) given, temperature 99.6 degrees Fahrenheit (F); -At 6:45 A.M., oxygen saturation 88%, temperature 98.4, complaints increased shortness of breath, senior care (the on-call physician exchange) notified; -At 6:55 A.M., per senior care, transferred the resident to the emergency room; -At 11:15 A.M., the resident returned from the emergency room via emergency medical services (EMS). The resident had a new diagnosis of RSV and new orders received to start Tessalon (a cough suppressant) 200 milligrams (mg) 1 by mouth as needed for cough and Medrol (mythelprednisolone - a steroid sometimes used to decrease inflammation in the lungs) 4 mg daily for five days. Staff assisted the resident from the stretcher to the bed. Residents vital signs residents temperature 98.9 degrees F and oxygen saturations 93% on 5 L/min/NC of oxygen. Resident did not complain of pain and no signs of distress. Staff placed water and call light in reach. Staff will continue to monitor. (Staff did not document communication with the resident's physician regarding the resident's return to the facility, the new diagnoses, or the new orders from the emergency room.) Record review of the resident's hospital general instructions at discharge, dated 11/5/22, showed the following: -Exacerbation of COPD,viral and bacterial pneumonia with hypoxemia (below-normal level of oxygen in blood), and RSV; -Needs 4 to 5 L of oxygen and prednisone (steriod). Administer Duoneb (an inhaler containing albuterol and ipratropium used for increased air flow to the lungs) every 4 hours; -Prescription medications: Tessalon 200 mg take one every 8 hours as needed for cough and Medrol dose pak 4 mg take according to package directions for five days. -Return to emergency department as needed and follow up with physician at the facility. Record review of the resident's physician's orders showed on 11/5/22 the resident returned from the emergency room with the following orders noted by Licensed Practical Nurse (LPN) A: -Diagnoses of RSV and pneumonia; -Tessalon 200 mg one by mouth every 8 hours as needed; -Medrol 4 mg take as directed. Record review of the resident's November medication administration record (MAR) showed no orders for or administration of Medrol, Tessalon, or Duoneb. Record review of the resident's nurse progress notes, dated 11/6/22, showed LPN A documented the following: -Untimed entry, the facility received a call from 911 at 2:00 P.M., 911 stated they received a call from the resident stating the facility had left the resident outside in the cold. The nurse went to the resident's room and checked on the resident. The resident stated he/she was trying to get the nurse to take his/her remote control. The resident then hit the nurse with the remote. The resident's remote placed on the resident's bedside table. The resident's call light and water were in reach of the resident; -Untimed entry, the nurse received a call from the resident's family asking the nurse to check on the resident. Upon the nurse's arrival to the room, the resident began shouting, I need air. The resident's vital signs showed oxygen concentration 97% on 5 L/min/NC of oxygen. The resident said, at least his/her oxygen level was good. The resident mentioned his/her family had him/her worked up and the nurse asked the resident if there was anything he/she could do. The resident said he/she just needed water and call light in reach. The nurse will continue to monitor; -Untimed entry, the resident's family called at 5:00 P.M. and stated the resident was not okay and the nurse needed to send the resident to the hospital now. The nurse informed the resident's family member he/she would check on the resident. When the nurse arrived in the room, the resident said his/her family member said the resident needed to go to hospital now. The nurse attempted to call another of the resident's family members, but he/she did not answer. The resident demanded to be sent to the emergency room. The nurse called 911 at 5:15 P.M., and emergency medical services (EMS) arrived at 5:30 P.M. and transported the resident to the hospital. During interviews on 11/21/22, at 12:20 P.M. and 12:45 P.M., LPN B said the following: -The nurse checked the emergency kit medication list and said the facility emergency kit did not contain Medrol or Tessalon; -If a resident returned from the hospital on the weekend, the nurse on duty should notify the physician of the orders via fax and send the medications orders to the after-hours pharmacy; -It is the nurse's responsibility to write the physician's orders onto the MAR and pull the medication from the emergency kit. If the medication is not available in the Emergency kit, the nurse should contact the resident's physician, if after hours or on a weekend. During an interview on 11/21/22, at 12:22 P.M., LPN A said the following: -On 11/5/22, when the resident returned from the hospital, LPN A handed the resident's new orders to the Certified Medication Technician (CMT) C, and notified him/her of the need to put the resident's new medication orders onto the resident's MAR; -It was the responsibility of the CMT to order the medications for the resident and place new orders on the resident's MAR; -The LPN said he/she did not contact the resident's facility physician about the resident's return from the hospital or about the new orders via phone, but rather faxed the physician; -The LPN said he/she was not aware staff did not document the new medication orders on the MAR and was not aware staff did not administer the medications; -If the CMT had informed the nurse that the resident's medications were not available, he/she would have contacted the DON or administrator to ask what to do. During an interview on 11/22/22, at 8:08 A.M., CMT C said the following: -He/she worked part-time at the facility as an aide and rarely passed medications; -He/she worked on 11/5/22 at the facility and passed medications to the residents; -The resident returned from the hospital emergency room on the afternoon of 11/5/22; -The CMT was not aware of any new medication orders for the resident; -The nurse on duty did not instruct the CMT to write medication orders on the resident's MAR or order any medications for the resident; -If a resident required a medication after noon on a Saturday, staff would have to drive to another town to obtain the medication, because the local pharmacy closed at noon on Saturdays. During an interview on 11/21/22, at 12:55 P.M., the Assistant Director of Nursing (ADON) said the following: -If a resident returned from the hospital on the weekend, the nurse should review the new orders from the hospital; -The nurse should then check the facility emergency kit to see if the newly ordered medications were available; -The nurse should contact the on-call physician to notify the physician of the resident's return to the facility and of any new orders from the hospital; -If the medications were not available in the emergency kit, the nurse should notify the physician; -CMTs were allowed to write orders on the MAR, but the nurse was ultimately responsible to ensure the medication was ordered and available to the resident. During interviews on 11/21/22, at 11:45 A.M. and 2:00 P.M., the Administrator said the following: -If a resident returned from the emergency room with physician orders for new medications for the resident, the nurse should pull the medication from the emergency kit located in the medication room; -If the medication was not available in the emergency kit, the nurse should contact the resident's physician to see if there was an alternate medication that would work instead; -If the resident required that specific medication and the local pharmacy was closed, the facility had a back-up pharmacy to contact on the weekends for emergency medications; -When a resident returns from the hospital, the nurse on duty should contact the resident's physician by phone to notify of the resident's return and to go over any new orders from the hospital; -The nurse should ensure the newly ordered medications were available to the resident by contacting the after-hours (back-up) pharmacy, if needed. MO00210067

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided two residents (Resident #7 and Resident #12), who required staff assistance, with timely showers as care planned and grooming assistance. The facility census was 32. Record review showed the facility did not provide a policy on bathing and grooming. 1. Record review of Resident #7's face sheet (a brief resident profile sheet) showed the following information: -admission date of 9/14/2019; -Diagnoses included arteriosclerosis (occurs when the blood vessels that carry oxygen and nutrients from heart to the rest of body (arteries) become thick and stiff) heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus without complications (pancreas produces little or no insulin), unspecified mononeuropathy of left lower limb (nerve damage), osteoarthritis, unsteadiness on feet, and personal history of traumatic brain injury. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/21/2021 , showed the following information: -Cognitively intact and usually understood; -No behaviors; -Required extensive assistance for dressing, toileting, and personal hygiene; -Required one person physical assist for bathing; -Unsteady balance; -Used walker; -Frequently incontinent of bladder; -Occasionally incontinent of bowel. Record review of the resident's care plan, updated on 1/14/2022, showed the following information: -Required assistance with completing daily activities of care safely; -One person staff assist with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Staff to orient resident as needed; -At risk for alteration in skin related to incontinence. Resident wore incontinence briefs; -Shower two times a week and as needed. Record review of the resident's shower sheets, dated January 2022 and February 2022, showed the following information: -Staff provided a shower on 1/16/2022, 1/20/2022, 1/27/2022, and 1/30/2022; -Staff provided a shower on 2/6/2022, 2/10/2022, and 2/17/2022; -The resident received a total of four showers for the month of January and three showers for the month of February. Observation on 3/01/2022, at 8:42 A.M., showed the following: -The resident in his/her room. The resident wore blue jeans and a blue button up shirt. Tobacco pieces were around the resident on the floor. The resident's shirt had tobacco and tobacco spit on it. During an interview and observation on 3/02/2022, at 1:39 P.M., the resident said the following: -He/she would like a shower one time per week; -The resident had on the same blue button up shirt and jeans as 3/01/2022. The shirt had food remnants and tobacco on it. Observation on 3/03/2022, at 8:58 A.M., showed the following: -The resident walked down the hall, wearing the same blue button up shirt and jeans as the prior two days. During an interview and observation on 3/3/2022, at 9:31 A.M., the resident said he/she puts on his/her own clothes. The resident had on the same clothes that he/she wore since 3/01/2022. The shirt and pants both had food and tobacco on the front. During an interview on 03/03/2022, at 1:35 P.M., Certified Nursing Assistant (CNA) E said the following: -The resident usually refuses to change his/her clothes one time per week. During interviews on 03/03/2022, at 9:55 A.M. and 1:20 P.M., CNA B said the following: -The resident doesn't like to take showers; -The resident does occasionally need assistance with dressing, but is mostly independent. -The resident has not refused to change clothes, but there has been times when he/she is embarrassed and staff will wait until he/she notices and is more receptive to help. During an interview on 03/03/2022, at 10:00 A.M., Registered Nurse (RN) D said the following: -The resident likes showers less than two times per week; -The resident requires set up for dressing and encouragement. During an interview on 03/03/2022, at 10:25 A.M., the MDS coordinator said the following: -The resident required one assist with showers. During an interview on 03/03/2022, at 12:45 P.M., the Director of Nursing (DON) said the following: -The resident is difficult and vocal, may not always want a shower; -The resident will wear the same clothes and sometimes needs help changing clothes. 2. Record review of Resident #12's face sheet (a brief resident profile sheet) showed the following information: -admission date of 8/24/2019; -Type 2 diabetes mellitus (pancreas produces little or no insulin), difficulty walking, need for assistance with personal care, and lack of coordination. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognition and usually understood; -No behaviors; -Required extensive assistance for dressing, toileting, and personal hygiene; -Required one person physical assistance for bathing; -Did not walk; -Always continent. Record review of the resident's care plan, updated on 1/03/2022, showed the following information: -Performed own daily activities of care, assist of one staff as needed with ADLs; -Assist resident with shaving; -Resident performs own ADLs, if he/she requires assist it will take one staff member; -Continent of bowel and bladder, at risk for alteration in skin; -Whirlpool as needed. Record review of the resident's shower sheets, dated January 2022 and February 2022, showed the following information: -Staff provided a shower on 1/1/2022, 1/22/2022, 1/25/2022, and 1/29/2022; -Resident refused a shower on 2/12/2022 due to not feeling well; -Staff provided a shower on 2/15/2022 and 2/19/2022; -The resident received four showers during the month of January and two showers during the month of February. During an interview on 3/01/2022, at 9:00 A.M., the resident said the following: -He/she used to receive two showers per week when first arriving at the facility. Now, it's every one to two weeks. He/she would like two showers per week, or at least one. The resident wore a purple shirt and blue pants. Observation of 3/01/2022, at 9:00 A.M., showed the following: -He/she was in the hall, wearing the same purple shirt and blue pants. The shirt had food on much of the front and the pants were also dirty. During an interview and observation on 03/02/2022, at 10:40 A.M., the resident said he/she has a history of skin issues. The resident pulled up his/her right pant leg and the skin appeared dry and there were several sores. The resident said his/her skin itches a lot from the waist down and staff will apply lotion or cream when giving a shower. The resident wore the same purple shirt and blue pants as the day prior. There was food and tobacco on the shirt and the pants appeared dirty as well. Observation on 03/03/2022, at 8:47 A.M., showed the following: -The resident had on the same clothes as the prior day, with food and tobacco on the shirt. The pants had a brown substance as well; -The resident pulled up the left pant leg, the skin appeared dry and there were sores on his/her leg. During interviews on 03/03/2022, at 10:00 A.M. and 1:35 P.M., CNA E said the following: -The resident likes two showers per week; -Not sure when the resident received his/her last shower; -The resident does well changing his/her own clothes. -The resident has not refused to change his/her clothes. During interviews on 03/03/2022, at 9:55 A.M. and 1:20 P.M., CNA B said the following: -The resident receives showers two times per week; -The resident does require assistance at times with dressing; -He/she does not believe Resident #12 has ever refused a shower; -The resident has not refused to change his/her clothes. During interviews on 03/01/2022, at 9:09 A.M., and on 03/03/2022, at 10:00 A.M., RN D said the following: -The resident has dry skin; -The resident receives two showers per week; -As far as RN D is aware, the resident is up to date on his/her showers; -The resident probably likes two showers per week, and a third would make him/her happy; -The resident requires set up only assist for dressing. During an interview on 03/03/2022, at 10:25 A.M., the MDS Coordinator said the resident required one staff assist with showers. During an interview on 03/03/2022, at 12:45 P.M., the Director of Nursing (DON) said the resident is pretty independent with changing clothes. 3. During an interview on 03/03/2022, at 10:00 A.M., CNA E said the following: -Showers are given to residents twice per week; -Resident's clothes are changed daily, whether independent or dependent; -All residents have clean clothes in the morning. During an interview on 03/03/2022, at 9:55 A.M., CNA B said the following: -Staff apply lotion when showering, and at times when assisting with toileting; -Resident's clothes are changed in the morning and when going to bed, whether the resident is independent. During an interview on 03/03/2022, at 10:00 A.M., RN D said residents are given showers two times per week. During an interview on 03/03/2022, at 10:25 A.M., the MDS Coordinator said the following: -Determines resident's needs by speaking to CNAs, review of ADL charting book, and also look back on Medicare A assessment sheets; -Care plans are documented for resident showers two times per week and as needed. During an interview on 03/03/2022, at 12:45 P.M., the DON said the following: -Residents are put on the shower list two times per week and care provided daily; -Some residents have showers every day; -Resident's clothes should be changed daily and as needed; -Not appropriate for residents to wear the same clothes several days.

Based on observation, record review, and interview, the facility failed to prevent a significant medication error when a nurse failed to prime the insulin pen needle per the manufacturer's guidelines before administering rapid acting insulin to one resident (Resident #31). The facility census was 32. Record review of the Novolog (a type of fast-acting insulin) website guidance, dated May 2018, showed the following information: -The Novolog FlexPen (a prefilled insulin pen): the method of administration may affect glycemic control (a medical term referring to the typical levels of blood sugar in person with diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose)) and predispose the person to hypoglycemia (abnormally low blood sugar) or hyperglycemia (abnormally high blood sugar). To avoid injecting air and ensure proper dosing, prime the pen (referred to as air shot, before each injection small amounts of air may collect in the cartridge during normal use) before each injection. Record review of the facility's Insulin Administration Policy, dated 2001 and revised September 2014, showed the following information: -The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. (The policy did not address priming of the pen needle or insulin pen preparation procedures.) 1. Record review of Resident #31's face sheet (general resident information sheet) showed the following information: -admission date of 5/6/2020 with a readmission date of 2/17/2021; -Diagnoses included type 2 diabetes mellitus (a chronic condition in which the body does not produce enough insulin). Record review of the resident's February 2022 physician order sheet (POS) showed the following information: -An order, dated 4/14/2021, to inject subcutaneously (under the skin) Novolog FlexPen insulin before meals with dosage of blood sugar result divided by 30, then subtract 3. Observation on 3/02/2022, at 11:37 A.M., showed Licensed Practical Nurse (LPN) A, with gloves applied, poke the resident's finger for a blood sugar level. LPN A appropriately pulled up the correct dose of Victoza (a once daily noninsulin medicine that lowers blood sugar) and administered it. LPN A calculated the correct dose of one unit of Novolog for the resident. LPN A applied a pen needle to the insulin pen and dialed it to one unit. LPN A did not prime the insulin pen. LPN A administered one unit of Novolog into the resident's abdomen without priming the pen. During an interview on 3/03/2022, at 11:56 A.M., LPN A said the nurses pass insulin to the residents. The nurses take the blood sugar level to get the results. Then the nurses take the cap off of the pen, attach the needle, clean the area of skin, pull off the pen needle cap, and administer the insulin after cleaning the resident's skin. He/she was never taught in nursing school about priming a pen needle. During an interview on 3/03/2022, at 9:45 A.M., Registered Nurse (RN) D said with rapid acting insulin, he/she gives a sliding scale dose depending on the resident's blood glucose result. He/she does the math, applies gloves, and that with pens he/she draws up two units to prime the pen needle. He/she asks the resident where they want the injection, then he/she wipes the area with alcohol, pinches the resident's skin, and injects the insulin and holds it there for five or six seconds before withdrawing the needle from the skin. He/she does it because that is how he/she was taught in school. During an interview on 3/03/2022, at 12:49 P.M., the Director of Nursing (DON) said the charge nurse on duty administers the insulin. The rapid acting insulin pen needle needs to be primed. The facility has provided an in-service on priming the pen needle. He/she took out the insert from the fast acting insulins for the in-service and used it to teach the nurses. During an interview on 3/03/2022, at 1:23 P.M., the administrator said the charge nurse is responsible for administering insulin. The facility does not have a policy on prepping insulin pens. Staff are to follow the manufacturer's guidelines, and that's what the facility's policy says. They have in-serviced staff more than one time on insulin pen priming and basic use of insulin pens.

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment and shelving units in a clean sanitary manner and failed to ensure the areas under the steam table and corner metal shelving were free from erosion. The facility census was 32 residents. Record review of the 2013 Missouri Food Code, showed the following information: -Equipment food-contact surfaces and utensils shall be clean to sight and touch; -The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material; -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -The physical facilities shall be cleaned as often as necessary to keep them clean. Record review of the facility policy, dated 2016, on Cleaning Rotation showed the following information: -Items cleaned weekly: Hoods, filters, and shelves; -Items cleaned annually: Ceilings; -Employees shall be aware of potential hazards and all accident or unsafe practices should be reported; -Report all broken or defective equipment and tools immediately 1. Observation of the kitchen on 2/28/2022, beginning at 10:02 A.M., showed the following: -The shelf below the steam table had an area of erosion, approximately the size of a large plate. The area had dark brown and white stains; -The lower shelf of the table in the corner, that houses pans, and various kitchen appliances, had an area of erosion, approximately the size of a large plate. The area had several white stains. Observation of the kitchen on 3/02/2022, beginning at 2:20 P.M., showed the following: -The shelf below the steam table, had an area of erosion, approximately the size of a large plate. The area had dark brown and white stains; -The lower shelf of the table in the corner, that houses pans, and various kitchen appliances, had an area of erosion, approximately the size of a large plate. The area had several white stains. During an interview on 3/02/2022, at 2:15 P.M. Dietary Aide (DA) F said the following: -No one person is in charge of cleaning certain parts of the kitchen, all staff are to clean the shelves, refrigerators and whatever needs cleaned; -They have a checklist of items to clean. During an interview on 3/02/2022, at 2:22 P.M., the Dietary Manager said the following: -He/she has a cleaning sheet for the kitchen; -All staff help clean shelves, floors, appliances and whatever needs cleaned; -He/she is aware of the erosion on the shelves. During an interview on 3/03/2022, at 9:00 A.M.,. the Maintenance Supervisor said the following: -Staff write down kitchen issues in a book at the nurses' stations and maintenance does what's needed. During an interview on 3/03/2022, at 1:00 P.M., the Administrator said the following: -The kitchen should be kept clean, there is a cleaning schedule; -Kitchen equipment should be replaced as needed, these replacements are requested through the administrator.

Based on record review and interview, the facility failed to follow facility policy to ensure staff completed employee tuberculosis (TB-a potentially serious infectious bacterial disease that mainly affects the lungs) screenings test on hire for five staff members (Registered Nurse (RN) D, Maintenance Supervisor, Certified Medication Technician (CMT) I, Certified Nursing Assistant (CNA) J, and CNA M), and failed to monitor resident tuberculosis screening tests on admission for three residents (Resident #5, Resident #21, and Resident #33). The facility census was 32. Record review of the Centers for Disease Control and Prevention website, updated 3/8/2021, showed the following: -The TB skin test is performed by injecting a small amount of fluid (called tuberculin) into the skin on the lower part of the arm; -A person given the tuberculin skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm; -Results should be documented in millimeters (mm); -A second skin test should be administered one to three weeks later; -The test should be read 48 to 72 hours after administration; -The results should be documented in mm. 1. Record review of the facility policy, titled Tuberculosis, Screening Residents for, dated August 2019, showed the following: -The facility shall screen all residents for TB infection and disease. Individuals identified with active TB shall be isolated from other residents and ancillary staff, and transported to an appropriate care facility as soon as possible; -The admitting nurse will screen referrals for admission and readmission for information regarding exposure to or symptoms of TB; -If a potential resident has been exposed to active TB or is at increased risk of TB infection he/she will be screened for TB using TB skin tests or interferon gamma release assay (IGRA-a blood test to check for TB infection). (The facility policy did not address timing of reading or placement of second step of the TB skin tests.) 2. Record review of Resident #5's face sheet (a brief summary sheet) showed the following: -admission date of 12/8/2021. Record review of the resident's TB screening/immunization record showed the following: -On 12/8/2021, facility staff documented administering a TB skin test to the resident's left forearm; -The facility staff did not document reading the test in 48 to 72 hours; -The facility staff did not document administering a second step TB test. 3. Record review of Resident #21's face sheet showed the following: -admission date of 6/10/2021. Record review of the resident's TB screening/immunization record showed the following: -On 6/10/2021, staff documented administering a TB skin test to the resident's right forearm; -Staff did not document reading the TB test within 48 to 72 hours; -On 6/17/2021, staff documented administering a TB skin test to the resident's left forearm; -Staff did not document reading the TB test within 48 to 72 hours. 4. Record review of Resident #33's face sheet showed the following: -admission date of 11/12/2021. Record review of the resident's TB screening/immunization record showed the following: -On 11/12/2021, staff documented administering a TB test to the resident's forearm; -Staff did not document reading the TB test within 48 to 72 hours; -Staff did not administer a second step TB test within two to three weeks following the first step TB test. 5. During an interview on 3/2/2022, at 3:10 P.M., Licensed Practical Nurse (LPN) A said it is the charge nurse's responsibility to do the annual and admission tuberculosis skin tests for residents. The tests should be read within 72 hours of administering and documented on a vaccination sheet in the chart. It is not acceptable to not read the test. During an interview on 3/3/2022, at 10:15 A.M., RN D said normally the Director of Nursing (DON) does the resident TB tests and since she is out ill, another nurse has taken the role of doing them. The test should be read after 72 hours and documented in the treatment administration record (TAR) and on the vaccination sheet. It is not appropriate to not read the test site or administer the 2nd step. 6. Record review of the facility policy, titled Tuberculosis, Employee Screening, dated March 2021, showed the following: -All employees are screened for latent (inactive) TB infection and active TB disease, using TB skin test, or IGRA and symptom screening prior to beginning employment; -Each newly hired employee is screened for latent and active TB after an employment offer has been made, but prior to the employee's duty assignment; -Screening includes a baseline test for latent TB using either a TB skin test or IGRA, an individual risk assessment, and symptom evaluation; -If the baseline test is negative and the individual risk assessment indicates no risk factors for acquiring TB, no additional screening is indicated; -If the baseline test is positive, but the individual risk assessment is negative and the individual is asymptomatic, a second test is conducted. 7. Record review of RN D's employee file showed the following: -He/she was hired on 10/5/2021; -Facility staff did not document administering a first step TB test; -Facility staff did not document reading the first step TB test; -Facility staff did not document administering a second step TB test; -Facility staff did not document a reading of the second step TB test. 8. Record review of CMT I's employee file showed the following: -He/she was hired on 1/11/2022; -Facility staff did not document administering a first step TB test; -Facility staff did not document reading the first step TB test; -Facility staff did not document administering a second step TB test; -Facility staff did not document a reading of the second step TB test. 9. Record review of the Maintenance Supervisor's employee file showed the following: -He/she was hired on 10/21/2021; -Facility staff did not document administering a first step TB test; -Facility staff did not document reading the first step TB test; -Facility staff did not document administering a second step TB test; -Facility staff did not document a reading of the second step TB test. 10. Record review of CNA J's employee file showed the following: -He/she was hired on 2/4/2022; -Facility staff did not document administering a first step TB test; -Facility staff did not document reading the first step TB test; -Facility staff did not document administering a second step TB test; -Facility staff did not document a reading of the second step TB test. 11. Record review of CNA M ' s employee filed showed the following: -He/she was hired on 10/22/2021; -Facility staff did not document administering a first step TB test; -Facility staff did not document reading the first step TB test; -Facility staff did not document administering a second step TB test; -Facility staff did not document a reading of the second step TB test. 12. During a phone interview on 3/3/2022, at 12:50 P.M., the DON said the charge nurse on duty is responsible for staff and resident TB tests. The tests should be read in three days and documented on a sheet that has the lot number, date, time, and which arm. The sheet is in the resident's chart, and staff's are on a card hanging at the nurses' station. It is never acceptable to not read a TB test or administer the 2nd step. During an interview on 3/3/2022, at 1:10 P.M., the Administrator said she expects staff TB initial tests to be completed on day of interview, or the first day of admission for a resident, read on first day of patient care or for the resident on 72 hours. The charge nurse is responsible for staff and resident TB tests. The 2nd step is to be administered in two to three weeks. It is never acceptable to not read the TB tests or not administer the 2nd step.

Based on record review, observation, and interview, the facility failed to store and prepare food in accordance with professional standards of practice and protect food from possible contamination when staff did not maintain clean surfaces, stored scoops in the dry food storage bins, and staff did not wear proper facial hair coverings. The facility census was 32. 1. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Record review of the facility policy, dated 2016, on Cleaning Rotation showed the following information: -Dining staff working at a steam table or serving area in the dining room should have appropriate hair covering. Observation of the kitchen on 2/28/2022, beginning at 10:02 A.M., showed the following: -Dietary Aide (DA) F prepared food and did not have a hair net covering his/her facial hair. Observation of the kitchen on 3/02/2022, beginning at 8:25 A.M., showed the following: -DA F prepared food and did not have a hair net on his/her facial hair. Observation of the kitchen on 3/02/2022, beginning at 12:09 P.M., showed the following: -DA F prepared food and did not have a hair net on his/her facial hair. During an interview on 3/02/22, at 2:15 P.M., DA F said the following: -He/she thinks the facility has a policy on facial hair coverings; -If wearing a mask, staff do not need to wear a facial hair covering; -No facial nets are provided by the facility. During an interview on 3/02/2022, at 2:22 P.M., the Dietary Manager said the following: -Kitchen staff does have a policy on facial hair, but did not know if facial hair is supposed to be covered. The facility has never provided any facial hair nets. 2. Observation of the kitchen on 2/28/2022, beginning at 10:02 A.M., showed the following: -Three dry food containers containing brown sugar, white sugar, and flour had scoops located inside of the containers (potentially contaminating the food). Observation of the kitchen on 3/02/2022, beginning at 12:09 P.M., showed the following: -Three dry food containers containing brown sugar, white sugar, and flour had scoops located inside of the containers. During an interview on 3/02/22, at 2:15 P.M., DA F said the following: -Scoops are not left in the dry food bins, except sometimes for a short time when staff are getting food out, and then they take them back out. During an interview on 3/02/2022, at 2:22 P.M., the Dietary Manager said the following: -He/she did not know for sure if the scoops are supposed to be left in the dry food bins. 3. Record review of the 2013 Missouri Food Codes showed the following information: -Equipment food-contact surfaces and utensils shall be clean to sight and touch; -The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material; -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -The physical facilities shall be cleaned as often as necessary to keep them clean. Record review of the facility policy, dated 2016, on Cleaning Rotation showed the following information: -Items cleaned weekly: Hoods, filters, and shelves; -Items cleaned annually: Ceilings; -Employees shall be aware of potential hazards and all accident or unsafe practices should be reported; -Report all broken or defective equipment and tools immediately. Observation of the kitchen on 2/28/2022, beginning at 10:02 A.M., showed the following: -Range hood extinguishing system located over the stove where staff prepared and cooked resident's food, had a buildup of lint that could drop onto the food and contaminate; -Two fans located on the walls, had a buildup of lint that could drop or blow into the resident's food and contaminate; -A metal shelf located against the wall, beside the sink, that stored things such as inverted pans, where the surfaces touched the shelves. The metal wire shelving unit had a build up of fuzzy lint where the the pans were stored. The interior surface of the pans had the potential to be contaminated by the fuzzy surface of the metal shelves; -Approximately 18 of the kitchen ceiling tiles had water stains and some were not flush with the ceiling. During an interview on 3/02/22, at 2:15 P.M. and 3/03/2022, at 12:35 P.M., Dietary Aide F said the following: -No one person is in charge of cleaning certain parts of the kitchen, all staff are to clean the shelves, refrigerators and whatever needs cleaned; -The facility has a checklist of items to clean; -Kitchen staff cleans the fans over the stove and on the walls; -The marks on the ceiling tiles are from the roof leaking. He/she thinks the roof may still leak. During an interview on 3/02/2022, at 2:22 P.M., the Dietary Manager said the following: -He/she has a cleaning sheet for the kitchen; -All staff help clean shelves, floors, appliances and whatever needs cleaned; -Anything to do with the ceiling is done by maintenance; -Fans are cleaned by kitchen staff; -Fans over the stove are cleaned by an outside company. During interviews on 3/03/2022, at 9:00 A.M. and 12:36 P.M., the Maintenance Supervisor said the following: -Staff write down kitchen issues in a book at the nurse's station, and maintenance does what's needed; -The water markings on the ceiling tiles may be from the air conditioner moisture. Ceiling tiles have water marks and a couple are bulging in the downward position. During an interview on 3/03/2022, at 1:00 P.M., the Administrator said the following: -The kitchen should be kept clean, there is a cleaning schedule; -Kitchen equipment should be replaced as needed, these replacements are requested through the administrator; -Kitchen staff should be wearing hair and facial nets if they have hair on their face.