**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to transcribe one resident's treatment orders in the medical record when the resident was readmitted to the hospital (Resident #1) and failed to accurately document completed wound treatments or treatment refusals by the resident on the Treatment Administration Record (TAR) for three residents (Residents #1, #4 and #2). The sample was 4. The census was 82.Review of the facility's Documenting/Implementing Doctors Orders policy, dated revised February 2025, showed:-Documentation: record all orders in the residents' chart. Review of the facility's Documentation policy, dated revised February 2025, showed:-Purpose: ensure resident clinical records are accurate, complete, secure, and compliant with facility requirements and professional standards;-Maintain clinical records complete, accurate, readily accessible, and systematically organized on each nursing unit;-Include essential documentation: admission assessments, diagnoses, care plans, progress notes, treatment, medications, vital signs, consents, and discharge summaries. Review of the facility's Pressure Ulcer: Prevention and Findings Reporting policy, undated, showed:-Purpose: to treat an identified pressure ulcer as soon as possible (ASAP) and initiate treatment;-If there is a need for a treatment, the charge nurse and or wound nurse, will phone the physician and implement the order as described;-The treatment will be placed on the TAR at the time the physician order is executed;-The wound nurse will confirm, and document wound and document wound care in a nurse's note;-Wound nurse will document all treatments on the TAR, just as the charge nurse would be expected to perform;-The charge nurse and wound nurse will review the resident for a change in condition and implement the appropriate skin care interventions as ordered by the physician or wound nurse practitioner. 1. Review of Resident #1's medical record, showed:-Alert and oriented times four (person, place, time and situation);-Dependent on staff for all activities of daily living (ADLs, grooming, dressing and bathing);-Diagnoses included bilateral lower extremity amputation, bilateral hand amputations and end stage renal disease (ESRD, the kidneys no longer work as they should to meet the body's needs). Review of the care plan, in use at the time of survey, showed:-Problem: resident is frequently incontinent of bowel and bladder (B & B) and is dependent with toileting hygiene. He/She requires minimal (min)/moderate (mod) assist with transfers. He/She had a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) to coccyx (tailbone) at a previous admission, 6/6/25: onset;-Goal: utilize interventions to help limit risk of skin breakdown;-Interventions included: monitor for skin breakdown and report to nurse/physician/family;-Problem: resident requires min/mod assist with bed mobility and transfers. He/She is dependent with toileting hygiene related to bilateral hand amputations. He/She is frequently incontinent of B & B. He/She had a prior Stage II pressure ulcer to his/her coccyx. He/She has a surgical wound to his/her chest per nurse's notes, 6/6/25: onset;-Goal: utilize interventions to help limit risk of skin breakdown;-Interventions included:-Apply protective or barrier lotion after incontinence;-Inspect skin complete body head to toe every week and document results;-Inspect skin daily with and care and bathing, and report any changes to charge nurse;-Treatments and dressings as ordered per physician. Review of the progress notes, dated 5/26/25 through 5/31/25, showed:-On 5/26/25 at 9:21 P.M., noted open area to resident's chest area measuring 2.5 centimeters (cm) X 2 cm. No odor noted but drainage present. Hyper granulation (an overgrowth of granulation tissue that extends beyond the wound's surface, forming a raised, red, and friable mass) noted. Area cleansed with Vashe wound cleanser (used for cleansing, irrigating, moistening and debriding acute and chronic wounds) and pat dry, a small amount of mupirocin ointment (topical antibiotic) placed to a small piece of collagen and applied to wound bed. Area covered with foam dressing. Treatment to be done every other day (QOD) and as needed (PRN) for saturation;-On 5/28/25, electronically signed on 6/5/25 at 12:05 A.M., resident was referred to wound practitioner, wound blister to the chest that opened. Initial assessment was scheduled for this day. Resident was unable to be seen by wound practitioner due to outside facility appointment which conflicted with the time in which wound practitioner made rounds at the facility. Review of the TAR, dated 5/26/25 through 5/31/25, showed:-A physician order for cleanse open area to chest with Vashe wound cleanser and pat dry. Apply a small amount of mupirocin ointment to a 2 x 2 cut piece of Puracol collagen (wound dressing). Apply to wound bed and cover with foam dressing. Treatment to be done QOD and PRN for saturation. Diagnosis: unspecified open wound of unspecified front wall of thorax (chest) without penetration into thoracic cavity, start date:5/28/2025. -Documentation showed on 5/28, 5/29 and 5/30 at 9:00 P.M., an X (medication not administered) was documented. On 5/31/25 at 9:00 A.M. and 9:00 P.M., an H (hold) was documented. Review of the progress notes, dated 5/26/25 through 5/31/25, showed no documentation why the treatment was not administrated or why the treatment was held. Review of the resident's hospital record, Post Care Hand Off, dated 6/5/25, showed:-Wounds:-Site: sternal (chest), first time assessed 6/1/25;-Site: coccyx (tail bone), first time assessed 6/1/25;-Discharge Review of Systems (ROS): chest: wound vacuum (Negative Pressure Wound Therapy (NPWT, wound vacuum (vac), is a treatment that pulls fluid and bacteria out of a wound to help it heal better) in place-sternum; -Discharge orders:-Wound Care Instructions: Location of wound(s} which need treatment(s}: -Sternum: continue NPWT with dressing changes every Monday, Wednesday and Friday. Next vac dressing change was 6/6/2025; -Sacrum (triangular bone at the base of the spine /bilateral gluteal (both sides of the buttocks), bedside nursing, please apply Critic-Aid Clear ointment (petrolatum-based, barrier ointment) twice a day (BID) and PRN. Review of the TAR, dated 6/1/25 through 6/30/25, showed:-A physician order for: cleanse open area to chest with Vashe wound cleanser and pat dry. Apply a small amount of mupirocin ointment to a 2 x 2 cut piece of Puracol collagen. Apply to wound bed and cover with foam dressing. Treatment to be done every QOD and PRN for saturation. Diagnoses: unspecified open wound of unspecified front wall of thorax without penetration into thoracic cavity, start date:5/28/2025 end date: 08/27/2025: -Documentation showed: 60 out of 60 opportunities an H (hold) was documented;-There was no physician order for the NPWT or for critic-acid ointment. Review of the progress notes, dated 6/1/25 through 6/30/25, showed:-On 6/4/25, electronically signed 6/5/25 at 12:05 A.M., Resident was unable to be seen by wound practitioner for initial assessment of blister to chest that has opened, due to resident being admitted to the hospital at this time;-On 6/5/25, electronically signed 6/6/25 at 12:20 A.M., readmitted from the hospital, dressing intact to sternum at this time. Skin warm and dry to touch. Skin turgor good. Skin color within normal limits;-No documentation when the resident went to the hospital;-No documentation the treatment was changed or why the treatment was not administrated or placed on hold. During an interview on 9/9/25 at 9:25 A.M., the Unit Manager said the resident had redness on his/her buttocks, but it never opened. The facility put barrier on it and it resolved in about a week. The resident went to the hospital on 5/30/25 and returned 6/6/25. When he/she returned to the facility, he/she had a wound vac. The facility ordered the wound vac and it probably arrived around 6/11/25. When the wound vac was not in place, the facility used wet to dry dressings. The resident often dislodged the wound vac because he/she said it itched. The admitting nurse was responsible for entering the treatment orders into the computer and placing the order on the TAR. Holding the treatment for mupirocin ointment was an oversight. It should have been discontinued when the resident returned from the hospital. 2. Review of Resident #4's medical record, showed:-Disoriented to time and place;-Dependent on staff for all ADLs-Diagnoses included atrial fibrillation (a-fib, irregular heart rhythm), dementia, anxiety and Parkinson's disease(a disorder of the central nervous system that affects movement, often including tremors). Review of the care plan, in use at the time of survey, showed:-Problem: resident is dependent with bed mobility, transfers via Hoyer lift, and toileting hygiene. He/She is incontinent of B&B. He/She had noted redness to coccyx upon admission. He/She also has a wound to left great toe with treatment in place as evidence by wound (pressure/diabetic/stasis) yes;-Goal: measures will be taken to prevent skin breakdown; utilize interventions to help limit risk of further skin breakdown; and measures will be taken to prevent further skin breakdown;-Interventions included: treatments and dressings as ordered per physician; notify physician of any worsening of skin breakdown;-Problem: Non-compliance with facility recommended interventions or physician orders as evidenced by refusing to take showers or get out of bed;-Goal: Resident will show signs of improved compliance or will have no new non-compliance related episodes;-Interventions: Accept resident's right to refuse and show respect for their decision; Educate resident on facility concerns associated with non­compliance. Review of the physician order sheet, dated 9/5/25, showed:-A physician order for air mattress to bed. Check for proper functioning every shift;-A physician order to cleanse left buttocks with wound cleanser and pat dry. Apply triple antibiotic ointment (TAO) to a 2 x 2 dressing and apply to wound bed. Cover with foam dressing. Treatment to be done every day and PRN for dressing displacement. Diagnosis: pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue) of left buttock, unspecified stage;-A physician order to cleanse sacrum wound with wound cleanser and pat dry. Apply Santyl to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Treatment to be done every day and prn for soiling. Diagnosis: pressure ulcer of sacral region, stage 3 (full thickness tissue loss, subcutaneous fat may be visible, but the bone, tendon or muscle is not exposed) Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) Review of the TAR, dated 8/11/25 through 9/9/25, showed:-A physician order for air mattress to bed. Check for proper functioning every shift; -Documentation showed: 8/11 through 9/9 a H was documented; -A physician order to cleanse left buttocks with wound cleanser and pat dry. Apply TAO to a 2 x 2 dressing and apply to wound bed. Cover with foam dressing. Treatment to be done every day and as needed for dressing displacement; -Documentation showed: on 8/16 through 8/18, 8/20, 8/22 through 8/24 and 9/8 were blank; On 8/25 through 9/2 and 9/5 and 9/6 an X was documented;-A physician order to cleanse sacrum wound with wound cleanser and pat dry. Apply Santyl to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Treatment to be done every day and as needed for soiling; -Documentation showed: on 8/16 through 8/18, 8/20, 8/22 through 8/24 and 9/8 were blank; On 8/25 through 9/2 and 9/5 an X was documented. Review of the progress notes, dated 8/11 through 9/9/25, showed:-No documentation the resident refused his/her treatments and no documentation showing why the treatment was not administered. During an interview on 9/9/25 at 9:25 A.M., the Unit Manager said if there was a blank on the TAR, she would not know if the treatment was administered or not. When an X was documented, the resident may have been in the hospital. It was difficult to tell when residents were out of the facility. The Unit Manager expected staff to document when a resident left the facility and when the resident returned. The resident had an air mattress on his/her bed. When the resident returned from the hospital, the nurse should have clicked on the air mattress to reactivate the order. 3. Review of Resident #2's medical record, showed:-admitted on [DATE];-Had a wound on sacrum on admission;-Diagnosis included dementia. Review of the care plan, in use at the time of survey, showed:-Problem: Skin breakdown-at risk for/actual breakdown present evidence by occasional incontinence, onset 8/8/25;-Goal: measures will be taken to prevent skin breakdown;-Interventions included: apply protective barrier after incontinence; inspect skin complete body head to toe every week and document results. Observation on 9/5/25 at 3:45 P.M. showed the resident's right buttocks had a quarter size patch of dry skin with three tiny, scabbed areas in the center of it and two tiny, scabbed areas on the outer side of the dry patch. The skin had a reddish-maroon discoloration at the coccyx and down the right side of the gluteal fold. Review of the physician order sheet, dated 9/5/25, showed:-A physician order to cleanse right glute (buttocks) open area with wound cleanser and pat dry. Apply Medi-honey (used for removing necrotic tissue and aides in healing) to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Change every day and prn for soiling or dressing displacement. Diagnoses: unspecified open wound of right buttock, dated 8/15/2025;-A physician order to cleanse with Vashe and pat dry, apply calmoseptine ointment (barrier) to cover area, leave open to air (OTA), to be done three times a day (TID) and PRN, dated 8/8/2025. Review of the TAR, dated 8/8/25 through 8/31/25, showed:-A physician order to cleanse with Vashe and pat dry, apply calmoseptine ointment to cover area, leave OTA, to be done TID and PRN; -Documentation showed: On 8/10, 8/11, 8/13 through 8/15, 8/17, 8/18 and 8/20 were blank; On 8/22 through 8/26 and 8/28 through 8/31 an X (not administered) was documented;-A physician order to cleanse right glute open area with wound cleanser and pat dry. Apply Medi-honey to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Change every day and PRN for soiling or dressing displacement; -Documentation showed: On 8/15 through 8/18 and 8/20 was blank; On 8/22 through 8/31 a X was documented. Review of the progress notes, dated 8/8/25 through 8/31/25, showed no documentation why the treatment was not administered or if the physician was made aware the treatment was not administered. Review of the TAR, dated 9/1/25 through 9/5/25, showed:-A physician order to cleanse with Vashe and pat dry, apply calmoseptine ointment to cover area, leave OTA, to be done TID and PRN; -Documentation showed: On 9/1 and 9/2, an X was documented;-A physician order to cleanse right glute open area with wound cleanser and pat dry. Apply Medi-honey to 2 x 2 gauze and apply to wound bed. Cover with foam dressing. Change every day and PRN for soiling or dressing displacement; -Documentation showed: On 9/1 and 9/2, an X was documented. Review of the progress notes, dated 9/1/25 through 9/5/25, showed no documentation why the treatment was not administered or if the physician was made aware the treatment was not administrated.4. During an interview on 9/5/25 at 3:53 P.M., Licensed Practical Nurse (LPN) A said the facility had a wound nurse who completed treatments sometimes. The nurse on the floor completed them when the wound nurse did not. If the nurse found a wound, he/she would notify the doctor and obtain treatment orders. The nurse who obtained the order was responsible for entering the orders into the computer.5. During an interview on 9/9/25 at 9:25 A.M., the Unit Manager said the nurse on the floor was responsible for completing the treatments. When the wound practitioner visited the facility, nurse management completed the treatments. On the weekends, the facility sometimes scheduled a third nurse who will do treatments, but overall, the floor nurse was responsible for completing the treatments. When a wound was found the nurse should assess the area, notify the physician to obtain treatment orders and document it. Documentation should include the location and a description of the wound along with approximate measurements. The wound practitioner measured and staged the wound. Treatments are documented on the TAR when they are completed. If a treatment was not completed, it should be documented on the TAR along with an explanation of why the treatment was not administered in the nurse notes. A blank on the TAR meant it was not done, or it was not marked off. The Unit Manager did not understand why there would be a blank on the TAR because when the audits are completed, if something was not completed it would show up red, and she has not seen a treatment that was red. If an H was documented, that meant the resident was in the hospital and the medication was held. She expected staff to accurately document when a resident left and returned to the facility.6. During an interview on 9/10/25 at 8:55 A.M., the Administrator said when a resident is admitted /readmitted to the facility, the admitting nurse was responsible for entering the treatment orders into the computer. Treatments should be documented when the treatments are completed. If a treatment was not competed, staff should document why it was not completed and notify the physician. A blank on the TAR meant it was not signed out. Treatments are being completed. When residents leave the facility and return to the facility, it should be documented in the progress notes. The Administrator expected staff to follow physician orders and the facility policies and procedures and for the medical record to be complete and accurate. 2598153

Based on observation, interview and record review, the facility failed to follow acceptable nursing practice when staff left medication in one resident's room, who did not have a physician order for self-administration or medications to be left at the bedside (Resident #27). The sample was 17. The census was 67. Review of the facility's Medication Administration policy, dated 6/1/18, showed: -Purpose: To administer oral medication in a safe, accurate, and effective manner; -Procedure: Administer medication and remain with the resident while medication is swallowed; Do not leave medications at bedside, unless specifically ordered by the prescriber. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/20/24, showed: -Cognitively intact; -Required maximum assistance from staff for oral hygiene, toileting, personal hygiene, bathing and upper and lower body dressing; -Diagnoses included high blood pressure, anemia (low levels of iron in the blood) and depression. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's medications could be left at bedside or that the resident could self-administer his/her medications. Review of the resident's Physician Order Sheets (POS), dated August, 2024, showed no order that the resident's medications may be left at bedside or that the resident may self-administer medications. Review of the resident Medication Administration Record (MAR), dated August, 2024, showed: -An order, with a start date 5/20/24, Cymbalta (anti-depressant) 30 milligrams (mg), give one capsule, twice daily, scheduled doses 8:00 A.M. and 5:00 P.M.; -An order, with a start date 1/3/24, lisinopril (used to treat high blood pressure) 5 mg, give one tablet daily, scheduled dose 8:00 A.M.; -An order, with a start date 1/3/24, metoprolol succinate extended release (ER) (used to treat high blood pressure) 25 mg, one tablet daily, scheduled dose 7:00 A.M., -An order, with a start date 3/9/22, multivitamin, give one tablet daily, scheduled dose 7:30 A.M.; -An order, with a start date 1/24/24, sertraline (anti-depressant) 150 mg, give one capsule, daily, scheduled dose 7:30 A.M.; -An order, with a start date 3/20/24, vitamin C 500 mg, give one tablet daily, scheduled dose 7:30 A.M.; -On 8/26/24, A.M. doses of Cymbalta, lisinopril, metoprolol succinate ER, multivitamin, sertraline and vitamin C were documented as administered. During observation and interview on 8/26/24 at 10:40 A.M., the resident lay in his/her bed with his/her bedside table positioned over the bed in front of the resident. The resident appeared drowsy. There were multiple pills in a clear medication cup on the resident's bedside table. There was no staff member in the room. The resident said staff will leave his/her medication at his/her bedside so he/she can take them when he/she is more awake. He/She did not know the names of his/her medications but thought he/she took something for his/her blood pressure. During an interview on 8/28/24 at 6:58 A.M., Certified Medication Technician (CMT) U said there are no residents in the facility who have physician orders to self-administer medications or that medications can be left at the bedside. The staff member administering the medication should wait for the resident to swallow the medications. No medications are to be left unattended at the bedside. During an interview on 8/29/24 at 9:40 A.M., Licensed Practical Nurse (LPN) C said medications are not to be left unattended by staff at the resident's bedside. Staff are to stay with the resident until the resident takes the medication. If the resident will not take the medications, then staff should document refused or try again later. There should be physician orders if medications can be left at the resident's bedside. During an interview on 8/29/24 at 12:40 P.M., the Director of Nursing (DON) said there is no resident in the facility who has a physician order to self-administer medications or that medications can be left at the bedside. Staff are expected to remain with the resident until all medications are taken. Medications are expected not to be left unattended at the bedside for the resident to take later.

Based on interview and record review, the facility failed to ensure the resident assessment was coded accurately to include a life expectancy of less than 6 months for all residents on hospice for one of one resident investigated for hospice (Resident #24). The census was 67. Review of Resident #24's medical record, showed the resident admitted to hospice on 5/10/24. Review of the resident's significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/21/24, showed: -Received hospice care; -Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months: No. During an interview on 8/27/24 at 1:00 P.M., the MDS Coordinator said she does not indicate a life expectancy of less than 6 months just because a resident is on hospice. It is only marked if the resident is actively dying. She was not aware that any resident admitted into hospice has a certification of terminal illness certifying a life expectancy of less than 6 months.

Based on observation, interview, and record review, the facility failed to coordinate assessments for the pre-admission screening and resident review (PASARR) program under Medicaid with the appropriate state-designated authority, to ensure that individuals with a mental disorder receive care and services in the most integrated setting appropriate to their needs for one of eight residents investigated for the preadmission screening. Of those eight, only one indicated a level II screening was required and the level II assessment for the resident was not completed (Resident #5). The census was 67. Review of Resident #5's medical record, showed: -The resident resided in a Medicaid certified bed; -A DA-124c form, dated 2/29/07, showed: -Section B: Level 1 screening criteria for serious mental illness; -Question #4: Has the person had serious problems in levels of functioning in the past 6 months: Yes; -This completes the level 1 screening. If you checked yes in #4 or #5 in section B, a level II screening is indicated for serious mental illness; -No documentation of a level II screening completed. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 4/10/24, showed: -Cognitively intact; -Diagnoses included dementia, manic depression (a mental illness characterized by manic highs and depressed lows), and reoccurring major depressive disorder; -Received antipsychotic and antidepressant medications; -Received Medicaid benefits. Observation on 8/26/24 at 10:37 A.M., showed the resident in his/her room in a wheelchair. He/She said he just got back from dialysis and has no care concerns. During an interview on 8/27/24 0 at 8:32 A.M., the Social Service Manager said she was not here when the resident's level I screen was done. She looked through her records, but she does not have records of a level II requested or completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate, and individualized care plans to address the specific needs of three of 17 sampled residents (Residents #9, #45, and #2). The census was 67. Review of the facility's Care Planning Policy and Procedure, dated 1/17/20, showed: -Objective: The facility's standard is to perform quality of care that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices; -A care plan will be developed upon admission. It will be update quarterly, and annual to ensure that there is a continuity of care and is in accordance with the individual's needs. Care plan will also be updated with a significant change of condition; -The care plan must be based upon the resident assessment, choices and advance directive, if any. As the resident's status changes, the facility, attending practitioner and the resident representative, to the extent possible, must review and/or revise the care plan goals and treatment choices. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/24, showed: -Diagnoses included Alzheimer's disease; -Moderately impaired cognition; -Substantial/maximal assistance required for toileting hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for problems with elimination. Frequently incontinent of bowel and bladder and requires extensive assistance with toileting and perineal care; -Interventions included: Assist with toileting before and after meals, at hour of sleep, and as needed. Monitor bowel movements daily. Provide perineal care after each incontinent episode; -The resident's behavior of playing in his/her stool not included in the care plan. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. He/She brought his/her hands out from under his/her blanket. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement was in the room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room and asked the resident why you doing that. The resident said he/she cannot help it. CNA A said give me your hands. He/She wiped the resident's hands with a paper towel, told the resident he/she was going to tell his/her CNA, and then exited the room and walked down the hall. No perineal care was provided. At 3:09 P.M., the resident self-propelled in a wheelchair out of his/her room and down the hall. The room continued to have a strong smell of bowel movement. The resident propelled him/herself into the television area near the nurse's station. The resident had a brown substance on his/her hands and under his/her nails. At 4:04 P.M., CNA A told the resident to head to the elevator for dinner. The resident propelled away towards the elevator. The resident's hands appear soiled. During an interview on 8/26/24 at 4:07 P.M., the Administrator said if a resident is observed to put his/her hands in stool, he expected staff to address this immediately. The resident's hands should be cleaned, and care provided. During an interview on 8/28/24 at 10:58 A.M., CNA A said the resident throws his/her poop. The CNAs pick it up, they can clean up the big messes and do the best they can. During an interview on 8/29/24 at 12:50 P.M., with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) L/Unit Manager, they said playing in stool is a behavior for the resident. This behavior should be included in the care plan. 2. Review of Resident #45's quarterly MDS, dated [DATE], showed the following: -Diagnoses included major depressive disorder, anxiety disorder, and Alzheimer's disease; -Cognitively intact. Review of the resident's care plan, in use at the time of survey, showed: -Resident is not care planned for refusal to allow staff to clean his/her room; -Resident is not care planned for storing food in his/her room. Observation on 8/26/24 at 11:24 A.M., of the resident's room, showed: -Multiple bugs in the three drawers by the resident's sink. Various food trash and packages were in the drawers; -Two bugs observed crawling on the resident's pillow. During an interview on 8/29/24 at 12:53 P.M., the DON said the resident has a history of refusing to let staff into his/her room to clean. The resident also frequently brings food into his/her room and stores it in his/her drawers. She expected the resident's care plan to reflect interventions for cleaning the resident's room and interventions for preventing bugs due to the resident's refusal. During an interview on 8/29/24 at 3:01 P.M., the Administrator said he expected the resident's care plan to reflect interventions for cleaning the resident's room and interventions for preventing bugs due to the resident's refusal to allow staff in his/her room and for storing food in his/her room. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Requires maximum assistance from staff for lower body dressing and putting on or taking off footwear; -Diagnoses include heart failure, renal (kidney) failure, dementia, and depression. Review of the resident's Medication Administration Record, dated August, 2024, showed: -An order, dated 1/29/24 at 6:00 A.M., to apply Tubi grips (an elastic tubular dressing that reduces swelling) to left lower limb and remove at 6:00 P.M.; Diagnosis: cellulitis (infection of the skin and tissue beneath the skin). Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's leg edema (swelling), cellulitis and Tubi grip application with goals and interventions. Observation and interview on 8/27/24 at 10:36 A.M., showed the resident sat in his/ her wheelchair in his/her room. CNA S removed both the resident's shoes and socks and lifted the resident's pant legs up, exposing the resident's lower extremities. The resident had moderate edema to both lower extremities. Indentations were visible in the resident's bilateral (both) calf areas from the resident's socks. The right leg appeared red and more edematous than the left lower extremity. CNA S said the resident has always had swelling to both his/her legs. CNA S was not aware of any special treatment to the resident's legs for his/her leg swelling or interventions to reduce swelling. During an interview on 8/29/24 at 12:40 P.M., the DON said resident's leg edema, cellulitis and Tubi grips are expected to be on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to follow physician orders and apply a Tubi grip (elastic tubular dressing that reduces swelling) to one resident's lower extremity (Resident #2), who has a medical history of chronic (long term) edema (swelling) and cellulitis (infection of the skin and tissue below the skin) and apply a dressing to one resident's (Resident #269) gastrostomy tube (g-tube, a tube that is surgically inserted into the abdomen and used for liquid nutrition and medications) site. The sample was 17. The census is 67. Review of the facility's physician order policy revised, 6/21/20, showed: -Policy: To transcribe and follow-physician orders accurately; -Procedure: Orders received by the physician are to be followed as prescribed. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/23/24, showed: -Mild cognitive impairment; -No behaviors; -Required maximum assistance from staff for lower body dressing and putting on or taking off footwear; -Diagnoses included heart failure, renal (kidney) failure, dementia and depression. Review of the residents Medication Administration Record (MAR), dated August, 2024, showed: -An order, dated 1/29/24, at 6:00 A.M., apply Tubi grip to left lower limb and remove at 6:00 P.M., diagnosis: cellulitis; -On 8/26, 8/27, and 8/28/24 the treatment was documented as completed. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's leg cellulitis and Tubi grip application. Observation on 8/26/24 at 3:30 P.M., showed the resident sat in his/her wheelchair. The resident lifted his/her pant legs up and exposed both lower legs. The resident was not wearing a Tubi grip. Observation and interview on 8/27/24 at 10:36 A.M., showed the resident sat in his/her wheelchair in his/her room. Certified Nursing Assistant (CNA) S removed both the resident's shoes and socks and lifted the resident's pant legs up, exposing the resident's lower extremities. The resident had moderate edema to both lower extremities. Indentations were visible in the resident's bilateral (both) calf area from the resident's socks. The right leg appeared red and more edematous than the left lower extremity. The resident was not wearing a Tubi grip. CNA S said the resident has always had swelling to both his/her legs. CNA S was not aware of any special treatment to the resident's legs for his/her leg swelling. Observation on 8/28/24 at 6:45 A.M., showed the resident sat in the dining room and self-propelled him/herself to his/her bathroom on the Garden Unit. The resident was not wearing a Tubi grip. During an interview on 8/29/24 at 9:45 A.M., Licensed Practical Nurse (LPN) C said the resident has chronic issues with leg swelling and cellulitis. LPN C was not aware of the Tubi grip order but thought it was a good idea to help with the resident's swelling. LPN C said he/she wasn't even sure if the facility had a Tubi grip supply. Treatments are not to be documented as completed if they are not. During an interview on 8/29/24 at 12:40 P.M., the Director of Nursing (DON) said she expected staff to follow physician orders and apply the resident's Tubi grip. Treatments are expected to be documented accurately. 2. Review of Resident #269's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Diagnoses of acute (short term) respiratory failure and dysphasia (difficulty swallowing). Review of the resident's Physician's Order Summary (POS), showed: -An order, dated 8/3/24, to cleanse g-tube site with wound cleanser and pat dry; Apply 4 x 4 split gauze to site and secure with tape. Observation on 8/26/24 at 10:32 A.M., showed no dressing at the resident's g-tube site. The resident's skin surrounding the g-tube site was reddened. Observation on 8/27/24 at 6:49 A.M., showed no dressing at the resident's g-tube site. The resident's skin surrounding the g-tube site was reddened with darker red drainage. During an interview on 8/27/24 at 12:32 P.M., the Nurse Practitioner (NP) observed the resident's g-tube site and said there was a presence of bloody drainage. He/She said there should be a dressing on the site if ordered by the physician. During an interview on 8/29/24 at 9:17 A.M., the Wound Nurse said nurses are responsible for putting dressings on the resident's g-tube site. He/She said dressings should be placed per physician orders. During an interview on 8/29/24 at 12:36 P.M., the DON said the night shift nurses are responsible for g-tube dressing changes. She expected the physician's orders to be followed. She expected the resident to have a dressing on his/her g-tube site.

Based on observation, interview and record review, the facility failed to ensure one resident, identified by the facility as dependent with mobility and high risk for development of pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) was routinely turned and repositioned by staff. The resident developed a new pressure ulcer to his/her coccyx (tailbone area) and upon identification of the pressure ulcer, staff failed to report it to the nurse, in accordance with the facility's policy (Resident #32). The sample was 17. The census was 67. Review of the facility's Policy and Procedure for Skin Protocol, dated 1/5/24, showed: -In order to prevent skin breakdown and promote the health of our residents, it is the policy of the facility to perform skin assessments on a weekly basis. Skin assessments are to be performed by a registered or Licensed Practical Nurse (LPN); -Procedure: The LPN or Registered Nurse (RN) are to visually inspect all areas of the body and note/document any abnormalities. If any abnormalities are found, the LPN or RN performing the skin assessment is to notify the physician, resident and/or resident representative, and Director of Nursing (DON). This will be performed weekly; -The Certified Nursing Assistants (CNAs), Nursing Assistants (NAs), Certified Medication Technicians (CMTs) are to monitor skin during bathing and clothing change and notify the nurse of any changes so that they can be assessed; -Residents may develop various types of skin alterations. At the time of the assessment and diagnosis of skin ulcer/wound, the clinician is expected to document the clinical basis which permit differentiate the ulcer type, especially if the ulcer has characteristics consistent with pressure ulcer but is determined not to be one. Review of Resident #32's medical record, showed: -Diagnoses included Parkinson's disease (brain disorder causing unintended or uncontrolled movements), dementia and depression; -A pressure ulcer risk assessment, dated 6/15/24, showed the resident at high risk for developing pressure ulcers; -A physician order, dated 6/24/24, to apply barrier cream to coccyx area as needed with each incontinent episode. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed: -Resident rarely/never understood; -Upper extremity impairment on both sides, lower extremity impairment on one side; -Dependent on assistance with mobility; -Resident at risk of developing pressure ulcers. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident at risk for/actual breakdown present. Resident is dependent with bed mobility, transfers, and toileting hygiene. He/She is incontinent of bowel and bladder. He/She had noted redness to coccyx upon admission and moisture barrier cream to be applied. He/She also has a wound to left great toe with treatment in place; -Interventions included: -Apply protective/moisture barrier cream after episodes of incontinence and as needed; -Assist resident to turn and reposition frequently; -Inspect skin daily with care and bathing, and report any changes to charge nurse -Position resident properly, use pressure-reducing or pressure-relieving devices (e.g. pillows, positioning wedges, and alternating pressure mattress) if indicated; -Position with pads and cushions to prevent pressure; -No documentation regarding the resident's refusal to be turned and/or repositioned, or the resident screaming when touched. Review of the resident's skin assessment, dated 8/26/24, showed: -Status: Skin color normal, dry; -Rash/redness: No; -Wound: No. Observations on 8/26/24 at 11:12 A.M., 11:54 A.M., 12:23 P.M., 12:58 P.M. and 1:28 P.M., showed the resident on his/her back in bed with his/her legs bent at the knee and positioned toward the right side of the bed. No cushions or pillows were underneath the resident's body. During an interview at 1:28 P.M., the resident said he/she was comfortable. He/She was unable to answer further questions regarding his/her skin care. Observation on 8/26/24 at 4:29 P.M., showed the resident on his/her back in bed with his/her legs bent at the knee and positioned toward the right side of the bed. No cushions or pillows were underneath the resident's body. Observations on 8/27/24 at 7:38 A.M., 8:49 A.M., 11:00 A.M., 12:16 P.M., 1:13 P.M., and 1:34 P.M., showed the resident on his/her back in bed with his/her legs bent at the knee and positioned toward the rights side of the bed. No cushions or pillows were underneath the resident's body. Observation on 8/28/24 at 6:54 A.M., showed CNA D entered the resident's room. The resident lay on his/her back. CNA D uncovered the resident and unsecured his/her brief. CNA D assisted the resident to his/her left side. Observation of the resident's buttocks, showed a small open area to the coccyx. The skin around the open area appeared mushy and white and extended out to an approximate quarter size. CNA D pointed to the open area. The resident had stool in the buttocks' crack. CNA D cleansed the resident, removed his/her gloves and washed his/her hands. CNA D then assisted the resident to be repositioned to his/her back and covered him/her, then said he/she gets off work at 7:00 A.M. The resident did not resist or scream during care. During an interview on 8/28/24 at 9:16 A.M., Wound Clinic Nurse F said the resident is seen for his/her toe wound. It is healing well. The resident was currently eating breakfast, so they would come back to do the treatment later. Observation on 8/28/24 at 9:22 A.M., Wound Clinic Nurse F and the facility Wound Nurse entered the resident's room and provided care to the resident's toe. Wound Clinic Nurse F said he/she was not aware of any other open areas on the resident. The Wound Nurse said no one told her of any new open areas on the resident. The Wound Nurse assisted the resident to his/her right side. Wound Clinic Nurse F observed the area to the resident's coccyx and said the area is opened and presents as a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) pressure ulcer and measured approximately 0.1 x 0.1 x 0.1 centimeters (cm). He/She instructed the Wound Nurse to clean the area, apply betadine (used to clean minor wounds), and apply a Mepilex dressing (foam dressing with adherent edges). Wound Clinic Nurse F said the opened area was caused by the resident laying on his/her back too much. The Wound Nurse cleaned the area, applied betadine, and covered it with a Mepilex dressing. The Wound Nurse said this should have been reported to her so she could assess the area and get an order. During an interview on 8/28/24 at 9:48 A.M., LPN E said he/she is the resident's nurse for day shift today. When night shift left, neither the nurse nor CNA reported any new open areas to the resident's buttocks. They should have, so he/she could follow up. During an interview on 8/29/24 at 9:50 A.M., CNA K said while providing care to the resident earlier this week, he/she noticed a small area on the resident's buttocks. He/She reported it to the nurse. The resident is total care and he/she is at high risk for skin breakdown. The resident is in bed all the time. Residents need to be turned and repositioned every two hours to get the pressure off their skin so it won't break down. The resident refuses to be turned and repositioned at times. During an interview on 8/28/24 at 10:58 A.M., CNA A said the resident has not been on his/her assignment this week, but he/she knows the resident well. The resident does not get out of bed and is very constricted. He/She does not like to get up and screams when touched. He/She requires total assistance from staff. He/She needs to be turned and repositioned by staff throughout the day, at least at every meal. Review of the resident's medical record, showed no documentation of a new skin issue noted to the resident's coccyx in the week preceding the identification of the Stage II pressure ulcer on 8/28/24. There was no documentation of his/her refusal to be turned and repositioned and no documentation of the resident screaming when touched. During an interview on 8/29/24 at 12:36 P.M. with the DON and LPN L/Unit Manager, they said residents should be turned and repositioned every two hours because long-term positioning can cause skin breakdown. The resident requires total assistance from staff and he/she is at high risk for skin breakdown. He/She is very contracted (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement) and it is very painful for him/her to move. It is very painful for him/her to be turned on his/her left side and they probably need to get him/her something for pain. He/She did not have a pressure ulcer on his/her coccyx upon admission. The DON was just notified today of the resident's new Stage II pressure ulcer on his/her coccyx. When staff identify a new skin issue, they are expected to communicate this to nurse management as soon as possible. The nurse should document the change and notify the physician to obtain orders for treatment. MO00236984

Based on observation, interview and record review, the facility failed to ensure one resident received tube feeding in accordance with physician orders to support adequate nutritional intake (Resident #32). The facility identified eight residents receiving tube feedings, three of which were sampled and problems were found with one. The sample was 17. The census was 67. Review of the facility's Specific Medication Administration procedures policy, dated 6/1/18, showed: -Guidance for staff to administer medications via feeding tube; -No any other guidance for staff related to the technical aspects of feeding tubes, including verification of functionality and feeding tube care. Review of Resident #32's medical record, showed diagnoses included dysphagia (swallowing disorder), heart failure and dementia. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -An order, dated 6/24/24, to turn off tube feeding at 8:00 A.M.; -An order, dated 6/30/24, for Jevity 1.5 cal (calorie-dense tube feeding formula) oral liquid, 65 milliliters (ml), gastrostomy tube (g-tube, tube that is placed directly into the stomach through an abdominal wall incision for administration of foods, fluid, and medications) at bedtime, turn feeding on at 8:00 P.M. and turn off at 8:00 A.M. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed: -Resident rarely/never understood; -Feeding tube while a resident; -Proportion of total calories the resident received through tube feeding: 51% or more. Observation on 8/27/24 at 7:13 A.M., showed the resident on his/her back in bed. The resident's tube feeding machine was off with no tube feeding container on the pole next to the resident's bed. Observation on 8/28/24 at 6:36 AM., showed the resident on his/her back in bed with the tube feeding machine off. A container of Jevity 1.5 cal hung on the pole next to the resident's bed, dated 8/27 at 8:00 P.M., with 800 ml left in the container. During an interview on 8/28/24 at 8:18 A.M., Licensed Practical Nurse (LPN) E said the resident's tube feeding is already off for the day. The night nurse told LPN E that the resident said he/she was full this morning and asked the night nurse to turn the tube feeding off. The resident has orders to receive tube feeding from 8:00 P.M. to 8:00 A.M. He/She also eats pureed food during the day, so it makes sense that he/she gets full. The resident is hard to understand, but can make his/her needs known. When the nurse cuts off a resident's tube feeding early, the nurse does not need to document anything in the resident's medical record. Observation on 8/29/24 at 7:11 A.M., showed the resident on his/her back in bed. The resident's tube feeding machine was off with no tube feeding container on the pole next to the resident's bed. Review of the resident's medical record, reviewed 8/29/24, showed no documentation regarding the resident's tube feeding being turned off early on 8/27//24, 8/28/24 and 8/29/24. During an interview on 8/29/24 at 8:48 A.M., the resident said his/her stomach does not hurt. He/She is not hungry or full. He/She does not know why his/her tube feeding was turned off early. During an interview on 8/29/24 at 10:01 A.M., LPN E said the resident has orders for tube feeding to be on at 8:00 P.M. and off at 8:00 A.M. It is not a requirement to notify the physician if a resident's tube feeding needs to be cut off early. This is similar to if a resident refuses breakfast, which would not be reported to the physician. If the resident's tube feeding is cut off early, he/she is still getting adequate nutrition during the day. When nursing staff turn the tube feeding off for the day, they should disconnect the tube and remove the container of formula. It would be particularly helpful for the resident's tube feeding to be removed since he/she won't get it back on for about 10 hours and he/she will need to be turned and changed during this time. When staff handle a container of tube feeding formula, they should write the date and time on the container. Containers cannot be reused. During an interview on 8/29/24 at 12:36 P.M. with the Director or Nurses (DON) and LPN L/Unit Manager, they said the resident has physician orders for his/her tube feeding to be on at 8:00 P.M. and off at 8:00 A.M. The tube feeding should be on during the entire time, from 8:00 P.M. to 8:00 A.M. If the tube feeding runs during the entire time like it is supposed to, there should not be a large amount of formula left in the container when it is turned off in the morning. A new bottle should be hung when the tube feeding goes back on, and the container should be labeled with the date, time and resident's name. If a tube feeding is turned off early, the container should be removed and the tubing should be disconnected. Staff should document the reason why the tube feeding was turned off early and notify the physician. During an interview on 8/29/24 at 2:52 P.M., the DON said the facility does not have a specific policy regarding tube feeding care. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expected residents to receive diets in accordance with physician orders. He expected physician orders for tube feeding to be followed. He expected staff to notify the physician if orders cannot be followed for whatever reason. MO00240891

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure side rails were accurately assessed as a necessary device prior to installation and use. The facility failed to obtain physician orders for the use of side rails and to document side rail use on care plans for four residents (Residents #32, #55, #47 and #50). The facility identified 47 residents with side rails in use. The census was 67. Review of the facility's Restraints/Side Rails policy, dated 4/28/17, showed: -Restraint Evaluation and Utilization Guideline: -The facility does not typically utilize restraints, however if a restraint is utilized to treat a resident's medical symptoms, to prevent injury and promote the highest practicable level of independence, careful evaluation will precede this decision; -The least restrictive device will be used; -The Interdisciplinary Team (IDT) will discuss the predisposing factors that resulted in the conclusion that restraint evaluation and utilization may be needed; -The need for the use of the restraint will be discussed with the resident and/or family representative. The facility will obtain a signed consent for the use of the restraint. The consent form will be placed in the medical record; -The facility will obtain a physician's order for the least restrictive device. The physician's order must include the medical symptoms for which device is to be used, type of device to be used; -The purpose of the Side Rail Utilization may be to: -Remind the resident not to get out of bed when medically contraindicated and/or medical equipment is attached to the resident; -Aid in turning and repositioning in the bed; -Providing a hand-hold for getting in or out of bed; -Assessment and documentation: -Assessment is completed to identify potential benefits from utilizing side rails and minimize risks; -If side rails are being considered, assessment will be completed at that time with ongoing reassessment (at least quarterly); -Care plan interventions are implemented when side rails are utilized and reviewed at least quarterly. 1. Review of Resident #32's medical record, showed: -Diagnoses included Parkinson's disease (brain disorder causing unintended or uncontrolled movements), dementia and depression; -No physician order for the use of side rails; -No signed consent for the use of side rails. Review of the resident's side rail evaluation, dated 6/25/24, showed: -Can resident independently get in and out of bed safely: No; -Has resident requested the use of side rails for their own comfort and safety: No; -Is the resident having problems with balance or poor trunk control: Yes; -Does the resident use the side rails for positioning, mobility or support: No; -No final determination made for use of side rails. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed: -Resident rarely/never understood; -Dependent on assistance for mobility. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident is at risk for falls. Resident is not ambulatory. His/Her left leg is contracted (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement); -No documentation related to the use of side rails. Observation on 8/26/24 at 1:28 P.M., showed the resident on his/her back in bed with U-shaped rails raised on both sides of the bed, at the head of the bed. During an attempted interview, the resident was unable to respond to questions regarding the side rails. Observations on 8/27/24 at 8:49 A.M. and 12:16 P.M., on 8/28/24 at 7:59 A.M., and on 8/29/24 at 7:11 A.M., showed the resident on his/her back in bed with U-shaped rails raised on both sides at the head of the bed. During an interview on 8/29/24 at 10:01 A.M., Licensed Practical Nurse (LPN) E said he/she is not sure why the resident has side rails because he/she cannot use his/her arms. 2. Review of Resident #55's medical record, showed: -Diagnoses included seizures, stroke, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following stroke; -No physician order for the use of side rails; -No signed consent for the use of side rails. Review of the resident's side rail evaluation, dated 2/29/24, showed type of side rail not indicated. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Upper and lower extremity impairment on one side; -Dependent on assistance to roll left and right. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident is at risk for falls. Resident requires total assist of two with bed mobility. He/She had a recent stroke with left sided hemiparesis and recently diagnosed with seizures; -No documentation related to the use of side rails. Observation on 8/26/24 at 12:58 P.M., showed the resident on his/her back in bed, on a low air loss mattress (mattress that provides a constant flow of air in the mattress). U-shaped rails were raised on both sides of the bed, at the head of the bed. The resident used his/her right arm to pull the right rail. During an interview, the resident said he/she was trying to use the rail to pull him/herself to move the pillow on his/her right leg. Observations on 8/27/24 at 7:13 A.M., 12:16 P.M., and 1:13 P.M., showed the resident in bed with U-shaped rails raised on both sides at the head of the bed. Observation on 8/28/24 at 8:15 A.M., showed the resident using his/her right arm to pull the right side rail. During an interview, the resident said he/she was trying to get out of bed. Observation on 8/29/24 at 7:11 A.M., showed the resident in bed with U-shaped rails raised on both sides at the head of the bed. During an interview on 8/29/24 at 10:01 A.M., LPN E said the resident can move one arm and can use the side rail on one side of the bed. 3. Review of Resident #47's quarterly MDS, dated [DATE], showed: -Diagnosis of end stage renal disease (ESRD, kidney failure); -Cognitively intact. Review of the resident's Physician Order Sheet (POS), showed no order for bilateral enabler rails. Observation on 8/27/24 at 7:38 A.M., and 8/28/24 at 10:18 A.M., showed the resident on his/her back in bed with bilateral enabler rails raised on both sides at the head of the bed. 4. Review of Resident #50's quarterly MDS, dated [DATE], showed: -Diagnoses of acute kidney failure and major depressive disorder; - Cognitively intact. Review of the resident's POS, showed no order for bilateral enabler rails. Observation on 8/26/24 at 1:03 P.M. and 8/27/24 at 10:18 A.M., showed the resident on his/her back in bed with bilateral enabler rails raised on both sides at the head of the bed. 5. During an interview on 8/29/24 at 9:15 A.M., the Wound Nurse said the nurses assess residents for the use of side rails. He/She said maintenance staff are responsible for installment of side rails and inspections of side rails. He/She expected staff to obtain a physician's order for the usage of side rails. 6. During an interview on 8/29/24 at 10:01 A.M., LPN E said the use of any type of side rails should be assessed by the nurse. The nurse assesses for side rails upon admission. He/She doesn't think a consent needs to be obtained, but a physician order is required. The use of side rails should be on the resident's care plan. 7. During an interview on 8/29/24 at 12:36 P.M. with the Director of Nurses (DON) and LPN L/Unit Manager, they said bed changes may result in some residents having side rails who should not have them. The facility needs to implement an audit system. Resident #32 cannot grip or use his/her side rails. Resident #55 has some stiffness in his/her upper body and side rails may not be effective for him/her. His/Her side rails may be more of a boundary for him/her and may be beneficial on one side. Resident #47 uses enabler rails to transfer to and from bed. Nurses should assess residents for the use of side rails within the first five days of admission. The facility does not obtain consents for the use of side rails. A physician order should be obtained for the use of side rails and should indicate what type of device is used. Side rail use should be indicated on the resident's care plan. 8. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expected nurses to assess residents for the use of side rails. He expected physician orders to be obtained for the use of side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident received nectar-thick liquids (Resident #269) and one resident received a mechanical-soft diet (Resident #32) in accordance with physician orders. The sample was 17. The census was 67. 1. Review of Resident #269's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/24, showed: -Diagnoses of acute respiratory failure and dysphagia (difficulty swallowing); -Moderately impaired cognition. Review of the resident's Physician's Order Sheet (POS), showed an order, dated 7/9/24, for nectar thickened liquids. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: resident receives a mechanical soft diet with nectar thickened liquids; -Goal: utilize interventions to help maintain weight and skin integrity; -Interventions: monitor oral intake of food and fluid, allow eating at own pace. Review of the resident's dietary order and communication slip, dated 7/9/24, showed the resident should receive mechanical texture food and nectar thickened liquids. Observation on 8/27/24 at 7:58 A.M., showed Certified Medication Technician (CMT) M administered medication to the resident. CMT M poured regular water from a pitcher into a cup and gave it to the resident. Upon the resident's request for more water, CMT M took the cup from the resident, filled it with more regular water, and gave it back to the resident. Observation on 8/28/24 at 12:49 A.M., showed Certified Nurse Aide (CNA) X delivered a lunch tray to the resident's room. CNA X placed regular lemonade onto the resident's tray and placed the tray in front of the resident to eat. 2. Review of Resident #32's medical record, showed diagnoses included dysphagia (swallowing disorder) and dementia. Review of the resident's admission MDS, dated [DATE], showed: -Resident rarely/never understood; -Mechanically altered diet received while a resident. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident is at risk for altered nutritional status. Resident receives a pureed diet fed by staff. He/She receives tube feeding from 8:00 P.M. to 8:00 A.M. due to poor appetite; -Interventions included provide diet as prescribed; -The care plan failed to reflect the resident's diet upgrade to mechanical soft texture, as assessed by Speech Therapy (ST) on 7/10/24. Review of the resident's ST treatment encounter note, dated 7/10/24, showed: -Precautions: Mechanical soft texture (upgraded via bedside on 7/10/24); -Educated nursing and kitchen staff on diet upgrade with voiced understanding. Review of the resident's POS, showed an order, dated 7/10/24, for mechanical soft diet with thin liquids. Review of the resident's dietary slips, in use at the time of survey, showed pureed diet for breakfast, lunch and dinner. Observation on 8/26/24 at 12:58 P.M., showed CNA K fed the resident a pureed brown food, a pureed orange food, and mashed potatoes. During an interview on 8/26/24 at 1:28 P.M., the resident said he/she ate lunch and is not hungry. He/She was unable to answer questions regarding his/her diet. Observation on 8/27/24 at 9:08 A.M., showed CNA K fed the resident pureed biscuits and gravy. During an interview, CNA K said the resident receives tube feeding at night and pureed food during the day. Observation on 8/27/24 at 1:28 P.M., showed CNA A fed the resident pureed food. During an interview on 8/28/24 at 8:18 A.M., Licensed Practical Nurse (LPN) E said the resident receives a pureed diet during the day. He/She eats really well. LPN E is not sure why the resident's diet is pureed. The resident is not an aspiration risk. During an interview on 8/28/24 at 10:58 A.M., CNA A said the resident receives tube feeding and a pureed diet. He/She needs assistance from staff to eat. Nursing staff know what type of diet the resident receives by checking the dietary slip that comes out with their meal trays. During an interview on 8/29/24 at 10:01 A.M., LPN E said if therapy makes a change to a resident's diet, therapy gives nursing a diet sheet, the nurse signs off on it, then tells dietary about the change. It is important for residents to receive their diets as ordered to ensure they don't choke. During an interview on 8/29/24 at 12:36 P.M. with the Director of Nurses (DON) and LPN L/Unit Manager, they said ST gave one of the nurses the new order for the resident to receive a mechanical soft diet, and the nurse entered the order in the medical record. The nurse should have filled out a diet order change slip when he/she put the order in. The diet order change slip would have been copied, with one copy going into the resident's chart and the other copy going to dietary so dietary could update the resident's dietary slip. 3. During an interview on 8/29/24 at 7:29 A.M., the Food Service Manager said she expected residents to receive their food and drinks according to their POS. 4. During an interview on 8/29/24 at 8:22 A.M., LPN L/Unit Manager said he/she expected staff to double check when passing room trays to residents to ensure they receive the proper food and drinks according to the resident's POS. 5. During an interview on 8/29/24 at 12:36 P.M. with the DON and LPN L/Unit Manager, they said they expected all residents to receive diets in accordance with physician orders. If staff is unsure about a resident's diet order, they should check the dietary slip that comes out with the resident's tray. Diet consistency, including liquids, should be reflected in the resident's physician orders. 6. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expected residents to receive diets in accordance with their physician orders. He expected nursing staff to communicate with dietary staff about any changes made to a resident's diet orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity when staff spoke to one resident in a disrespectful manner regarding the resident's hygiene and failed to provide care to promote his/her dignity (Resident #9), staff failed to provide one resident with grooming and feeding assistance (Resident #168) and staff entered one resident's room without knocking (Resident #34). In addition, staff failed to wear name badges to identify themselves to residents. The sample was 17. The census was 67. Review of the facility's Resident's Rights, provided to residents upon admission, showed the right to be treated with respect and dignity. Review of the facility's undated Resident Privacy/Dignity/Customer Service policy, showed: -Staff will always aim to communicate with residents in a manner which respects their individuality and needs, taking their view and needs into account; -Staff will protect the dignity, particularly modesty, of very ill or confused patients who may act inappropriately and present challenging behavior while the root cause of the problem is ascertained and treated. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/24, showed: -Diagnoses included Alzheimer's disease; -Moderately impaired cognition; -Substantial/maximal assistance required for toileting hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for problems with elimination. Frequently incontinent of bowel and bladder and requires extensive assistance with toileting and perineal care (care to the surface area between the thighs, extending from the pubic bone to tail bone); -Interventions included: Assist with toileting before and after meals, at hour of sleep, and as needed. Monitor bowel movements daily. Provide perineal care after each incontinent episode. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. He/She brought his/her hands out from under his/her blanket. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement was present in the room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room and asked the resident why you doing that. The resident said he/she cannot help it. CNA A said give me your hands. He/She wiped the resident's hands with a paper towel, told the resident he/she was going to tell his/her CNA, and then exited the room and walked down the hall. No perineal care was provided. At 2:55 P.M., the resident remained in bed on his/her back. The smell of bowel movement permeated the room. At 3:09 P.M., the resident self-propelled in a wheelchair out of his/her room and down the hall. The room continued to have a strong smell of bowel movement. The resident propelled him/herself into the television area near the nurse's station. The resident had brown matter on his/her hands and under his/her nails. A smell of bowel movement was noted when standing close to the resident. At 4:04 P.M., CNA A told the resident to head to the elevator for dinner. The resident propelled away towards the elevator. No personal care was provided. The resident's hands appear soiled. During an interview on 8/26/24 at 4:07 P.M., the Administrator said if a resident is observed to put his/her hands in stool, he expected staff to address this immediately. The resident's hands should be cleaned and care provided. He would deal with this right now. The Administrator went and talked with CNA A. Observation on 8/26/24 at 4:09 P.M., showed CNA A got on the elevator to head down to the dining room. He/She said CNA B was the resident's CNA today. Shift change is at 3:00 P.M., so he/she was not sure who the resident's CNA was now. CNA A went to the main dining room and told the resident I have to wash your hands cause you was being nasty. The resident looked down and said oh. The resident had two other residents at his/her side when this was said. The CNA took the resident to the shower room on the first floor and assisted the resident to wash his/her hands at the sink. 2. Review of Resident #168's medical record, showed: -admission date 8/23/24; -Diagnoses included injury of neck, pain in hand and vertigo (dizziness). Observation on 8/26/24 at 10:59 A.M., showed the resident sat in a wheelchair in his/her room. The resident's hair was in a disheveled ponytail, with sections of hair loose and outside of the ponytail. During an interview, the resident said he/she was admitted to the facility three days ago for therapy. He/She just had surgery on the discs in his/her neck and does not have full use of his/her arms. Staff has not helped him/her brush his/her hair since he/she was admitted . Staff dropped of his/her breakfast tray this morning and left it there without helping him/her. Observation on 8/27/24 at 8:45 A.M., showed the resident in a wheelchair in his/her room. CNA K delivered a tray of breakfast to the resident's room, said he/she would come back to feed the resident, and left the room. During an interview, the resident said staff do not offer to help him/her. He/She is doing the best he/she can to fend for him/herself. The staff lack compassion. The resident became tearful during the interview. At 9:13 A.M., the resident remained seated in his/her room with the breakfast tray untouched. During an interview, the resident said the facility staff lack compassion and care. It makes him/her sad and he/she does not want to ask them for help. He/She is sitting in his/her wheelchair with his/her pants not fully pulled up, leaving his/her bottom uncovered on the wheelchair, because he/she cannot lift his/her pants up all the way. At 12:13 P.M., the resident remained seated in his/her wheelchair with pants not pulled up all the way. During an interview on 8/28/24 at 9:11 A.M., the resident said staff come into his/her room without knocking on the door or telling him/her who they are. Sometimes they are not wearing name badges and they don't tell him/her their names. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis of depression. Observation on 8/26/24 at 11:42 A.M., showed the resident in bed in his/her room. During an interview, CNA A entered the resident's room without knocking or announcing him/herself. He/She was not wearing a name badge. CNA A asked the resident if his/her call light was on and the resident said no. CNA A left the room. The resident said staff do this all the time. Staff just walk right on in his/her room without knocking first. 4. Observation on 8/29/24 at 10:01 A.M., showed Licensed Practical Nurse (LPN) E with no name badge while working at the nurse's station. During an interview, LPN E said staff should wear name badges while working. He/She never got around to getting a badge. Staff should knock and announce themselves when entering resident rooms because this is their home. 5. During an interview on 8/28/24 at 10:58 A.M., CNA A said staff should knock and announce themselves when entering a resident's room so the resident knows who is coming into their room. Staff are required to wear name badges while working. 6. During an interview on 8/29/24 at 12:50 P.M., with the Director of Nursing (DON) and LPN L/Unit Manager, they said residents should be treated with dignity and respect. Staff should not scold the residents. Staff are expected to knock and announce themselves before entering a resident's room for dignity and respect. Staff are expected to wear name badges while they are working. The DON did not wear a name badge during the interview. 7. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expected staff to knock upon entering a resident's room. This is a privacy and resident rights issue. He expected staff to wear name badges in the facility during their shift. He expected residents to be treated with dignity and respect. MO00239684 MO00240891 MO00240930

Based on observation, interview and record review, the facility failed to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) are honored within the same day, and the facility failed to ensure resident funds in excess of $100.00 (or $50.00 for Medicaid residents), were held in an interest-bearing account. This affected 40 residents whose funds were handled by the facility. The census was 76. 1. During a group interview on 8/29/24 at 10:04 A.M., seven residents, whom the facility identified as cognitively intact, said requests for personal funds are limited to $20.00. If a resident wants more than $20.00, they have to wait. During an interview on 8/29/24 at 11:03 A.M., the Business Office Manager (BOM) said she handles requests for cash made by residents who have funds held by the facility. She usually only does $20.00 for cash withdrawals. She prefers to do smaller amounts like $20.00, in case the resident misplaces their money. Years ago, she was told residents could only get $20.00 per day, unless they go out of the facility, at which point they can request more money. The BOM was not aware requests for up to $49.00 should be honored by the facility within 24 hours for Medicaid residents. 2. Observation on 8/29/24 at 11:03 A.M., showed the BOM counted the petty cash amount on hand, totaling $4,938.17. She was not aware that cash on hand had to be limited to $50.00 for Medicaid residents, and $100.00 for Medicare residents, and that any overage must be in an interest-bearing account. Review of the facility's balance report and census, showed: -The facility holds funds for 36 Medicaid residents. The total amount of cash on hand for the residents should be $1800.00; -The facility holds funds for four non-Medicaid residents. The total amount of cash on hand for the residents should be $400.00. 3. During an interview on 8/29/24 at 2:55 P.M., the Administrator said it has always been the facility's policy to provide up to $20.00 when residents request personal funds. If a resident wants more than $20.00, the facility will ask the resident what they are purchasing and might contact their loved one to run the request by them. They don't want to chance the resident losing their money. He expected funds held in excess of $50.00 for Medicaid residents, or $100.00 for non-Medicaid residents, to be held in an interest bearing account.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' rooms and medical equipment and resident common areas were clean and homelike, affecting 13 of 17 sampled (Residents #9, #24, #43, #69, #32, #55, #27, #2, #50, #4, #269, #47 and #45). The facility also failed to ensure the 200 veranda hallway had clean floors. The census was 67. Review of the facility's housekeeping disinfecting cleaning schedule, revised 2/24/23, showed: -Housekeeping staff is responsible for the cleaning and disinfection of resident's room. Staff have responsibilities that are scheduled on a daily, weekly, and monthly basis. Housekeepers are responsible for every resident room on their halls which includes suites, gardens and terrace; -Disinfects bathrooms toilet and rails. Wipe sink and clean mirrors with Spic and Span. If nursing staff has to change sheets make sure the bed is disinfected with chemicals depending if the room is a deep clean or vacant room make sure bed is made. Sweep rooms starting from the top of the rooms to the outside room. Check privacy curtains to see if it needs to be laundered and put back up in the room before the end of the day. Clean Air Conditioning(AC) units and wall are cleaned. Make sure all furniture nightstands bed side tables are wiped off and cleaned. Make sure toilet tissue paper towels and soap is stocked in the room before mopping from top to bottom. After mopping room make sure wet floor sign is outside the door. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/24, showed: -Diagnosis of Alzheimer's disease; -Moderately impaired cognition; -Required substantial/maximal assistance for toileting hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for problems with elimination. Frequently incontinent of bowel and bladder and requires extensive assistance with toileting and perineal care (care to the surface area between the thighs, extending from the pubic bone to tail bone); -Interventions included: Assist with toileting before and after meals, at hour of sleep, and as needed. Monitor bowel movements daily. Provide perineal care after each incontinent episode. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. He/She brought his/her hands out from under his/her blanket. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement in the room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room, wiped the resident's hands with a paper towel, and then exited the room and walked down the hall. On 8/26/24 at 2:55 P.M., the resident remained in bed on his/her back. The smell of bowel movement permeated the room. Observation on 8/26/24 at 5:59 P.M., showed CNA A entered the resident's room and assisted the resident to be cleaned. A strong odor of bowel movement permeated the room. Observation showed brown matter smeared on the sheets, blankets, pillow, and on the wall. CNA A changed the resident's linen. The wall was not cleaned. Observation of the floor under the bed, showed several small balls of brown matter along the wall on the right side of the bed and near the head of the bed. A plastic cup, used gloves, and paper towels were also under the bed. Observation on 8/27/24 at 6:46 A.M., showed a strong odor of bowel movement in the room. The trash that had been on the floor under the bed was no longer present. The balls of brown matter remained on the floor under the bed. At 12:13 P.M., the balls of brown matter had been cleaned up, but smears of brown matter were still visible under the bed. On 8/28/24 at 6:21 A.M. and 8/29/24 at 9:22 A.M., the resident lay in bed, asleep. The smears of brown matter remained under the bed. During an interview on 8/28/24 at 10:58 A.M., CNA A said housekeeping cleans rooms once a day, but they do not mop under furniture. The resident throws his/her poop. The CNAs pick it up, they can clean up the big messes and do the best they can. They need housekeeping to clean up the rest but housekeeping does not clean. 2. Review of Resident #24's significant change MDS, dated [DATE], showed: -Diagnoses included manic depression and schizophrenia(mental illness that affects how people think, feel, and behave); -Cognitively intact. Observation and interview on 8/26/24 at 10:24 A.M., showed the resident lay in bed. The floor in the resident's room appeared dirty with debris, dirt, and dried spills throughout. Behind the resident's head of bed, were large gashes in the wall, vertically up and down the wall. The resident said it bothers him/her to have the wall so scratched up. 3. Review of Resident #43's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Dependent on assistance with toileting; -Diagnoses included hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body), depression, and anxiety. Review of Resident #69's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required substantial/maximum assistance with toileting; -Diagnoses included hemiplegia or hemiparesis and anxiety. During an interview on 8/27/24 at 1:11 P.M., Residents #43 and #69 said the toilet in the bathroom they share runs all the time and it is annoying. Resident #43 said the bathroom door has to stay shut at night or it will keep him/her awake. Both residents said the water in their bathroom sink does not get hot. The residents require staff assistance when they become soiled and staff clean them up with cold water. Resident #69 said the water has not been getting hot for a long time. When he/she tells staff, they say there is nothing that can be done. Observation on 8/27/24 at 1:50 P.M., showed the residents' toilet ran intermittently while not in use. The hot water faucet turned on and ran continuously for two minutes. The hot water measured 86.6 degrees Fahrenheit (F). During an interview on 8/28/24 at 1:54 P.M., Licensed Practical Nurse (LPN) C said the sink's water has been like this for a long time and he/she has told management. Observation on 8/28/24 at 6:57 A.M., showed the residents' toilet ran intermittently while not in use. The hot water faucet turned on and ran continuously for two minutes. The hot water measured 82.4 degrees F. During an interview on 8/28/24 at 10:58 A.M., CNA A said the residents' toilet runs and Resident #43 prefers the bathroom door to be shut because of this. The water in the residents' sink does not get hot. The toilet and sink have been this way for two years. All resident rooms should have hot water. During an interview on 8/29/24 at 2:20 P.M., the Maintenance Director said he has been working with the facility for 10 days. He was not aware of any concerns with the toilet running or the water temperature in the residents' room. He expected water temperatures to be within range. He does not routinely check water temperatures in resident rooms. He expected staff to fill out a work order for these issues. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expected staff to report issues with the environment, such as running toilets and sinks without hot water, to himself or the Maintenance Director. He expected water temperatures to be within the appropriate range. He expected residents to be provided with a comfortable environment. 4. Review of Resident #32's admission MDS, dated [DATE], showed: -Resident rarely/never understood; -Dependent for assistance with mobility; -Diagnoses included dementia and depression. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Dependent for assistance with all activities of daily living; -Diagnosis included stroke. Observations on 8/26/24 at 11:54 A.M 12:34 P.M., 1:28 P.M., and 4:29 P.M., and on 8/27/24 at 7:13 A.M. and 12:16 P.M., showed splatters of a dried beige substance on top of Resident #55's oxygen concentrator, fall mat, and floor underneath the resident's tube feeding pole. Dirt and debris were on the floor with three tube caps on the floor underneath the head of Resident #32's bed. Observations on 8/28/24 at 6:39 A.M. and 8:15 A.M., and on 8/29/24 at 7:11 A.M., showed splatters of a dried beige substance on top of Resident #55's oxygen concentrator, fall mat, and floor underneath the resident's tube feeding pole. 5. Review of Resident #27's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses include high blood pressure and depression. Observation and interview on 8/26/24 at 10:40 A.M., and on 8/27/24 at 9:15 A.M., showed the resident lay in bed. The resident's bedside table was cluttered with old food wrappers, medication cups and an empty soda bottle. Behind the resident's bed were multiple food wrappers, a white and blue pill, food crumbs and dead roaches. The resident's bathroom had brown roaches crawling on the door and wall of the bathroom. The resident said he/she thought someone cleaned his/her room daily but wasn't sure. During an interview on 8/27/24 at 9:15 A.M., a family member said he/she has not seen anyone deep clean the resident's room in several months. The family member he/she normally cleans the resident's room. 6. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, renal (kidney) failure, dementia and depression. Observation on 8/26/24 at 10:30 A.M. and 3:30 P.M., and on 8/28/24 at 6:45 A.M., showed the resident in his/her wheelchair in his/her room. The resident's bed was positioned against the wall. Behind the resident's bed and dresser were an empty water cup, crumbs, a white dried liquid and dead roaches. The resident's overhead bedside table was covered with a sticky substance. The resident's bathroom had brown roaches crawling on the walls of the bathroom. During an interview on 8/29/24 at 8:15 A.M., Housekeeper V said housekeepers move the furniture and beds out to deep clean with sweeping and mopping about once or twice a month. Housekeeping can clean the resident's bedside tables off when needed. 7. Review of Resident #50's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnoses of acute kidney failure and major depressive disorder. Observations on 8/26/24 at 1:03 P.M., 8/27/24 at 12:13 P.M., and 8/28/24 at 10:18 A.M., showed the resident's room to have sticky floors with debris, the AC unit had dust accumulation and debris on the inside and out, and a dirty privacy curtain with various brown stains. 8. Review of Resident #4's quarterly MDS, dated [DATE], showed the following: -Cognitively intact. -Diagnoses of anxiety disorder and major depressive disorder. Observations on 8/26/24 at 10:54 A.M., and 8/28/24 at 10:25 A.M., showed the resident's AC unit had dust accumulation and debris on the inside and out. 9. Review of Resident #269's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition. -Diagnosis of acute respiratory failure. Observations on 8/26/24 at 10:34 A.M., 8/27/24 at 6:57 A.M., and 8/28/24 at 10:18 A.M., showed the resident's room with sticky floors with dark splattered matter on the resident's fall mat and surrounding floor. Dust build up was on the inside and outside of the AC unit. 10. Review of Resident #47's quarterly MDS, dated [DATE], showed the following: -Cognitively intact. -Diagnosis of end stage renal disease. Observations on 8/26/24 at 11:24 A.M., 8/27/24 at 7:38 A.M., and 8/28/24 at 10:18 A.M., showed brown smears on the wall by the resident's bed. The AC unit had dust and debris accumulation on the inside and outside. 11. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included major depressive disorder, anxiety disorder and Alzheimer's disease. Observations on 8/26/24 at 11:12 A.M., 8/27/24 at 10:45 A.M., and 8/28/24 at 10:17 A.M., showed the resident's floor was sticky with various debris and liquid spills. The resident's closet had dead bugs on the ground, along with cobwebs. The wall behind the resident's bed had dust build up and cobwebs. The AC had dark speckled matter that covered the top of the unit and on the windowsill. 12. Observation of the 200 hall TV area, showed: -On 8/26/24 at 4:04 P.M., crumbs and debris on the floor throughout the area. An area of light brown substance smeared near the entrance to the B200 hall. Dried spills with dirt and debris stuck to the spill scattered throughout the area; -On 8/27/24 at 6:51 A.M., some of the loose debris had been swept up. The smeared brown substance and dried spills with stuck on debris remained; -On 8/28/24 at 8:13 A.M., crumbs and debris on the floor throughout the area. An area of light brown substance smeared near the entrance to the B200 hall. Dried spills with dirt and debris stuck to the spills, scattered throughout the area; -On 8/29/24 at 9:22 A.M., crumbs and debris on the floor throughout the area. An area of light brown substance smeared near the entrance to the B200 hall. Dried spills with dirt and debris stuck to the spill scattered throughout the area. 13. Observation of the B200 and C200 halls, on 8/26/24 at 4:04 P.M., 8/27/24 at 6:51 A.M., 8/28/24 at 8:13 A.M., and 8/29/24 at 9:22 A.M., showed several dried spills and debris throughout the floor. Dust and debris stuck to the various spills. Crumbs and debris gathered near the edges of the halls. 14. Observation of the front entrance walkway, sitting area and down the A200 hall, showed: -On 8/26/24 at 10:00 A.M. and 8/27/24 at 7:48 A.M., several areas with speckled dried spills, with dust and debris stuck to the spills, throughout the front entrance and extended through the A200 hall. The sitting area near the entrance had several pinkish reds dried spots/spills scattered around on the floor, the drips were approximately the size of dime to penny sized. Blue debris was stuck to the floor that appeared to be small pieces, smaller than dime size, of painter's tape, stuck on various areas of the floor; -On 8/28/24 at 8:13 A.M., the front entrance appeared to be mopped. The blue bits of what appeared to be painter's tape remained stuck to the floor; -On 8/29/24 at 9:22 A.M., the blue bits of what appeared to be painter's tape remained stuck to the floor. 15. During an interview on 8/28/24 at 10:58 A.M., CNA A said housekeeping staff is shorthanded. CNAs pitch in to help clean. Housekeeping staff clean resident rooms once a day, but they don't mop under furniture. Resident #9 throws his/her feces and CNAs pick it up, clean up the big messes and do the best they can, but they need housekeeping staff to help too, but housekeeping staff don't clean. There is no housekeeping staff working in the evenings. When housekeeping leaves around 3:00 P.M., they lock up their cleaning supplies and nursing staff do not have access to the cleaning supplies if they need them. Housekeeping staff come in at 7:00 A.M. A lot of messes can be made between 3:00 P.M. and 7:00 A.M. The facility needs housekeeping staff to work later to help keep things clean. 16. During an interview on 8/29/24 at 8:28 A.M., Housekeeper R said housekeeping staff work 7:00 A.M. to 3:00 P.M. He/She wishes there was housekeeping staff in the evenings because it would help keep the facility cleaner. A lot happens between 3:00 P.M. and 7:00 A.M., and the rooms are a mess when day shift comes in. If housekeeping worked in the evening, the rooms would not be so horrible. Some rooms require more attention and time because some of the residents are [NAME]. Resident rooms are cleaned daily. The daily routine is to empty trash cans, clean toilets, wipe counters and tables, stock toilet paper and paper towels, sweep, and mop. Housekeeping staff should mop underneath furniture. There is no deep cleaning schedule. If staff notice a room requires deep cleaning, they mark it on a board in the basement and the Housekeeping Supervisor addresses it. If rooms are cleaned properly, they won't need to be deep cleaned. 17. During an interview on 8/29/24 at 12:36 P.M. with the Director of Nurses (DON) and Licensed Practical Nurse (LPN) L/Unit Manager, they said staff should clean up spills, such as tube feeding formula. Housekeeping staff should clean resident rooms daily. Housekeeping staff work day shift and do not work in the evenings. 18. During an interview on 8/29/24 at 2:20 P.M., the Maintenance Director/Housekeeping Supervisor said the prior Housekeeping Supervisor left on the 19th of this month, so he was assigned the position. There are five housekeeping staff employed at the facility. They work day shift, 7a-3p. Then, no one from housekeeping is at the facility until the next morning. Housekeeping staff do not leave any cleaning supplies out when they leave for the day. They will take care of spills before the end of the shift. If there is a spill that happens overnight, it might have to wait until the next day, unless nursing staff decide to help out. There are typically three housekeeping staff working per day. One on the 100 halls, one on the 200 halls, and a floor tech. The floor tech is responsible for all halls, common areas, shower rooms, dining room, etc. The other staff are responsible for resident rooms on their halls. The floor tech should clean the floors throughout the common areas, daily. The housekeeping staff assigned to a floor should clean each room daily. Cleaning the rooms includes cleaning the floors, sweeping and mopping. This includes mopping under the furniture and beds and moving the furniture if needed, wiping down tables, sinks, vents, AC units, and cleaning the bathroom and toilets. Privacy curtains should be observed for stains. Maintenance concerns are reported via a work slip. These are given to him and he handles them from there. If needed, he will consult the administrator to develop a plan. Staff should fill out a work order for gouges in the walls. The turn around time depends on how bad the issue is. MO00238869 MO00239680 MO00240930

Based on interview and record review, the facility to develop a policy for and complete background checks for all newly hired employees, to include the Nurse Aide (NA) Registry (checks for Federal Indicators (FI) given to individuals found guilty of abuse, neglect, and misappropriation of resident property) for thee of five newly hired employees sampled. The census was 67. Review of the facility's Policy on Background Checks, revised 8/29/24, showed: -The facility will conduct background checks on all employees before they start working at the facility; -Upon hire background checks will be completed two days prior to the employee start date; -Human Resources (HR) will conduct an annual Family Care Safety screening and quarterly Employee Disqualification List (EDL) screening; -The policy failed to identify which background checks will be completed prior to hire; -The policy failed to require the NA Registry check for all staff to ensure the staff has no Federal Indicators. Review of Dietary Aide P's employee file, showed: -Date of hire 6/6/24; -No NA registry check. Review of Licensed Practical Nurse (LPN) O's employee file, showed: -Date of hire 7/5/24; -No NA registry check. Review of Housekeeping Aide N's employee file, showed: -Date of hire 2/23/24; -No NA registry check. During an interview on 8/27/24 at 1:04 P.M., the Human Resources/Staffing Coordinator said employee background checks include the Family Care Safety Registry (FCSR) and Employee Disqualification List (EDL) check. The NA registry is only checked for the Certified Nursing Assistants, Nursing Assistants, Certified Medication Technicians, and nurses. She was not aware that the NA registry needed to be checked on all staff to check for federal indicators.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal hygiene. Resident #9 was not provided care after having a bowel movement and getting that bowel movement on his/her hands. In addition, the resident was not checked for incontinence or cleaned, resulting in the resident's brief being saturated through his/her pants (Resident #9). One resident was not provided showers or hair washing for an extended period of time and the hair care that was provided was not sufficient to cleanse the hair, resulting in the resident's hair becoming matted in a hard thick clump (Resident #32). In addition, staff failed to provide basic activities of daily living to include brushing residents' hair, providing feeding assistance, providing baths and/or showers, and providing nail care for four residents (Residents #168, #269, #29, and #16). The sample was 17. The census was 67. Review of the facility's Activity of Daily Living (ADL) policy, dated 8/17/20, showed: -It is the standard of the facility to promote the highest level of health and hygiene for the residents residing at the facility, while promoting the utmost independence. In order to adhere to this standard, it is the policy that any resident that is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal oral hygiene; -Assistance with the bathroom: Refers to the residents ability to use the toilet room, transfer on/off the toilet, clean themselves, change absorbent pads or briefs, and adjust clothes; -Assistance with ADLs will be performed if the ADLs cannot be performed independently by the resident. The level of assistance with ADLs provided by staff are based on the residents ability to maintain highest level of health and hygiene. Review of the facility's Peri Care (perineal care, care to the surface area between the thighs, extending from the pubic bone to tail bone) policy, dated 1/5/20, showed: -Purpose: To clean the perineum and to prevent infection and odor; -Wash hands, put on cloves, drape the resident for privacy; -Wipe the resident from front to back thoroughly cleaning the genitals. Repeat process until disposable wipe is free of soiling and discard; -Remove gloves, wash hands, apply gloves; -Wipe the peri rectal area from front to back. Repeat until disposable wipe is free of soiling and discard. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/24, showed: -Diagnoses included Alzheimer's disease; -Moderately impaired cognition; -Substantial/maximal assistance required for toileting hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for problems with elimination. Frequently incontinent of bowel and bladder and requires extensive assistance with toileting and perineal care; -Interventions included: Assist with toileting before and after meals, at hour of sleep, and as needed. Monitor bowel movements daily. Provide perineal care after each incontinent episode. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. He/She brought his/her hands out from under his/her blanket. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement in the room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room and asked the resident why you doing that. The resident said he/she cannot help it. CNA A said give me your hands. He/She wiped the resident's hands with a paper towel, told the resident he/she was going to tell his/her CNA, and then exited the room and walked down the hall. No perineal care provided. At 2:55 P.M., the resident remained in bed on his/her back. The smell of bowel movement permeated the room. At 3:09 P.M., the resident self-propelled in a wheelchair out of his/her room and down the hall. The room continued to have a strong smell of bowel movement. The resident propelled him/herself into the television area near the nurse's station. The resident had a brown substance on his/her hands and under his/her nails. A smell of bowel movement was noted when standing close to the resident. At 4:04 P.M., CNA A told the resident to head to the elevator for dinner. The resident propelled away towards the elevator. No personal care was provided. The resident's hands appear soiled. During an interview on 8/26/24 at 4:07 P.M., the Administrator said if a resident is observed to put his/her hands in stool, he expected staff to address this immediately. The resident's hands should be cleaned, and care provided. He will deal with this right now. The Administrator went and talked with CNA A. Observation on 8/26/24 at 4:09 P.M., showed CNA A got on the elevator to head down to the dining room. He/She said CNA B was the resident's CNA earlier today. Shift change is at 3:00 P.M., so he/she was not sure who the resident's CNA is now. CNA A went to the main dining room and took the resident to the shower room on the 1st floor. He/She assisted the resident to wash his/her hands at sink. There was a large amount of brown debris under the resident's nails and on his/her hands and fingers. CNA A assisted to wash the resident's hands using three different scrubs in order to get all of the dried debris off of the resident's hands. CNA A brought the resident to the table in in the main dining room. No perineal care was provided. CNA A said when he/she went into the resident's room earlier, he/she was playing in his/her stool. He/She cleaned his/her hands at that time, but he/she did not provide perineal care. He/She told the resident's CNA the resident needed care. This behavior of playing in stool is a normal for the resident and is why he/she does not have a roommate. Observation on 8/26/24 at 4:22 P.M., showed the resident remained in the dining room and waited for dinner. Observation on 8/26/24 at 5:49 P.M., showed the resident returned to the second floor from the main dining room. He/She self-propelled around at the nurse's station. CNA A then told the resident to go in to his/her room and he/she was going to clean him/her. The resident propelled to his/her room and transferred him/herself to bed. At 5:59 P.M., CNA A entered the resident's room with supplies. He/She asked the resident to stand up and sit back in his/her wheelchair so he/she could change the bed. As the resident stood and pivoted, the back of the resident's pants appeared very wet near the buttocks area and between the legs. A strong odor of bowel movement permeated in the room. Observation showed stool smeared on the sheets, blankets, pillow, and on the wall. CNA A placed gloves on and made the resident's bed, changing his/her gloves and sanitized his/her hands after touching the soiled linen and before placing the clean linen on the bed. CNA A assisted the resident to stand, removed his/her pants, and lowered his/her brief. The brief was saturated with dark colored urine and stool. As the resident started to stand, the resident began to have another bowel movement. CNA A assisted the resident into the bathroom and onto the toilet. During an interview on 8/29/24 at 12:50 P.M., with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) L/Unit Manager, they said the aide or any nursing staff can clean a resident's hands if they appear soiled. Residents should be cleaned if they are known to have a bowel movement. Residents who are incontinent should be checked every two hours and cleaned up before meals. 2. Review of Resident #32's admission MDS, dated [DATE], showed: -admission date 6/24/24; -Resident is rarely/never understood; -Rejection of care behavior not exhibited; -Upper extremity impairment on both sides, lower extremity impairment on one side; -Dependent for assistance with personal hygiene; -Diagnoses included dementia, Parkinson's disease (brain disorder causing unintended or uncontrolled movements), depression, and generalized muscle weakness. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident has a self-care deficit; -Goals: Resident will maintain or improve self-care area of dressing, grooming, hygiene, and bathing. Resident will accept assistance with area of dressing, grooming, hygiene, and bathing; -Interventions included provide assistance with self-care as needed; -The care plan failed to identify the resident's individual needs and preferences related to bathing, including the resident's dependence on staff for assistance with personal hygiene and grooming. Review of the facility's shower schedule, undated, located in the shower binder at the nurse's station, showed the resident scheduled to receive showers during day shift on Wednesdays and Saturdays. Review of the resident's shower sheets for July and August 2024, showed: -On 7/10/24 and 7/24/24, shower sheets completed and signed by a CNA and a nurse. No notes regarding the resident's hair; -On 8/1/24, shower sheet completed and signed by a CNA. Not signed by a nurse. No notes regarding resident's hair; -No other shower sheets completed. Observations on 8/26/24 at 11:12 A.M., 12:34 P.M., 1:28 P.M., 4:29 P.M., and 6:19 P.M., showed the resident on his/her back in bed. His/Her hair was disheveled and in a ponytail at the top of his/her head. Large chunks of white flakes were throughout the resident's hair, from the crown of his/her head to the end of his/her ponytail. Observations on 8/27/24 at 7:13 A.M. and 8:49 A.M., showed the resident on his/her back in bed with his/her hair in a disheveled ponytail. Large chunks of white flakes were throughout the resident's hair, from the crown of his/her head to the end of his/her ponytail. Observation on 8/27/24 at 11:00 A.M., showed the resident on his/her back in bed with his/her hair in a disheveled ponytail. The back of his/her head was bald with clumps of hair on his/her pillow. His/Her hair was matted into a large clump on the side of his/her head. During an interview, the resident shook his/her head no when asked if his/her hair had been washed recently. Observation on 8/28/24 at 6:54 A.M., showed CNA D entered the resident's room. The resident lay on his/her back. CNA D uncovered the resident and unsecured his/her brief. CNA D assisted the resident to his/her left side. The resident's hair was matted and stuck straight out from the left side of his/her head in a large clump. Large chunks of white flakes stuck in the matted hair. During an interview on 8/28/24 at 10:58 A.M., CNA A said staff follow a shower schedule at the nurse's station. When a shower or bed bath is completed, staff fill out a shower sheet and put it in the binder at the nurse's station. Staff should mark any observed issues on the shower sheet and report it to the nurse, including flakes in a resident's hair. The resident requires total assistance from staff with his/her care needs. He/She does not get out of bed and screams when touched. CNA A is not sure why the resident screams or if it is due to pain. The resident gets bed baths. Staff use a wet washcloth to wash the resident's hair. They have tried using regular shampoo in the past. CNA A does not know how the resident's hair got the way it has. His/Her hair has been this way for about a month. Observation on 8/29/24 at 8:48 A.M., showed the DON entered the resident's room. The resident lay on his/her back in bed. The DON lifted the resident's head and observed the resident's hair matted into a large clump. Large chunks of white flakes were throughout the resident's hair. The DON explained to the resident that his/her hair was matted and needed to be cut. The resident said he/she wanted staff to try brushing his/her hair first. The DON asked CNA K to look at the resident's hair and CNA K entered the resident's room and observed the resident's hair. CNA K said he/she has tried to get the resident to wash his/her hair, but the resident says no. CNA K said while giving bed baths, he/she has been wetting a washcloth and rubbing it on top of the resident's head. During an interview on 8/29/24 at 8:52 A.M., CNA K said the resident was admitted to the facility a couple of months ago with his/her hair in a ponytail. CNA K tried to wash the resident's hair, but the elastic band holding the ponytail wouldn't come out and the resident's hair started pulling away from his/her scalp. CNA K left the elastic band in the resident's hair and thought someone else would try to get it out. CNA K has given the resident several bed baths and uses a wet washcloth to push the resident's hair back and wipe the flakes out of his/her hair. CNA K told one of the nurses about the flakes in the resident's hair. The resident does not have a medicated shampoo. During an interview on 8/29/24 at 10:01 A.M., LPN E said the resident is total care, receives bed baths, and does not like to get up. He/She is in pain all the time and does not like to be touched. Yesterday, LPN E heard the resident's hair was matted. The resident lays toward one side all day, so LPN E can see how his/her scalp would get like this. He/She would have expected staff to notify the nurse if they observed flakes in the resident's hair. The nurse could notify the physician to get a medicated shampoo. If staff observe the resident's hair is matted so severely it cannot be brushed, they should report it to the nurse. The nurse would notify the family about the resident's hair to see if there is anything they can do or get consent to cut the resident's hair. Because of the resident's pain, staff could make sure the resident gets a Tylenol or pain medication before getting a shower to stay ahead of the pain. During an interview on 8/29/24 at 9:03 A.M., the DON said the resident's hair did not get like this overnight. She expected staff to have reported the resident's matted hair, flakes, and refusals to have his/her hair washed. She expected staff to get the resident's family involved if the resident has been refusing. She expected the nurse to notify the resident's physician about the flakes in the resident's hair so an order could be obtained for a medicated shampoo or topical treatment. 3. Review of Resident #168's medical record, showed: -admission date 8/23/24; -Diagnoses included unspecified injury of the neck, pain in unspecified hand, and vertigo (dizziness). Review of the resident's care plan, in use at the time of survey, reviewed 8/26/24, showed: -Care area/problem: Resident has a self-care deficit; -Goals included: Resident will maintain or improve self-care area of dressing, grooming, hygiene, and bathing. -Interventions included provide assistance with self-care as needed. Observation on 8/26/24 at 10:59 A.M., showed the resident sat in a wheelchair in his/her room. The resident's hair was in a disheveled ponytail, with chunks of hair loose and outside of the ponytail. During an interview, the resident said he/she was admitted to the facility three days ago for therapy. He/She just had surgery on the discs in his/her neck and does not have full use of his/her arms. Staff has not helped him/her brush his/her hair since he/she was admitted . Staff dropped off his/her breakfast tray this morning and left it there without helping him/her. Observations on 8/26/24 at 12:21 P.M. and 1:14 P.M., showed the resident sat in a wheelchair in his/her room. His/Her hair was in a disheveled ponytail, which had chunks of hair loose and outside of the ponytail. During an interview at 1:14 P.M., the resident said his/her hair is a mess and he/she does not like it that way. Being disheveled makes him/her very uncomfortable. Review of the resident's Occupational Therapy (OT) evaluation, dated 8/26/24, showed: -Goal: Patient will complete all activities of daily living (ADL)/self-care tasks with independence. Baseline, as of 8/26/24: Dependent; -Functional skills assessment: Substantial/maximal assistance with eating. Dependent with personal hygiene and dressing. Observation on 8/27/24 at 8:45 A.M., showed the resident in a wheelchair in his/her room. CNA K delivered a tray of breakfast to the resident's room, said he/she would come back to feed the resident, and left the room. During an interview, the resident said staff do not offer to help him/her. He/She is doing the best he/she can to fend for him/herself. The staff lack compassion. The resident became tearful during the interview. At 9:13 A.M., the resident remained seated in his/her room with breakfast tray untouched. During an interview, the resident said the facility staff lack compassion and care. It makes him/her sad and he/she does not want to ask them for help. He/She was sitting in his/her wheelchair with his/her pants not fully pulled up, leaving his/her bottom uncovered on the wheelchair, because he/she cannot lift his/her pants up all the way. At 12:13 P.M., the resident remained seated in his/her wheelchair with his/her pants not pulled up all the way. Observation on 8/28/24 at 9:11 A.M., showed the resident sat in wheelchair. His/Her hair was in a disheveled bun and said his/her friend put his/her hair in a bun yesterday. Staff have not offered to help him/her brush his/her hair or to assist him/her in taking a bath or shower since he/she was admitted to the facility. During an interview on 8/28/24 at 10:58 A.M., CNA A said the resident is a new admission. Staff should get report from the nurse about what type of assistance is needed. The resident needs some assistance from staff with eating and brushing his/her hair. Staff should offer and provide this assistance as needed. During an interview on 8/29/24 at 10:01 A.M., LPN E said the resident is a new admission to the facility. When he/she first arrived at the facility, his/her arms were not really mobile at all. Now, he/she can use his/her lower arms. Staff still need to help him/her with some things and should provide assistance, like brushing the resident's hair. During an interview on 8/29/24 at 12:36 P.M. with the DON and LPN L/Unit Manager, they said they expected staff to provide assistance to the resident as needed. 4. Review of Resident #269's quarterly MDS, dated [DATE], showed the following: -Diagnosis of acute respiratory failure; -Moderately impaired cognition. Review of the resident's care plan, dated 6/24/24 and in use at the time of the survey, showed: -Focus: Resident has a self-care deficit. He/She requires extensive assist with most of his/her ADL care. He/She is not ambulatory at this time; -Goal: Utilize interventions to help resident become as independent as possible while making sure his/her needs are met; -Interventions: Encourage resident to participate in ADLs and praise accomplishments and give resident as many choices as possible about care. Observation on 8/26/24 at 10:32 A.M., 8/27/24 at 6:50 A.M., and 8/28/24 at 12:40 P.M., showed the resident's finger nails to be at various lengths with dark matter underneath the nails. During an interview on 8/29/24 at 7:51 A.M., CNA S said CNAs are responsible for trimming residents' nails during showers or as needed. He/She expected residents' nails to be trimmed and clean. During an interview on 8/29/24 at 12:50 P.M., the DON said all nursing staff are able to trim residents' nails. She said nurses are responsible for trimming the nails of residents with diabetes. She expected residents to have clean, trimmed nails. 5. Review of Resident #29's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -Requires maximum assistance from staff with personal hygiene and bathing; -Diagnoses include heart disease and stroke. Review of the resident's care plan, in use at the time of survey, showed: -Care area: Self-care deficient; -Interventions: Give the resident as many choices as possible. Encourage the resident to complete as much self-care as possible independently or as possible. Provide assistance with self-care as needed. Observation and interview on 8/26/24 at 10:50 A.M., showed the resident lay in bed with fingernails on both hands that were approximately one-fourth inch long, with jagged edges and with brown matter underneath. The resident said he/she did not like his/her nails that long and thought they looked dirty. During observation and interview on 8/29/24 at 9:30 A.M., the resident said he/she received a shower the evening before, but the staff did not trim his/her nails. He/She could not trim his/her nails by him/herself. The resident's fingernails on both hands were approximately one-fourth inch long, with jagged edges, and with brown matter underneath. During an interview on 8/27/24 at 9:15 A.M., CNA S said nail care is part of the residents' routine showers and bathing care. 6. Review of Resident #16's, admission MDS, dated [DATE], showed: -Cognitively intact; -No rejection in care; -Requires maximum assist from staff for bathing, upper body dressing and personal hygiene; -Dependent on staff for lower body dressing; -Diagnosis included: diabetes, peripheral vascular disease (PVD, constricts the blood flow to lower extremities) and lung disease. Review of the resident's care plan, in use at the time of survey, showed: -Care Area: Self- care deficient related to the resident has an above the knee amputation (AKA) and requires maximum assistance with transfers, turning, grooming, positioning, and dressing. -Interventions: Occupational therapy (OT) and physical therapy (PT) evaluation as needed. Provide self-care as needed. During observation and interview on 8/26/24 at 10:25 A.M. and 4:07 P.M., 8/27/24 at 1:15 P.M., 8/28/24 at 8:40 A.M., and 8/29/24 at approximately 9:00 A.M., the resident lay in bed with a yellow facility gown and a blue cardigan sweater. The resident's hair was frizzy and had small knots of hair at the back of his/her head. The resident said he/she would like to get out of bed, look in the mirror, and be able to fix his/her own hair because he/she used to be a beautician. He/she gets a bed bath from staff but is normally just cleaned after he/she is incontinent. His/Her clothing does not get changed. He/She would like to get his/her clothing changed. During an interview at 8/27/24 at 1:15 P.M., the resident's family member said he/she visits the resident about once a week and has never seen the resident out of bed. The resident always wears a hospital gown and never wears any of his/her own personal clothing. The resident also has his/her own wheelchair with chair cushion. During an interview 8/28/24 at 8:40 A.M., Wound Clinic Nurse F said it is important for the resident to get out of bed to promote circulation and off load pressure. During an interview on 8/29/24 at 7:50 A.M., CNA S said the resident should be getting his/her clothing changed daily but the resident will refuse at times to get out of bed. During an interview on 8/29/24 at 9:45 A.M., LPN C said the resident would benefit from at least two hours a day getting out of bed and should be getting his/her clothing changed daily. During an interview on 8/29/24 at 12:40 P.M., the DON said she expected the resident to have his/her clothing changed daily and to get out of his/her of bed if the resident will allow staff to do so. 7. During an interview on 8/28/24 at 10:58 A.M., CNA A said some residents have their own hairbrushes, but the facility only supplies combs for the rest of the residents. There is a shared hairbrush used for residents who do not have their own individual hairbrush. CNA pointed at a hairbrush in the common area by the nurse's station, and said it was used this morning on several residents seated in the common area. 8. During an interview on 8/29/24 at 10:01 A.M., LPN E said residents should be provided with showers or bed baths in accordance with the facility's shower schedule and the resident's needs and preferences. When staff assist in completion of a shower or bed bath, they should document it on a shower sheet. The shower sheet should be given to the nurse for them to review and sign. Once reviewed by the nurse, the shower sheet goes in the binder at the nurse's station, which is reviewed by the DON. Staff should document any observed issues on the shower sheet and immediately report the issues to the nurse. 9. During an interview on 8/29/24 at 12:36 P.M. with the DON and LPN L/Unit Manager, they said the facility does have a sufficient supply of hairbrushes. Each resident should be provided with their own individual hairbrush. It would not be acceptable to use a shared hairbrush on all residents. CNAs are responsible for trimming residents' nails and cleaning residents' hands. Staff should document all bed baths and showers on shower sheets. Any area of concerns should be indicated on the shower sheet. If a resident refuses a shower or bed bath, staff should document this on the shower sheet and notify the nurse. The nurse should notify the family and physician. Ongoing refusals should be documented on the residents' care plan. MO00234383 MO00239684 MO00238437 MO00238869 MO00239680 MO00240891 MO00240930

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide individual activities designed to meet the interests of and to support the psychosocial well-being of each resident, in accordance with needs and preferences for three residents (Residents #32, #9, and #55). The census was 67. 1. Review of Resident #32's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed: -Resident rarely/never understood; -Dependent on assistance for mobility; -Somewhat important to resident to have books, newspapers, and magazines to read; -Somewhat important to resident to go outside to get fresh air when the weather is good; -Somewhat important to resident to participate in religious services or practices; -Very important to resident to listen to music he/she likes; -Very important to resident to do things with groups of people; -Very important to resident to do his/her favorite activities; -Diagnoses included dementia, Parkinson's disease (brain disorder causing unintended or uncontrolled movements), and depression. Review of the resident's care plan, in use at the time of survey, showed no documentation regarding the resident's needs and preferences related to activities. Review of the resident's medical record, showed no activity assessments. Review of the Activity Director's activity documentation from July and August 2024, showed: -On 8/1/24, staff documented the resident participated in Resident Photo List activity; -No other documentation of other activities offered to the resident in July or August 2024. Observations on all days of the survey, from 8/26/24 through 8/29/24, showed the resident in bed in his/her room. No observations of 1:1 activities offered or provided to the resident. No observations of the resident out of his/her room and participating in group activities. During an interview on 8/27/24 at 12:16 P.M., the resident nodded and shook his/her head to respond to questions and nodded his/her head yes when asked if he/she was bored. 2. Review of Resident #9's annual MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included Alzheimer's disease; -Interview for activity preferences: -How important is it to you to listen to music you like: Somewhat important; -How important is it to you to be around animals such as pets: Somewhat important; -How important is it to you to keep up with the news: Somewhat important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important. Review of the resident's care plan, in use at the time of the survey, showed: -Prefers to participate in individual activities/self-directed activities; -No goals for activities specified; -Interventions: Encourage participation and positive feedback and praise. Explore and obtain past interest and potential re-motivation. Offer activity cart/wellness on wheels supplies: Games, reading materials, audio books, music supplies, health/wellness, education, cognitive games, spiritual materials. Provide a schedule of events to post in his/her room. Provide materials, equipment or supplies for preferred activity pursuits. Provide one-on-one interventions, to include music therapy, maintenance program, health education, and sensory stimulation. Review of the resident's Activity Interest and Initial Assessment, dated 3/6/22, showed: -Activity interests and initial assessment: Bingo, books, listening to music, sitting outside for fresh air, movies, news, other TV/Internet activity interests; -Activity environment preferences: Day room/activity room; -Activity preferences that are very important to the resident: Listening to music. Participating in favorite activities. Reading books, newspapers, or magazines. Spending time outdoors; -Cognitive adaptions and interventions: Needs reminders of activities. One-on-one activities. Review of the resident's medical record, showed only one, one-on-one activity documented since admission. No further activity participation documented. Review of the resident's one-on-one visit, dated 4/2/24, showed: -Sensory stimulation, snack/hydration, nail care; -Duration: 20 minutes; -Location: In room; -Response: Resident enjoys nail care and decorations added to his/her room. Resident likes to explore with activity direction, but easily loses track of activity/attention. Activity director paints resident's nails and helps decorate the room with his/her instruction of how they want it set up. Review of the resident's Activities Quarterly/Annually Assessment, dated 7/17/24, showed: -Preferred activity setting: In-room, dining room, other. Resident roams building when not stationed in his/her room or in the dining hall; -Cognitive status: Disorganized thinking; -Behavior: Wanders intrudes on others; -Resident will roam if not supervised or informed on where to go. Resident likes being stationed at a table or by a window to enjoy nature scene; -Participates in individual leisure activities: No; -Resident likes to be near television, but does not focus on what is on/easily distracted; -Other: Listening to music, socializing with others, visiting the beauty shop, crafts; -Staff to provide: one-on-one interventions: Encouragement, provide schedule of programs; -Staff to provide activity cart visits, verbal reminders, assistance to and from groups. Observation on 8/26/24 at 2:06 P.M., showed the resident in his/her room in bed, on his/her back. The resident had a brown substance on his/her hands and under his/her nails. A strong odor of bowel movement was in the room. No activity calendar was posted in the resident's room. At 2:20 P.M., Certified Nursing Assistant (CNA) A entered the resident's room and asked the resident why you doing that. The resident said he/she cannot help it. CNA A said give me your hands. He/She wiped the resident's hands with a wipe, told the resident he/she was going to tell his/her CNA, and then exited the room and walked down the hall. At 2:55 P.M., the resident remained in bed on his/her back. At 3:09 P.M., the resident self-propelled in a wheelchair out of his/her room and into the television area near the nurse's station. At 4:04 P.M., CNA A told the resident to head to the elevator for dinner. The resident propelled away towards the elevator. At 4:22 P.M., the resident remained in the dining room and waited for dinner. At 5:49 P.M., the resident returned to the second floor from the main dining room. He/She self-propelled around at the nurse's station. CNA A then told the resident to go in to his/her room and he/she is going to clean him/her. The resident propelled to his/her room and transferred him/herself to bed. Observation on 8/27/24 at 6:46 A.M., showed the resident in a wheelchair near the 200-hall nurse's station. Observation on 8/28/24 at 6:21 A.M., showed the resident in bed, asleep. No observations of staff interacting with the resident or providing mental stimulation outside of routine resident care. 3. Review of Resident #55's medical record, showed diagnoses included stroke and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following stroke. Review of the resident's activity assessment, dated 3/18/24, showed: -Interest in games: Bingo; -Interest in arts and crafts: Coloring, drawing, painting; -Specify any types of reading/writing that patient prefers: Resident expressed interest in simple reads, such as magazines; -Interest in music: Listening to music; -Interest in socializing with others: Phone calls, social visits; -Interest in outdoor activities: Sitting outside; -Interest in TV/Internet: Game shows, movies; -Interest in other areas: Resident does not mind trying out simple activities, but prefers to be offered options to pick through; -Activity environment preferences: Day room/activity room, self-directed, resident prefers to be offered options and picks through what he/she wants; -Chooses not to participate in group activities; -Types of activities patient participates in: Activity Director brings activity cart to resident's room to pick through; -Participation level in activities: Behaviors in activities is appropriate, responsive to one to one visits; -Activity schedule preference: Afternoon, evening; -Activity preferences that are very important to resident: Listening to music, participating in favorite activities, reading books, newspapers, or magazines; -Physical adaptations and interventions: Activity Director does room visits with this resident; -Cognitive adaptions and interventions included one to one activities. Review of the resident's significant change MDS, dated [DATE], showed: -Moderate cognitive impairment; -Dependent on assistance for mobility; -Somewhat important to resident to do his/her favorite activities; -Somewhat important to resident to get outside to get fresh air when the weather is good; -Very important to resident to have books, newspapers, and magazines to read; -Very important to resident to listen to music he/she likes. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident has a need for/prefers socialization activities; -Goal and interventions: Blank; -The care plan failed to identify the resident's specific needs and preferences related to activities. Review of the Activity Director's activity documentation from July and August 2024, showed: -On 8/2/24, staff documented the resident participated with assistance in Nail Care activity; -On 8/6/24, staff documented the resident taken already, for Room Visit activity; -On 8/8/24, staff documented the resident's name on the list of Room Visits. Participation level was not indicated; -No other documentation of other activities offered to the resident in July or August 2024. Observations on all days of the survey, from 8/26/24 through 8/29/24, showed the resident in bed in his/her room. No observations of 1:1 activities offered or provided to the resident. No observations of the resident out of his/her room and participating in group activities. 4. During an interview on 8/29/24 at 12:11 P.M., the Activity Director said she has been working with the facility since February 2024. She does not have a specific list of residents who receive 1:1 activities. There is no set schedule for residents to receive 1:1 activities. Residents #32 and #55 are bed bound. She sees them in their rooms, but not on a specific schedule. When residents do not come to the group activities, she tries to see them later in that day. She does not have any additional documentation of activities provided to Residents #32 and #55. She needs to work on her documentation and getting more structure for the residents at the facility. She does not do formal activity assessments. She does do some activity assessments in the electronic medical record (EMR) when residents are newly admitted . She checked the EMR and verified there is no activity assessment for Resident #32. Residents need activities for their quality of life. 5. During an interview on 8/29/24 at 12:36 P.M. with the Director of Nurses (DON) and Licensed Practical Nurse (LPN) L/Unit Manager, they said it is hard to keep Resident #9's attention, but he/she enjoyed watching others do puzzles and interactions with staff. Activity staff should learn about the residents to see what activities they would benefit from. Residents #32 and #55 are total care and they are in bed most of the time. It is very painful for resident #32 to move. It is expected that Residents #32 and #55 receive 1:1 activities. 1:1 activities should be offered to residents who cannot or do not want to attend group activities. It is expected that all residents be offered activities in line with their needs and preferences. Activities can help improve the quality of a resident's life. Activities can help decrease behaviors. It is expected for residents at risk of social isolation to be offered activities. 6. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expects residents who are unable or unwilling to attend group activities to be offered/provided 1:1 activities. He expects the Activity Director to have a schedule/routine for providing activities to residents who are risk of social isolation.

Based on interview and record review, the facility failed to ensure the activity program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. The census was 67. Review of the facility's Facility Assessment Tool, updated 11/2/23, showed: -Facility resources needed to provide competent support and care for the resident population every day and during emergencies included: -Therapy services (e.g., activities professionals); -In addition to nursing staff, other staff needed for behavioral healthcare and services included Activity Director; -Staff training/education and competencies: Upon hire, all staff go through formal orientation for education and competency testing; -No documentation regarding the training requirement for a qualified Activity Director. During an interview on 8/29/24 at 12:11 P.M., the Activity Director said she began working in her position with the facility in February 2024. During an interview on 8/29/24 at 2:13 P.M., the Activity Director said she had no training in activities when she began working with the facility. The Director of Nurses (DON) helped train her a little bit. She is not licensed, registered, or certified as an Occupational Therapist or in activities. This is her first job as an Activity Director. She has expressed interest in taking Activity Manager classes and this has been discussed with the facility's owner, but she has not been signed up for classes or received a certification, yet. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expects the facility to employ a qualified Activity Director. The Activity Director had some training with the previous Activity Director. There are plans for the Activity Director to get certified, but she has not signed up for classes, yet.

Based on observation, interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 67. Review of the facility's Narcotic Count Change of Shift Policy, dated 1/4/23, showed: -Narcotics must be counted with the nurse or Certified Medication Technician (CMT) at the change of shift; The nurse and CMT must count the total number or cards and packages and note total on count sheet; Each care and package must be counted to ensure that the total number of narcotics is accurate and matches that total number of narcotics in the card or package; The nurse or CMT arriving for their shift and leaving their shift must initial the change of shift count sheet; If any discrepancies are noted at the change of shift the nurse or CMT are to notify the Director of Nursing (DON) or nursing management immediately. 1. Observation on 8/26/24 at 11:35 A.M., showed the Garden Unit nurses cart did not have a narcotic count sheet dated August, 2024. 2. Observation and interview on 8/26/24 at 11:40 A.M., showed the Garden Unit CMT cart did not have a narcotic count sheet dated August, 2024. CMT M said someone must have taken it because it was in the book earlier. During an interview on 8/29/24 at 11:50 A.M., the DON said the Garden Unit narcotic sheets dated August, 2024 could not be located. 3. Review of the Terrace Unit, Controlled Substance Shift Change Count Check Sheet, dated August, 2024, showed: -26 out of 50 shifts did not have a total number of packages noted; -Eight out of 50 shifts with no staff initials for the shift change count; -16 out of 50 shifts had only one staff initial for the shift change count. During an interview on 8/28/24 at 6:58 A.M., CMT U said the narcotic count is to be completed with one on-coming staff member and one off-going staff member every shift, every day. During an interview on 8/29/24 at 9:45 A.M., Licensed Practical Nurse (LPN) C said the narcotic sheets are to be available on each cart that has narcotics. The sheets should indicate the number of packages and initials of the staff counting. The narcotic count is to be completed with one on-coming staff member and one off-going staff member every shift, every day. The nurses and CMTs work twelve hour shifts. 4. During an interview on 8/29/24 at 11:50 A.M., the DON said it is expected for CMTs and nurses to count the narcotics every day on every shift. The count should be completed with one on-coming staff member and one off-going staff member. The number of packages counted is expected to be written on the shift count sheet.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals stored in a medication room refrigerator had a temperature log in one of two medication rooms observed. In addition, staff failed to keep a medication cart locked when left unattended. The census was 67. Review of the facility's Medication Storage policy dated, 6/1/18, showed: -Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier; -Procedures: All medications are maintained within the temperature ranges noted in the United States Pharmacopoeia (USP, an organization that sets standard for health care products) and the Centers for Disease Control (CDC); Medications and biologicals are stored at their appropriated temperatures and humidity according to the USP guidelines for temperature ranges; The facility should maintain a temperature log in the storage area to record temperatures at least one a day; Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1. Observation and interview on 8/27/24 at 8:25 A.M., showed the Garden Unit medication room with a small black refrigerator. The refrigerator had multiple insulin pens and insulin vials. A thermometer hung on the inside of the refrigerator door. The refrigerator temperature logs were not available for review. Certified Medication Technician (CMT) M searched in the medication room and the nurses station but could not locate any temperature logs. CMT M said the Unit Manager checks the temperatures. During an interview on 8/29/24 at 12:40 P.M., the Director of Nurses (DON) and Licensed Practical Nurse (LPN) L/Unit Manager said temperatures are expected to be checked by nursing staff on the night shift every day. The temperature logs for the Garden Unit medication room refrigerator could not be located. 2. Observation on 8/28/24 at 9:12 A.M., showed the nurses' medication cart on Garden Unit was unlocked. There were multiple residents returning from breakfast, ambulating with walkers and self-propelling in wheelchairs past the unlocked medication cart. The nurse was not near the medication cart. At 9:25 A.M., LPN Y returned to the medication cart and then locked the medication cart. During an interview on 8/28/24 at 11:46 A.M., CMT T said the medication cart should be locked every time the staff member walks away from the cart. It is to ensure residents don't get into the medications cart and remove something they shouldn't. There are many confused residents on the Garden Unit and locking the medication cart ensures resident safety. During an interview on 8/29/24 at 9:45 A.M., LPN C said the medication cart is to be locked every time the staff member walks away. Locking the medication cart ensures resident safety. During an interview on 8/29/24 at 12:40 P.M., the DON said all medication carts are expected to be locked when the staff leave the cart. The DON expected all medication carts to always be locked when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide residents food that is palatable and at a safe and appetizing temperature for two residents (Residents #24 and #45) and residents on the Veranda hall. The sample was 17. The census was 67. Review of the facility's meal service temperatures policy, revised January 2019, showed: -Purpose: to ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: meals temperatures shall be monitored by the dietary manager and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees. 1. Review of Resident #24's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/21/24, showed: -Cognitively intact; -Diagnoses included manic depression and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 8/26/24 at 10:24 A.M., the resident said he/she eats meals in his/her room. He/She said the food is not good and the temperature is usually too cold. 2. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included major depressive disorder, anxiety disorder and Alzheimer's disease. During an interview on 8/26/24 at 11:14 A.M., the resident says the food is not good and is sometimes cold. 3. Observation on 8/28/24 at 9:10 A.M., of breakfast trays served on the Veranda hallway, showed the following: -Pancakes measured at 105.2 degrees Fahrenheit (F); -Sausage measured at 99.5 degrees F. 4. Observation on 8/28/24 at 1:02 P.M., of lunch trays served on the Veranda hallway, showed the following: -Mashed potatoes measured at 100.4 degrees F; -Chicken fried steak measured at 107.4 degrees F; -Cooked carrots measured at 95.7 degrees F. 5. During an interview on 8/29/24 at 7:25 A.M., Dietary Aide G said food should be served to residents at a safe and palatable temperature. He/She said this is important to keep residents from getting sick. 6. During an interview on 8/29/24 at 7:29 A.M., the Food Service Manager said she expected food to be delivered to residents at a safe and palatable temperature. She said this is important so residents get their food while it is still hot. 7. During an interview on 8/29/24 at 1:00 P.M., the Director of Nursing (DON) said she expected food to be delivered at the correct and palatable temperature. 8. During an interview on 8/29/24 at 3:01 P.M., the Administrator said he expected food to be delivered at a safe and palatable temperature. MO00240930

Based on observation, interview and record review, the facility failed to follow hair restraint policies while preparing food, keep the kitchen equipment clean and floors free of trash and grime. This had the potential to affect all residents who eat from the facility kitchen. The census was 67. Review of the facility's food service policy, undated, showed: -The facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes; -Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Review of the facility's dietary cleaning schedule, undated, showed: -Items to be cleaned: walk in refrigerator are to be swept and mopped, the fryer is to be cleaned inside and out. 1. Observation on 8/26/24 at 10:10 A.M., 8/27/24 at 8:38 A.M., and 8/29/24 at 6:38 A.M. of the kitchen, showed: -The deep fryer had sticky liquid streaks on the sides of the fryer; -The dry storage room had food debris and various trash wrappers on the ground; -The walk-in refrigerator had food debris and trash wrappers on the ground under the racks. 2. Observation on 8/27/24 at 8:31 A.M., showed: -The Administrator and Maintenance Aide W walked into the kitchen during breakfast preparations. Maintenance Aide W did not wear a hairnet or beard net and walked up to the oven where eggs were being cooked. His/Her beard was approximately 1 inch long; -Dietary Aide G walked up to the steam table where the cook was dishing out breakfast plates with a hair net on that did not cover all his/her hair. His/Her hair hung out of the hairnet in the back and was approximately 10 inches long. Observation on 8/28/24 at 7:56 A.M., showed Food Service Assistant J stood over the steam table with uncovered food. His/Her hair net was pulled back and exposed approximately 1 inch of uncovered hair. 3. During an interview on 8/29/24 at 7:25 A.M., Dietary Aide G said hairnets should be worn in the kitchen and anytime staff are around food. This is important for sanitation. All kitchen staff are responsible for cleaning the floors in the kitchen, dry storage room, and walk in refrigerator. 4. During an interview on 8/29/24 at 7:29 A.M., the Food Service Manager said she would expect any staff member who comes in the kitchen during meal prep times to wear hair restraints. This includes hair nets and beard nets. Hair restraints should be worn correctly. All kitchen staff are responsible for sweeping the floors in the kitchen. The cook is responsible for cleaning the fryer. 5. During an interview on 8/29/24 at 3:01 P.M., the Administrator said he would expect the kitchen and appliances to be clean. He would expect for staff to be wearing hair restraints properly when in the kitchen.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include dialysis access sites and centrally inserted intravenous (IV) lines, urinary catheters, wounds requiring treatment, and tube feedings administered via a feeding tube surgically inserted into the stomach through the abdomen, for nine of nine residents sampled for EBP (Residents #68, #32, #269, #55, #16, #29, #62, #69, and #5). The facility also failed to follow proper infection control practices during medication administration when staff touched the residents' medications and stuck their fingers into stock medication bottles to dig out medication, for two residents (Residents #269 and #45). In addition, the facility failed to ensure newly hired employees had their first step purified protein derivative (PPD, used to determine the presence of tuberculosis) read prior to starting at the facility and that the PPD results were read within 24 to 48 hours after administered, for four of five newly hired employees sampled. The sample was 17. The census was 67. Review of the facility's Matrix for Providers CMS form 802, provided during the annual survey, showed: -The facility identified seven residents as receiving tube feedings: -Of those seven, five were investigated for EBP (Residents #68, #32, #269, #55, and #29) -The facility identified one resident as having a urinary catheter: -Of the one, the resident was investigated for EBP (Resident #62); -The facility identified three residents as receiving dialysis: -Of the three, two were investigated for EBP (Residents #69 and #5); -The facility identified one resident as having intravenous access: -Of the one, the resident was investigated for EBP (Resident #68). Review of the most recent pressure ulcer/wound report, dated 8/21/24, showed six residents identified as having wounds. Of those six, two were included in the sample (Residents #32 and #16). Review of CMS memo QSO-24-08-NH, dated March 20, 2024, showed: -Subject: Enhanced Barrier Precautions in Nursing Homes; -CMS is issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of EBP to align with nationally accepted standards; -EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status (MDROs); -The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control; -EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -Examples of chronic wounds include, but are not limited to, pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction), diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; -Indwelling medical device examples include central lines, urinary catheters, and feeding tubes; -EBP should be used for any residents who meet the above criteria, wherever they reside in the facility; -For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: -Dressing; -Bathing/showering; -Transferring; -Providing hygiene; -Changing linens; Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube; -Wound care: any skin opening requiring a dressing; -Effective Date: April 1, 2024. Observation during all days of survey, from 8/26/24 through 8/29/24, showed no EBP signs posted on any resident doors and no PPE besides gloves available to staff for any resident room in the facility. 1. Review of Resident #68's medical record, showed: -An order dated 8/3/24, custom order night shift cleanse gastrostomy tube (g-tube, feeding tube) incision site with wound cleanser and pat dry. Apply 4x4 split gauze to site and secure with tape; -An order dated 8/16/24, for vancomycin (antibiotic) 1.25 gram IV solution 275 milliliter (ml) IV every 12 hours. Observation on 8/27/24 at 9:18 A.M., showed the resident in his/her room, in bed, and covered with a blanket. At 9:26 A.M., Licensed Practical Nurse (LPN) C entered the room, put on gloves, and exposed a single lumen peripherally inserted central catheter (PICC, intravenous access line inserted into a central vein) line and said this was the IV access site used for the resident. No EBP sign was posted on the door and no gown available to staff or worn. Observation on 8/28/24 at 6:25 A.M., showed the resident lay in bed. A phlebotomist with the lab company stood at the resident's side and drew blood from the resident's left-hand. The phlebotomist wore gloves. No EBP sign was posted on the door and no gown available to the phlebotomist or worn. 2. Review of Resident #32's medical record, showed: -An order dated 6/25/24, for Peg-tube (a type of feeding tube) dressing one time per day. Cleanse PEG site with warm water, pat dry and apply split gauze. Secure with tape. Document any signs and symptoms of infection; -An order dated 8/14/24, custom order, day shift cleanse left great toe wound with wound cleanser and pat dry. Apply Mupirocin (antibiotic) ointment to open area. Cover with 2x2 gauze and wrap with small piece of Coband (wrap). Wrap with just enough to wrap around wound one time. Treatment to be done every day. Observation on 8/28/24 at 6:54 A.M., showed Certified Nursing Assistant (CNA) D entered the resident's room. The resident lay on his/her back with his/her tube feeding connected to the g-tube, but turned off. CNA D uncovered the resident and unsecured his/her brief. CNA D assisted the resident to his/her left side. Observation of the resident's buttocks showed an open area to the coccyx (tailbone area). The opened area appeared reddened and had no dressing in place. CNA D pointed to the open area. The resident had stool in the buttocks crack. CNA D cleansed the resident, removed his/her gloves, and washed his/her hands. He/She wore no gown. CNA D then assisted the resident to be repositioned to his/her back and covered. No EBP sign was located on the resident's door or gowns available to staff for use. Observation on 8/28/24 at 9:22 A.M., showed Wound Clinic Nurse F and the facility Wound Nurse entered the resident's room. The Wound Nurse cleaned the resident's bedside table with a bleach wipe and placed a clean barrier down. Both staff sanitized their hands and the Wound Nurse applied gloves. Wound Clinic Nurse F said the area to be treated is to the toe and is a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) and is healing well. The Wound Nurse set out the supplies to provide care to the left toe. No gown was worn. Wound Clinic Nurse F uncovered the resident. The resident's tube feeding was connected to the g-tube but turned off. Wound Clinic Nurse F placed a towel under the resident's foot. He/She wore no gloves. No other PPE was worn. Wound Clinic Nurse F said he/she was not aware of any other open areas on the resident. The Wound Nurse said no one had told her of any new open areas on the resident. The Wound Nurse cleaned the resident's toe and applied the ordered treatment. As the area was treated, both staff leaned over the resident and their lab coats hung on the resident and the resident's bed. The Wound Nurse then wrapped the residents' foot with the wrap and said this helps keep the dressing on. The Wound Nurse removed her gloves and washed her hands with soap and water. The wound nurse assisted the resident to his/her right side. Wound Clinic Nurse F observed the area to the resident's coccyx and said the area is opened and presents as a stage II. He/She instructed the Wound Nurse to clean the area, apply betadine, and apply a Mepalex dressing (foam dressing with adherent edges). Wound Clinic Nurse F said the opened area was caused by the resident laying on his/her back too much. The Wound Nurse cleaned the area, applied betadine, and covered with a Mepalex dressing. The Wound Nurse removed her gloves and washed her hands. The Wound Nurse applied gloves and both staff assisted to position the resident onto on his/her right side with pillows. No EBP sign was located on the resident's door or gowns available to staff for use. 3. Review of Resident #269's medical record, showed an order dated 8/3/24, custom order, night shift cleanse g-tube site with wound cleanser and pat dry. Apply 4x4 split gauze to site and secure with tape. Observation on 8/27/24 at 7:39 A.M., showed Certified Medication Technician (CMT M) entered the resident's room and covered him/her with a blanket. He/She then grabbed the resident's arm to put a blood pressure cuff on the resident's right wrist. The resident's blood pressure was measured and the CMT F removed the blood pressure cuff. CMT M then assisted the resident to reposition in bed by grabbing his/her hands and assisting to move his/her legs. He/she wore no gown. No EBP sign was located on the resident's door or gowns available to staff for use. 4. Review of Resident #55's medical record, showed an order dated 5/1/24, for Jevity 1.5 Cal (liquid meal replacement) 70 ml per hour. At 6am start continuous feeding, at 6am to 10pm. 200 water flush every 4 hours. Observation on 8/26/24 at 1:04 P.M., showed CNA K entered the resident's room and assisted to feed the resident pureed food. No gown or gloves were worn. No EBP sign was located on the resident's door or gowns available to staff for use. On 8/27/24 at 9:18 A.M., CNA K entered the resident's room and assisted to feed the resident pureed food. No gown or gloves were worn. No EBP sign located on the resident's door or gowns available to staff for use. At 12:14 P.M., the resident lay in bed. Tube feeding Jevity 1.5 infused at 70 ml per hour. No EBP sign located on the resident's door or gowns available to staff for use. 5. Review of Resident #16's medical record, showed a wound clinic note, dated 8/21/24: -Evaluate and treat multiple pressure wounds to the right foot, right lateral (outer) foot, and sacrum (tailbone area), below the knee amputation to the left leg; -Goal: Resolve open pressure wounds with weekly visits until closure. Observation and interview on 8/28/24 at 8:40 A.M., showed the resident lay in his/her bed on his/her right side and the Wound Nurse and the Wound Clinic Nurse F stood on each side of the resident's bed with gloved hands. The Wound Clinic Nurse F said they had just completed the resident's coccyx dressing. The resident was repositioned on his/her left side by the Wound Nurse and the Wound Clinic Nurse F. The Wound Nurse removed the resident's right heel protector, and the resident's right foot and heel dressing. Wound Clinic Nurse F cleaned the resident's right foot and heel wound with a dry gauze and measured the resident's wounds. The Wound Nurse leaned over the resident's bed and cleaned the resident's right foot and heel wound with wound cleanser and redressed the resident's wounds. The Wound Nurse's name badge and uniform top touched the resident's leg and bedding while cleaning and redressing the resident's wound. The resident's heel protector was reapplied by Wound Clinic Nurse F. The Wound Nurse and the Wound Clinic Nurse covered the resident with a bed sheet and blanket. The Wound Nurse and the Wound Clinic Nurse F did not wear a gown during the resident's treatment. No EBP sign located on the resident's door or gowns available to staff for use. 6. Review of Resident #29's medical record, showed an order dated 2/6/24, for peg-tube dressing, night shift change dressing to peg tube insertion site daily, monitor for signs and symptoms of infection, notify physician of any changes. Observation on 8/27/24 at 9:15 A.M., showed the resident lay in his/her bed. CNA S applied gloves and assisted the resident to turn to his/her left side. CNA S removed the resident's brief, and the resident was checked for incontinence. The resident was dry and was repositioned by CNA S to his/her back. The resident's bed sheets were adjusted and pulled up over the resident. No gown was worn during the resident's care. No EBP sign located on the resident's door or gowns available to staff for use. 7. Review of Resident #62's medical record, showed an order dated 6/20/24, for Foley (brand of urinary catheter) and suprapubic catheter (a urinary catheter surgically inserted through the abdomen and into the bladder) every 2 shift, cleanse peri-area and catheter tubing with warm soap and water. Observation on 8/28/24 at 7:47 A.M., showed the resident in his/her room and sat in a chair. He/She wore long pants and said he/she does have a urine bag attached to his/her leg. The urine drains from a tube inserted into his/her abdomen. No EBP sign located on the resident's door or gowns available to staff for use. 8. Review of Resident #69's medical record, showed an order dated 12/18/20, for every 2 shift, monitor shunt/graft/fistula (different types of dialysis access sites) for signs and symptoms of infection and adequate circulation. Observation on 8/27/24 at 1:15 P.M., showed LPN C donned gloves and pulled the resident's gown down at the neck of and said the resident used to have a dialysis access site in his/her arm, then he/she had a blockage and now his/her dialysis site is in her upper right chest. He/She now has a double lumen central main line access site. LPN C wore gloves but no gown worn. No EBP sign located on the resident's door or gowns available to staff for use. 9. Review of Resident #5's medical record, showed an order dated 11/16/22, custom order every 2 shift, check bruit and thrill (the sound made and vibration felt as blood passes through the shunt) left forearm atrial venous (AV). Observation and interview on 8/26/24 at 11:01 A.M., showed the resident in his/her room in a wheelchair. A dressing was intact to his/her left arm, just above the elbow near the bicep area. The resident said this was his/her dialysis access site. Staff monitor it when he/she returns from dialysis. The dialysis company applies the dressing while at dialysis. It is a shunt. He/She just got back from dialysis. He/She has no concerns with care and is very happy. No EBP sign was located on the resident's door or gowns available to staff for use. 10. During an interview on 8/29/24 at 9:50 A.M., CNA K said he/she did not know what EBP is. 11. During an interview on 8/29/24 at 9:12 A.M., the Wound Nurse and unit manager said she did not know what EBPs are. She has not received any training on it. 12. During an interview on 8/29/24 at 7:51 A.M., CNA S said he/she did not know what EBP was and has received no training on it, but there is personal protective equipment (PPE) in central supply. 13. During an interview on 8/29/24 at 9:45 A.M., LPN C said he/she had no idea what EBP was, and he/she had not received any education or in-servicing on EBP. 14. During an interview on 8/29/24 at 12:50 P.M., with the DON and LPN L/Unit Manager, they said the administrator had approached them a while back about a new requirement for gowns and other PPE during routine care. They did not believe it applied to them, so it was not implemented. 15. During an interview on 8/29/24 at 2:55 P.M., the administrator said regarding the requirement for enhanced barrier precautions, he did bring it to the DONs attention, and she said she did not feel it was relevant to them. Nothing has been implemented. 16. Review of the facility's Medication Administration policy, dated 6/1/18, showed; -Oral medication administration; -For solid medications: Pour or push the correct number of tablets or capsules into the souffle' (medication) cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. 17. Review of Resident #269's face sheet, undated, showed diagnoses that included: respiratory failure, gastro-esophageal reflux disease (heartburn, GERD), anxiety disorder, high blood pressure and kidney disease. Observation on 8/27/24 at 7:45 A.M., showed CMT M prepared to pass medications for residents on the Garden Unit CMT cart. CMT M removed one acid reducer 20 milligram (mg) tablet and one renal (kidney) vitamin 0.8 mg tablet out of the facility stock bottle by placing his/her ungloved fingers into the bottle to retrieve the medications and then placed the medication into a clear medication cup. CMT M removed one amlodipine (used to treat high blood pressure) 10 mg tablet; one apixaban (blood thinner) 5 mg tablet; one benztropine (used to treat muscle tremors) 0.5 mg tablet; one buspirone (used to treat anxiety) 15 mg tablet; one clonidine (used to treat high blood pressure) 0.1 mg tablet; and one escitalopram (used to treat depression and anxiety)10 mg tablet by popping the medication out of the medication bubble card into his/her ungloved hand and then placing it into the clear medication cup. CMT M then placed the medication in a clear sleeve and crushed medications. CMT T then mixed the crushed medication in pudding and administered the medications to the resident. 18. Review of Resident #45's face sheet, undated, showed diagnosis that included: Alzheimer's disease, depression, and anxiety. Observation on 8/27/24 at 7:54 A.M., showed CMT M removed one loratadine (medication used to treat allergy symptoms) 10 mg tablet out of the facility floor stock bottle with ungloved fingers, placed it in a clear medication cup and administered the medication to the resident. 19. During an interview on 8/28/24 at 11:46 A.M., CMT T said medications that are in the facility stock bottles are to be dispensed by shaking the medication into the lid of the bottle and then place it in the medication cup. The medications should not be dispensed by placing fingers in the medication bottle. The bubble pack medications are to be popped directly into the medication cup. The medications should not be placed in the staff's hand first. The resident's medication should never be touched prior to administration. It is poor infection control practices. 20. During an interview on 8/29/24 at 9:45 A.M., LPN C said the medication should be directly placed into the medication cups. Staff should not be touching the medication prior to giving it to the resident. If they do have to touch the medications, then they should be wearing gloves. 21. During an interview on 8/28/24 at 12:50 P.M., the DON said that staff are expected to use proper infection control practices and not directly touch the resident's medication prior to administration. 22. Review of the facility's undated PPD Tuberculosis Testing and Screening policy for employees, showed: -A two step PPD skin test is to be administered on all new employees prior to employment with the first step being completed prior to start date, unless the test was performed within the past month; -If the initial test is negative after 48 to 72 hours, the second PPD test is to be given. Review of Staff AAA's employee file, showed: -Date of hire 10/2/23; -First step PPD administered on 10/2/23; -First step PPD read late on 10/6/23. Staff BBB's employee file, showed: -Date of hire 6/6/24; -First step PPD administered on 6/5/24; -First step PPD read negative on 6/8/24. Staff CCC's employee file, showed: -Date of hire 7/5/24; -First step PPD administered on 7/5/24; -First step PPD read negative on 7/8/24. Staff DDD's employee file, showed: -Date of hire 11/30/23; -First step PPD administered on 11/30/23; -First step PPD read late on 12/4/24. During an interview on 8/27/24 at 1:04 P.M., the HR/Staffing Coordinator said the first date working in the facility does not necessary correspond to the date of hire. She will provide the first date worked for the sampled staff. Nursing staff is responsible for new employee PPDs. Review of the list of staff first date worked, showed Staff AAA, Staff BBB, Staff CCC, and Staff DDD's date of hire was the same as their first date worked. During an interview on 8/29/24 at 12:50 P.M., with the DON and LPN L/Unit Manager, they said they way they have done it, is make sure the first step is given by date of hire, but they are not reading it before the staff start. They were not aware of the requirement that the first step be read prior to starting. PPDs should be read within 2-3 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify possible areas of entrapment to reduce the risk of accidents for four residents (Residents #55, #32, #47, and #50). The facility identified 47 residents with side rails in use. The census was 67. Review of the FDA (Federal Drug Administration) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed: -It is suggested that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment; -The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement; -Bed rails (commonly used synonymous terms are side rails, bed side rails, grab bars and safety rails), may be an integral part of the bed frame or they may be removable and at times are used either as a restraint, a reminder or an assistive device; -There are seven potential entrapment zones in hospital beds. Review of the facility's Restraints/Side Rails policy, dated 4/28/17, showed: -Side Rail Guideline: -The assessment and documentation also includes measuring the gaps between the rail(s) themselves and the gaps between the side rail and the mattress. A visual review is performed to assess that the mattress does not shift/slide allowing for an increased gap between the bed and the side rail; -The policy failed to provide guidance for routine inspections of side rails after installation, as part of a regular maintenance program. 1. Review of Resident #55's medical record, showed diagnoses included seizures, stroke, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following stroke. Review of the resident's side rail evaluation, dated 2/29/24, showed: -Type of side rail not indicated; -No documentation of maintenance inspection for gap measurements. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/6/24, showed: -Cognitively intact; -Upper and lower extremity impairment on one side; -Dependent on assistance to roll left and right. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident is at risk for falls. Resident requires total assist of two with bed mobility. He/She had a recent stroke with left sided hemiparesis and recently diagnosed with seizures; -No documentation related to the use of side rails. Observation on 8/26/24 at 12:58 P.M., showed the resident on his/her back in bed, on a low air loss mattress (mattress that provides a constant flow of air in the mattress). U-shaped rails were raised on both sides of the bed, at the head of the bed. The resident used his/her right arm to pull the right rail, which moved several inches as the resident pulled. During an interview, the resident said he/she was trying to use the rail to pull him/herself to move the pillow on his/her right leg. Observation on 8/28/24 at 8:15 A.M., showed the resident using his/her right arm to pull the right side rail. The rail moved back and forth approximately five inches. During an interview, the resident said he/she was trying to get out of bed. 2. Review of Resident #32's medical record, showed diagnoses included Parkinson's disease (brain disorder causing unintended or uncontrolled movements), dementia, and depression. Review of the resident's side rail evaluation, dated 6/25/24, showed: -Type of side rail not indicated. Review of the resident's admission MDS, dated [DATE], showed: -Resident rarely/never understood; -Dependent on assistance for mobility. Review of the resident's care plan, in use at the time of survey, showed: -Care area/problem: Resident is at risk for falls. Resident is not ambulatory. His/Her left leg is contracted (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement); -No documentation related to the use of side rails. Observation on 8/26/24 at 1:28 P.M., showed the resident on his/her back in bed with U-shaped rails raised on both sides of the bed, at the head of the bed. During an attempted interview, the resident was unable to respond to questions regarding the side rails. Observations on 8/27/24 at 8:49 A.M. and 12:16 P.M., on 8/28/24 at 7:59 A.M., and on 8/29/24 at 7:11 A.M., showed the resident on his/her back in bed with U-shaped rails raised on both sides at the head of the bed. 3. Review of Resident #47's quarterly MDS, dated [DATE], showed: -Diagnosis of end stage renal disease (ESRD, kidney failure); -Cognitively intact. Observation on 8/26/24 at 11:23 A.M., showed the resident's bed with bilateral enabler rails. Review of the resident's medical record, showed no documentation of side rail inspections to identify areas of entrapment. 4. Review of Resident #50's quarterly MDS, dated [DATE], showed: -Diagnoses of acute kidney failure and major depressive disorder; -Cognitively intact. Review of the resident's medical record, showed no documentation of side rail inspections to identify areas of entrapment. Observation on 8/26/24 at 1:13 P.M., showed the resident's bed with bilateral enabler rails. 5. During an interview on 8/29/24 at 10:01 A.M., Licensed Practical Nurse (LPN) E said Maintenance is responsible for installing and inspecting side rails for safety. 6. During an interview on 8/29/24 at 12:36 P.M. with the Director of Nurses (DON) and LPN L/Unit Manager, they said Maintenance installs and inspects side rails. 7. During an interview on 8/29/24 at 2:28 P.M., the Maintenance Director said he has worked with the facility for 10 days and does not have a system in place for side rail inspections, yet. Maintenance staff installs side rails on resident beds. Side rails should be measured for safety. Side rails should be inspected routinely because they can get loose over time. Side rails should be secure to prevent the risk of entrapment. 8. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he expected side rails to be inspected by Maintenance on a routine basis. Side rails should be inspected to reduce the risk of entrapment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility's pest control program was effective in preventing roaches, which affected eight of 17 sampled residents (Residents #45, #27, #2, #46, #43, #168, #34 and #67). The census was 67. Review of the facility's pest control policy, revised 4/22/23, showed: -Parkwood has a contract with CES Pest Control Company. CES will come out every 2 weeks to spray for bugs and use traps for both bugs and other pests. If additional spraying is needed Parkwood will call CES to come out and spray. A log book is in the front office for CES to sign whenever staff indicates a certain area needs attention for spraying. Any staff member can write a request in the log book for CES to spray or put down traps. If a resident room needs more then the CES spraying Parkwood will move the resident(s) in that room temporarily so that the room can be bug bombed. Clothes will be sent down to laundry and beds and drawers will be cleaned. 1. Review of the facility's pest control logs, showed the company initialed treatments as completed on 6/13/24 in a resident's room for roaches, 6/27/24 in a resident's room for roaches, 7/11/24 in a resident's room for roaches, 8/8/24 in a resident's room for roaches and 8/22/24 in a resident's room for roaches. The pest control company did not document recommendations for facility staff. There were no entries by staff for areas that needed attention for spraying. 2. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/7/24, showed: -Cognitively intact; -Diagnoses included major depressive disorder, anxiety disorder and Alzheimer's disease. Observation on 8/27/24 at 10:43 A.M., of the resident's room, showed: -Two red roaches crawling on the resident's sink; -A dead red roach inside a box of gloves stored on resident's sink; -Three sink drawers with various dead and living roaches. Drawer number one had food trash and opened packages of cookies. Dead red roaches were on the resident's wash cloths. Three live red roaches crawled in the drawer. The drawer had dark, brown tiny specked matter in various areas. The second and third drawer had various live red roaches crawling in the drawer. The drawer had dark, brown tiny specked matter in various areas. -The top drawer of the resident's nightstand had two live roaches crawling on the resident's masks; -One live red roach was on the resident's pillow. Observation on 8/28/24 at 10:15 A.M., of the resident's room, showed: -One red roach crawling on the resident's sink; -A dead red roach inside a box of gloves stored on resident's sink; -Three sink drawers with various dead and live roaches. Drawer number one had food trash and opened packages of cookies. Dead red roaches were on the resident's wash cloths. Two live red roaches crawled in the drawer. The drawer had dark, brown tiny specked matter in various areas. The second and third drawer had various live red roaches crawling in the drawer. The drawer had dark, brown tiny specked matter in various areas. -The top drawer of the resident's nightstand had two live roaches crawling on the resident's masks; During an interview on 8/27/24 at 10:45 A.M., the resident said seeing all the bugs in his/her room makes him/her feel sick. He/She said housekeeping staff have not cleaned his/her room for at least six months. He/She eats most of his/her meals in his/her room. During an interview on 8/29/24 at 12:53 P.M., the Director of Nursing (DON) said the resident has a tendency to store food in his/her room and has not allowed staff to come into his/her room to clean. She expected interventions to be put in place for staff to follow in order to keep the resident's room clean and free from bugs. She said the state of the resident's room is unacceptable. She expected the resident's room to be clean and free from bugs. 3. Review of Resident #27's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis included high blood pressure and depression. During observation and interview on 8/26/24 at 10:40 A.M., the resident's bathroom had approximately 12 brown roaches crawling on the door and wall of the bathroom. The resident insisted the door be closed immediately so the roaches do not come in his/her room. He/She has seen the roaches for many months and doesn't like it. Sometimes he/she will see someone spray the room but it is obvious that whatever is sprayed is not working. During observation and interview on 8/27/24 at 9:15 A.M., the resident had a personal stainless steel pink cup with a lid on his/her bedside table. In the bottom of the cup, there were two dead brown roaches. A family member was sweeping the resident's room as a brown roach crawled up the resident's wall. The family member hit the roach with the broom. The resident's family member said the roaches are everywhere and he/she has seen them in the resident's room for several months. The resident's bathroom door also had multiple roaches crawling in and out of a small hole at the top of the door. 4. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, renal (kidney) failure, dementia and depression. Observation on 8/28/24 at 6:45 A.M., showed the resident sat in the dining room and self-propelled him/herself to his/ her bathroom on the Garden Unit. The resident turned the light on in the bathroom and three brown roaches were crawling on the wall of the bathroom. The resident then used the restroom. The resident was not aware of the roaches on the bathroom wall. 5. Review of Resident #46's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included depression, anxiety and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 8/26/24 at 1:19 P.M., the resident said he/she has seen bugs in his/her room. Observation on 8/27/24 at 9:10 A.M., showed a full trash can in the middle of the resident's room. Two cockroaches crawled in and out of the trash can. One cockroach crawled out of the trashcan and into a hole in the back of the resident's dresser. During an interview on 8/27/24 at 9:11 A.M., Certified Nursing Assistant (CNA) K said there are a lot of cockroaches in the resident's room. 6. Review of Resident #43's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included depression and anxiety. During an interview on 8/26/24 at 11:26 A.M., the resident said he/she has seen roaches in his/her room. Someone comes around the facility and sprays for them. Observation on 8/27/24 at 1:54 P.M., showed a pile of clothing on the floor in the middle of the resident's room. Two cockroaches crawled in and out of the clothing. 7. Review of Resident #168's medical record, showed diagnoses included unspecified injury of neck and vertigo (dizziness). Observation on 8/26/24 at 10:59 A.M., showed a bait trap underneath the sink in the resident's bathroom. The bait trap was full of bugs. During an interview on 8/26/24 at 10:59 A.M., the resident said he/she was admitted to the facility three days ago. He/She just had surgery on his/her spine and cannot move his/her arms very well. Cockroaches crawl all over the wall in his/her room and it freaks him/her out. Cockroaches crawl around the floor in his/her bathroom and he/she has to lift his/her feet when he/she is on the toilet because if they get on him/her, he/she cannot move his/her arms to knock them off. 8. Review of Resident #34's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis included depression. During an interview on 8/26/24 at 11:42 A.M., the resident said there are cockroaches in his/her room. They crawl on him/her at night. He/She has seen someone spray the halls for bugs, but they do not spray in the resident's room. 9. Review of Resident #67's care plan, in use at the time of the survey, showed resident has a self-care deficit: Resident has chronic obstructive pulmonary disease (COPD, lung disease) and is on continuous oxygen. He/She needs limited assistance with toileting, dressing, grooming and transfers. Gets easily exerted. During an interview on 8/26/24 at 10:24 A.M., the resident said his/her only concern is all the roaches. He/She sees them in his/her room. 10. During an interview on 8/27/24 at 10:42 A.M., CNA S said all management is aware of the roach problem and the number of roaches in the residents' rooms is out of control. 11. During an interview on 8/28/24 at 10:58 A.M., CNA A said there are cockroaches throughout the facility. An exterminator comes out the facility twice a month, but the cockroaches are still everywhere. 12. During an interview on 8/29/24 at 8:15 A.M., Housekeeper V said he/she was aware of the brown roaches. There is a insect spray in the housekeeping closet they can use as needed. The residents have too many opened food items that attract the roaches. 13. During an interview on 8/29/24 at 9:50 A.M., CNA K said the cockroaches in the facility have been getting worse. Someone comes out to the facility to spray for them, but they spray the halls and trash room, but not really the resident rooms. Nursing staff do what they can to help by stepping on the bugs, buying their own bug spray, keeping food out of resident rooms, and encouraging residents to eat in the dining room instead of their rooms. 14. During an interview on 8/29/24 at 2:28 P.M., the Maintenance Director said he has seen an issue with pests in the facility. During his first week working at the facility, he removed all items in one resident room and had housekeeping deep clean it, then spray it for pests. The bugs came back. An outside pest control company comes to the facility every other week. The pest control company does not meet with him after their visits and he did not know if they made any recommendations to help with pest control. 15. During an interview on 8/28/24 at 2:45 P.M., the Administrator said the facility has a contract with an outside pest control company to come out to the facility twice a month and as needed or requested. Staff document areas of concern in a binder kept at the front office. When the pest control company comes out, they check the binder and initial it when they are done spraying. They do not provide the facility with invoices or written recommendations. During an interview on 8/29/24 at 2:55 P.M., the Administrator said he is aware of an issue with cockroaches in the facility. He expected all staff to ensure trash cans are emptied, clothing is off the floor, and food is properly stored in resident rooms to assist with pest control. The facility has been using the same pest control company since at least 2018. MO00239684 MO00238437 MO00239658 MO00240891 MO00240930

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 42 opportunities, 5 errors occurred, resulting in an 11.9% error rate (Residents #3 and #4). The census was 67. Review of the facility's Medication policy dated, June 1, 2018, showed: -ADMINISTRATION PROCEDURES FOR ALL MEDICATIONS; -Policy: To administer medications in a safe and effective manner; -Procedures: Review 5 Rights (3) times: -Prior to removing the medication package/container from the cart/drawer; -Check MAR for order. -Check the label against the order on the medication administration record (MAR); -After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR or treatment administration record (TAR), and controlled substance sign out record, if indicated; -If resident refuses medication, document refusal on MAR or TAR. Research refusals for possibility of dry mouth, resident reluctance, development of swallowing difficulty; -Notification of Physician/Prescriber: -Persistent refusals; -Held medications for pulse, blood pressure, low or high blood sugar, or other abnormal test results, vital signs, resulting in medications being held; -Suspected adverse drug reactions. 1. Review of Resident #3's medical record, showed: -Diagnoses included multiple subsegmental pulmonary emboli (blood clots), unspecified convulsions (rapid involuntary muscle contractions that cause uncontrollable shaking and limb movement) and major depression; -An order, dated 9/13/23, for Eliquis (blood thinner used to prevent blood clots) 5 milligrams (mg) twice daily before meals; -An order, dated 10/25/23, for Zoloft (antidepressant) 100 mg once daily at 7:30 A.M.; -An order, dated 11/7/23, for Hydralazine (treats high blood pressure) 100 mg, one tablet before meals and at bedtime Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/21/23, showed the resident received antidepressant and anticoagulant medications while in the facility. During a medication administration observation on 1/23/24 at 9:13 A.M., Certified Medication Technician (CMT) A: -Administered Eliquis 5 mg 30 minutes after the resident returned to his/her room after eating breakfast; -Administered Hydralazine 100 mg 30 minutes after the resident returned to his/her room after eating breakfast; -Did not administer Zoloft 100 mg. During an interview on 1/23/24 at 9:30, CMT A said the resident was out of Zoloft and a nurse would have to order it. 2. Review of Resident #4's medical record, showed: -Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath); -An order dated 3/30/23, for sitagliptin phosphate (treats diabetes) 25 mg one tablet once a day; -An order dated 4/26/23, for fluticasone propionate 50 one-millionth of a gram (mcg)/actuation nasal spray (used to treat allergies) two sprays to each nostril once a day. During a medication administration observation on 1/23/24 at 8:50 A.M., CMT A: -Did not administer sitagliptin phosphate 25 mg; -Did not administer fluticasone propionate 50 mcg/actuation. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/23/24 at 9:00 A.M., CMT A said the resident was out of sitagliptin phosphate 25 mg and he/she would reorder it. The resident also did not have any fluticasone propionate 50 mcg/actuation. He/She would reorder both medications. 3. During an interview on 1/123/23 at 12:09 P.M., the Director of Nursing (DON) said medications should be reordered in a timely manner, so residents don't miss any doses of medications. The CMTs and nurses know how to reorder medications.

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to do neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) per the facility's policy for one of three residents sampled for falls (Resident #3). The sample was six. The census was 70. Review of the facility's Fall Management Guidelines Policy, dated 10/20/21, showed: -Following a resident's fall: the licensed nurse assesses the resident for injuries (including neuro checks if indicated) and provides necessary treatment; the physician and resident's representative are notified; appropriate interventions are implemented; continue ongoing assessment and documentation by licensed nurses per practice; the licensed nurse documents occurrence on the 24-hour nursing summary; -Procedure: Objective: record the resident's current vital signs, response to neurological assessment, current labs if applicable, identify any pertinent disease or diagnosis, any medications that could contribute to falling, history of previous falls and evidence of impaired safety judgement; -Ongoing assessment including neurological, pain and alert charting documentation shall occur per policy; -The policy failed to show how often neuro checks should be completed and for how long. Review of a computer generated Neuro Check Sheet, used by the facility, showed it directed staff to perform neuro checks initially, then every 15 minutes times four, then every 30 minutes times two, then every 60 minutes times two then every shift times six. Review of Resident #3's medical record, showed: -The resident was alert and orientated times three (person, place and time); -Diagnoses included: wound on lower leg, venous insufficiency (failure of the veins to adequately circulate the blood), atrial fibrillation (A-Fib, irregular heart rhythm) , heart failure, neuropathy (abnormality of the nervous system), chronic obstructive pulmonary disease (COPD, lung disease), high blood pressure and high cholesterol; -Required total assistance of staff for bed mobility and transfers. Review of the care plan, in use at the time of the survey, showed: -Problem: Resident was at risk for falls related to high risk fall score, evidenced by problem with balance; 1-2 general health conditions present; Transfer: total dependence; Mobility: immobile. Onset date 8/18/23; -Goal: Resident safety will be maintained through next review date; -Interventions: Assess contributing factors related to fall history; assess medications for contributing factors; assist resident with activities of daily living (ADLs) as needed; keep call light and most frequently used personal items within reach; therapy referral as indicated; wheel chair. Review of the progress notes, showed: -On 8/19/23 at 7:05 A.M., Resident was found on floor by aide taking care of him/her. The aide had gone to check on him/her for services at 5:15 A.M. No injuries noted; the doctor and Director of Nursing (DON) were notified and the family member was called on phone. Vitals (Blood Pressure (B/P), Pulse (P), Respirations (R) and Temperature (T)) were stable; -On 8/19/23 at 8:51 A.M. tramadol (medication for severe pain) 50 milligram (mg) tablet was administered for pain; at 9:22 A.M., pain evaluation showed pain at 3 (based on a scale 1-10, 3 equates to noticeable pain) or less; -There was no other post fall documentation. Review of the Incident/Accident Report dated 8/19/23, showed: -Type of incident: fall; -Reported by date/time: 8/19/23 at 5:59 A.M.; -Witnesses: no; -Type of injury: no apparent injury; -B/P (normal 90/60 through 120/80) was 152/88, the same B/P was recorded for lying, sitting and standing; -P (normal 60 through 100) was 91; -R (normal 12 through 18) was 18; -T (normal 97.8 through 99.1) was 97.9; -Oxygen Saturation (amount of oxygen in the blood)(O2 sat 95% through 100%) was 91%; -Do you plan to initiate a neuro check schedule? Yes; -Start time? 5:45 A.M.; -Action taken: neuro check, Medical Doctor (MD) notified; -Disposition: In house observation. Review of the electronic medical record, showed no neuro checks were documented. Review of the vital signs located in the electronic medical record, dated 8/19/23, showed: -At 6:21 A.M., B/P 152/88, P 93, R 18, T 97.9; -At 6:23 A.M., B/P 165/91, P 87, R 18, T 97.8; -At 6:24 A.M., B/P 156/76, P 81, R 18, T 97.6; -At 6:26 A.M., B/P 166/78, P 77, R 18, T 97.6; -At 6:27 A.M., B/P 148/80, P 77, R 18, T not documented; -At 6:28 A.M., B/P not documented, P 77, R 18, T 97.7 -At 8:50 A.M. pain scale of 5 (moderately strong pain) documented; -At 8:54 A.M., B/P 151/93 no other vital signs documented; -At 8:55 A.M., B/P 151/93, P 98, no other vital signs documented; -At 9:06 A.M., B/P 151/93, P 98, R 18, T 97.7; -At 9:07 A.M., B/P 149/94, P 96, R 18, T 98.1; -At 11:35 A.M., B/P 133/79, P 94, R 18, T 97.3; -No vital signs documented after 11:35 A.M. During an interview on 10/3/23 at 1:55 P.M., Certified Medication Technician (CMT) A said if a resident fell, he/she would stay with the resident and yell out for help. Then, he/she would make sure the resident did not have any injuries and start taking the resident's vital signs while he/she waited on the nurse to arrive. During an interview on 10/3/23 at 2:00 P.M., CNA B said if a resident fell, he/she would tell the nurse. The nurses and the CMTs did residents' vital signs. During an interview on 10/3/23 at 2:15 P.M., Nurse C said staff notified him/her if a resident fell. Then he/she assessed the resident, did vital signs and neuro checks, notified the doctor and the Power of Attorney (POA) and documented the incident in the nurse's notes and on the report sheet. Neuro checks were started immediately, then completed every 15 minutes times four, then every 30 minutes times two, then every hour times two, then every shift times 72 hours. Neuro checks were documented in the computer and the computer generated the schedule. CNAs, CMTs and nurses could do vital signs but only the nurses did the neuro checks. If a resident was on a blood thinner, Nurse C would send the resident to the hospital to be checked out. During an interview on 10/4/23 at 6:10 A.M., Nurse D said if a resident fell, he/she would assess the resident, check to see if the resident had an injury or pain and ensure neuro checks were in place. If the resident was ok, the resident would be assisted up. Nurse D would write up the incident report, document the incident in the nurse's notes and on the report sheet, and notify the doctor, DON and resident's responsible party. Neuro checks were completed on residents who hit their head or who had an unwitnessed fall. The nurses were responsible for doing the vital signs and the neuro checks. Neuro checks were documented in the computer and the computer generated a form. The CNA reported to him/her the resident was on the floor. He/She went into the resident's room and found the resident on the floor holding onto the table next to the bed. The resident was trying to move him/herself on the floor. The resident was alert and did not hit his/her head. The resident denied pain and had no indication of pain. Staff used the Hoyer lift (mechanical lift) to assist the resident off the floor. Nurse D said he/she started neuro checks and documented them in the computer and notified the MD, DON and the resident's family of the incident. During an interview on 10/4/23 at 6:30 A.M., Nurse E said if a resident fell, he/she would assess the resident, check the resident's vital signs, notify the MD, family and DON, document the incident in the nurse's notes and on the 24 hour report sheet. If the fall was unwitnessed or if the resident hit their head, he/she would also do neuro checks. Neuro checks are documented in the computer. During an interview on 10/4/23 at 10:40 A.M., the Director of Nursing (DON) said falls were communicated verbally shift to shift and on the 24 hour shift report. When a resident fell, the nurse would assess the resident, notify the MD and family of the incident, complete an incident report and document it in the nurse's notes. If the resident hit their head or if the fall was unwitnessed the nurse would also do neuro checks. Neuro checks were documented in the computer and the computer generated a schedule for when neuro checks were due. Neuro checks were important to make sure you didn't have any changes going on with the resident. Staff should also document in the nurse's notes every shift for 72 hours after a resident falls. When the resident fell, he/she was on the fall matt and he/she did not hit his/her head. The nurse assessed the resident and did an initial neuro check. The resident's family visited that afternoon and they did not notice a change in the resident's condition. The DON would expect for staff to follow the facility's policy and procedures. During an interview on 10/4/23 at 12:24 P.M., the Administrator said he would expect for staff to follow the facility's policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three residents had sufficient medication available to administer as ordered. The facility also failed to notify the residents' physician when their medications were not available for administration (Residents #103, #101 and #106). The sample was seven. The census was 73. Review of the facility's Medication Orders Policy, dated 6/1/18, showed: -Before a controlled drug (drugs, medications, substances, and certain chemicals whose use and distribution are tightly controlled because of their abuse potential or risk) can be dispensed, the pharmacy must be in receipt of a valid prescription with all Drug Enforcement Administration (DEA) required elements from a person lawfully authorized to prescribe. A chart is not equivalent to a prescription for a controlled drug. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription to ensure delivery of medication; -A valid hard copy prescription must be transmitted via fax to the pharmacy by the prescriber or the prescriber's agent. The original hard copy prescription must be in the possession of the pharmacy in order to dispense; -The facility contacts the prescriber for direction when delivery of a medication will be delayed, or the medication is not or will not be available; -Additional supplies of controlled drugs are ordered by the facility from the provider pharmacy. Reorders for controlled substances should be made allowing for appropriate time for the pharmacy to obtain the prescription and assure an adequate supply is on hand. Review of the list of medications available in the Pyxis (an automated medication dispensing system) provided by the facility, dated 8/9/23, showed: -Hydrocodone 10 milligram (mg)-acetaminophen (APAP) 325 mg (pain pill) was available in the Pyxis; -Oxycodone immediate release (IR) 5 mg (pain pill) medication was available in the Pyxis; -Oxycodone 7.5 mg-APAP 325 (pain pill) was not available in the Pyxis. 1. Review of Resident #103's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/29/23, showed: -Cognitively intact; -Diagnoses included: pain, unspecified. Review of the care plan, in use at the time of the survey, showed: -Problem: Resident has pain to his/her abscesses (a buildup of a pus that can affect any part of the body) on his/her lower abdomen. He/She said the pain is severe right after dressing changes. He/She states that pain medication makes pain tolerable; -Goal: Utilize interventions to help maintain pain at a tolerable level; -Interventions: Administer pain medications as ordered. During an interview on 8/9/23, at 10:40 A.M., the resident said he/she had pain daily in his/her tummy. He/She received routine pain medications and sometimes the facility ran out. It could take three to four days before the medication came in. The nurses told the resident, the pharmacy would only send so many days worth of medication. The facility had to reorder it and they were waiting for the medication to come in. Review of the Medication Administration Record (MAR) dated 6/1/23 through 6/30/23, showed: -An order for: Percocet 7.5 milligrams (mg)-325 mg tablet (Oxycodone hcl /acetaminophen), give one tablet by mouth every four hours, check pain scale, diagnoses (dx) pain, start date: 4/12/23; -At 3:30 A.M., on 6/4, 6/5 and on 6/24, an X was documented; -At 7:30 A.M., on 6/6 and 6/11, an X was documented; -At 11:30 A.M., on 6/11, 6/20 and 6/23, an X was documented; -At 3:30 P.M., on 6/4 and 6/11, an X was documented; -At 7:30 P.M., on 6/4, 6/5 and 6/23, an X was documented; -At 11:30 P.M. on 6/3, 6/4 and 6/9, an X was documented. During an interview on 8/10/23 at 9:45 A.M., The Director of Nursing (DON) said, an X on the MAR meant either the medication was not signed out or the medication was not administered. Review of the MAR, dated 7/1/23 through 7/31/23, showed: -An order for: Percocet 7.5 milligrams (mg)-325 mg (Oxycodone hcl/acetaminophen), give one tablet by mouth every four hours, check pain scale, dx: pain, start date: 4/12/23; -At 3:30 A.M. on 7/21, 7/26 and 7/28, an X was documented; -At 7:30 A.M. on 7/26 and 7/27, an X was documented; -At 11:30 A.M., on 7/25, 7/26 an 7/27, an X was documented; -At 3:30 P.M., on 7/25 and 7/27, an X was documented; -At 11:30 P.M., on 7/12, an X was documented. Review of the progress notes dated 6/1/23 through 7/31/23, showed: -On 6/11/23 at 10:37 P.M., a temporary order for the resident to have Percocet 5/325 mg by mouth every four hours until 7.5-325 mg by mouth every four hours arrived from pharmacy. Order was noted in computer; -No other documentation to show if the physician was notified when the resident did not receive his/her medication. 2. Review of Resident #101's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: pain, unspecified. Review of the care plan, in use at the time of survey, showed: -Problem: Pain evidenced by site: right and left shoulder, knee and leg and lower back. Pain description: throbbing/aching, shooting pain. Pain frequency: daily. Pain medication improves pain; -Goal: Resident will be at a level of comfort that the he/she judges as acceptable; -Interventions: Administer pain medication as ordered. During an interview on 8/9/23 at 11:24 A.M., the resident said he/she had pain in his/her left shoulder and back and received routine pain medication. The facility sometimes ran out of his/her pain medication but he/she did not know why. Review of the MAR, dated 6/1/23 through 6/30/23, showed: -An order for: Hydrocodone 10 mg-APAP 325 mg tablet, take one tablet by mouth every eight hours dx: pain, start date was 11/30/20; -At 6:00 A.M., on 6/10, 6/11 and 6/19, an X was documented; -At 2:00 P.M. on 6/18, an X was documented; -At 10:00 P.M. on 6/18, an X was documented. Review of the Resident's Pyxis log, provided by the facility, showed: -On 6/10/23, three tablets were pulled from the Pyxis (one tablet at 1:27 P.M. and two tablets at 6:16 P.M.); -On 6/11/23, three tablets were pulled from the Pyxis (one tablet at 3:08 P.M. and two tablets at 6:31 P.M.); -No documentation showed the medication was pulled from the Pyxis for the 6:00 A.M. dose on 6/10, 6/11, or on 6/19; -No documentation showed the medication was pulled on 6/18/23. Review of the MAR, dated 7/1/23 through 7/31/23, showed: -An order for: Hydrocodone 10 mg-APAP 325 mg tablet, take one tablet by mouth every eight hours dx: pain, start date was 11/30/20; -At 10:00 P.M. on 7/9, an X was documented; -At 2:00 P.M. on 7/27, an X was documented. Review of the Resident's Pyxis log, provided by the facility, showed no documentation Hydrocodone was pulled from the Pyxis on 7/9/23 or 7/27/23. 3. Review of Resident #106's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included: pain, unspecified. Review of the care plan, in use at the time of survey, showed: -Problem: Resident has frequent complaint of lower back pain and general pain. He/She takes Oxycodone (pain pill) routinely. Evidenced by site: lower back. Pain frequency, daily. Pain medication improves pain; -Goal: Resident will be at a level of comfort he/she judges as acceptable; -Interventions: Administer pain medication as ordered. Review of the MAR, dated 6/1/23 through 6/30/23, showed: -An order for: Oxycodone 10 mg (Oxycodone hcl) one tablet by mouth three times per day, check pain scale, dx. pain unspecified; -On 6/17/23 at 8:00 A.M. and 4:00 P.M., an X was documented. Review of the MAR, dated 7/1/23 through 7/31/23, showed: -An order for: Oxycodone 10 mg (Oxycodone hcl) one tablet by mouth three times per day, must crush at all times, if refused crush then hold, check pain scale, dx: pain unspecified; -On 7/16/23 at 4:00 P.M., an X was documented; -On 7/17/23 at 8:00 A.M., an X was documented. Review of the Resident's orders for the Pyxis log, dated 5/16/23 through 7/17/23, showed: -Oxycodone was not pulled on 6/17/23; -On 7/17/23, six tablets were pulled from the Pyxis. Four tablets were pulled at 12:56 P.M. and two tablets were pulled at 8:44 P.M. Review of the progress notes, dated 6/1/23 through 7/31/23, showed no documentation the physician was notified when the medication was not administered. 4. During an interview on 8/9/23 at 10:16 A.M., Registered Nurse (RN) C said if a resident did not have their pain medication, he/she would check the Pyxis. If the medication was in the Pyxis, he/she would pull the medication and give the medication. If the medication was not available in the Pyxis, he/she would give the resident Tylenol and call the physician. The physician would send a script over to the pharmacy right away. 5. During an interview on 8/10/23 at 7:20 A.M., Licensed Practical Nurse (LPN) A, said, if a resident's medication was not available, he/she would order the medication from the pharmacy. If the medication was available in the Pyxis, he/she would pull the medication from the Pyxis. If the medication was a controlled substance it would take two staff members, either two nurses or a certified medication technician (CMT) and a nurse, to pull the medication from the Pyxis. There were always two staff members available to pull the medication. When the medication card had about three or four pills left on the card, LPN A would reorder the medication from the pharmacy. He/She could tell if a medication had been reordered or not by looking in the computer. After the medication had been ordered, but had not arrived at the facility, someone would follow up with the pharmacy to see why the medication was not sent out. When a medication is pulled from the Pyxis it is communicated to the next shift during report. 6. During an interview on 8/10/23 at 2:36 P.M., LPN B said if a medication was not available, he/she would check the Pyxis. If the medication was in the Pyxis, he/she would pull the medication, administer it and call the pharmacy to check on the medication. If the medication was not available in the Pyxis, he/she would call the physician and enter whatever orders were given into the Pyxis. He/She would then pull the medication from the Pyxis. The Pyxis documented everything and was connected to the pharmacy. When Resident #103 was out of Percocet 7.5 mg, the physician gave orders for another dose of medication that was in the Pyxis. Resident #101 and #106 always got their medication. 7. During an interview on 8/11/23 at 12:00 P.M., the Director of Nursing (DON) said she believed the facility ordered residents' medications from the pharmacy timely. But, the pharmacy had to wait on the physician to send the script before they could send the medication out. The DON would expect for staff to document when medications were administered. If a medication was not available, she would expect for staff to reach out to the physician and to the pharmacy to try to get the medication delivered as soon as possible. The DON would also expect for the staff to notify the physician if the medication was not administered and document if any new orders were received in the nurses notes. She expected staff to follow physician orders and the facility's policies and procedures. MO00222205 MO00218195

Based on observation, interview and record review, the facility failed to follow acceptable nursing standards of practice related to enteral tube (a tube that is inserted directly into the stomach to provide food, fluid, and medication) medication administration for one resident (Resident #81). The facility failed to remove an order for a wanderguard (an electronic monitoring device used to keep residents at risk for elopement safe) and nursing staff continued to document the device as checked twice a day when the resident did not wear the device (Resident #6). The sample was 19. The census was 92. 1. Review of the facility's Specific Medication Administration Procedures, dated 6/1/18, showed the following procedures for enteral tube. Types of enteral tubes include the gastric tube, (g-tube) medication administration: -The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietician, and consultant pharmacist; -Prepare medications for administration; -With gloves on, check for proper tube placement using air and auscultation only. Never check placement with water; -Check gastric content for residual feeding. Return residual volumes to the stomach. Review of Resident #81's care plan, in use at the time of the survey and reviewed on 4/19/23, showed: -Care area/problems: Altered nutritional status: Enteral feeding monitoring. Presence of a g-tube; -Goal: Tolerate tube feeding without complications; -Interventions: Monitor tolerance of tube feeding. Review of the resident's medical record on 4/19/23, showed the resident had an enteral tube and received medications administered via enteral tube. Observation on 4/19/23 at 9:33 A.M., showed Registered Nurse (RN) C administered the resident's morning medications via the resident's g-tube. RN C prepared the resident's medications and placed gloves on. The resident was awake and alert, and able to assist RN C with getting the g-tube ready. RN C drew up approximately 10 cubic centimeters (cc) of air into the syringe, placed his/her stethoscope onto the resident's stomach, and injected the air into the resident's stomach while listening. He/She then checked gastric residual and returned the residual to the stomach before removing the syringe and administering medications via gravity. During an interview on 4/19/23 at 9:54 A.M., RN C said if the resident experienced gastric distress during medication administration, he/she would be able to report that. During an interview on 4/20/23 at 11:50 A.M., the Director of Nursing (DON) said she was aware that it is no longer acceptable standards of practice to check g-tube placement with an air bolus. The policy should reflect current acceptable standards of practice. 2. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/20/23, showed: -Moderate cognitive impairment; -Wandering behavior: Not exhibited; -Diagnoses include dementia, heart failure and depression. Review of the resident's care plan, in use at the time of the survey, showed no facility identified concerns related to safety and elopement risk. Review of the resident's electronic physician order sheet (ePOS) showed an order, dated 11/9/22, for a wanderguard bracelet 2 shifts, check placement every shift. Applied to right ankle. Review of the resident's elopement risk evaluation, dated 1/13/23, showed a score: 5 (low risk). Review of the resident's treatment administration record (TAR), from December 2022 through April 2023, showed: -December 2022: Wanderguard Bracelet documented as checked every shift; -January 2023: Wanderguard Bracelet documented as checked every shift; -February 2023: Wanderguard Bracelet documented as checked every shift; -March 2023: Wanderguard Bracelet documented as checked every shift; -April 2023: Wanderguard Bracelet documented as checked every shift; Observation on 4/17/23 at 9:45 A.M., and 3:30 P.M., 4/18/23 at 6:12 A.M. and 10:19 A.M. and on 4/19/23 at 8:15 A.M., showed no wanderguard on the resident or on the resident's wheelchair. During an interview on 4/19/23 at 8:40 A.M., Certified Nursing Assistant (CNA) F said he/she did not think the resident wore a wanderguard. CNA F checked the resident and verified the resident did not have a wanderguard. During an interview on 4/19/23 at 8:45 A.M., Licensed Practical Nurse (LPN) U said the resident is not an elopement risk. The resident was an elopement risk when he/she was ambulatory but now that the resident used a wheelchair, that has changed. The resident went to the hospital in January when he/she had a foot wound. When the resident returned from that hospital stay, he/she was in a wheelchair and the resident still uses a wheelchair and does not walk. The resident's swelling affects his/her mobility. During an interview on 4/19/23 at 8:50 A.M., the Unit Manager said the resident should not have an order for a wanderguard if the resident is not wearing one. The wanderguard placement check should not be on the resident's TAR. The Unit Manager said the 0 marked on the TAR means that it was checked so it should not be marked. She expected staff to not chart the wanderguard placement was checked if the resident does not have a wanderguard.

Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities to meet the interests and well-being of Resident #37 by failing to assist the resident from bed to wheelchair and to the activity location (Resident #37). The resident sample was 18. The census was 92. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/23, showed: -admission date of 9/6/22; -Cognitively intact; -Diagnoses of hypertension and major depressive disorder. Review of the Resident's Care Plan, dated 3/31/23, showed: -Care Area: Resident requires extensive to total assist with ADL's. She is total assist with Hoyer lift (mechanical lift) with two staff for transfers and maximum assist with grooming, toileting, positioning, and bathing; -The resident was not care planned for assistance to activities. Record review of the Resident's one on one activities charting log for April 2023, showed that he/she should regularly be checked on in his/her room by activity staff, and a volunteer who comes to the facility has been assigned to visit with the resident. The log did not have documentation of the resident being seen in April for one on one activities. During an interview on 4/17/23 at 10:28 A.M., the resident said he/she attends activities when desired, but usually misses the activities due to no assistance to his/her wheelchair from bed. During an interview on 4/18/23 at 10:32 A.M., the Activity Director (AD) said the resident does not come to group activities often. She said the resident will request help to get out of bed, but staff do not respond to the resident. The AD said the resident would like to participate in BINGO and movies if staff were to help him/her out of bed. During an interview on 4/18/23 at 12:08 P. M., the resident said that BINGO was tomorrow and that he/she was going to ask staff to get him/her up tomorrow to play. Observation on 4/19/23 at 2:09 P. M., showed other residents in the dining room waiting for BINGO to start. The resident was not present. During an Interview on 4/19/23 at 2:11 P.M., the resident said he/she wanted to get up for BINGO and that his/her Certified Nurse Assistant (CNA) told the resident he/she would come back to assist him/her to the wheelchair. Observation on 4/19/23 at 2:30 P.M., showed the resident still not present in the dining room for BINGO. During an interview on 4/20/23 at 7:39 A.M., the AD said the resident was not present for BINGO the previous day and had not been brought to the dining room. During an interview on 4/20/23 at 9:33 A.M. CNA L said the A D was in charge of assisting residents to activity locations. CNA L said it would be expected for nursing staff to assist residents to their wheelchairs. During an interview on 4/20/23 at 11:50 A.M. the Director Of Nursing(DON) said all staff are expected to assist residents to activities. She would expect nursing staff to assist residents from their bed to their wheelchair if the resident requested it. If resident is unable to get out of bed she would expect one on one activities to be provided. During an interview on 4/20/23 at 12:41 P.M., the Administrator said he would expect nursing staff to help the AD assist residents to activity locations. He said it is not acceptable for nursing staff to not follow through when a resident requested to get out of bed.

Based on observation, interview and record review, the facility failed to provide wound care as ordered by the physician for one resident (Resident #67). The resident had orders for daily wound care for three wounds, which was not completed for three days. Staff charted wound care was completed, although the dressings showed they were not by the date on indicated on the dressings and confirmed by the wound nurse. The sample was 19. The census was 92. Review of Resident #67's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/19/23, showed: -Cognitively intact; -Resident is at risk of developing pressure ulcers: Yes -Resident has unstageable pressure ulcers: Yes, 1; -Resident has diabetic foot ulcers: Yes, 1 -Diagnoses included diabetes, high blood pressure, anxiety, depression, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and manic depression. -Review of the resident's care plan, dated 2/24/23, showed: -Problem: Skin breakdown: Open area to bilateral ankles. At risk for developing pressure ulcers related to diagnosis of diabetes; -Goal: Resident's pressure ulcers will have signs of improvement, utilize approaches to help prevent further skin breakdown; -Interventions: Treatments and dressings as ordered by the physician, keep skin clean and dry, assist resident to turn and reposition frequently. Review of the resident's electronic medical record, showed: -An order, dated 4/5/23, Cleanse left ankle with diabetic wound cleanser (DWC); apply calmoseptine (moisture barrier) to periwound (tissue surrounding a wound) and Triad (cream that adheres to moist skin) to wound bed; cover with calcium alginate (a water-insoluble, gelatinous, cream-colored substance that can be created through the addition of aqueous calcium chloride to aqueous sodium alginate) and dry dressing daily and as needed if displaced or soiled; -An order, dated 4/5/23, Day shift cleanse right ankle with DWC; apply calmoseptine to periwound and Triad to wound bed; cover with calcium alginate and dry dressing daily and as needed is displaced or soiled; -A order, dated 4/5/23, Day shift cleanse right heel with DWC; apply Triad to wound bed; cover wound with dry dressing daily and as needed is displaced or soiled; -A late entry progress note, dated 4/17/23 and signed 4/19/23 at 10:21 A.M. by the Wound Nurse: Resident refused treatment change to bilateral ankles and right heel. Resident stated, I'm tired, I just want to go to sleep. Review of the resident's treatment administration record (TAR) on 4/20/23 at 11:00 A.M., showed: -Day shift cleanse left ankle with DWC; apply calmoseptine to periwound and Triad to wound bed; cover with calcium alginate and dry dressing daily and as needed if displaced or soiled. Start 4/5/23; -4/5/23 and 4/7/23 marked X (Medication has not been administered); -4/16/23 and 4/17/23 marked 0 (Medication has been administered); -4/17/23, 4/18/23, and 4/19/23 blank.; Day shift cleanse right ankle with DWC; apply calmoseptine to periwound and Triad to wound bed; cover with calcium alginate and dry dressing daily and as needed if displaced or soiled. Start 4/5/23; -4/5/23 and 4/7/23 marked X; -4/16/23 and 4/17/23 marked 0; -4/17/23, 4/18/23, and 4/19/23 blank; -Day shift cleanse right heel with DWC; apply Triad to wound bed; cover wound with dry dressing daily and as needed if displaced or soiled. Start 4/5/23. -4/5/23 and 4/7/23 marked X; -4/16/23 and 4/17/23 marked 0; -4/17/23, 4/18/23 and 4/19/23 blank. -The key located at the bottom of each page of the TAR showed: -O: Medication has been administered; -X: Medication has not been administered. Observation on 4/18/23 at 1:05 P.M., showed the resident lay in bed. The Wound Nurse and Wound Nurse Practitioner entered to provide wound care for the resident. The Wound Nurse looked at the left ankle dressing and said the date on the dressing was 4/15/23. The Wound Nurse said the date of the resident's right heel and right ankle dressing showed 4/15/23. The Nurse Practitioner said the wounds look macerated (occurs when skin is in contact with moisture for too long. Macerated skin looks lighter in color and wrinkly. It may feel soft, wet, or soggy to the touch) which may be due to the dressings not being changed as ordered. During an interview on 4/18/23 at 1:05 P.M., the Wound Nurse said he/she went to do the dressing on 4/17/23, but she did not get to the room until late and the resident wanted to sleep. The resident said it was after 11:30 P.M. and he/she just wanted to sleep. During an interview on 4/18/23 at 1:10 P.M., the Wound Nurse said physician orders should be followed. The dressing should be changed daily and she is the nurse who provided wound care on 4/15/23. The Wound Nurse was not sure which nurse was assigned to provide wound care on 4/16/23. She was assigned to the resident on 4/17/23. She did not get to the resident until late and the resident was already asleep so she did not provide wound care. The Wound Nurse said missing one day is fine, three days is not. During an interview on 4/20/23 at 12:29 P.M., the Administrator said he expected treatments to be completed as ordered. MO00168399 MO00169127 MO00171251 MO00215337

Based on observation, interview and record review, the facility failed to ensure a resident received the proper care necessary to maintain good personal hygiene and to prevent infection and odor for one of three residents observed (Resident #62). The census was 92. Review of the facility's Peri-Care (perineal care, cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) policy, dated January 25, 2017, showed: -Purpose: To cleanse the perineum. To prevent infection and odor; -Cleansing resident from front to back thoroughly cleaning right and left genitals rotating disposable wipe between each wipe; -Wipe the peri rectal area from front to back using a disposable wipe; -Wipe the buttocks from the center of the body to the outside of the body with a disposable wipe; -Repeat process until disposable wipe is free of soiling and discard. Review of Resident #62 annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/29/22, showed: -Severe cognitive impairment; -Requires extensive staff assistance for toileting, mobility, transfers and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses included: chronic obstructive pulmonary disease (COPD, lung disease) and congestive heart failure (CHF). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: the resident is incontinent of bowel and bladder; -Goal: the resident will be clean and odor free; -Interventions: staff keep skin clean and dry. Observation and interview on 4/18/23 at 6:22 A.M., showed the resident lay in bed when Nurse's Aide (NA) B entered his/her room to provide peri care. NA B gathered the wipes and brief, greeted the resident, and explained to the resident that he/she was going to clean him/her up. NA B removed the resident's brief and provided peri care. NA B failed to provide thorough peri care by not cleansing genitals, not cleansing the pubic area from center of the body outward up to hip to cleanse all areas that were in contact with the brief, nor did he/she provide thorough peri care to the gluteal folds. During an interview on 4/20/23 at 2:35 P.M., the Director of Nursing said residents should receive thorough and complete peri care as needed per their bowel and bladder incontinence peri care policy.

Based on observation, interview and record review, the facility employed non-certified Nurse Aides (NAs) for more than 4 months without them becoming certified. Observation of personal care provided to a resident by one of the NAs, showed the NA was not competent to provide care consistent with acceptable nursing practices or following proper infection control practices (Resident #62). Two NAs were identified to work more than 4 months without becoming certified. The census was 92. Review of the Facility Assessment, dated 11/22/22, showed: -Average daily census 71-81; -Resident support/care needs included: Activities of daily living, mobility and fall preventions, bowel and bladder, and skin integrity; -Facility resources needed to provide competent support and care for our resident population every day and during emergencies, included: Nursing services (e.g., Director of Nursing (DON), Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA), medication aide or technician, and Minimum Data Set (MDS) nurse; -Facility resources did not address the use of non-certified nursing assistants (NA); -Staff training/education and competencies: Upon hire, all staff go through formal orientation for education and competency testing, ongoing education and in-servicing is completed twice a month and as needed throughout the month; -Staff training/education and competencies did not address the training or oversight needs of NAs or the requirement for NAs to become certified within 4 months of hire or be removed from direct resident care. Review of the facility's list of current staff as of 4/17/23, showed: -NA B- date of hire, 9/6/22; -NA D- date of hire, 10/3/22. Review of Resident #62's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/29/22, showed: -Severe cognitive impairment; -Requires extensive staff assistance for toileting, mobility, transfers and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease) and congestive heart failure (CHF, a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). -Review of the resident's care plan, in use at the time of the survey, showed: -Focus: the resident is incontinent of bowel and bladder; -Goal: the resident will be clean and odor free; -Interventions: staff keep skin clean and dry. Observation on 4/18/23 at 6:21 A.M., showed Nursing Assistant (NA) B exited a room across the hall from Resident #62's room while wearing gloves and dragged a bag of soiled linen from the room, into the hall and then into the resident room. NA B then re-entered the other room, made a resident's bed while wearing the same gloves used to handle the dirty linen bag. NA B then re-entered the resident's room with the same gloves on. NA B went to the resident's closet and sorted through the clothes that hung within while wearing the same gloves. NA B then exited the room with the gloves on. At 6:27 A.M., NA B returned to the room with a clean brief, and no longer wore the gloves. He/she placed gloves on, but did not wash or sanitize his/her hands prior. NA B used the controller to raise the resident's bed. The bag of dirty linen from the other room sat on the floor next to the resident's bed. NA B assisted the resident to his/her back, obtained disposable wipes, unfastened the resident's brief, wet with urine, and provided care. While wearing the same gloves, he/she assisted the resident to turn to his/her right side. He/she removed the soiled brief from under the resident and finished providing care. NA B wore the same soiled gloves and placed the clean brief under the resident, assisted the resident to his/her right side by touching the resident's hips and legs with the soiled gloves, and then assisted the resident to his/her back, then secured the brief. NA B used the bed controller to lower the bed, picked up the soiled linen bags from the floor and tied it closed. He/she then opened the room door with the soiled gloves on and exited the room, walked down the hall to the soiled utility room, used the soiled gloves to enter the code to the door, then touched the doorknob to open the door. He/she disposed of the soiled bag and exited the soiled utility room, then he/she removed his/her gloves. He/she did not wash or sanitize his/her hands. He/she then assisted to propel a resident in their wheelchair to the sitting area prior to using hand sanitizer. NA B failed to provide thorough peri care by not cleansing the genitals, not cleansing the pubic area from center of the body outward up to hip to cleanse all areas that were in contact with the brief, nor did he/she provide thorough peri care to the gluteal folds. During an interview on 4/20/23 at 9:27 A.M., the Human Resources/Staffing Coordinator said NA's have class on Tuesdays. The classes are not held at the facility, but the facility uses the same classes for all NAs hired. The facility even offers transportation to the classes, but it can be hard to get the NAs to attend. The CNA training class is responsible to get NAs certified. When someone passes their NA exam, she is informed by the class instructor. She does not follow up with the NAs prior to that. During an interview on 4/20/23 at 11:50 A.M., the DON said care should be provided to residents per acceptable standards of practice. During an interview on 4/20/23 at 12:29 P.M., the administrator said NAs should be certified within 4 months of hire. The facility assessment should address the use of NAs, their specific competency and training needs, and the requirement to be certified in 4 months.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity when the Director of Nursing (DON) confronted a resident in the hall in front of Certified Nurse Aide (CNA) F, raised her voice, and talked disrespectfully to them. CNA F was later observed to talk disrespectfully to the same resident during a different interaction (Resident #1). In addition, staff entered Resident #37's room to make personal phone calls and FaceTimed (video called) when in the hall during a fire alarm, where residents could potentially be seen by the other person on the phone. The census was 92. Review of the Resident Rights, provided to residents upon admission, showed residents had the following resident rights: -The right to be treated with respect and dignity; -The right to voice grievances to the facility or other agency or entity that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their long-term care facility stay. 1. Review of Resident #1's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/11/23, showed: -Cognitively intact; -No behaviors exhibited; -No rejection of care; -Bathing- physical help in part of bathing activity required; -Used a wheelchair; -Diagnoses included stroke, dementia, anxiety disorder and depression; -Care area assessment summary: Activities of daily living (ADL) functional/rehab potential and mood state triggered as care areas and marked as care planned by the facility. Review of the resident's care plan, in use at the time of the survey and reviewed on 4/18/23, showed: -Care area/problem: Impaired physical mobility. Left sided weakness, diagnosis of stroke, problem with balance, supervision to transfer, limited assist to ambulate, and uses wheelchair; -Goal: Maintain or improve physical function in bed mobility, transfer, ambulation, locomotion and range of motion; -Interventions: Give resident as many choices as possible about care. Provide appropriate level of assistance to promote safety of resident. Requires limited assistance. Requires supervision; -Care area/problem: Behavior changes. Resident had episode of yelling and cursing at staff, onset 1/17/23: -Goal: Demonstrate improvements in behavior; -Interventions: Allow to express his/her feelings. Analyze key times, places, circumstances, triggers, and what de-escalates behaviors. Assess external contributors. When the resident becomes upset, give time to calm down if safe environment and reproach later. Observation on 4/17/23 at 11:50 A.M., showed the resident approached three surveyors in the hall and said he/she wanted to talk to them about concerns he/she had. The DON walked up behind the resident with Certified Nursing Assistant (CNA) F and said in a loud and aggressive tone that staff can give him/her a shower now. The resident responded that he/she will take the shower, but he/she would like more than just one shower a month. The DON raised his/her voice to a yelling volume and said in an aggressive tone and with an angry look on her face, please stop! and told the resident that the resident knew he/she got two showers a week. The resident appeared to become upset and said no and began to disagree with the DON. The DON interrupted the resident and said you go downstairs she was going to have CNA F go down to give him/her a shower. The DON then threw up her arms and walked out to the staff smoking area. CNA F and the resident went down the hall towards the elevators. Observation on 4/17/23 at 12:25 P.M., showed the resident approached the surveyor in the hall and wanted to talk about concerns he/she had. The resident said he/she wanted a shower since their last shower was on 4/6/23. The resident said he/she was told he/she would get a shower today. The resident was not sure if he/she would get a shower because he/she does not get along with CNA F. The resident said he/she told them he/she wanted one before lunch. The resident said he/she will ask if he/she can have his/her shower now. The resident propelled himself/herself towards the open area of the unit where several staff members stood in that area and CNA F sat in a chair. Resident #1 asked CNA F if he/she could get his/her shower now. CNA F replied, You know no one gets a shower at lunch, so why are you asking? I already told you a CNA from upstairs is coming down just for you after lunch is over. The resident said ok and put his/her head down then propelled himself/herself back toward the dining room. During an interview on 4/20/23 at 12:29 P.M., the Administrator said residents have the right to be treated with dignity and respect. It is not appropriate to confront residents in the hall. It is not acceptable for staff to raise their voice at a resident when disagreeing. During an interview on 4/20/23 at 12:48 P.M., the DON said she was informed by the administrator of concerns regarding the way she spoke to Resident #1 and she felt the way she responded to and talked to the resident was appropriate. She felt she handled the situation well. 2. Observation on 4/20/23 at 1:27 P.M., showed Housekeeper E on his/her cell phone using FaceTime video during a fire drill on a hall nearest Terrace C. His/Her camera held up such that the entire screen was visible to passerby and the small box was open at the top of the screen with a persons' face visible on the phone screen. When he/she noticed that he/she had been seen on the cell phone with screen opened to FaceTime, Housekeeper E said out loud he/she had to go to the bathroom because the fire alarm was too loud and he/she could not hear. He/She walked briskly towards the bathroom nearest the nursing station on the hall and entered the bathroom. 3. During an observation on 4/19/23 at 8:20 A.M., a staff person was heard in a resident's room. The staff member said, I can't talk right now, state is in the building. Licensed Practical Nurse (LPN) U observed coming out from behind the privacy curtain in Resident #37's room with his/her cell phone in his/her hand. Resident #37 was in the room and laying in bed. 4. During an interview on 4/20/23 at 2:50 P.M., the Administrator said it was not appropriate for any staff to be on their phone. It is not acceptable to use FaceTime video while working. He would not expect any staff to be on their phone at all while at work and there were no cell phone signs posted throughout the facility. He expected staff to follow the facility no cell phone policy. 5. During a resident counsel interview with 10 residents, on 4/18/23 at 2:30 P.M., residents said: -Staff do not respect resident's rights; -Staff will sometimes say things like go to your room or this doesn't have to do with you when they are talking in the hall; -Staff use cell phones all over the facility. Staff use cell phones while passing medications; -Staff sometime use foul language. MO00177101 MO00186467 MO00206765 MO00207521 MO00209603 MO00215066 MO00216107

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, by not ensuring privacy curtains, air conditioning (AC) units, walls, floors, handrails, shared showers, shared bathrooms and equipment were clean. The sample was 19. The census was 92. Review of the Housekeeping Disinfecting Cleaning Schedule, revised 2/24/23, showed: -Housekeeping staff is responsible for the cleaning and disinfection of residents' room. Staff have responsibilities that are scheduled on a daily, weekly and monthly basis; -Housekeepers are responsible for every resident room on their halls, which includes Suites, Gardens and Terrace; -Cleaning consists of: -Pull all trash in the rooms and bathrooms; -Disinfects bathrooms, toilets, rails; -Wipe sink and clean mirrors with Spic and Span; -If nursing staff has to change sheets, make sure the bed is disinfected with chemicals depending if the room is a deep clean or vacant room, make sure bed is made; -Sweep rooms starting from the top of the rooms to the outside of the room; -Check privacy curtains to see if it needs to be laundered and put back up in the room before the end of the day; -Clean AC units and walls; -Make sure all furniture, nightstands, bed side tables are wiped off and cleaned; -Make sure toilet tissue, paper towels, and soap are stocked in the room before mopping from top to bottom; -After mopping room, make sure wet floor sign is outside the door. Review of the facility's Floor Technicians Cleaning Scheduled, revised on 2/24/23, showed: -Floor techs are responsible for maintaining all floors in common areas and disposal of all trash on Terrace and Garden level in the soiled utility closets; -Cleaning scheduled for floor techs consist of: -Pulling trash out of the soiled utility closets and taking trash to dumpsters twice a day, once in the morning and before shift ends; -Cleaning shower rooms on Garden and Terrace level before 10:00 A.M.; -Sweep and mop dining rooms after breakfast and lunch; -Dust mop all hallways which include Garden, Terrace and Suites; -Sweep and mop all nurses' stations; -Sweep and mop all soiled utility closes on Terrace and Garden level; -Sweep, mop and disinfect elevators; -Upon request, cleaning baseboards when needed or quarterly. 1. Observation of Resident #16's room, showed the following: -On 4/17/23 at 10:00 A.M., a dirty, used disposable incontinence pad on the floor, next to the resident's bed. The resident's privacy curtains had a brown substance on them. The AC vent was covered in a brown dirt-like substance and the vents had dust; -On 4/17/23 at 3:30 P.M., brown substance remained on the resident's privacy curtains. A dirty used disposable incontinence pad was on the ground in the corner of the room. The AC unit continued to have brown dirt like substance along the top and dust was visible in the vents; -On 4/18/23 at 8:09 A.M., the dirty used disposable incontinence pad from the day before, still on the floor in the corner of the room. [NAME] substance was still visible on the privacy curtains; -On 4/18/23 at 1:03 P.M., the dirty used disposable incontinence pad still in the corner of the resident's room, brown substance still visible on the privacy curtains, and dust in the AC vent; -On 4/19/23 at 7:41 A.M., brown substance remained on the privacy curtains and dust on the AC vent. [NAME] dirt like substance continued to cover the top of the AC unit. 2. Observation of Room A102 on the Garden level, on 4/18/23 at 6:20 A.M., 4/19/23 at 1:45 P.M., and 4/20/23 at 7:40 A.M., showed the privacy curtain for Bed A with a brown smear in the shape of a handprint on the privacy curtain. 3. Observation of the bathroom for room C101 on the Garden Level on 4/17/23 at 9:43 A.M., 4/18/23 at 6:12 A.M. and 10:15 A.M., and on 4/19/23 at 8:15 A.M., showed a large smear of feces on the left side of the toilet from the seat down the side. There is a smear of feces around the toilet seat. An adult brief lay on the floor on the opposite side of the toilet. There were two smears of feces on the wall under the toilet paper holder. A package of wipes sat on the back of the toilet with approximately two crumpled wipes on top of the package. During an interview on 4/19/23 at 8:30 A.M., Certified Nurse Aide (CNA) F said housekeeping and aides are both responsible for the trash in resident rooms. If it involves urine or feces, the aides are responsible to clean it up and then let housekeeping know. The housekeepers cannot mop up urine. CNA F said if he/she saw feces on a toilet, he/she would clean it up and then let housekeeping know. During an interview on 4/19/23 at 8:35 A.M., Housekeeper E said he/she is responsible for cleaning the rooms and bathrooms every day. The housekeeper also said he/she mops and sweeps every day as well. During an interview on 4/19/23 at 8:40 A.M., CNA F said the bathroom in room [ROOM NUMBER] should be cleaned. CNA F had no idea how long the bathroom had been like that. Observation on 4/19/23 at 12:40 P.M., showed the bathroom smelled like bleach and with a smear of brown feces on the side of the toilet. During an interview on 4/19/23 at 1:55 P.M., the Housekeeping Supervisor said she would not consider that bathroom clean. 4. Observation of the Suites Level on 4/17/23 at 9:00 A.M., 4/18/23 at 9:07 A.M., and on 4/19/23 at 1:55 P.M., showed outside room S125, splashes of an off white substance dripped down and dried on the wall. The handrails in the same area had a large amount of the off-white drip like substance. A table next to the couch also had the off white drips and splatter on the top and sides. The floor edges and on the floor board down the Suites level, showed a buildup of dark colored debris that extended approximately a half inch to 2 inches from the wall and up the baseboard in some places. At the nurse's station, an area of the baseboard was missing and another area peeled away from the wall. 5. Observation on 4/19/23 at 9:07 A.M., showed two trash cans, a yellow and blue can, sat against the wall in this area. Visible off-white splashes and drips were on the cans. Discolored splatters were on the floor where the cans sat. At 1:42 P.M., the blue can overflowed and the lid balanced on a bag of soiled linen, approximately 1 foot from the top rim of the can. During an interview on 4/19/23 at 9:28 A.M., Registered Nurse C said the blue can is for soiled linen and the yellow can is for trash. 6. Observation throughout the Terrace level, on 4/17/23 at 9:00 A.M., 4/18/23 at 9:07 A.M., and on 4/19/23 at 1:55 P.M., showed a buildup of debris and dark discoloration along the perimeters of the walls and on the baseboards, on the A, B, C and D halls. 7. Observation of Terrace level C hall on 4/17/23 at 9:00 A.M., 4/18/23 at 9:07 A.M., and on 4/19/23 at 1:55 P.M., showed near the end of C hall, two areas with dried spills. One area with dark colored drips ranging in size from half dollar to pea size and cover an area of about three 12 inch x 12 inch floor tiles. The second area with reddish colored drips that ranged in size from larger than half dollar to pea size and covered an area of three 12 inch x 12 inch floor tiles. 8. Observation of the Garden level women's community shower/bathroom, showed: -On 04/17/23 at 10:12 A.M., a smear of feces on the seat of the toilet with two brown spots on the floor next to the toilet and a small brown smear on the side of the sink. -On 4/18/23 at 6:12 A.M., the same brown spots on the floor as the previous day , as well as the same smudge of feces on the sink. During an interview on 4/19/23 at 1:55 P.M., the Housekeeping Supervisor said she would not consider that bathroom/shower room clean. 9. During an interview on 4/19/23 at 1:55 P.M., the Housekeeping and Laundry Supervisor of the Terrace level, Suites level and Garden level said on an average day, there are three housekeepers working. Housekeepers work the day shift only, 7:00 A.M. to 3:00 P.M. There are no housekeepers on the evening or night shift. In addition, there is a floor tech who works the day shift. One housekeeper is assigned the Suites level resident rooms and is also responsible for common areas such as offices and shower rooms. One housekeeper is responsible for resident rooms on the Terrace level. One housekeeper is responsible for the resident rooms on the Garden level. The floor tech is responsible for the halls in all areas. Kitchen staff are responsible for the main dining room. The floor tech has been off all week, but she still expected the floors to be cleaned and spills cleaned. Nursing staff always have access to brooms and mops and can ask the laundry staff for cleaning chemicals on the evening shift, if needed. She is not sure who is responsible to clean biological waste, such as bowel movement or urine, but believes it should be the responsibility of the nursing staff. She does not feel there are enough housekeeping staff, but the facility is working to hire more. 10. During the resident council meeting on 4/18/23 at 02:55 P.M., conducted with 10 residents, the residents said the woodwork, walls, windows, and baseboards could be a lot cleaner. 11. During an interview on 4/20/23 at 11:50 A.M. the Director of Nursing (DON) said if nursing staff go into a resident's room and see dirty linen or disposable incontinence pads, she expected them to remove them from the resident's room. 12. During an interview on 4/20/23 at 12:06 P.M., the DON said the Housekeeping Supervisor was responsible for cleaning privacy curtains. The DON did not know what the cleaning schedule was. The DON expected the privacy curtains to be free of feces or other soiled material. 13. During an interview on 4/20/23 at 12:29 P.M., the Administrator said the facility should be safe, clean and homelike. If liquids are spilled, housekeeping should clean them, because they have mops available. Anyone can clean up a spill because housekeeping is not available 24/7. Spills should be cleaned up as soon as possible. Splatters on the walls, handrails and furniture should be cleaned. Housekeeping is responsible for this. There is a routine for cleaning privacy curtains, but if one becomes soiled, staff should report this to housekeeping so they can be cleaned sooner. MO00185176 MO00186467 MO00207824 MO00210012 MO00215066 MO00215463

Based on interview and record review, the facility failed to electronically transmit resident Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, in a timely manner for 3 of 3 months reviewed. The census was 92. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument manual, version 1.18.11 dated October 2023, showed: -All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System; -Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument and all tracking or correction information; -The manual includes a submission timeframe table for MDS record types. Review of the facility's CMS submission, MDS final validation report, dated 1/26/23, showed: -20 records in submission file; -9 records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 2/13/23, showed: -52 records in submission file; -34 records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 3/1/23, showed: -20 records in submission file; -8 records submitted late. Review of the facility's CMS submission, MDS final validation report, dated 3/13/23, showed: -31 records in submission file; -20 records submitted late. During an interview on 4/20/23 at 12:29 P.M., the Administrator said the facility has two MDS Coordinators responsible for completing resident MDS'. He expect MDS to be transmitted to CMS per the timeframes outlined in the MDS manual.

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, for three of three narcotic books reviewed. The census was 92. Review of the facility's Narcotic Count Change of Shift policy, dated 1/4/23, showed: -Narcotics must be counted with the nurse/certified medication technician (CMT) at the change of shift; -The nurse/CMT must count the total number of cards/packages and note the total on the count sheet; -Each card/package must be counted to ensure that the total number of narcotics is accurate and matches the total number of narcotics in the card/package; -The nurse arriving for their shift and leaving their shift must initial the change of shift count sheet; -If any discrepancies are noted at change of shift nurse/CMT is to notify the Director of Nursing (DON) or nurse management immediately. 1. Review of the April 2023 CMT narcotic book, for Terrace C & D hall, reviewed on 4/19/23 at 8:22 A.M., showed: -15 of 37 shifts with no oncoming and/or off-going staff initials; -19 of 37 shifts with only one staff initials. 2. Review of the April 2023 CMT narcotic book, for Terrace A & B hall, reviewed on 4/19/23 at 8:25 A.M., showed: -19 of 37 shifts with no oncoming and/or off-going staff initials; -17 of 37 shifts with only one staff initials. 3. Review of the April 2023 nurse narcotic book, for the Suites hall, reviewed on 4/19/23 at 8:30 A.M., showed: -Three of 37 shifts with no oncoming and/or off-going staff initials; -10 of 37 shifts with only one staff initials. During an interview on 4/20/23 at 11:50 A.M., with the DON, Unit Manager, and Wound Nurse, they said both the nurses and CMTs work 12 hour shifts. Staff should count narcotics during shift change between each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their infection control protocols and universal standards when a staff member used a plunger to clear a clogged sink, did not disinfect the sink and used it to wet a towel which they then used to provide perineal care for two residents. Staff did not adequately wash their hands (Resident #50 and Resident #13). Another staff member cross-contaminated when he/she wore soiled gloves and took soiled items in a resident's room for one resident (Resident #62) and dragged soiled trash bags on the floor. Staff also failed to perform proper hand hygiene when providing care. Staff failed to sanitize shared equipment, such as blood pressure cuffs, between residents. Additionally, staff improperly cleaned a blood sugar finger stick (BSFS) machine with an alcohol wipe. The sample was 19. The census was 92. Review of the facility's undated Hand-Washing: Do's and don'ts policy, showed: -Hand-washing is an easy way to prevent infection. Understand when to wash your hands, how to properly use hand sanitizer; -When to wash your hands: As you touch people, surfaces, and objects throughout the day, you accumulate germs on your hands. In turn, you can infect yourself with these germs by touching your eyes, nose, or mouth. Although it is impossible to keep your hands germ-free, washing our hands frequently can help limit the transfer of bacteria, viruses and other microbes; -Always wash your hands before: Treating wounds, giving medicine, or caring for a sick or injured person; -Always wash your hands after: Using the toilet or changing a brief. Treating wounds or caring for a sick or injured person. Handling garbage, household or garden chemicals, or anything that could be contaminated, such as a cleaning cloth or soiled shoes; -Hand-washing doesn't take much time or effort, but it offers great rewards in terms of preventing illness. Adopting this simple habit can play a major role in protecting your health. Review of the facility's Peri-Care (perineal care, cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone), dated 1/25/17, showed: -Purpose: To cleanse the perineum (the area between the anus and the scrotum or vulva). To prevent infection and odor; -Procedure included: Wash hands. Put on gloves, provide care to the genital area, remove gloves and wash hands. Apply gloves. Provide care to the rectal area. Remove gloves, wash hands. Tie off trash bag and take to soiled utility. 1. Review of Resident #50's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/19/23, showed: -Severe cognitive impairment; -Required limited assistance with transfers, dressing and toilet use; -Supervision with personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses include diabetes, dementia, anxiety, and depression. Observation on 4/18/23 at 6:20 A.M., showed Certified Nursing Assistant (CNA) V and CNA W enter the resident's room to provide perineal care for the resident. CNA W turned on the faucet to the sink while CNA V stood next to the resident and unfastened the resident's brief. A strong odor of urine was present and the resident's reusable pad appeared soaked/stained with urine. CNA W let the water run and put on gloves. CNA V said the sink was clogged and turned the water off. The sink was full of water. CNA V went in the resident's bathroom and grabbed a plunger. He/She used the plunger to unclog the sink then placed the plunger in the bathroom. Staff did not disinfect the sink after using the plunger. CNA V and CNA W washed their hands and put on new gloves. CNA V placed two pairs of gloves on each hand. CNA W wet a towel in the sink and added soap while CNA V turned the resident onto his/her right side. CNA W wiped the resident's back and then the resident's bottom area. CNA W placed a clean pad and brief on the resident, while wearing the same gloves, and reached in the bedside table drawer and obtained cream. CNA W put the barrier cream on the resident, while still wearing the same gloves and instructed the resident to roll to his/her back. CNA V rolled the resident to his/her left side and pulled out the dirty linen/brief from under the resident. CNA V placed the dirty items in a plastic bag and removed the top pair of gloves. CNA V rolled the resident to his/her back and fastened the resident's brief and straightened the resident's gown. CNA W, while wearing the same gloves, fastened the right side of the resident's brief and placed the barrier cream back in the nightstand. CNA W started to clean the nightstand. He/She still wore the same gloves. He/She organized items on the bedside table and picked up spilled chips and placed them in the empty chip bag. CNA V threw the bag of chips away. CNA V removed his/her gloves and washed his/her hands. Both CNAs left the room with CNA W. During an interview on 4/20/23 at 11:50 A.M., the Director of Nurses (DON), Unit Manager and Wound Nurse said during personal care, gloves should be changed between dirty and clean. The DON expected hands to be washed with soap and water, not the use of sanitizer, with glove changes. Staff should not touch the resident or clean surfaces with soiled gloves. 2. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses include dementia, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and chronic obstructive pulmonary disorder (COPD, lung disease). Observation on 4/18/23 at 6:50 A.M., showed CNA V and CNA W re-enter the resident's room to provide care to Resident #50's roommate. CNA V and CNA W washed their hands and put on gloves. CNA V placed 4 gloves on each hand. CNA V turned on the water for the sink that had clogged. He/She put soap on a towel and wet the towel in the sink. CNA W rolled the resident to his/her right side. The resident had dry skin foot flakes that went on the bed when the resident's blanket was removed. CNA V went over to the resident and wiped the resident from front to back with the wet towel. CNA V removed a pair of top gloves and wiped the flakes off the end of the bed to the floor. He/She grabbed barrier cream with the same gloves and placed the cream on the resident's bottom area. CNA W removed the brief and dirty linen and put them in a bag. CNA V instructed CNA W to remove his/her gloves. CNA W straightened the resident's reusable pad before he/she removed a top pair of gloves. He/She removed the other pair of gloves and washed his/her hands. CNA V removed the rest of his/her gloves and wiped more skin flakes off the bed. He/She placed the same blanket on the resident. During an interview on 4/20/23 at 11:50 A.M., the DON, Unit Manager and Wound Nurse said during personal care, gloves should be changed between dirty and clean. The DON expected hands to be washed with soap and water, not the use of sanitizer, with glove changes. Staff should not don multiple pairs of gloves. The use of multiple pairs of gloves does not replace the need for hand hygiene with soap and water. 3. Review of Resident #62's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Requires extensive staff assistance for toileting, mobility, transfers and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease) and congestive heart failure (CHF, a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). -Review of the resident's care plan, in use at the time of the survey, showed: -Focus: the resident is incontinent of bowel and bladder; -Goal: the resident will be clean and odor free; -Interventions: staff keep skin clean and dry. Observation on 4/18/23 at 6:21 A.M., showed Nursing Assistant (NA) B exited a room across the hall from the resident's room while wearing gloves and dragged a bag of soiled linen from the room, into the hall and then into the resident room. NA B then re-entered the other room and made a resident's bed while wearing the same gloves used to handle the dirty linen bag. NA B then re-entered the resident's room with the same gloves on. NA B went to the resident's closet and sorted through the resident's hanging clothes, while wearing the same gloves. NA B then exited the room with the gloves on. At 6:27 A.M., NA B returned to the room with a clean brief, and no longer wore the gloves. He/She donned gloves, but did not wash or sanitize his/her hands prior to donning the gloves. NA B used the controller to raise the resident's bed. The bag of dirty linen from the other room sat on the floor next to the resident's bed. NA B assisted the resident to his/her back. He/She obtained disposable wipes, unsecured the resident's brief, wet with urine, and provided care. While wearing the same gloves, he/she assisted the resident to turn to his/her right side. NA B removed the brief from under the resident and finished providing care. NA B wore the same soiled gloves and placed a clean brief under the resident, assisted the resident to his/her right side by touching the resident's hips and legs with the soiled gloves, and then assisted the resident to his/her back. NA B then secured the brief. NA B used the bed controller to lower the bed, picked up the soiled linen bags from floor, and tied it closed. He/She opened the room door with the soiled gloves on, exited the room, walked down the hall to the soiled utility room, used the soiled gloves to enter the code to the door, then touched the doorknob to open the door. NA B disposed of the soiled bag and exited the soiled utility room, then he/she removed his/her gloves. He/She did not wash or sanitize his/her hands. NA B then assisted to propel a resident in a wheelchair to the sitting area prior to using hand sanitizer. During an interview on 4/20/23 at 9:57 A.M., CNA S said soiled linen should be removed from the room immediately and taken to the soiled utility room. Soiled linen should never be taken to another resident's room. During an interview on 4/20/23 at 10:33 A.M., Licensed Practical Nurse (LPN) U said soiled linen should be removed immediately by any nursing staff and taken to the soiled utility room. Soiled linen should never be taken from one room to another. During an interview on 4/20/23 at 11:50 A.M., the DON, Unit Manager and Wound Nurse said during personal care, gloves should be changed between dirty and clean. The DON expected hands to be washed with soap and water, not the use of sanitizer, with glove changes. Staff should not touch the resident or clean surfaces with soiled gloves. Gloves should not be worn from one room into another. Soiled linen bags should be taken to the soiled utility room, not into other rooms. Soiled linen bags should not be drug on the floor, but should be carried. 4. Observation on 4/19/23 at 9:28 A.M., showed Registered Nurse (RN) C entered Resident #82's room with a blood pressure cuff on a rolling cart and took his/her blood pressure. After obtaining the reading, RN C washed his/her hands and exited the room with the blood pressure machine. RN C did not cleanse the machine after use. RN C then entered Resident #81's room with the blood pressure cuff and obtained the resident's blood pressure. Once completed, RN C washed his/her hands and exited the room with the blood pressure cuff. He/She failed to cleanse the blood pressure cuff. RN C then prepped and administered Resident #81 his/her morning medications. The blood pressure cuff remained in the hall next to the medication cart. At 9:59 A.M., RN C took the blood pressure cuff and without cleaning it first, entered room S122 with the machine and closed the door. During an interview on 4/20/23 at 9:57 A.M., CNA S said shared blood pressure cuffs should be cleaned in between residents. During an interview on 4/20/23 at 10:33 A.M., Licensed Practical Nurse (LPN) U said shared medical equipment, such as blood pressure cuffs, should be cleaned between each resident use. During an interview on 4/20/23 at 11:50 A.M., the DON, Unit Manager and Wound Nurse said shared medical equipment, such as blood pressure cuffs, should be sanitized between resident uses. The facility uses a micro-ban spray that is quick and easy to use. 5. Observation on 4/19/23 at 8:25 A.M., showed LPN U enter room B110 to obtain the resident's blood sugar. LPN U left the resident's room and wiped the BSFS machine with an alcohol wipe and continued to obtain resident blood sugars. At 8:40 A.M., LPN U and Unit Manager were in the A Hall of the Garden area. LPN U wiped both BSFS definition machines with an alcohol wipe. During an interview on 4/20/23 at 7:38 A.M., LPN U said there are two BSFS machines. The residents share them. He/She said the BSFS machines are cleaned with alcohol pads between residents. During an interview on 4/20/23 at 11:50 A.M., the DON, Unit Manager and Wound Nurse said staff should not use an alcohol wipe to clean shared BSFS machines. Staff should follow the policy and use the approved wipes for the BSFS machines. MO00215463

Based on interview and record review, the facility failed to ensure quality assurance performance improvement (QAPI) meetings consisted of the required committee members when the medical director failed to attend the facility's QAPI meetings. The census was 92. Review of the facility's Roles and Responsibilities of QAPI policy, undated, showed: -QAPI meets monthly the third week of the month to establish QAPI projects and all personnel involved in QAPI projects. Purpose of meeting is to establish roles and responsibilities of educators and trainers on how quality assurance project will be established and performed for all members of the QAPI team; -QAPI team consists of nursing, housekeeping, maintenance, activities, social services, dietary, management, and administrative staff; -The policy does not differentiate between QAPI meetings and quality assurance (QA) meetings, and does identify the Medical Director or her designee as a required member of the QA committee. Review of the facility's QAPI and QA sign-in sheets for the last 12 months, reviewed 4/20/23, showed the Medical Director or her designee not in attendance. During an interview on 4/20/23 at 12:56 P.M., the Administrator said the facility holds QAPI meetings on a monthly basis and QA meetings on a quarterly basis. QAPI and QA meetings are held to identify immediate needs and individual projects for each department, or global, long-term projects. The Medical Director is invited to attend QA and QAPI meetings, but has not attended a meeting during the past year.

Based on observation, interview and record review, the facility failed to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for one resident's missing a coat. Staff failed to investigate the missing coat, failed to ensure management was made aware of the missing coat and sent the resident out in the community wrapped in a blanket in place of a coat, for one of 18 sampled residents (Residents #76). The census was 90. Review of the facility's Resident Protection Investigation Paths, dated 12/14/18, showed: -Determine whether a missing item is theft: All missing items need to be investigated in accordance with the facility's missing item protocol. However, the loss of an item in and of itself does not constitute theft. The theft of socks, underwear, housecoats, glasses, hearing aids or dentures is very unlikely, despite the initial concerns of an upset resident or family member; -A confused resident taking another resident's property is not misappropriation of resident property because it is not deliberate misplacement. An item lost in laundering process is not theft. Other administrative action needs to be taken to protect resident property; -If the items appear to be lost and not stolen, report that conclusion in the Final Investigation Report, but continue a search for the missing item, using the facility's missing item protocol. Review of Resident #76's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/19, showed: -Cognitively intact; -Required no staff assistance with activities of daily living (ADLs); -Wheelchair for mobility; -Dialysis; -Diagnoses included high blood pressure, diabetes, hyperkalemia (low potassium), high cholesterol, anxiety, and depression. Review of the resident's inventory sheet, dated 1/24/19, showed: -One coat; -One pair of shoes; -Three pairs of slacks; -Three undershirts. During an interview on 1/22/20 at 7:17 A.M., the resident said he/she did not want to go to an outside appointment because his/her coat was missing. While he/she was in the hospital, someone stole it and now all he/she has is a jacket. He/she did not want to go to the appointment wrapped in a blanket over the jacket, it made him/her feel like he/she looked like a bum. Observation of the resident on 1/22/20 at 7:30 A.M., showed he/she propelled his/her wheelchair into the common area beside the nurse's station and yelled his/her coat was still missing and he/she didn't want to go to his/her appointment without a warm coat. Observation and interview on 1/22/20 at 7:45 A.M., inside the laundry room, Laundry Aide L and Laundry Aide M both said they were unaware the resident was missing a coat. Laundry Aide M said he/she would look for an extra coat on the unclaimed items rack, while looking through the unclaimed items rack, he/she said no coats were available. During an interview on 1/22/20 at 7:50 A.M., the Housekeeping Manger said the resident always says he/she wants something. If he/she sees something, he/she claimed it's his/hers. He/she came here from the hospital with nothing but gowns. Review of the website, weather.com, showed the outside temperature on 1/22/20 at 8:30 A.M., 24 degrees Fahrenheit (F), which felt like 16 degrees F. Observation and interview on 1/22/20 at 9:00 A.M., showed the resident seated beside his/her room in his/her wheelchair. A sack lunch sat on his/her lap. He/she said he/she was taking the sack lunch to eat while at the appointment. The resident wore a knit cap and a light weight black zip up hoodie, he/she said staff were unable to find him/her a coat. Layered behind the resident on the back of the wheelchair was a white blanket. At 9:12 A.M., the transport attendant stood at the nurse's station as he/she waited to take the resident to his/her appointment. He/she said the last time he/she picked the resident up, it was real cold outside, in the teens. The resident was wearing a light weight hoodie and he/she put the hoodie up over his/her head and covered him/her with a blanket because he/she did not want the resident to get sick. Observation on 1/24/20 at 8:50 A.M., showed the resident seated in the dining room, his/her lunch sack on the table in front of him/her. The resident wore a grey sweater type jacket, with a black blanket on his/her lap. At 9:16 A.M., the resident left the facility in a wheelchair, assisted by Activity Aide O, the resident's jacket unzipped, his/her shoulders wrapped in a blanket. During an interview on 1/25/20 at 11:43 A.M., the resident said he/she still did not have a coat. He/she wore a jacket and a blanket to the appointment yesterday and looked like a bum. During an interview on 1/24/20 at 10:10 A.M., the administrator said no staff members had informed him the resident needed a coat. He would have expected staff to let him know he/she was in need of a coat. He was aware the resident had jackets, he had previously provided the resident with a jacket but was unaware the resident needed a coat. He would expect staff to make management aware of missing items.

Based on observation, interview and record review, the facility failed to ensure residents were able to self-administer medication only if the interdisciplinary team has determined that this practice is clinically appropriate, for two residents found to have medications left at the bedside for self-administration (Residents #139 and #49). The census was 90. Review of the facility's undated Self-Administration of Medication policy, showed: -Policy statement: For administration of medications by a resident the individuals must be deemed competent for self-administration prior to the physician or authorized prescriber ordering the medication via a self-administration assessment. This assessment will be completed initially upon request to self-administer, quarterly and upon change of condition from baseline to ensure continued safe-administration; -Specific medication orders are written by the physician or authorized prescriber, for self-administration by the resident, including the medication, dose, frequency, route, indication, and whether the medication is to be stored at bedside; -If kept at bedside, the medication shall be labeled as Bedside Medication by the pharmacy. When additional medication is needed, the nurse shall notify the pharmacy; -Patient education shall include information on the medication, dose, frequency, route, indication, and expected actions or side effects; -Documentation of patient education for self-administration of medications shall be made in the patient medical record and plan of care. 1. Review of the Resident #139's medical record, showed: -No physician's orders to self-administer medication; -No assessment to self-administer medications. Observation on 1/22/20 at 8:48 A.M., showed the resident in his/her bed with his/her eyes closed. There was a small medication cup with one pill inside on the resident's bedside table. The resident opened his/her eyes and confirmed that it was his/her Percocet in the cup. The nurse brought it in but did not watch him/her take the pill. The resident said, they are not supposed to do that. During an interview on 1/20/20 at 9:07 A.M., Licensed Practical Nurse (LPN) A confirmed he/she administered the resident's medication. The resident had not been assessed or had orders to self-administer. 2. Review of Resident #49's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/24/19, showed: -Cognitively intact; -Wheelchair for mobility; -Skin/ulcer treatment: Application of ointments/medication other than on feet; -Diagnoses included, anemia, heart failure, high blood pressure, anxiety and depression. Review of the resident's medical record, showed: -An order dated 9/23/19, for Nystatin (antifungal), 100,000 unit powder, apply topically three times a day. Apply under bilateral breasts and abdominal fold; -An order dated 12/12/19, for Aspercreme (used for temporary relief of minor arthritis pain, muscle aches and strains). Apply three times a day as needed for right shoulder pain; -No order to self-administer medication; -No assessment for self-administration. Observation and interview on 1/23/20 at 11:30 A.M., showed three medications were on the resident's bed side table inside a clear plastic baggie, the contents included the topical medications, nystatin, Monistat (used to treat fungal infections and yeast infections), and Aspercreme. The resident said he/she applied the medications when he/she needed them. 3. During an interview on 1/27/20 at 3:23 P.M., the Director of Nursing (DON) said medications at bedside should only be left at bedside if the resident had an order, or if order states the resident can administer to themselves. All medications, including treatment medications should be secured on the medication cart or the treatment cart.

Based on interview and record review, the facility failed to accurately reconcile bank statements for 5 of 12 months reviewed. The census was 90. 1. Record review of the facility's resident trust statements, showed the following: -July 2019: Bank statement ending balance, showed an amount of $53,821.63; -The facility monthly reconciliation form, showed an ending balance amount of $39,925.76; -Neither amounts matched the resident ledger; -August 2019: Bank statement ending balance, showed an amount of $67,375.75; -The facility monthly reconciliation form, showed an ending balance amount of $58,971.54; -Neither amounts matched the resident ledger; -September 2019: Bank statement ending balance, showed an amount $51,480.65; -The facility monthly reconciliation form, showed an ending balance amount of $47,102.91; -Neither amounts matched the resident ledger; -October 2019: Bank statement ending balance, showed an amount of $42,783.15; -The facility monthly reconciliation form, showed an ending balance amount of $43,249.57; -Neither amounts matched the resident ledger; -November 2019: Bank statement ending balance, showed an amount of $48,292.80; -The facility monthly reconciliation form, showed an ending balance amount of $40,430.35 -Neither amounts matched the resident ledger. 2. During an interview on 1/23/20 at 10:50 A.M., business office manager said he/she has been in charge of resident funds for two years; however, he/she does not reconcile the resident's trust account. The corporate office reconcile the trust. He/she was not aware the months July through November were not accurately reconciled. 3. During an interview on 1/27/20 at 11:00 A.M., the administrator confirmed the corporate office is responsible for the resident trust account. He would expect the trust account to be accurately reconciled monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notice to the resident or their legal representative of the facility bed hold policy at the time of transfer to the hospital, for three residents who were recently transferred to the hospital for various medical reasons (Residents #64, #139, and #32). The sample was 18. The census was 90. Review of the facility's undated transfer and discharge policy, showed when a resident is transferred or discharged from the facility, a discharge letter is sent with the resident. The letter will indicate the name of the resident with the date, the reason for the discharge and the location to where the resident is sent. The social service department will keep a copy of the letter in the binder and at the first of the following month the list of all the residents will be faxed to the ombudsman. Any resident that is given an emergency discharge letter, will have the letter faxed to the ombudsman on the same day. Any 30 day discharge letter that is given to the resident/responsible party will also be faxed to the ombudsman. The facility will only send a bed hold letter if the census was 95 percent or greater. The log sheet that is faxed to the ombudsman will be kept in the social service office. 1. Review of Resident #64's medical record showed: -On 1/6/20, the resident was sent to the hospital; -On 1/9/20, resident returned to the facility; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 2. Review of Resident #139's medical record, showed: -admitted to the facility on [DATE]; -Transferred to the hospital on [DATE]; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 3. Review of Resident #32's medical record, showed: -admitted to the facility on [DATE]; -Transferred to the hospital on [DATE]; -No documentation the resident and/or their representative received written notice of the facility's bed hold policy at the time of transfer. 4. During an interview on 1/24/20 at 11:15 A.M., the Director of Nursing (DON) said to her knowledge, the facility does not have a bed hold policy. The staff have not sent any bed hold paperwork with the resident's when they are sent to the hospital, regarding holding the resident's bed. 5. During an interview on 1/24/20 at 12:42 P.M., the administrator said staff do not issue a bed hold to residents who discharge to the hospital because the facility census is low and it should not be an issue for the resident to return to the facility and back to their former room.

Based on interview and record review, the facility failed to ensure the services provided or arranged by the facility meet professional standards of practice by failing to ensure all physician orders were followed when staff failed to obtain a daily blood pressure prior to administration of a blood pressure medication and/or administered blood pressure medication when the results were outside normal parameters, for one resident (Resident #42). The sample size was 18. The census was 90. Review of Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/25/19, showed: -Cognitively intact; -Diagnoses includes atrial fibrillation (irregular heart beat), coronary artery disease (heart disease), heart failure, hypertension (HTN, high blood pressure) and stroke. Review of the resident's physician orders sheet (POS), dated 1/1/20 through 1/31/20, showed: -An order, dated 9/26/19, for Clonidine (medication to treat high blood pressure), 1 milligram (mg) tablet, administer 0.5 mg twice a day for high blood pressure; -An order, dated 9/27/19, for Clonidine, 1 mg, take 1/2 tablet by mouth for systolic blood pressure (SBP, top number, amount of pressure in your arteries during the contraction of your heart muscle) greater than 150 or diastolic blood pressure (DBP, bottom number, when your heart muscle is between beats) greater than 85. Systolic blood pressure check and diastolic blood pressure check for diagnosis of HTN. Review of the resident's medical record, showed: -A progress note dated 12/5/19, the resident was observed by the certified medication technician (CMT) on the ground, sitting up Indian style on the floor by the night stand. Resident did not complain of any pain, no apparent injury, no redness, no discomfort, able to move all extremities to baseline, vital signs taken, blood pressure 177/110, physician notified, family notified and aware. No new orders. CMT and certified nurse aide (CNA) helped the resident up from the floor; -No documentation of administration of the Clonidine ordered for an SBP above 150 or DBP above 85. Review of the resident's blood pressure record, for 12/1/19 through 1/27/20, showed: -On 12/5/20: -At 10:38 A.M., 161/96; -At 7:29 P.M., 177/100; -At 7:23 P.M., 164/89; -At 7:31 P.M., 160/95; -At 7:33 P.M., 162/91 -At 7:34 P.M., 158/87; -At 7:35 P.M., 158/86; -At 7:37 P.M., 160/86; -On 12/6/19: -At 7:14 A.M., 160/83 -At 7:15 A.M., 162/75; -On 12/7/19: -At 6:59 A.M., 144/86; -At 7:53 P.M., 152/82; -On 12/8/19: -At 6:33 A.M., 196/108; -At 6:34 A.M., 196/108; -On 1/6/20, 155/95. Review of the resident's Medication Administration Record (MAR), dated 12/1/19 through 1/31/20, showed: -Clonidine 0.5 mg as needed for SBP greater than 150 or DBP greater than 85, not administered as ordered on 12/5, 12/6, 12/7, and 12/8/19. Review of the resident's MAR, dated 1/1/20 through 1/27/20, showed: -Clonidine 0.5 mg as needed for SBP greater than 150 or DBP greater than 85, not administered on 1/6/20. During an interview on 1/22/20 at 9:04 A.M., the resident said nursing staff do not take his/her blood pressure. He/she cannot remember the last time it was obtained. He/she was aware his/her blood pressure was high. He/she did not know if the blood pressure medications were working if staff did not check his/her vitals. During an interview on 1/27/20 at 3:23 P.M., the Director of Nursing (DON) said the facility does not have a specific time or frequency for when residents' blood pressures are to be taken. If there is a reason for it to be done, it would be obtained. If there were blood pressure parameters, she would expect staff to obtain the resident's blood pressure daily. She would expect staff to follow physician's orders and administer the as needed Clonidine when the resident's blood pressure increased.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received services to maintain good personal hygiene by failing to provide showers and nail care for one resident who was dependent on staff for care needs (Resident #12). The sample was 18. The census was 90. Review of the facility's shower policy, revised 1/2017, showed: -Purpose: To provide showers on a bi-weekly basis; -A shower schedule will be maintained at each nurse's station for each division reflecting days and shift for each room/bed shower to be completed. Accommodations for requested days of the week or times will be made; -Residents right to refuse showers will be respected and addressed via the plan of care; -Refusals will be communicated to the responsible party if applicable, social service will be advised and the primary care physician and psychiatric consultant may be notified if indicated for repetitive refusals; -Nails are to be assessed trimmed and cleaned as needed; -Shaving is to be performed as needed; -Certified nursing assistants (CNA) will perform a visual assessment of a resident's skin when giving the resident a shower; -Shower sheets will be reviewed by the charge nurse; -The charge nurse will completed an assessment, record findings in the medical record, complete physician notification, secure treatment orders, referrals or devices as needed and assess for pain and pain management needs; -The charge nurse will forward all completed shower sheets to the clinical nurse managers; -Clinical nurse managers will ensure a shower sheet is received for each shower and ensure interventions are in place for any areas identified during showers; -Shower sheets will be kept in the clinical manager's office for a period of 2 weeks. Review of Resident #12's electronic medical record (EMR), showed the following diagnoses included: -Mental disorder; -Unspecified intellectual disabilities. Review of the resident's care plan, revised on 1/9/20, showed: -Problem: The resident requires extensive assistance with completing activities of daily living (ADLs); -Goal: Resident will accept assistance with area of dressing, grooming, hygiene and bathing; -Approach: Break down tasks into manageable segments. Encourage resident to complete as much self-care as possible independently or with minimal assistance. Encourage resident to participate in ADLs and praise accomplishments. Provide assistance with self-care as needed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/9/19, showed: -Extensive assistance with all personal hygiene. Review of the facility's shower book labeled terrace level, reviewed on 1/21/19 at 3:50 P.M., showed the following for the resident: -A note in front of shower book: shower schedule and shower sheets will be placed in the shower book for the week. Do not remove or change any shower or sheets for the shower book. Any changes to the shower book must be completed by a charge nurse or management. Showers and shower sheets are to be completed daily as assigned (even hospice residents). Note any empty rooms, refusals, or skin concerns are placed on shower sheet and to notify charge nurse; -Showers scheduled Monday and Thursday day shift for the resident; -One shower sheet for the resident, dated Thursday 1/16/20; -No documentation of a shower provided or refused on Monday 1/20/20. Further review of the resident's EMR, reviewed on 1/21/19, showed no documentation of shower refusals for the month of January, 2020. Observations of the resident during the survey, on 1/21/20 at 3:50 P.M., showed the resident had slightly oily hair, food in his/her facial hair, stains on his/her shirt, and he/she was unshaven. During interview with Licensed Practical Nurse (LPN) A on 1/22/20 at 8:40 A.M., he/she said when there is not a shower sheet filled out for a certain resident, then it probably means that the shower did not get done. During an interview with Certified Nursing Assistant (CNA) B on 1/22/20 at 2:24 P.M., he/she said staff shave the resident and the resident never refuses showers. Further observation of the resident, showed: -On 1/22/20 at 2:30 P.M., the resident appeared unshaven, with oily hair and his/her hair appeared not to have been combed; -On 1/23/20 at 1:59 P.M., the resident had a brown substance under his/her nails on the left hand. The resident said he/she did not know when his/her showers were scheduled; -On 1/24/20 at 9:25 A.M., the resident had a brown substance under the nails on both hands; -On 1/27/20 at 9:44 A.M., the resident was unshaven and his/her fingernails long with a brown substance under the nails on both hands. During an interview on 1/27/20 at 2:45 P.M., CNA C said he/she was unsure if he/she is expected to trim the resident's fingernails. During an interview on 1/27/20 at 3:29 P.M., the Director of Nursing (DON) said that staff is to follow the shower schedule and if the resident refuses twice, the resident will have a shower on the next scheduled shower day. Shower sheets are to be filled out, even if the resident refuses. Staff is to report shower refusal to the charge nurse. Staff is expected to inspect and clean fingernails on shower days. CNAs and nurses can trim fingernails.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice when staff failed to address an observed skin irritation and bleeding for one resident. The staff also failed to notify the resident's physician and family and failed to document the observation and report the findings to oncoming nursing shifts (Resident #28). The sample was 18. The census was 90. Review of the facility's skin assessment policy, dated 8/17/17, showed: -In order to prevent skin breakdown and promote the health of the residents, it is the policy to perform skin assessments on a weekly basis. Skin assessments are to be performed by a registered nurse (RN) or licensed practical nurse (LPN); -Procedure: The LPN or RN are to visually inspect all areas of the body and note/document any abnormalities. If any abnormalities are found, the LPN or RN performing the skin assessment is to notify the physician, resident and/or resident representative and Director of Nursing (DON); -Residents may develop various types of skin ulceration. At the time of the assessment and diagnoses of a skin ulcer/wound, the clinician is expected to document the clinical basis (e.g., underlying condition contributing to the ulceration, wound edges and bed, location, shape, condition of the surrounding skin) which permit differentiating the wound type, especially if the wound has characteristics consistent with a pressure ulcer, but is determined not to be one. Review of Resident #28's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/29/19, showed: -Severe cognitive impairment; -Total staff assistance for all care needs; -Nutritional needs met with tube feeding (hollow tube inserted into the stomach to provide liquid nutritional needs); -No skin rashes or irritations. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: At risk for skin breakdown related to the resident noted to be confined to his/her bed and total staff assistance for all care needs; -Goal: Measures will be taken to prevent skin breakdown; -Interventions: Assist the resident to turn and reposition frequently, inspect the resident's skin from head to toe weekly, document findings and keep his/her skin clean and dry. Weekly treatment documentation to include measurement of each area of skin breakdown to include width, length, depth, and type of skin irritation and drainage. Review of the resident's weekly skin assessment, dated 1/20/20, showed: -Skin: toes receiving treatment, no other skin irritations or irregularities noted. During an observation and interview on 1/22/20 at 10:06 A.M., LPN A lifted the resident's hospital gown and exposed the resident's abdomen. An area of redness noted under both of the right and left breast. The entire area under the right breast bleeding. LPN A said oh, I didn't know about that. I haven't been told anything. I will put some ointment on there and call the doctor right away. LPN A said the resident is in bed most of the time and he/she is overweight and can sweat under his/her skin folds. The irritation appeared to be from moisture and may need an antifungal ointment. Review of the resident's progress notes and physician order sheet (POS), reviewed on 1/22/20 at 11:20 A.M. and 12:45 P.M., showed no additional documentation of the skin irritation and bleeding. No notification of the skin changes to the resident's responsible party or to the resident's physician. During an interview on 1/22/20 at 1:05 P.M., the resident's responsible party said that he/she had been aware the resident had open areas to his/her feet and the facility had provided treatments to the feet. He/she had not been notified of any additional skin concerns or changes. Further review of the resident's progress notes, showed: -On 1/22/20 at 7:24 P.M., the resident noted to be resting in bed at this time. Resident turned and repositioned every two hours for comfort. Tube feeding infusing without difficulty. No signs or symptoms of pain or discomfort. Will continue to monitor and note any new changes; -The progress note did not address the redness under either breast or bleeding under the right breast. No notification of the next of kin or of the resident's physician noted or notification of nursing staff of the observations made on 1/22/20 at 10:06 A.M.; -On 1/23/20 at 6:04 A.M., the resident noted in the bed resting, no signs or symptoms of pain or distress noted. Respirations even and unlabored; -The progress note did not address the redness under either breast or bleeding under the right breast. No notification of the next of kin or of the resident's physician noted or notification of nursing staff of the observations made on 1/22/20 at 10:06 A.M. Further review of the resident's POS, reviewed on 1/23/20 at 10:45 A.M., 2:22 P.M., and on 1/24/20 at 9:02 A.M., showed no new orders for skin ointment or treatment under the breast. During an observation and interview on 1/24/20 at 9:31 A.M., the wound nurse, LPN D raised the resident's hospital gown. He/she used gloved hands and lifted and exposed the skin under the resident's breasts. The skin under the resident's left breast noted to have a small reddened area approximately 3 centimeters (cm) long. The skin under the right breast noted to be reddened, irritated and an area of skin noted to be cracked and measured approximately 6.5 cm long. LPN D stated he/she would review the resident's orders for treatments. He/she had not been notified of any skin changes the resident experienced. Review of the resident's weekly skin assessment, dated 1/24/20, showed friction, rash and shear (skin against skin rubbing) under both breasts. During an interview on 1/24/20 at 10:25 A.M., the DON and wound nurse, LPN D said they expected when the nurse observed the change in skin on 1/22/20, he/she should have called the physician and family. He/she should have written a nurse note to document the change and also filled out a skin assessment form and turned the skin assessment form in to the wound nurse so the wound nurse could perform a skin assessment and perform weekly wound monitoring. LPN D said he/she had measured the area under the breast, called the physician and was waiting for an order. The areas had not been bleeding but was red and open. The areas were probably caused from moisture and will probably receive an order for Nystatin (used to treat fungal irritation) ointment or powder. Further review of the resident's progress notes, showed on 1/24/20 at 10:30 A.M., LPN D had been notified of redness to the resident's breast folds, the skin had been assessed upon being notified. The area under the resident's left breast measured 4.5 cm long x 1.0 cm wide x 0.1 deep. No active drainage or bleeding noted. The area under the resident's right breast noted to have cracked skin and measured 10 cm long x 1.0 cm wide x 0.1 cm deep. The area under the right breast had redness. No active drainage or bleeding. Call placed to the physician to notify of the reddened areas to both breast folds. Unable to reach the resident's personal physician, the new order obtained from the facility medical director for antifungal powder to be applied every shift and as needed (PRN). Further review of the resident's POS, showed an order dated 1/24/20, to clean under both breast folds with soap and water, rinse, pat dry and apply Nystatin powder every shift and PRN until healed.

Based on observation, interview and record review, the facility failed to ensure a resident receives appropriate treatment and services for the use of an indwelling urinary catheter (a tube inserted into the bladder to drain urine) for one resident. The facility identified three residents as having an indwelling urinary catheter, two were included in the sample of 18 and issues were identified with one resident (Resident #8). The census was 90. Review of the facility's undated Catheter Care policy, showed: -Purpose: To monitor the necessity of urinary catheters and to maintain the patency of these catheters; -Procedure: Document the involvement of the resident/representative in the discussion of the risks and benefits of the use of a catheter, removal of the catheter when criteria or indication for use is no longer present, how long use is anticipated, and the right to decline the use of the catheter; -Write an order on the physician's order sheet for the catheter with the reason for the catheter. Must have acceptable diagnosis for use; -Maintain catheter tubing below bladder level, anti-reflux drainage systems only are utilized, maintain tubing coiled to gravity, ensure privacy bag in intact and ensure catheter tubing does not make contact with the floor; -Catheter care every shift; -Timely and appropriate assessments related to the indication for the use of an indwelling catheter. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/23/19, showed: -Moderate cognitive impairment; -Two staff assistance for transfers; -One staff assistance for bed mobility, dressing, toileting, and personal hygiene; -Wheelchair for mobility; -Indwelling catheter: Not indicated as used; -Urinary continence: Not rated, resident had a catheter or no urine output for seven days; -Diagnoses included anemia and elevated cholesterol. Review of the resident's electronic physician order sheet (ePOS), dated 1/1/20 through 1/31/20, showed: -An order, dated 5/11/19, for an indwelling urinary catheter catheter, 16 French (FR, gauge used to measure size of catheter), record output every shift; -An order, dated 5/11/19, for catheter care, every shift. Review of the resident's care plan, in use during the survey, showed: -Problem: Urine retention; -Interventions: Indwelling urinary catheter, 16 FR, resident will be free of complications of indwelling catheter. Assess for bladder distention, small frequent voids, dribbling, and resident complaint of bladder feeling full. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding. Care/changing of urinary catheter as ordered. Encourage adequate fluid intake, offer at frequent intervals. Observation and interview on 1/21/20 at 10:45 A.M., the resident complained he/she occasionally had burning with his/her indwelling urinary catheter. He/she was seated in his/her electric wheelchair, the catheter tubing draped up and over resident's right arm rest, above bladder level. At 5:46 P.M., the resident sat in his/her room, his/her catheter tubing draped up and over the right arm rest of his/her wheelchair. He/she said staff would be bringing him/her dinner, he/she usually ate in his/her room. During an interview on 1/27/20 at 4:06 P.M., the Director of Nursing (DON) said the catheter tubing should be positioned below the resident's bladder. The tubing above the bladder could cause an inability of the urine to drain, which could lead to infection. She expected staff to ensure proper placement of catheter tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who require dialysis (process of filtering toxins from the blood for individuals with kidney failure) receive such services, consistent with professional standards of practice by failing to follow the facility policy and provide ongoing communication with the dialysis center for two residents. The facility identified five residents as receiving dialysis. Of those five, three were included in the sampled of 18 and issues were identified with two (Residents #76 and #64). The census was 90. Review of the facility's Dialysis Policy, dated 9/1/19, showed: -It is the standard at the facility to meet the health care needs of its residents. As such, the facility will ensure that residents who require dialysis will receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences; -Professional standards of practice include: -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; -Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; -If a resident has been identified as needing/has been prescribed dialysis, the facility will assist the resident, will transport to and from an off-site certified dialysis facility for dialysis treatments; -The dialysis facility is responsible for the medical management for the end state renal (kidney) disease including dialysis treatments, performed offsite or onsite. It is the responsibility of the dialysis facility to provide all necessary equipment and supplies for the provision of the dialysis treatments, including maintenance and repair as needed, testing/monitoring water and dialysate (dialysis solution) quality for dialysis treatment, and for the training of individuals providing the dialysis; -Shared Communication between the Nursing Home and the Dialysis facility: -Ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff is imperative in providing optimal care for the resident. The charge nurse is designated as the contact staff at the facility to communicate with the dialysis staff. For a resident receiving dialysis, the charge nurse will communicate with the attending physician/practitioner, resident/resident representative, and dialysis staff regarding any significant changes in a resident's status that may impact the dialysis portion of the care plan. A dialysis communication form may be utilized to assist with communication between facilities; -Canceling or postponing dialysis: The nephrologist (kidney physician)/dialysis team, the resident's attending practitioner must be notified of the canceled or postponed dialysis treatment and responses to the change in treatment must be documented in the resident's medical record; -Resident refusal: The resident/resident representative has the right to refuse dialysis treatment. In this case, risks/benefits or treatment should be communicated and documented. This discussion should be coordinated approach with both dialysis and nursing home staff. 1. Review of Resident #76's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/19, showed: -Cognitively intact; -Required no staff assistance with activities of daily living (ADLs); -Wheelchair for mobility; -Dialysis; -Diagnoses included high blood pressure, diabetes, hyperkalemia (low potassium), high cholesterol, anxiety, and depression. Review of the resident's care plan, in use during the survey, showed: -Problem: Received dialysis Monday, Wednesday and Friday. Pick up time is 10:00 A.M.; -Interventions: -Avoid taking blood pressures and/or injections in shunt (dialysis access site) limbs; -Arrange transportation to and from dialysis; -Monitor weight; -Provide resident with takeout meal if not in facility at meal time; -The care plan did not address the use of the dialysis communication form. Review of the resident's electronic physician order sheet (ePOS), dated 1/1/10 through 1/31/20, showed an order, dated 12/6/19, Monday, Wednesday and Friday upon rising, complete dialysis communication form and send with resident to dialysis. Review of the resident's medical record, showed no completed dialysis communication forms. During an interview on 1/24/20 at 10:01 A.M., Licensed Practical Nurse (LPN) G said the resident had left for dialysis and he/she did not have a dialysis communication sheet because they are not required to fill one out for him/her. During an interview on 1/23/20 at 3:45 P.M., the Director of Nursing (DON) said prior to her coming to the facility, staff were not doing very well on completing the dialysis communication forms. She believed staff were doing better on the first floor, but downstairs, she doubted they were completed as order. She would expect staff to complete the forms and follow the physician's orders. 2. Review of Resident #64's quarterly MDS, dated [DATE] showed: -Cognitively intact; -Dialysis; -Diagnosis includes: end stage renal disease (ESRD, chronic irreversible kidney failure), diabetes, and high cholesterol. Review of the residents care plan, in use during survey, showed: -Problem: Renal failure with dialysis; -Goal: resident will not experience complications secondary to dialysis; -Interventions: After dialysis treatment, observe resident for adverse reaction to treatment; arrange transportation to and from dialysis; avoid taking blood pressure and or injections in shunt limbs; monitor weight; provide resident with takeout meal if not in the facility at meal time; resident receives dialysis treatment three times a week on Monday, Wednesday and Friday's. Review of the resident's ePOS, showed an order dated 1/23/20, for: -Monday, Wednesday and Friday on upon rising complete dialysis communication form and send with resident to dialysis. Blood pressure check, pulse check, respiration check, temperature check, oxygen saturation (percentage of oxygen in the blood) check, weight check; -Dialysis Monday, Wednesday and Friday; -Check bruit and thrill (the sound heard and vibration felt at the dialysis access site) every shift. Review of the resident's medical record, showed: -Dialysis communication form, the portion to be completed by dialysis, blank on 12/20/19, 12/31/19, 1/3/20, 1/6/20, 1/17/20; -No completed dialysis communication form dated 12/13/19, 12/16/19, 12/18/19, 12/23/19, 12/25/19, 1/8/20, 1/13/20, and 1/15/20. During an interview on 1/23/20 at 3:30 P.M., the DON said the facility has not been documenting well on the dialysis patients, especially the residents on the first floor. The facility was not documenting on dialysis patients prior to him/her coming to the facility. She has been at the facility for two months.

Based on observation, interview and record review, the facility failed to ensure residents are free of significant medication errors, for one resident when the facility staff administered the wrong dose of insulin (Resident #84). The census was 90. Review of the facilities Specific Medication Administration Procedure, Administration procedure for all Medications policy, dated 6/1/18, showed: -Policy: to administer medications in a safe and effective manner; Procedure: Review five rights three times: Prior to removing the medication package/container from the cart/drawer; check the medication/treatment administration record for order; check for vital signs, other tests to be done during/prior to medication administration; Prepare resident for medication; Prior to removing the medication from the container, check the label against the order on the medication administration record; note any supplemental labeling that applies; obtain and record any vital or other monitoring parameters ordered or deemed necessary prior to medication administration; after administration, return to cart, replace medication container, and document administration in the medication administration record. 1. During an observation on 1/22/20 at 9:00 A.M., showed: Licensed Practical Nurse (LPN) G, said Resident #84's finger stick blood sugar was 350. LPN G administered 17 units of Lispro insulin (a short acting medication used to treat diabetes) and 40 units of Tresiba insulin (a long acting medication used to treat high blood sugars). At 9:10 A.M., LPN G administered 3 more units of Lispro insulin. LPN G had ran out of Lispro insulin, and needed to get a second vial to complete the dose. Review of the resident's electronic physician order sheet (ePOS) showed: -Tresiba 20 units subcutaneous (under the skin) one time per day; -Lispro 100 unit/mL subcutaneous per sliding scale three times a day: 0-69 = 0 units; 70-120 = 5 units; 121-150 =10 units; 151-200 =12 units; 201-250 =14 units; 251-300 =16 units; 301-350=18 units; Greater than 351 then 20 units; -Dex 4 glucose chewable tablet (medication used to treat low blood sugar), four tablets by mouth as needed for blood sugar 60-80, recheck blood sugar in 15 minutes; -GlucaGen (medication used to treat low blood sugar) Hypo Kit 1 mg injection, one kit intramuscular (into the muscle) every 10 minutes as needed for low blood sugar. Administer for low blood sugar less than 60. Repeat accu check in 10 minutes and glucagen in 15 minutes. During an interview on 1/22/20 at 11:00 A.M., the Director of Nursing (DON) verified the dose of Tresiba should be 20 units not 40 units. During observation on 1/22/20 at 11:10 A.M., Registered Nurse (RN) K, checked the residents blood sugar, the reading was 214. The resident said he/she felt alright. During an interview 1/22/20 at 11:10 A.M., the DON said they were calling the doctor and the residents responsible party. During an interview on 1/22/20 at 11:30 A.M., pharmacist N said, Tresiba is a long acting insulin and it would peak around nine hours but it may not peak like a traditional insulin. He/she would expect the finger stick blood sugars to be lower and to monitor for hypoglycemia. During an interview on 1/22/20 at 12:50 P.M., the DON said the facility contacted the resident's endocrinologist to notify him/her 40 units of Tresiba insulin was administered, and the doctor said, the resident would be fine. RN K, said the resident had been on 40 units of Tresiba insulin and the dose was decreased to 20 units on 12/4/19. The DON said he/she spoke with the nurse who gave the insulin, the nurse was nervous and the finger stick was 351 this morning and was documented as 351. The DON also stated he/she has already started reviewing the six rights of medication administration with staff.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are labeled in accordance to current acceptable professional standards for two of five observed nurse medication carts, one of two observed nurse treatment carts and one of three observed medication rooms. The census was 90. Review of the facility's Medication Ordering and Receiving from Pharmacy policy, dated 6/1/18, showed: -Policy: Medications are labeled in accordance with the facility requirements and state and federal laws. Only the dispensing pharmacy/registered pharmacist can modify, change, or attach prescription labels; -Procedures: Labels are permanently affixed to the outside of the prescription container. No medication is accepted with the label inserted into a vial. If a label does not fit directly onto the product, e.g. eye drops, the label may be affixed to an outside container or carton, but the resident's name, at least must be maintained directly on the actual product container; -Each prescription medication label should include the following: The resident name, specific directions for use, including route of administration, medication name, strength of medication, prescriber's name, date dispensed, quantity of medication, beyond use date, pharmacy information, prescription number and any accessory information if needed; -Resident-specific nonprescription labeled medication (not floor stock) that are not labeled by the pharmacy are kept in the manufactures original container and identified with the resident's name. Facility personnel may write the residents name on the container or label as long as the required information listed is not covered; -Medication labels are not to be altered, modified, or marked in any way by the nursing personnel. Contents are not transferred from one container to another. Under no circumstances are unattached labels requested or accepted from the pharmacy. Only the pharmacy or the registered pharmacist may place a label on the medication container; -Floor stock medications may be labeled as floor stock or house supply and kept in the original manufacture's container. The manufactures or pharmacy label should include the following: medication name, strength, quantity, accessory/auxiliary instructions, lot number, expiration date, manufacturer and or distributor; -When medications are ordered for use at the resident's bedside, the medication label contains, in addition to the instructions for use, a notation that it may be self-administered and stored at the bedside. 1. Observation on 1/22/20 at 6:50 A.M., of the first floor medication room, showed: -One vial of tuberculin (TB, a medication used to help test for tuberculosis) opened and undated when opened; -No lock or security measures noted on the outside of the refrigerator, nor did the refrigerator have a lock box inside the refrigerator to store controlled substances. 2. Observation on 1/22/20 at 6:55 A.M., of the first floor treatment cart, showed: -Two tubes of silver sulfanilamide cream (topical antibiotic) one percent (1%), one tube noted to be missing resident identifiers, the second tube did not have the identifying label; -One tube of Triamcinolone acetonide 0.1 %; (steroid), the tube did not have the identifying label; -One tube of Nystatin cream (used to treat fungal infections), unlabeled and contained no resident name for use; 3. Observation on 1/22/20 at 7:00 A.M., of the first floor medication cart, showed: -Two boxes of liquid lorazepam intensol (used to treat anxiety, which should be refrigerated) stored in a locked box on the unrefrigerated medication cart. Review of the lorazepam intensol manufacturer's information, showed store at cold temperature, refrigerate. 4. Observation on 1/22/20 at 6:48 A.M., of the suite nurse medication cart, showed: -One bottle of latanoprost eye drops (used to treat glaucoma), not dated when opened; -One bottle of bottle of timolol maleate (used to reduce eye pressure) 0.5 percent (%) eye drops. The bottle noted to be undated when opened. Registered Nurse (RN) I and Licensed Practical Nurse (LPN) J said that all of the medications should be individually labeled with the resident's name. All eye drops should be dated when the medication is opened and include the expiration date on the medication container itself. If staff discovered a medication that is unlabeled or undated the medication should be destroyed and a new container obtained, labeled, dated and reordered for stock supply. Review of the latanoprost eye drop manufacturer's information, showed once a bottle is opened for use, it may be stored at room temperature for 6 weeks. Review of the timolol maleate eye drop manufacturer's information, showed discard the eye drops 4 weeks after opening. 5. During an interview on 1/22/20 at 7:30 A.M., LPN F said the vial of TB medication in the refrigerator should have a date on it. The medication should be dated when it is opened by the nurse. The nurse who opens the medication should date the medication. LPN F looked at the tubes of medication with what appeared to have had the labels pulled off and said the writing was very light, but did not give names of residents who the medications belonged to. Staff always store the liquid lorazepam on the medication cart, not in the refrigerator. 6. During an interview on 1/27/20 at 3:22 P.M., the Director of Nursing (DON) said medications should be labeled with resident's name on them unless the medication is a stock medication. If the medication is a stock medication, it is ok for the medication not to have a label on it. If the medication is not a stock medication, there should be a label on the medication. The medication should include the date when opened and expiration date. If there is no label on the medication, the medication should be thrown away and a new container obtained, dated, labeled with the resident name and expiration date. Controlled substances should be stored under two locks and liquid lorazepam should be kept in the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure ordered STAT (immediate) laboratory testing had been obtained and results received in a timely manner for one resident and failed to obtain a laboratory test for one additional resident (Resident's #38 and #52). The sample was 18. The census was 90. 1. Review of Resident #38's care plan, updated 11/15/19, showed: -Problem: Occasionally incontinent; -Goal: Measures will be taken to prevent skin breakdown; -Interventions: Staff to assist to change incontinence pad as soon as possible after voiding, provide daily skin inspections, keep the skin clean, dry and free of irritants. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/16/19, showed: -Moderate cognitive impairment; -Felt depressed two to six days; -No behaviors; -Limited staff assistance needed with toileting and hygiene; -Frequent urinary incontinence; -Diagnoses of depression and stroke. Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 1/6/19 at 11:41 A.M., for a STAT urinalysis (UA, used to test the urine for infection) one time only. The diagnoses used noted as other specified depressive episodes. Review of the resident's progress notes, showed: -On 1/6/20 at 5:52 P.M., the resident noted to have behaviors, threatened to hit the administrator, unusual behavior for the resident. Next of kin notified and requested a STAT UA, the resident's physician called and a new order given for the STAT UA. The urine sample obtained and picked up by lab at 11:00 A.M.; -No further documentation or lab results noted. Review of the resident's lab reports, showed a urinalysis laboratory and culture results, dated 1/14/19: -Specimen collected: 1/14/16 at 10:45 A.M.; -Specimen reported: 1/16/19 at 3:40 P.M.; -Results: positive for mucus, white blood cells (infection fighting cells) and nitrates (indicates a bacterial infection); -The attached culture results, showed the urine same positive for Escherichia coli (e-coli, common bacteria found to cause infections). The culture results recommended Ciprofloxacin (Cipro, antibiotic used to treat bacterial infections) for the treatment; -No UA report dated 1/6/20. Further review of the resident's ePOS, showed: -An order dated 1/14/19 at 11:14 A.M., for Cipro 250 milligram (mg) give one tablet by mouth twice a day for seven days for a urinary tract infection (UTI). Further review of the resident's progress notes, showed: -On 1/14/20 at 11:26 A.M., received a new order from the physician to obtain a STAT UA with culture for behaviors. The urine sample collected and placed in the refrigerator. The laboratory called and notified to pick up sample; -On 1/14/20 at 11:36 A.M., the physician gave a new order to begin Cipro, 250 mg take one tablet twice a day for seven days for a UTI. The resident's first dose administered from the facility's emergency medication supply (E-kit). The resident's next of kin made aware of the results and the order for antibiotic. During an interview on 1/27/20 at 1:15 P.M., the Director of Nursing (DON) said the facility does not have a policy for STAT labs. She called the facility's laboratory provider and the laboratory provider told her that the turnaround time for STAT labs was 5 hours from the time the sample was picked up from the facility to providing results to the facility. The facility did not have any paperwork to show the agreement with the laboratory provider. It is the responsibility of the charge nurse to get immediate samples for STAT laboratory orders. The original STAT order was given to the nurse on 1/6/20 and it appeared the original sample was not obtained or followed up on by the staff. A delay in testing or results could worsen an infection and delay treatment time. 2. Review of Resident #52's annual MDS, dated [DATE], showed: -Cognitively intact; -The resident required limited assistance of one staff for transfers and extensive assistance of one staff for toileting, and the resident was frequently incontinent of bowel and bladder; -Diagnosis included: high blood pressure, diabetes, high cholesterol, Alzheimer's disease, enlarged prostate with lower urinary tract symptoms, generalized anxiety disorder and major depressive disorder. Review of the resident's progress notes, dated 1/2/20, showed; -The resident had a blood sugar level of 397 at 11:30 A.M., the nurse administered insulin; blood sugar was rechecked and the physician was notified. Order for additional insulin was received and to obtain an order for a UA, Complete Blood Count (CBC, a blood test used to evaluate overall health and detect disorders such as anemia and/or infection) and Basic Metabolic Panel (BMP, a blood test of the body's fluid balance, levels of electrolytes, and how well the kidneys are working). Review of the resident's ePOS, dated 1/1/20 through 1/27/20, showed: -BMP diagnosis: type two diabetes mellitus without complications start date 1/2/20; -CBC one time only, diagnosis: type two diabetes mellitus without complications, start date 1/2/20; -No order for UA was on the physician order sheet. Review of the resident's lab reports, showed no UA obtained on 1/2/20. Further review of the resident's medical record, showed: -Seen by the physician on 1/4/20 at the skilled nursing facility. The plan was to order a UA, and adjust the resident's insulin. Review of the resident's care plan, in use during survey, showed: -Problem: At risk for problems with elimination (bowel and bladder), The resident is frequently incontinent related to restricted mobility and urgency; takes Lasix (water pill) routinely; requires moderate assist with changing and personal care; requires limited assistance for toileting; mobility, needs assistance; mentally aware of toileting needs, sometimes; bladder, frequently incontinent due to stress or urgency; bowel, frequently incontinent; -Goal: Resident will be assisted with incontinence to ensure social acceptance; -Interventions: Assist to toilet as needed; check resident every two hours and assist with toileting as needed; monitor for signs and symptoms of urinary tract infection; provide personal care after each incontinent episode; uses briefs. During an interview on 1/27/20 at 3:22 P.M., the DON said the UA was not obtained on 1/2/20. The nurse called the doctor and obtained an order but the doctor the nurse called was not the resident's primary doctor. The resident had been going back and forth between two doctors. The doctor the nurse called had seen the resident and was one of the doctors the resident was going back in forth with. The DON said once the nurse realized he/she called the wrong doctor, the nurse should have contacted the correct doctor to verify the orders. But they did not realize it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for three residents with missing behavior documentation, sleep disturbance documentation and/or non-phrenological interventions implemented, and had improperly documented diagnoses (Residents #42, #32 and #38). The sample was 18. The census was 90. 1. Review of the Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/25/19, showed: -Cognitively intact; -Diagnoses includes coronary artery disease, heart failure, high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), pneumonia, diabetes, hyperlipidemia (high level of lipids), stroke, dementia, anxiety, depression, asthma, and respiratory failure; -No behaviors; -Antipsychotics, antidepressant, and antianxiety medications administered in the last seven days; -Hypnotics administered in the last four days; -Gradual dose reduction (GDR) attempted: No; -Drug regimen review: no issues. Review of the resident's care plan, dated 12/13/19, showed: -Problem: Insomnia related to melatonin (natural sleep supplement) and Ambien (sleeping pill). Evidenced by abnormal sleep pattern; -Goal: Utilize approaches in order to help resident; -Interventions: -Assess for fall risk; -Check as quietly as possible during the night in order to help prevent waking resident; -Discourage excessive caffeine consumption; -Document excessive awake times during the night. Monitor for effectiveness of medications; -Discourage daytime napping; -Encourage activity/exercise during the day; -Evaluate appropriateness and effectiveness and attempt periodic dose reduction; -Monitor behaviors every shift; -Provide an environment conductive to sleep; -Provide medications as ordered; -Psych consult as needed. Review of the resident's electronic physician order sheet (ePOS), dated 12/1/19 through 1/31/20, showed: -An order, dated 5/9/19, for Ambien 5 milligram (mg), one tablet by mouth at bedtime for insomnia. The Ambien discontinued on 12/31/19; -An order, dated 11/29/19, for melatonin 10 mg, one tablet by mouth at bedtime for insomnia. Review of the resident's Medication Administration Record (MAR), dated 12/1/19 through 12/31/19, showed Ambien 5 mg, one tablet by mouth at bedtime administered as ordered. The Ambien was discontinued on 12/20/19. Further review of the resident's POS, showed: -An order, dated 12/30/19, for Ambien 10 mg, one tablet by mouth at bedtime as needed for insomnia. The Ambien discontinued on 1/3/20; -An order, dated 1/3/20, for Ambien 10 mg, one tablet by mouth at bedtime as needed for insomnia. The Ambien discontinued on 1/4/20; -An order, dated 1/4/20, for Ambien 10 mg, one tablet by mouth at bedtime as needed for insomnia. The Ambien discontinued on 1/10/20; -An order, dated 1/14/20, for Ambien 10 mg, one tablet by mouth at bedtime as needed for insomnia. The Ambien discontinued on 1/14/20; -An order, dated 1/14/20, for Ambien 5 mg, one tablet by mouth at bedtime as needed for insomnia. Review of the resident's MAR, dated 1/1/20 through 1/31/20, showed: -Ambien 10 mg, one tablet by mouth at bedtime as needed administered on 1/3, 1/6, 1/7, 1/8, 1/11, 1/13/20; -Ambien 5 mg, one tablet by mouth at bedtime as needed as administered on 1/15 and 1/22/20 -Melatonin 10 mg, one tablet by mouth a bedtime administered as ordered. Review of the resident's medical record, showed no documentation of the resident excessive awake times during the night or monitor for effectiveness of sleep medications administered. Observation and interview on 1/22/20 and 1/24/20, showed: -On 1/22/20 at 9:04 A.M., the resident lay in bed. Licensed Practical Nurse (LPN) A said the resident does not get dressed until late in the afternoon; -On 1/24/20 at 9:58 A.M., the resident lay in bed. He/she just woke up and would like for the surveyor to return later. At 12:17 P.M., the resident he/she had the best sleep in a long time. He/she was on Ambien 10 mg, but the psychiatrist decreased it to 5 mg and it made him/her very upset. The resident found a new psychiatrist and now he/she is on Ambien 6.5 mg. He/she always had insomnia. Staff told his/her spouse that he/she sleeps at night, but the resident said he/she does not sleep. Staff does not keep track of his/her sleeping schedule or offer him/her anything other than medications during the nights he/she cannot sleep. He/she is administered Ambien at 11:00 P.M. He/she is usually up in the morning at 10:00 A.M. During an interview on 1/24/20 at 12:25 P.M., LPN P said the resident likes to sleep in. He/she is on a lot of medications. It had affected his/her sleep. During an interview on 1/23/20 at 3:42 P.M., the Director of Nursing (DON) said the resident had a history of insomnia. There were changes to the Ambien due to his/her diagnoses. The psychiatrist discontinued his/her Ambien and he/she has a sleep study scheduled for the end of the month. The doctor changed the Ambien orders and prescribed it to the resident after the psychiatrist discontinued it. The resident said he/she does not sleep at night; however, staff confirmed he/she does. There is no documentation of staff keeping track of the resident's sleep schedule, when he/she is awake and when he/she is asleep. Documentation has not been consistent. 2. Review of Resident #32's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, diabetes, hyperlipidemia, anxiety, depression, asthma, respiratory failure, and obstructive sleep apnea; -No behaviors; -Anti-depressants and hypnotic administered in the last seven days; -Anti-anxiety medications administered in the last three days. Review of the resident's care plan, dated 5/17/19, showed no documentation of a diagnosis of insomnia or the rationale for the use of Ambien. Review of the resident's ePOS, showed: -An order, dated 11/9/19, for Ambien 5 mg. One tablet by mouth, one time per day for major depressive disorder. The Ambien discontinued on 12/18/19; -An order, dated 12/18/19, for Ambien 10 mg. One tablet by mouth, one time per day for insomnia. The Ambien discontinued on 1/23/20; -An order, dated 1/23/20, for Ambien, 10 mg tablet by mouth daily per day for insomnia. Review of the resident's MAR, dated 1/1/20 through 1/31/20, showed: -Ambien 10 mg, one tablet by mouth, one time per day administered as ordered. It was discontinued on 1/23/20; -Ambien 10 mg, one tablet by mouth, one time per day was administered as ordered. Review of the resident's medical record, showed no documentation of the resident's insomnia, issues and concerns with sleep, and rationale for the use of Ambien. During an interview on 1/27/20 at 3:23 P.M., the DON said she would expect staff to document the resident's history of insomnia, monitor and document sleep. She would expect the use of Ambien and the rationale for it to be documented. 3. Review of Resident #38's quarterly MDS, a federally mandated assessment instrument completed by facility staff, dated 11/16/19, showed: -Moderate cognitive impairment; -No mood or behaviors; -Took antidepressants daily; -Antipsychotic taken daily; -Diagnoses included stroke, allergies, nose bleed, nutritional deficit and chronic pain. Review of the resident's ePOS, showed: -An order dated 2/21/19, for Lexapro (antidepressant) 10 mg daily for other specified depressive disorder; -An order dated 8/28/19, for Risperdal (antipsychotic) 0.25 mg take one tablet daily twice a day for other specified depressive disorder. Review of the care plan, updated on 11/18/19, showed: -Problem: the resident takes an antidepressant medication: -Goal: The resident will be at a level of comfort that he/she judged as acceptable; -Interventions: Staff administer the medication as ordered, monitor the resident closely for worsening of depression or suicidal behaviors or thinking and monitor for falls; -Problem: The resident takes an antipsychotic medication: -Goal: The resident will be at a level of comfort that he/she judged as acceptable; -Interventions: Staff monitor behaviors every shift and document, staff observe possible side effects every shift for muscle rigidity, bladder retention, low blood pressure, balance problems, tremors, tardive dyskinesia (TD, side effect of antipsychotic medications can cause stiff, jerky uncontrolled movements of the face and body). Review of the resident's medical record, showed no documentation for behavior monitoring or assessment of the use of antipsychotics. During an interview on 1/27/20 at 3:23 P.M., the DON said documentation should be complete.

Based on observation, interview and record review, the facility failed to implement and effective infection prevention and control program by failing to follow the facility's transmission based precaution policy for one resident on isolation (Resident #288). The sample was 18. The census was 90. Review of the facility's Transmission Based Precautions Isolation Precautions policy, dated 11/7/17, showed: -This policy outlines the precautions required to prevent transmission of infectious agents. Standard precautions are to be followed at all times. Additionally, transmission-based precautions may be required on a case by case basis and will be determined by the Director of Nursing (DON); -Transmission-Based Precautions include standard precautions, and are divided into three categories: Contact Precautions, Droplet Precautions and Airborne Precautions; -Suspected and or positive for Clostridium difficile (c-diff., a bacteria that causes diarrhea): -A sign must be placed on the room door to not enter until speaking with the nurse; -The resident is placed on Contact Isolation, which requires the wearing of isolation gown and gloves whenever in the residents room (all staff, visitors and vendors); -Strict hand washing with soap and water (no using the alcohol foam) is a must before leaving the resident room. Review of Resident #288's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/16/19, showed: -Severe cognitive impairment; -Required extensive assistance, for grooming, dressing, bathing, toileting and transfers; -Frequently incontinent of bowel and bladder; -Other services: Isolation while resident and while not a resident; -Diagnosis included: heart failure, high blood pressure, diabetes, high cholesterol, and enter colitis (infection of the colon) due to c-diff. Review of the residents care plan, in use during survey, showed: -Problem: Contact isolation required evidenced by c-diff; -Goal: Prevent/manage the likelihood of complications due to isolation; -Inventions: contact isolation precautions are to be used during all aspects of care; educate resident and family members on standard precautions and the importance of handwashing. Observation during survey, showed: -On 1/21/20 at 11:00 A.M. and 1/22/20 at 7:00 A.M., outside the residents room was a three drawer container with gowns, mask and gloves. Inside the residents room was two hampers with no red bags hanging in them. No sign on the resident's door prompting visitors to see the nurse before entering; -On 1/22/20 10:00 A.M., a red sign was on the resident's door. The sign said: Please see nurse. Thank You. During an interview on 1/21/20 at 2:20 P.M., Certified Nurse Aide (CNA) H said the resident was on contact isolation. During an interview on 1/22/20 at 2:00 P.M., Licensed Practical Nurse (LPN) E said the resident was on isolation because he/she had c-diff. During interview on 1/24/20 at 1:30 P.M., LPN G said, the resident has been on isolation since he/she got home from the hospital, and the isolation was being discontinued today. Isolation precautions is communicated to staff by the sign on the door. During an interview on 1/27/20 at 3:22 P.M., the DON said isolation precautions are communicated by a sign on the door.

Based on interview and record review, the facility failed to ensure each resident had the opportunity to receive the pneumococcal vaccine, unless documentation showed the vaccine was medically contraindicated, refused or the resident was already immunized by failing to offer the pneumococcal vaccine to three residents (Residents #18, #28, and #8) out of five residents sampled for the pneumococcal vaccine. The resident sample was 18. The facility census was 90. 1. Review of Resident #18's medical record, showed the following information: -admission date of 10/12/17; -Diagnoses included high blood pressure, diabetes, stroke, seizure disorder, and depression; -No documentation in the medical record or electronic medical record that the pneumococcal vaccine was offered or received. 2. Review of Resident #28's medical record, showed the following information: -admission date of 7/23/13; -Diagnosis included high blood pressure, seizure disorder, and anxiety disorder; -No documentation in the medical record or electronic medical record that the pneumococcal vaccine was offered or received. 3. Review of Resident #8's medical record, showed the following information: -admission date of 4/9/19; -Diagnoses included anemia and gastroesophageal reflux disease (GERD, acid reflux); -No documentation in the medical record or electronic medical record that the pneumococcal vaccine was offered or received. 4. During an interview on 1/27/20 at 3:23 P.M., the Director of Nursing said the pneumococcal should be offered every five years. She would expect the facility to keep record of when it was offered and when the last received the vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure the resident's environment remains as free of accident hazards as is possible when a closet door fell and hit a resident (Resident #76). In addition, the facility left potentially harmful treatment supplies accessible to residents in a resident room (Resident #28) and in a small storage area on one unit. This had the potential to affect all residents who were able to move freely around the facility. The census was 90. Review of the facility's Accidents Policy, dated 10/15/19, showed: -The health and safety of each resident is of the upmost importance at the facility. In order to obtain and maintain the highest level of health and safety for its residents, the facility will ensure: -The resident environment remains as free of accident hazards as is possible; -Each resident receives adequate supervision and assistance devices to prevent accidents; -The facility is committed to developing a culture of safety and implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents; -All staff are to be involved in observing and identifying potential hazards' in the environment, while taking into consideration the unique characteristics and abilities of each resident; -Evaluation and analysis, implementation of interventions, and monitoring and modification of identified hazards and risks are all interdisciplinary processes that take place once hazards and risks are identified are to be documented and communicated across all disciplines; -Morning standup meeting is conducted Monday through Friday and report is given on every resident in the community. Any incident or accident that is reported to the entire management staff is reported and a plan of care to assist with reducing the risk of the incident or accident is developed for all disciplines involved to follow. When an accident or incident has occurred, the nurse will complete an assessment and it is the responsibility of the director of nursing (DON) and administrator to complete by reviewing the occurrence and signing off. The charge nurse will notify the Physician and obtain any orders if needed. Also the charge nurse will notify the family or responsible party if the resident is not their own responsible party. The charge nurse will initiate any services needed immediately for an injury or accident to assure the best outcome for care of the resident. 1. Review of Resident# 76's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/19, showed: -Cognitively intact; -Required no staff assistance with activities of daily living (ADLs); -Wheelchair for mobility; -Diagnoses included high blood pressure, diabetes, hyperkalemia (low potassium), high cholesterol, anxiety, and depression. During an interview on 1/22/20 at 7:51 A.M., the resident said his/her closet door fell on him/her, hit him/her in the face and knocked over his/her wheelchair. Review of the facility's Incident/Accident Report, dated 8/19/19, showed the following for the resident: -Incident type, skin tear to left inner arm; -Reported by resident; -Witnessed, no; -Location of incident, resident room, bed; -Activity at time of incident, reaching; -Equipment involved, other/closet door; -Cognitive status, moderately impaired; -Pain rate at present, scale from 1 through 10 (10 being the worse), 6; -Resident made nurse aware he/she was reaching for clothing and the closet door began to fall and he/she caught it with his/her left hand before it could hit his/her body. Door being too heavy for resident to place on floor, it slowly fell down his/her left arm onto the floor; -Comments, maintenance repaired door, 8/20/19, placed back on track, encourage resident to ask for assistance. Review of the resident's medical record, showed a physician note, dated 9/24/19, patient stated the closet door fell on him/her and scratched his /her nose, there is a raw area. Observation and interview on 1/22/20 at 8:09 A.M., the maintenance director said he was not aware the resident's closet door fell on him/her. The maintenance director walked to the resident's room and said he was not aware one of the resident's sliding closet doors was missing. Staff should have submitted a work order. It must have gotten missed. The closet doors are on the maintenance preventative maintenance (PM) program to be completed monthly. During an interview on 1/23/20 at 11:38 A.M., Licensed Practical Nurse (LPN) E said he/she recalled the incident with the closet door and thought it happened in the summer. The resident called for help, the CNA immediately helped the resident and made LPN E aware and he/she could not remember if x-rays were ordered. Observation and interview on 1/23/20 at 11:43 A.M., showed the resident seated in his/her wheelchair inside his/her room, the resident now has sliding closet doors that appeared new. The resident said he/she has brand new closet doors, but the closet door had been missing since it fell off and hit him/her in the face. Review of the facility's PM program, showed the resident's closet doors were to be checked weekly, with the recent checks completed on 1/9/20 and 1/16/20. The maintenance director said he was unaware they were to be completed weekly and there's always something that gets missed. During an interview on 1/23/20 at 12:00 P.M., the maintenance director said he reviewed his orders and could not find one for August regarding the resident's closet door. The door might have come off the track because it did not connect at the bottom or have a faceplate at the top to catch it, if it became disconnected. During an interview on 1/27/20 at 4:50 P.M., the administrator said he would have expected staff to follow the policy and have checked the doors, evaluated/and or replaced the closet doors, taking a proactive measure to make sure the doors were safe and to prevent future injuries. 2. Review of Resident #28's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Total staff assistance for all care needs; -Nutritional needs met with tube feeding (hollow tube inserted into the stomach to provide liquid nutritional needs); -Received treatments to the feet. Observations of the resident's room, on 1/21/20 at 10:24 A.M., 11:45 A.M., and 4:45 P.M., on 1/22/20 at 9:06 A.M. and 1:38 P.M., on 1/23/20 at 9:35 A.M., 2:21 P.M., and 4:04 P.M., and on 1/24/20 at 9:24 A.M., showed two half full bottles of povidone iodine topical antiseptic and two bottles of wound cleanser spray in an open box that contained wound care supplies on the bedside table. The resident's bedroom door remained open. Review of the safety data sheet for povidone iodine, showed: -Hazard identification: acute toxicity oral, maybe harmful if swallowed; -First aid measures: -Eye contact: flush the eyes with large amounts of water for at least 15 minutes. If irritation persists, seek medical attention; -Skin contact: if irritation develops, wash the area with water. Get medical attention if irritation persists; -Inhalation: remove person to fresh air. Seek medical attention if discomfort persists; -Ingestion: If swallowed, call a physician immediately. Rinse the mouth and throat thoroughly with water. Do not induce vomiting unless directed to do so by the physician. Never give anything by mouth to an unconscious person. If vomiting occurs spontaneously, keep the person's head below the hips to prevent aspiration of the liquid into the lungs. During an interview on 1/27/20 at 3:23 P.M., the Director of Nursing (DON) said all medications, including treatment medications should be secured on the medication cart or the treatment cart. 3. Observation of a small storage room, at the end of the hall C, on the first floor, with a sign on the door saying: No eating! No lounging! No breaking! This is not a break room, showed: -On 1/21/20 at 11:00 A.M., the door to the room unlocked. Inside the room, in a box, was two bottles of Dakin's solution (a strong antiseptic that kills most forms of bacteria and viruses); -On 1/22/10 at 1:26 P.M., the two bottles of Dakin's remained in the same room, and door to the room remained unlocked; -On 1/23/20 at 11:43 A.M., the two bottles of Dakin's remained in the same room and door to the room remained unlocked. During an interview on 1/27/20 at 3:22 P.M., the DON said Dakin's solution should be kept in a locked room. Review of the facility's medication storage policy, dated 6/1/2018, showed: -Policy: Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications; -Procedure: Only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication supplies are locked when not attended by persons with authorized access; -All refrigerated medications should be kept at a refrigerator at a temperatures between two degrees Celsius (C) or 36 degrees (F, Fahrenheit) and eight degrees C or 46 F; -Controlled substances requiring refrigeration are stored within a locked box within the refrigerator. The box must be attached to the inside of the refrigerator. MO00162700

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs by failing to complete a gradual dose reduction (GDR) as indicated for one resident of eight residents investigated for unnecessary psychotropic medications(Resident #43). The sample size was 18. The census was 90. Review of Resident #43's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/28/19, showed: -Cognitively intact; -Required no assistance by staff for activities of daily living (ADLs); -Wheelchair/walker for mobility; -Medications included: -Antipsychotics, 7 days a week; -Antidepressants, 7 days a week; -Diagnoses included dementia, seizure disorder, depression, and diabetes. Review of the resident's electronic physician order sheet (ePOS), dated 1/1/20 through 1/31/20, showed: -An order, dated 7/13/19, for Effexor XR (antidepressant, generic name of Venlafaxine HCL) 75 milligram (mg) capsule, 1 capsule every evening; -An order, dated 7/13/19, Effexor XR 150 mg capsule, 1 capsule every evening; -An order, dated 1/15/20, Trazodone (sedative and antidepressant) 150 mg at bedtime. Review of the resident's attending physician/prescriber pharmacy review, dated 1/11/20, showed: -Gradual Dose Reduction requirement for psychotropic medications; -The resident is on Venlafaxine ER 225 mg PO daily in the evening and Trazodone 100 mg PO daily at bedtime. Could his/her Venlafaxine be reduced to 150 mg PO daily in the evening; -If dose reductions are clinically contraindicated, please document accordingly; -Physician/Prescriber response, blank. Review of the resident's medical record, showed no documentation the GDR for venlafaxine as contraindicated or attempted. During an interview on 1/23/20 at 3:33 P.M., the Director of Nursing (DON) said the pharmacy recommendations for a GDR goes to the nurse, the nurse faxes them to the physician and the physician is supposed to reply within 24 hours. The facility did not have a system in place to make sure the pharmacy recommendations are followed up on with the physician.

Based on observation and interview, the facility failed to ensure staff protected food from contamination by not ensuring drinks were covered while serving residents in the dining room. This had the potential to affect all residents in who dined in the facility. The census was 90. Observation of the resident dining room, showed: -On 1/21/20 at 5:27 P.M., staff pushed a two tiered serving cart through the dining room beside seated residents. Approximately 20 drinks, sat on the bottom tier of the cart and were uncovered; -On 1/22/20 8:39 A.M., dietary staff pushed a two tiered serving cart through the dining room, beside seated residents. A tray on top of the cart filled with orange juice and milk, sat uncovered; -On 1/23/20 at 12:15 A.M., dietary staff pushed a two tiered serving cart, passing drinks in the dining room, beside seated residents, all of the drinks on both tiers were uncovered; -On 1/23/20 12:44 P.M, 20 cups of pink drinks, uncovered, sat on top of a two tiered serving cart next to the handwashing sink, while staff were observed washing their hands. During an interview on 1/27/20 at 4:50 P.M., the dietary manager said she did not have a policy in regard to safe food handling but would expect staff to ensure food and drinks were covered to protect against coughs or sneezes and/or any type of possible contamination.