Based on interview and record review, the facility failed to maintain an effective system of records and disposition of controlled medications when staff could not locate two cards of a controlled medications and failed to destroy the discontinued controlled medication in a timely fashion for one resident (Resident #1). The facility census was 56. On 04/02/24, the Assistant Director of Nursing (ADON) was notified of the Past Non-Compliance that occurred on 04/01/24. The ADON notified the physician, the Director of Nursing (DON), and the Administrator. The Administrator notified the Ozark Police Department. The DON and ADON completed an narcotic count audit. Administration interviewed staff and residents and reviewed the camera surveillance. The Administrator suspended the employee pending completion of the investigation. Administration completed in-service education with all licensed nurses and certified medication technicians (CMT) regarding controlled substances. The noncompliance was corrected on 04/10/24. Review of the facility's policy titled Controlled Substances, dated 04/2007, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances; -Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises; -Controlled substances must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together. Both individuals must sign the designated narcotic record; -If the count is correct, a control sheet must be made for each substance. Do not enter more than one prescription per page. This record must contain: name of resident, name and strength of the drug, quantity received, number on hand, name of physician, prescription number, name of issuing pharmacy, dated and time received, time of administration, method of administration, signature of person receiving medication and signature of nurse administering medication; -Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services (DON) or Designee; -The Director of Nursing Services or Designee shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings; -When a resident or patient is transferred or discharged from the facility, Schedule II drugs may not be given to the resident to take with them and may not be returned to the pharmacy, but must be destroyed in accordance with established policies. Review showed the facility did not provide a policy related to destruction of controlled medications. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 07/21/23 and discharge date of 04/01/24; -Diagnoses included arthritis of the left knee and dementia. Review of the resident's care plan, revised 08/02/23, showed the following: -The resident had a potential for pain related to knee replacement with a wound infection; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Monitor, record, and report to the nurse any signs or symptoms of non-verbal pain; -Monitor, record, and report to the nurse resident complaints of pain or requests for pain treatment; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; -Report to the nurse any change in usual activity attendance patterns or refusal to attend activities related to signs, symptoms or complaints of pain or discomfort. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 03/06/24, showed the following: -Cognitively intact; -The resident had occasional pain and was on a scheduled pain medication regimen. Review of the resident's April 2024 Physician's Order Sheet (POS) showed the following: -An order, dated 07/21/23 and discontinued 07/25/23, for oxycodone HCL (a drug to treat moderate to severe pain) 5 milligram (mg) tablet, give 5 mg by mouth (PO) every four hours as needed for severe pain with maximum daily amount of 30 mg. Review of the resident's July 2023 Medication Administration Record (MAR) showed staff did not administer oxycodone to the resident from 07/21/23 through 07/25/23. Review showed the facility did not provide a narcotic control sheet for the oxycodone. Review of the facility's investigation, dated 04/02/24, showed the following: -On 04/02/24, at approximately 8:30 A.M., it was reported to the ADON there was a potential discrepancy in the narcotic count; -An audit was completed and it was noted narcotics for the discharged resident had been removed from the cart. The resident had discharged the afternoon of 04/01/24; -The resident's narcotics had not been destroyed by nurse leadership as the resident was just discharged ; -An investigation was initiated by the facility; -Upon completion of the investigation, the facility acknowledged there was sufficient evidence to support employee Licensed Practical Nurse (LPN) E had diverted what is believed to be unknown medication from the facility. During an interview on 04/18/24, at 1:18 P.M., CMT D said the following: -When he/she arrived at work, he/she counted medications with the night nurse; -They first counted the number of medication cards and bottles of narcotics and then the total amount of pills and ensured both counts matched the narcotic sheets; -If he/she noticed a discrepancy, he/she checked the computer to see if a dose was given and not documented on the narcotic sheet. If a discrepancy remained, he/she notified the ADON and did not accept the cart until the discrepancy was resolved; -On 04/02/24, he/she pulled a medication card out of the cart and the number did not correspond with the narcotic sheet. He/she immediately took this to the ADON and the ADON found them signed as given in the computer and not marked on the narcotic sheet; -Later the same day, he/she emptied a card of narcotics and went to mark it off on the narcotic record and notices the narcotic record had two cards of Norco marked off with his/her signature forged on the narcotic sheet. He/she immediately stopped what he/she was doing and took this to the ADON and that prompted a search of both the CMT and the nurses' carts; -He/she counted with LPN E that morning. During an interview of 04/18/24, at 4:18 P.M., LPN B said the following: -When he/she and LPN E counted the medication, the resident's oxycodone was in the cart; -He/she knew this because he/she counted this medication since 07/2023. -On 04/01/24, he/she and LPN E counted the medications in the nurses' cart together; -When he/she counted with the oncoming nurse, the oncoming nurse had the cart and he/she gave the numbers from the narcotic book. During an interview on 04/18/24, at 1:55 P.M., LPN C said the following: -When he/she arrived at work, he/she counted medications with the night nurse on the nurses' cart and the CMT counted medications with the same nurse on the CMT cart; -They counted the number of narcotic cards and then the number of pills to ensure they were the same as the narcotic record; -If he/she noticed a discrepancy, he/she did not accept the cart and notified the ADON immediately. At times, the ADON oversaw the counts; -When he/she gave a narcotic medication, he/she documented this in the computer and in the narcotic log that showed the amount of pills and cards. During an interview on 04/18/24, at 11:45 A.M., Registered Nurse (RN) A said the following: -CMTs count medications with the next shift; -When nursing or CMTs gave a narcotic, they documented this in the narcotic book with the time, their initials, date given and how many pills left; -If he/she noticed a discrepancy, he/she would first recount the medication, not take control of the medication cart until the count was correct, and notified the DON; -The facility required two RNs to destroy medications. Until the medications were destroyed, the medications remained in the cart and nursing staff or CMTs counted them daily. During an interview on 04/18/24, at 2:11 P.M., the ADON said the following: -She found the narcotic log for adding or removing cards of medication showed LPN E removed four cards of oxycodone, but the ADON realized the resident only had two cards of this medication; -She looked for the narcotic log that showed the amount of pills for the oxycodone and could not find it and never did find it; -The resident's oxycodone was not in the cart. The resident had one card of 30 pills and one card of 12 pills and he/she never used that medication. During an interview on 04/18/24, at 3:23 P.M., the DON said the following: -Nursing staff should have destroyed the resident's oxycodone a long time ago if it was discontinued on 07/25/23; -Nursing staff should have pulled the oxycodone off the cart the day it was discharged . During an interview on 04/18/24, at 3:52 P.M., the Administrator said the following: -The DON and ADON destroyed medications and she had a discussion with the DON and ADON about how long the resident's oxycodone stayed in the cart; -The DON and ADON should have destroyed the oxycodone; -She was unable to account for 42 pills of oxycodone and all indicators pointed to LPN E took the medication. MO00234123

Based on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers when staff failed to document physician notification of wound development/changes, failed to obtain orders for all treatments provided, failed to document complete and routine assessments of wounds, failed to consistently implements identified interventions, and failed to update the care plan timely regarding actual skin breakdown and intervention changes for one resident (Resident #24) of seven sampled residents. The facility census was 56. Review of the facility's policy Prevention of Pressure Injuries, revised April 2020, showed the following: -Assess the resident on admission for existing pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) risk factors. Repeat the risk assessment weekly and upon any changes in condition; -Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living - bathing or showering, dressing, getting in and out of bed or a chair, using the toilet, and eating); -Identify any signs of developing pressure injuries such as non-blanchable erythema (discoloration of the skin that does not turn white when pressed); -Inspect pressure points (sacrum (the large triangle bone in the lower spine that forms part of the pelvis), heels (back part of the foot), buttocks (the two fleshy parts that form the lower rear area of a human), coccyx (small bone or tailbone), elbows, and ischium (a paired bone of the pelvis that forms the lower and back part of the hip bone)); -Wash the skin after any episodes of incontinence; -Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team; -Use a barrier product to protect skin from moisture; -Use incontinence products with high absorbency; -Evaluate, report, and document potential changes in the skin. Review of the facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, showed the following: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers to include immobility, recent weight loss, and a history of pressure ulcer(s) (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device); -The nurse may describe and document/report the following: -Assessment of pressure sore including location, stage, length, width and depth, present of exudates or necrotic tissue, pain assessment, mobility status, and current treatments; -The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers; -The physician will assist the staff to identify the type and characteristics of an ulcer; -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, dressings and application of topical agents; -During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with poorly-healing wounds; -The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions; -Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions, and affected by factors influencing wound development or healing. Review of the facility's Wound Care Policy, revised October 2010, showed the following: -Staff were to document type of wound care; date and time the wound care was provided; name and title of staff performing the wound care; any change in the resident's condition; all assessment data (such as wound bed color, size, drainage, etc) when inspecting the wound, and any problems or complaints made by the resident related to the procedure, in the resident's medical record. 1. Review of Resident #24's face sheet (document that gives admission information at a glance) showed the following: -admission date of 12/09/22; -Diagnoses included spinal stenosis (spaces inside the bones of the spine get too small and affects mainly the neck and lower back); Type 2 diabetes mellitus (high blood sugar) with other diabetic kidney complication; moderate protein-calorie malnutrition (poor dietary intake to cause muscle wasting and loss of body fat); chronic atrial fibrillation ( abnormal heart rhythm); peripheral neuropathy (damage that affects any part of the peripheral nervous system that transmits vital information from brain and spine to the body); chronic kidney disease (kidney damage where they are less likely to filter waste and fluid out of the blood); and anemia (a lack of red blood cells that leads to reduced oxygen flow to the body's organs). Review of the resident's care plan, revised on 12/20/22, showed the following: -Staff to perform skin audits per facility protocol and report all abnormalities noted to the physician; -Staff to check all of body for breaks in skin and treat promptly as ordered by the physician. Review of the resident's progress notes, dated 12/11/23, showed the staff assessed the resident as a high risk for development pressure ulcers. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/12/24, showed the following: -Resident's cognition was intact and resident was interviewable; -Always incontinent of bowel and bladder; -At risk for pressure ulcers; -No unhealed pressure ulcers; -Has pressure reducing device for chair and bed; -Applications of ointments/medical other than to feet. Review of the resident's care plan, revised 12/15/23, showed the following: -Potential for impairment to skin integrity related to incontinence of bowel and bladder and weakness and decreased mobility and use of wheelchair for locomotion; -Apply a moisture barrier cream as needed; -Pressure relieving/reducing mattress on bed when in bed and pressure relieving/reducing cushion in wheelchair when in the wheelchair; -Staff to perform Braden scale (tool used to predict pressure ulcer risk for developing pressure ulcers) quarterly and as needed (PRN) per facility protocol; -Perform skin audits per facility protocol and report all abnormalities noted to physician; -Staff to perform treatments per prescription and ensure effectiveness. If area worsens, notify the physician. -Staff to ensure resident was repositioned and buttocks (the two round fleshy parts that form the lower rear area of the trunk) was offloaded (minimize or remove weight to help prevent and heal pressure ulcers) at least every two hours and as needed. Review of the resident's Treatment Administration Record (TAR), dated December 2023, showed the following: -Staff to monitor for coccyx/perineal area for breakdown and/or bleeding one time a day; -Skin assessment weekly every day shift on Thursday; -Offload coccyx as tolerated related to pain every day and evening shift for pain; -Barrier cream to perineal area three times a day and as needed for excoriation; -Staff documented they completed these interventions and treatments. Review of the resident's shower sheet, dated 12/21/23, showed the following: -Shower aide circled the lower sacrum on the diagram of the stick figure person's back on the shower sheet and wrote two open breakdown at the top area of the resident's bottom; -The nurse commented at the bottom of the sheet chronic open area to coccyx (the triangular bone at the very bottom of the spine or tailbone), stage II (partial thickness loss of dermis (top layer of skin) presenting as a shallow open ulcer with red or pink wound bed, without slough (shedding skin) or bruising. May also present as an intact or open/ruptured blister); superficial, with treatment in place. Review of the resident's skin evaluation only note, dated 12/21/23, showed the following: -Staff documented the resident had current skin excoriation (skin is scraped, red or abraded or coming off) on the resident's coccyx that measured one centimeter width and one centimeter length; -Staff documented the resident had ongoing chronic area to the coccyx that was being treated daily and PRN. Staff was to apply a cushion to the wheelchair for further pressure relief prevention. (Staff did not document notifying the resident's physician of the area.) Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or any new interventions. Review of the resident's skin/wound progress note, dated 12/24/23, showed there was an open area to the coccyx surrounded by discoloration. Staff educated to reposition the resident every two hours and apply barrier cream every shift and as needed with incontinence episodes. (Staff did not document notifying the resident's physician of the area.) Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or new interventions related to the area. Review of the resident's skin/wound progress note, dated 12/25/23, showed the resident had a small open area on the coccyx. A small mepilex (multilayer foam dressing designed for use on the sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) to prevent pressure ulcers) was put on the area. Staff were to lay the resident down first and get the resident up last. (Staff did not document notifying the resident's physician of the area.) Record review of the resident's Physician's Order Sheet, dated December 2023, showed no orders for use of mepilex on the wound. Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or new interventions related to the area. Review of the resident's skin evaluation only note, dated 12/28/23, showed the resident had a pressure area on the coccyx with no odor, tunneling (skin loss and depth), or undermining (the damage under the tissue was larger than what appears at the surface). Staff noted this was a new skin issue to the coccyx and applied barrier cream to the pressure ulcer. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer. Staff did not documentation notifying the physician of the area.) Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or new interventions related to the area. Review of the resident's shower sheet, dated 12/29/23, showed the shower aide circled the diagram of the stick figure's sacrum and said open. There were no nurse comments at the bottom of the form. Review of the resident's nurse's progress note, dated 01/02/24, showed the physician saw the resident's skin and gave a new order for a treatment of medihoney (for removal of necrotic (death of cells and tissue which eventually becomes black, hard, and leathery) tissue and aids in wound healing) for use on pressure ulcers) to the buttocks topically twice a day with foam dressing. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's POS, dated 01/02/24, showed an order for medihoney wound and burn dressing external paste to apply to buttocks abrasion two times a day in the morning and in the evening and to apply a foam dressing. Review of the resident's care plan showed staff did not update the care plan with the area to the coccyx or new interventions related to the area. Review of the resident's shower sheet, dated 01/04/24, showed the shower aide circled the diagram of the stick figure's small area at the top of the resident's buttocks and wrote open sore. Review of the resident's shower sheet, dated 01/11/24, showed the shower aide circled the diagram of the stick figure's area from the top of the lower spine coccyx to the bottom of the buttocks and wrote big open spot on bottom. The staff documented they applied a treatment. Review of the resident's skin only evaluation note, dated 01/11/2024, showed the resident had excoriation on the coccyx. There was no new skin issues noted and staff did treatment on the present skin wound. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's shower sheet, dated 01/19/24, showed the shower aide circled the diagram of the stick figure's area from the upper buttock to the sacrum and circled in the middle and wrote open. Review of the resident's skin only evaluation note, dated 01/19/24, showed the resident had a pressure ulcer/injury on the coccyx that was a Stage II and unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.) (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's shower sheet, dated 01/25/24, showed the shower aide circled the diagram of the stick figure's sacrum area and wrote open. The nurse did not make any comments about the open skin at the bottom of the form. Review of the resident's physician's examination form, dated 01/30/24, showed the nurse practitioner saw the resident for coccyx pain-MASD (moisture-associated skin damage) and UTI (urinary tract infection), and documented to continue current treatment and offload as tolerated. Review of the resident's progress notes, dated 01/31/24, showed staff documented an entire area of abraded skin from center of anus (opening which solid waste matter leaves the body) to lower back with no open skin areas noted. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's skin only evaluation note, dated 02/01/24, showed the resident's skin had excoriation on the coccyx. The skin tissue was warm. There was a treatment in place. (Staff did not document a full assessment including measurements of length, width, depth, or further description of the pressure ulcer.) Review of the resident's shower sheet, dated 02/05/24, showed the shower aide circled the diagram of the stick figure's resident's buttocks and wrote open and deep. The charge nurse signed it. Review of the resident's shower sheet, dated 02/08/24, showed the shower aide on the diagram of the stick figure circled the sacrum and wrote open. Review of the resident's shower sheet, dated 02/12/24, showed the shower aide on the diagram of the stick figure, circled the entire buttocks and wrote open. Observation and interview on 02/21/24, at 12:49 P.M., showed the resident sat in a wheelchair in the resident's room. The resident said he/she was waiting on staff to assist him/her back into bed after lunch. The resident said he/she had a sore that developed while a resident at the facility. He/she said staff would leave him/her in a wheelchair for extended periods, instead of assisting him/her back to bed. Staff appeared to be doing something to treat the redness. Observations on 02/21/24, at 1:58 P.M., showed the resident in bed on his/her left side. Certified Nurse Aide (CNA) Q put on gloves, and removed the resident's incontinence brief and opened up the resident's buttocks to check the skin. CNA Q said, Oh, it's a pressure ulcer. There was a red excoriated area approximately seven to eight centimeters in length by three to four centimeters in width with an approximately three centimeter slit, open area (Stage II pressure ulcer) in the center of the coccyx with yellowish slough and moisture. There was no dressing covering the pressure ulcer and the incontinence brief was wet with urine. CNA Q went to get the nurse to assess this area. During an interview on 02/21/24, at 1:58 P.M., the resident said he/she had sores for quite some time and the nurse puts ointment on them. During interview on 02/21/24, at 2:09 P.M., Licensed Practical Nurse (LPN) O said the resident had a treatment order for medihoney and it was done daily. He/she was not sure when the treatment was usually, done but it had not been done yet that day. He/she does not stage any wounds. The wound nurse did this. He/she thought the Associate Director of Nursing (ADON) was the wound nurse and did the treatment. He/she usually worked evenings, but would go ahead and do the treatment. Observation on 02/21/24, at 2:16 P.M., showed LPN O brought in wound care supplies to do the wound treatment. CNA R and CNA Q assisted the nurse. LPN O measured the outer reddened excoriated skin as 8.5 cm by 4.5 cm width, but did not measure the Stage II pressure ulcer in the middle of the coccyx. The nurse cleaned the area with wound cleanser, then patted it dry, applied skin prep around the edges of the reddened abrasion skin, applied medihoney, and the border gauze foam dressing. During interview on 02/21/24, at 2:16 P.M., CNA R said he/she would have expected the border foam dressing on the resident. He/she said the dressing came off due to the resident's urine and bowel incontinence. If they told the nurse when the dressing came off, the nurse would come and put a dressing on it. Review of the resident's progress note, dated 02/21/24, showed there was a wound on the resident's coccyx. (Staff did not document the length, size, depth, characteristics of the pressure ulcer). Observation on 02/23/24, at 9:49 A.M., showed the resident was in bed on his/her right side. The resident said he/she needed to be changed and said he/she hadn't had a treatment on his/her bottom done since yesterday. During observation and interview on 02/23/24, at 9:58 A.M., CNA G answered the resident's call light who said he/she was a little wet (with urine). CNA G prepared to do perineal care. The resident's dressing was on the resident's buttocks, but was not dated and the urine had seeped underneath the dressing. While the resident lay on his/her side, he/she was urinating more. When CNA S came into the room and turned the resident to his/his left side, he/she said it looked like the resident had a pressure sore and it had changed. It had gotten bigger and irritated since they began the honey treatment. CNA G said the area looked a lot worse. They performed incontinence care and put a clean incontinence brief on the resident and said the nurse will come in to do the dressing. Observation and interview on 02/23/24, at 10:15 A.M., showed the following: -The resident said he/she had a sore on his/her bottom; -The staff were doing a treatment on his/her bottom; -The resident said back in December 2023, he/she was left sitting in his/her wheelchair for over five hours which was too long. That was when his/her bottom started hurting; -The resident's wheel chair had no cushion, -The resident said his/her wheel chair did not have a cushion in it, and he/she will place a pillow in the wheelchair. Observation on 02/23/24, at 10:16 A.M., the ADON went into the resident's room to observe the resident's skin on his/her bottom. The resident was lying on his/her left side, and the ADON loosened the side of the incontinence brief enough to look down the side of the resident's buttock without opening the right buttock to exam the inner buttock and coccyx, then re-attached the incontinence brief. While assessing the resident's wound, he/she said this wound was not on his/her tracking system since it was not bad enough. During an interview on 02/23/24, at 10:16 A.M., the ADON said the physician looked at the resident's pressure ulcer and ordered the medihoney and dressing which the physician reviewed weekly. The ADON said he/she was not a wound nurse and did not stage wounds since it was not in his/her scope of practice. There was a weekly tracker for wounds and this resident was not on this weekly tracker or the weekly wound report. If staff do not tell him/her, he/she does not know if it the skin continued to get worse. The ADON said, in his/her opinion the resident's skin had not gotten worse, but it was not healing. It was an open pressure ulcer. He/she would probably stage the resident's skin as a Stage 1 for the peri-wound (the area around the Stage 2 pressure ulcer) and a Stage 2 in the center. He/she would recommend the wound care company to see the resident since it was not healing quick enough. Observation on 02/23/24, at 10:16 A.M., showed no cushion in the resident's wheelchair in the room. During interview on 02/23/24, at 2:40 P.M., CNA F said if skin was starting to break down, or anything, they he/she would report this to the nurse so they would come and assess the resident's skin and put barrier cream on it. Review of the resident's Nurse Practitioner's (NP) pressure wound evaluation, dated 02/23/24, showed the following: -Pressure ulcer determined to be Stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling after debridement (removal of dead or unhealthy tissue from wound)); -Sacral chronic Stage 3 pressure injury measuring 1.9 centimeters (cm) by 3.6 cm width by 0.1 cm depth, width area of 6.84 square cm. No tunneling and undermining noted and tunneling; a moderate amount of serous (yellow fluid draining out of the wound) drainage noted with no odor. Wound bed had no granulation (the development of new tissue and blood vessels in a wound during healing process). 76-100% slough (yellow/white dead skin cells accumulate in the wound bed) , no eschar (collection of dead tissue present within the wound) and no epithelialization (process of covering the surface skin lost) present. The periwound (the surrounding area of the wound edge) skin was moist. The secondary diagnosis for this wound is MASD; -Recommended to apply calcium alginate dressing to wound base and to change dressing daily and as needed for soiling, saturation, or unscheduled removal. During interview on 02/26/24, at 1:32 P.M., the Director of Nursing (DON) said she would expect staff to do a full body skin assessment weekly on all residents. The charge nurse assigned to the residents would do the skin assessments and if anything changes from the previous assessment, they were to do another skin assessment. If there was a new admission, they were to do a full body skin assessment. She would expect staff to follow the treatment order. The nurses can assess the wounds, but it was subjective. She would trust the wound care company and their knowledge. If a dressing was ordered twice a day, she would expect this completed as ordered. She would expect to change a dressing treatment order if the pressure ulcer had gotten worse or had not or was not getting better, they would call and get an order to change the dressing. She would expect staff to let the nurse know to change the dressing if it became wet or soiled. The ADON was responsible for the wound tracking report. When she looked at the resident's skin a while back, it was not flagged as an issue. His/her skin looked macerated. If a pressure ulcer was open, it was a Stage II. The cushions in the wheelchair stay in the wheelchairs and the covers typically were changed. The resident had an order for a protective cushion to bilateral feet and to offload the coccyx, but not order for a protective cushion in his/her wheelchair. The cushions for the wheelchairs were stored at therapy and not that you had to go through therapy to get a cushion though. During an interview on 02/26/24, at 6:40 P.M., the Administrator said staff were expected to assess residents' skin upon admission, when there was a change in the resident's condition even with their skin, and any pressure area. Staff were to do a weekly skin assessment on residents. She would expect staff to provide pain control with any skin treatment. The DON was to assess the resident's skin if it got worse and would involve the wound care company to evaluate the resident for wound care.

Based on interview and record review, the facility failed to ensure any resident weight loss was unavoidable when staff failed to identify weight loss, failed to notify the physician and register dietician of weight loss, failed to care plan weight loss, and failed to implement new interventions to prevent future weight loss for one resident (Resident # 22). The facility census was 56. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated September 2017, showed the following: -The nursing staff will monitor and document the weight and dietary intake of residents; -The staff and physician will define residents with weight loss and significant risk for impaired nutrition; -The staff will report to the physician any significant weight loss; -The staff and physician will identify pertinent interventions based on identified causes; -The staff and physician will monitor nutritional status in response to interventions. 1. Review of Resident #22's face sheet (brief resident profile sheet) showed the following information: -admission date of 08/04/22; -Diagnoses included dementia, diabetes, chronic obstructive pulmonary disease (COPD - a group of lung diseases making it difficult to breathe), and hypothyroidism (deficient amount of thyroid hormone). Review of the resident's physician order sheet, dated 08/04/22, showed the following information: -Regular diet; -Obtain weight once per month. Review of the resident's care plan, revised 08/17/22, showed the following information: -Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs; -Dietary consult for nutritional regimen as needed; -Offer substitutes for foods not eaten; -Encourage to drink extra fluids with meals and in between meals; -Observe for adverse reactions to antidepressant therapy: change in appetite, appetite loss and weight loss; -Maintain adequate nutritional status by maintaining weight within 5% of baseline and consuming at least 50% of at least two meals daily; -Observe for significant weight loss: three pounds in one week, greater than 5% in one month, greater than 7.5% in three months, or greater than 10% in six months; -Registered dietician to evaluate and make diet change recommendations. Review of the resident's vital signs showed on 08/03/23, the resident weighed 141 pounds. Review of the resident's dietary services progress note, dated 08/17/23, showed the following information: -Current weight 141 pounds; -Regular diet order; -Annual evaluation shows weight is stable at 141 pounds; -Labs reviewed and stable; -Able to make needs known; -Recommended to continue current care plan. Review of the resident's vital signs showed the following information: -On 09/04/23, the resident weighed 139 pounds (a loss of 4 pounds); -On 10/02/23, the resident weighed 137 pounds (a loss of 2 pounds in a month and 6 pounds total); -On 11/01/23, the resident weighed 132 pounds (a loss of 5 pounds in a month and 11 pounds total); Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/07/23, showed the following information: -Severe cognitive impairment; -Able to feed self; -Did not indicate any weight loss. Review of the resident's care plan showed staff did not update the care plan with the weight loss and any new interventions. Review of the resident's dietary notes showed regarding the resident's weight loss of a referral to a registered dietician (RD). Review of the resident's vital signs showed the following information: -On 12/01/23, the resident weighed 134 pounds (a gain of 2 pounds); -On 01/01/24, the resident weighed 129 pounds (a loss of 5 pounds in a month and 12 pounds total); -On 02/05/24, the resident weighed 124 pounds (a loss of 5 pounds in a month and 17 pounds total); -On 02/23/24, the resident weighed 122 pounds (a loss of 2 pounds in two weeks and 19 pounds total). Review of the resident's care plan showed staff did not update the care plan with the weight loss and any new interventions. Review of the resident's dietary notes showed regarding the resident's weight loss of a referral to a RD. Review of the resident's progress notes, dated 09/2023 to 02/2024, showed staff did not document regarding the resident's weight loss or physician notification of weight loss. During an interview on 02/23/24, at 11:45 A.M., Certified Nurse Aide (CNA) E said getting the resident to eat can be hard at times. The resident always comes to the dining room, but sometimes leaves before meals are served and staff must go get him/her and remind him/her that he/she hasn't eaten. During an interview on 02/23/24, at 12:16 P.M., Dietary Aide (DA) M said staff document the percentage of food eaten of all residents. The resident is hit or miss. Sometimes he/she eats good and sometimes he/she does not. Dietary does not weigh the residents, the CNA's weigh them. The Dietary Manager (DM) will add fortified shakes if he/she is concerned about a resident losing weight. The resident is not currently on any fortified shakes. During an interview on 02/23/24, at 1:01 P.M., CNA G said the CNA's weigh the residents. Some residents they weigh weekly and some they weigh monthly. It depends on the physician orders. The nurse will tell them who needs to be weighed. They will write down the weight and give to the nurse to review and document. During an interview on 02/26/24, at 9:00 A.M., CNA F said all residents are weighed weekly. The CNA will give the weights to the nurse or the restorative aide to review, document, and follow up on. There is currently no one with weight loss. If he/she is aware that a resident is losing weight, he/she will give them chocolate milk in the morning and any supplement shakes they have ordered. He/she is updated on the plan of care from either the nurse or report from the previous shift. During an interview on 02/26/24, at 9:09 A.M., Nursing Aide (NA) H said there are currently no residents with weight loss. The nurse will inform the CNAs of any resident with weight loss. The nurse will leave a list of residents that need to be weighed. The CNA's weigh the residents and let the nurse know their weight. The nurse will document the weights and follow up as needed. During an interview on 02/26/24, at 09:15 A.M., Registered Nurse (RN) I said he/she does not have any residents he/she is currently monitoring for weight loss. The CNA's weigh the residents. Either the nurse or the restorative aide will document the weights. If a resident is losing weight, the RN will have the CNA document the percentage of food eaten at every meal. The data is reviewed at the care plan meetings with the Assistant Director or Nursing (ADON), Director of Nursing (DON), and the Administrator. During an interview on 02/26/24, at 10:45 A.M., DM J said he/she has not been reviewing resident weights for months due to being short staffed. If weight loss is identified, nursing and the RD are notified. Supplements and shakes would then be ordered. The resident eats better at breakfast. If the resident has to wait too long, he/she leaves the dining room and nursing must go get him/her and remind him/her that he/she has not eaten. During an interview on 02/26/24, at 11:25 A.M., RD K said that the Dietary Manager fills out a referral form so that the following residents would be seen by the RD and includes all new admissions, readmissions, annuals, tube feeds, and weight loss residents. The RD will also check with the DON and the charge nurse if they have any residents they have concerns with while he/she is at the facility. There is a RD at the facility once per month. The RD was not notified of the resident's weight loss. During an interview on 02/26/24, at 1:15 P.M., Registered Dietician (RD) L said that a RD comes to the facility every month. RD L said the last time he/she was at the facility was 02/13/24. He/she will observe the residents that the Dietary Manager has listed for him/her to observe. RD L does not remember seeing the resident on the list to be seen. RD L said that any weight loss over 10 % is considered significant weight loss and those are the residents he/she typically sees. RD L said he/she usually will first visit with the resident to determine whether the weight loss was planned or unplanned. He/she will also make sure the resident is not on hospice. RD L said he/she normally will first add food and extra calories to meals, as well as add in-between meal snacks to the resident with significant weight loss before adding supplements. RD L said that he/she would have expected to be notified of the resident's weight loss. During an interview on 02/26/24, at 1:35 P.M., Restorative Aide (RA) N said that every resident gets weighed either weekly or monthly depending on the physician orders. The DON will print off a list of all residents that have had weight loss or a decline in general. The DON will discuss this information with the DM and up-date the residents care plans. The resident has not had a real drastic weight loss that he/she is aware of. During an interview on 02/26/24, at 6:40 P.M., the Director of Nursing (DON) and the Administrator said that the RA N will notify the DON if a resident has a 5% weight loss in a week. DON said he/she can also run a report and then he/she would notify the Dietary Manager. The resident does flag on significant weight loss. He/she has had a decline in his/her cognition. He/she eats good sometimes then refuses to eat other times. The resident was started on TwoCal HN 2.0 (nutritional supplement) three times a day on 02/23/24 . It should have been started earlier. The physician was notified on 02/23/24.

Based on observation, interview, and record review, the facility failed to provide care for all residents on oxygen per professional standards of practice when staff failed to ensure oxygen equipment was cared for in a manner to prevent possible contamination or bacteria growth, when staff failed to administer oxygen per physician orders, and when staff failed to care plan regarding oxygen use and the care of oxygen equipment for one resident (Resident #42). The facility census was 56. Review of the facility's policy titled Oxygen Administration, revised October 2010, showed the following: -Verify that there is a physician's order for this procedure; -Review the physician's orders or facility protocol for oxygen administration; -Review the resident's care plan to assess for any special needs of the resident; -After completing the oxygen set up or readjustment, document the date and time performed, the name and title of individual performing, the rate of oxygen flow, route and rationale and the frequency and duration of the treatment in the resident's medical record. Review showed the facility did not provide a specific policy for changing oxygen tubing, nasal cannula, and dehumidifier. 1. Review of Resident #42's face sheet (a brief resident profile) showed the following: -admission date of 10/10/23; -Diagnoses include acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues of your body), chronic obstructive pulmonary disease with (acute) exacerbation (COPD - a group of lung diseases that block airflow and make it difficult to breathe with a sudden worsening in airway function), atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease), and chronic kidney disease. Review of the resident's Physician Order Sheet (POS), dated 10/26/23, showed an order for oxygen saturation level of less than 90%, apply oxygen at two liters per nasal cannula. Staff to call physician if oxygen saturation drop has occurred and oxygen has been applied. Staff can apply as needed for oxygen saturation level less than 90%. Review of the resident's care plan, last reviewed 12/07/23, showed the facility did not care plan for the resident's oxygen use or care of the oxygen concentrator, humidifier, tubing, or nasal cannula. Review of resident's significant change Minimum Data Set (MDS - federally mandated assessment tool completed by staff) dated 01/17/24, showed the following: -Resident cognitively intact; -Dependent on staff for transfers; -Uses wheelchair; -Walking did not occur. -Resident receives oxygen therapy. Review of the resident's February 2024 Medication Administration Record (MAR) showed the following: -An order, dated 10/26/23, for if oxygen saturation level less than 90%, apply oxygen at two liters per nasal cannula. Call physician if oxygen saturation drop has occurred and oxygen has been applied as needed for oxygen saturation less than 90%. Observation and interview on 02/20/24, at 1:39 P.M., showed the following: -Resident laid in bed receiving oxygen per nasal cannula; -The resident said he/she is on continuous oxygen at three liters of oxygen per minute; -The concentrator was set at five liters of oxygen per minute; -There was no label on the tubing to show when the tubing was last changed; -The resident was appeared to be short of breath. Observation and interview on 02/21/24, at 8:50 A.M., showed the following: -The resident sat in his/her wheelchair watching television in his/her room; -The resident said he/she just finished a breathing treatment; -He/she was receiving oxygen per nasal cannula at the rate of five liters per minute; -The resident said he/she is supposed to be receiving oxygen at three liters per minute; -No label on the tubing showing when it was last changed. Observation and interview on 02/23/24, at 12:45 P.M., with the resident showed the following: -The resident was sat in his/her wheelchair with staff preparing a breathing treatment; -Resident received oxygen per nasal cannula at five liters per minute; -The resident said he/she is on continuous oxygen and never touches the oxygen concentrator to turn up or down; -The resident said the liters per minute should be set to three; -No label on the tubing showing when it was last changed. Observation on 02/26/24, at 7:09 A.M., showed the resident in the dining room eating breakfast. His/her portable oxygen tank was set at three liters per minute. Observation and interview on 02/26/24, at 9:56 A.M., showed the following: -Resident sat in room sitting in his/her wheelchair receiving oxygen per nasal cannula at three liters per minute; -No label on the tubing showing when it was last changed; -The resident said he/she has not observed staff changing the tubing or nasal cannula since she/she admitted to the facility. During an interview on 02/26/24, at 3:10 P.M., Certified Nurse Assistant (CNA) A said the following: -He/she does not change oxygen tubing or cannulas and does not think CNAs perform the task at the facility; -He/she would only increase or decrease a resident's oxygen liters if requested by the nurse; -He/she believes the resident's oxygen is set at three liters, but cannot recall the physician orders; -He/she is not aware if staff increased the oxygen to five liters. During an interview on 02/26/24, at 3:39 P.M., CNA B said the following: -Nurses change oxygen tubing, nasal cannulas, and dehumidifiers at the facility; -He/she never increases or decreases the liters on oxygen concentrators: -He/she does not remember what the resident's oxygen liters are supposed to be set, but physician orders determine the number of liters. During an interview on 02/26/24, at 3:44 P.M., Licensed Practical Nurse (LPN) C said the following: -Nurses change oxygen tubing, nasal cannulas, and dehumidifiers once per week per the treatment administration record (TAR), usually specified to day and time; -He/she has changed tubing and nasal cannulas at the facility; -Staff use physician orders to determine when to change the oxygen equipment and visual indicators such as a hole in the tubing; -Staff should place tape with date, time and initials on or near tubing after changing; -Staff use physician orders to determine the amount of oxygen liters per minute to set oxygen concentrators; -Nurses only should increase or decrease oxygen liters in the event of an emergency and follow up with a physician's; -He/she has never changed the resident's oxygen equipment; -He/she looked at the resident's medical record and said the physician order is for the oxygen liters to be set at two. During an interview on 02/26/24, at 4:00 P.M., Registered Nurse (RN) D said the following: -Staff should check physician orders or the medication administration record (MAR) to determine the number of liters of oxygen for a resident; -Staff rely on the TAR for prompting to change the oxygen equipment such as tubing; -Staff should put a date and time on tape of after changing oxygen equipment; -Nurses change the oxygen equipment at the facility, but she does not know if there is a specific date or time for all oxygen equipment changes; -Staff should not increase or decrease oxygen liters for extended periods of time without an order, only for emergency situations; -He/she has changed the resident's oxygen equipment, but it has been over a month. During an interview on 02/26/24, at 6:28 P.M., the Director of Nursing (DON) and the Administrator said the following: -Staff should change oxygen equipment weekly; -There should be a physician's order to change oxygen equipment weekly and the information should be on the TAR; -Staff should document date and time of oxygen equipment change on tape and place on the equipment; -Staff should have residents' oxygen liters set at amount in physician orders; -Staff should notify the physician if a resident's needs for oxygen increase; -The resident's physician orders are for the oxygen liters to be set at two liters; -Staff increasing oxygen liters without an order can be dangerous for residents who retain carbon monoxide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed ensure medication error rates below 5% when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.) the insulin pens before administering insulin to three residents (Residents #6, #3, and #20). The facility had three medication errors out of 34 opportunities for error resulting in a facility medication error rate of 8.82%. The facility census was 56. Review of the facility policy regarding insulin administration, revised September 2014, showed the following: -Purpose to provide guidelines for the safe administration of insulin to residents with diabetes; -The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use; -Insulin delivery: pens-containing insulin cartridges deliver insulin subcutaneously through a needle. Review of How to Use FlexPen, dated September 2021, showed before administering insulin with a FlexPen the pen should be primed by the following steps: -Turn dose selector to two units; -Hold FlexPen with the needle pointing up and gently tap the cartridge a few times to make any air bubbles collect at the top; -Keep needle upwards and press the push-button all the way in. A drop of insulin should appear on the needled tip; -Repeat the process, no more than six times, until a drop of insulin is present. If a drop is not present, a different pen must be used. Review of the Instructions for use Humalog (fast acting insulin) KwikPen, dated 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up and push dose knob until it stops. Insulin should be at the tip of the needle; -Repeat, no more than four times, until insulin is visible. 1. Review of Resident #6's face sheet (admission information at a glance) showed the following: -admission [DATE]; -Diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose). Review of the resident's physician's order, dated 02/08/24, showed an order for Novolog (rapid acting insulin) FlexPen subcutaneous (administered under the skin) solution pen-injector 100 unit/milliliter (ml) administered before meals per following sliding scale: -If blood sugar level is 70 mg/deciliter (dL) to 130 mg/dL, administer no insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer two units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer four units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer six units of insulin; -If blood sugar level is 301 mg/dL to 350 mg/dL, administer eight units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer ten units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 15 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 18 units of insulin. Observation on 02/21/24, at 10:59 A.M., showed Licensed Practical Nurse (LPN) P took the glucometer (device use to measure blood sugar levels) into the resident's room, completed an accucheck (blood sugar level check), and got the blood glucose (sugar) reading of 301 mg/dL. LPN P took the glucometer back to the cart and retrieved the resident's Novolog FlexPen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the eight units of Novolog insulin, returned to the resident's room and administered the insulin to the resident. The LPN did not prime the pen prior to the insulin administration. 2. Review of Resident #3's face sheet showed the following: -admission date of 09/28/18; -Diagnoses included type 2 diabetes mellitus with mild diabetic retinopathy (retina eye disease) and with diabetic mononeuropathy (nerve damage that often damages nerves in the legs and feet). Review of the resident's physician order, dated 04/24/23, showed Humalog KwikPen subcutaneous solution pen injector 100 units/ml, administer before meals per sliding scale: -If blood sugar level is 70 mg/dL to 130 mg/dL, do not administer insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer two units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If blood sugar leave is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 30 units of insulin. Observation on 02/21/24, at 11:15 A.M., showed LPN P took the glucometer into the resident's room, completed an accucheck, and got a blood glucose reading of 193 mg/dl. LPN P took the glucometer back to the cart and retrieved the resident's Humalog Kwikpen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the 8 units of Humalog insulin, went into the room, and administered the insulin to the resident. The LPN did not prime the insulin prior to administration of the insulin. 3. Review of Resident #20's face sheet showed the following: -admission date of 03/22/21; -Diagnoses that included type 2 diabetes mellitus. Review of the resident's physician's order, dated 06/01/22, showed an order for Novolog Flexpen, inject at meal times per following sliding scale: -If blood sugar level is 70 mg/dL to 130 mg/dL, do not administer insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If blood sugar level is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 30 units of insulin. Observation on 02/21/24, at 11:26 A.M., showed LPN P took the glucometer into the resident's room, completed an accucheck and got the blood glucose reading of 274 mg/dL. LPN P took the glucometer back to the cart and retrieved the resident's Novolog Flexpen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the 10 units of Novolog insulin, went into the resident's room, and administered the insulin to the resident. The LPN did not prime the insulin pen prior to administering the insulin. 4. During an interview on 02/22/24, at 12:12 P.M., LPN P said he/she will do the accucheck on the resident's blood sugar and then will look at the resident's orders for insulin and the sliding scale for the amount of insulin he/she was to administer to the resident. He/she will dial up the units on the insulin pen and will administer this to the resident and hold the pen for ten seconds. He/she knew to prime an insulin pen like one to two milliliters (ml), but thought this was completed once a day. He/she did not know to prime a resident's insulin pen with each administration to the resident. He/she did not prime the three residents' insulin pens during the medication pass yesterday on 02/21/2024. 5. During interview on 02/26/24, at 11:03 A.M., the Director of Nursing (DON) said he/she would expect staff to administer insulin to residents with the insulin pens by priming the pen with at least two units insulin before administering to the resident. 6. During interview on 02/26/24, at 6:40 P.M., the Administrator said staff were to administer insulin to the residents with insulin pens by priming the insulin pen according to policy and manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed ensure all residents were free from significant medication errors when staff failed to to prime (removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.) the insulin pens before administering insulin to three residents (Residents #6, #3, and #20). The facility census was 56. Review of the facility policy regarding insulin administration, revised September 2014, showed the following: -Purpose to provide guidelines for the safe administration of insulin to residents with diabetes; -The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use; -Insulin delivery: pens-containing insulin cartridges deliver insulin subcutaneously through a needle. Review of How to Use FlexPen, dated September 2021, showed before administering insulin with a FlexPen the pen should be primed by the following steps: -Turn dose selector to two units; -Hold FlexPen with the needle pointing up and gently tap the cartridge a few times to make any air bubbles collect at the top; -Keep needle upwards and press the push-button all the way in. A drop of insulin should appear on the needled tip; -Repeat the process, no more than six times, until a drop of insulin is present. If a drop is not present, a different pen must be used. Review of the Instructions for use Humalog (fast acting insulin) KwikPen, dated 07/2023, showed the pen needs to primed before each use. The pen should be primed by the following steps: -Turn dose knob to two units; -Hold pen with needle pointing up; -Tap the cartridge holder gently to collect air bubbles at the top; -Continue holding the pen with needle pointing up and push dose knob until it stops. Insulin should be at the tip of the needle; -Repeat, no more than four times, until insulin is visible. 1. Review of Resident #6's face sheet (admission information at a glance) showed the following: -admission [DATE]; -Diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose). Review of the resident's physician's order, dated 02/08/24, showed an order for Novolog (rapid acting insulin) FlexPen subcutaneous (administered under the skin) solution pen-injector 100 unit/milliliter (ml) administered before meals per following sliding scale: -If blood sugar level is 70 mg/deciliter (dL) to 130 mg/dL, administer no insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer two units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer four units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer six units of insulin; -If blood sugar level is 301 mg/dL to 350 mg/dL, administer eight units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer ten units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 15 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 18 units of insulin. Observation on 02/21/24, at 10:59 A.M., showed Licensed Practical Nurse (LPN) P took the glucometer (device use to measure blood sugar levels) into the resident's room, completed an accucheck (blood sugar level check), and got the blood glucose (sugar) reading of 301 mg/dL. LPN P took the glucometer back to the cart and retrieved the resident's Novolog FlexPen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the eight units of Novolog insulin, returned to the resident's room and administered the insulin to the resident. The LPN did not prime the pen prior to the insulin administration. 2. Review of Resident #3's face sheet showed the following: -admission date of 09/28/18; -Diagnoses included type 2 diabetes mellitus with mild diabetic retinopathy (retina eye disease) and with diabetic mononeuropathy (nerve damage that often damages nerves in the legs and feet). Review of the resident's physician order, dated 04/24/23, showed Humalog KwikPen subcutaneous solution pen injector 100 units/ml, administer before meals per sliding scale: -If blood sugar level is 70 mg/dL to 130 mg/dL, do not administer insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer two units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If blood sugar leave is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 30 units of insulin. Observation on 02/21/24, at 11:15 A.M., showed LPN P took the glucometer into the resident's room, completed an accucheck, and got a blood glucose reading of 193 mg/dl. LPN P took the glucometer back to the cart and retrieved the resident's Humalog Kwikpen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the 8 units of Humalog insulin, went into the room, and administered the insulin to the resident. The LPN did not prime the insulin prior to administration of the insulin. 3. Review of Resident #20's face sheet showed the following: -admission date of 03/22/21; -Diagnoses that included type 2 diabetes mellitus. Review of the resident's physician's order, dated 06/01/22, showed an order for Novolog Flexpen, inject at meal times per following sliding scale: -If blood sugar level is 70 mg/dL to 130 mg/dL, do not administer insulin; -If blood sugar level is 131 mg/dL to 180 mg/dL, administer four units of insulin; -If blood sugar level is 181 mg/dL to 240 mg/dL, administer eight units of insulin; -If blood sugar level is 241 mg/dL to 300 mg/dL, administer ten units of insulin; -If blood sugar level is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar level is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar level is 401 mg/dL to 450 mg/dL, administer 25 units of insulin; -If blood sugar level is 451 mg/dL to 500 mg/dL, administer 30 units of insulin. Observation on 02/21/24, at 11:26 A.M., showed LPN P took the glucometer into the resident's room, completed an accucheck and got the blood glucose reading of 274 mg/dL. LPN P took the glucometer back to the cart and retrieved the resident's Novolog Flexpen from the cart. LPN P used hand sanitizer on his/her hands, dialed up the 10 units of Novolog insulin, went into the resident's room, and administered the insulin to the resident. The LPN did not prime the insulin pen prior to administering the insulin. 4. During an interview on 02/22/24, at 12:12 P.M., LPN P said he/she will do the accucheck on the resident's blood sugar and then will look at the resident's orders for insulin and the sliding scale for the amount of insulin he/she was to administer to the resident. He/she will dial up the units on the insulin pen and will administer this to the resident and hold the pen for ten seconds. He/she knew to prime an insulin pen like one to two milliliters (ml), but thought this was completed once a day. He/she did not know to prime a resident's insulin pen with each administration to the resident. He/she did not prime the three residents' insulin pens during the medication pass yesterday on 02/21/2024. 5. During interview on 02/26/24, at 11:03 A.M., the Director of Nursing (DON) said he/she would expect staff to administer insulin to residents with the insulin pens by priming the pen with at least two units insulin before administering to the resident. 6. During interview on 02/26/24, at 6:40 P.M., the Administrator said staff were to administer insulin to the residents with insulin pens by priming the insulin pen according to policy and manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain an effective infection control program when when staff failed to sanitize the glucometer (used to check blood sugar levels) after performing accuchecks and failed to have a clean, sanitary barrier to place the glucometer on while performing the accuchecks for four of four residents (Residents #6, #3, #20 and #5) during the medication pass and when staff failed to wash and/or sanitize hands properly during and after a dressing change for one resident (Resident #1). The facility census was 56. 1. Review of the facility policy Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, showed the following: -Non-critical items are those that come in contact with intact skin, but not mucous membranes. Most non-critical reusable items can be decontaminated where they are used; -Reusable items are cleaned and disinfected or sterilized between residents; -Intermediate and low-level disinfectants for non-critical items included ethyl or isopropyl alcohol. 2. Review of the [NAME] Quintet AC Blood Glucose Meter Owner's Manual showed the following: -Indirect transmission of Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV) during the delivery of healthcare services has been increasingly reported; -The cleaning procedure is to remove dust, blood, and body fluid from the surface and should be performed whenever the meter is visibly dirty. The disinfecting procedure is necessary to kill pathogens such as HIV, HBV, and HCV on the device; -The meter must be cleaned and disinfected after use on each patient; -Thoroughly wipe the entire surface of the meter with disinfecting wipes listed to clean any possible dirt dust blood and other body fluids; -Take another disinfecting wipe and wipe the meter thoroughly (all blood and body fluids should be cleaned from surface before using the disinfecting wipe to wipe the meter thoroughly); -Allow the surface to remain wet for two minutes; -Allow to air dry; -Clean and disinfect the outside of the device only. 3. Review of the facility policy Obtaining a Fingerstick Glucose Level, revised October 2011, showed the following: -Place the equipment on the bedside stand or over bed table and arrange the supplies so that they can be easily reached; -Always ensure that blood glucose meter intended for reuse are cleaned and disinfected between resident uses. 4. Review of Resident #6's face sheet (admission information at a glance) showed the following: -admission [DATE]; -Diagnoses that included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose). Observation on 02/21/24, at 10:59 A.M., showed Licensed Practical Nurse (LPN) P took the [NAME] Quintet AC glucometer out of the top of the treatment cart. He/she sanitized his/her hands with hand sanitizer from on top of the cart and took the glucometer into the resident's room and laid it on the resident's dresser top without sanitizing the dresser top or using a barrier to lay the glucometer on. The LPN got the droplet of blood on the test strip and placed it into the glucometer, got the reading, took the glucometer out to the cart, removed his/her gloves, and disposed of the strip and gloves. LPN P used hand sanitizer on his/her hands, prepared the insulin pen with the number of units and then went into the room and administered the insulin to the resident. He/she returned to the cart and did not clean and sanitize the glucometer. The LPN laid the glucometer on top of the cart. 5. Review of Resident #3's face sheet showed the following: -admission date of 09/28/18; -Diagnoses that included type 2 diabetes mellitus with mild diabetic retinopathy (retina eye disease) and with diabetic mononeuropathy (nerve damage that often damages nerves in the legs and feet). Observation on 02/21/24, at 11:15 A.M., showed LPN P used hand sanitizer, put on gloves, and took the [NAME] Quintet AC glucometer into the resident's room, laid the glucometer on the resident's bedside table without sanitizing the top of the bedside table or putting a barrier down to lay the glucometer on, got the droplet of blood on the test strip, and placed into the glucometer. LPN P took the glucometer and placed it on top of the cart, without cleaning and sanitizing the glucometer, removed his/her gloves, and disposed of the test strip and gloves. LPN P sanitized his/her hands, prepared the resident's pen with the number of insulin units, and went into the resident's room and administered the insulin to the resident. He/she returned to the cart, did not clean and sanitize the glucometer. He/she moved on to the next resident's room to do an accucheck. 6. Review of Resident #20's face sheet showed the following: -admission date of 03/22/21; -Diagnoses included type 2 diabetes mellitus. Observation on 02/21/24, at 11:26 A.M., showed LPN P used hand sanitizer, put on gloves, and took the [NAME] Quintet AC glucometer without first cleaning and sanitizing the glucometer, into the resident's room, laid the glucometer on the resident's bedside table without sanitizing the top of the bedside table or putting a barrier down to lay the glucometer on, got the droplet of blood on the test strip, and placed into the glucometer. LPN P took the glucometer and placed it on top of the cart, removed his/her gloves, sanitized his/her hands, prepared the resident's pen with the number of insulin units and then went into the resident's room and administered the insulin to the resident. When he/she returned to the cart, he/she took an alcohol swab and cleaned the glucometer, but did not sanitize the glucometer, before laying it on top of the cart. During interview on 02/21/24, at 11:35 A.M., LPN P said he/she tried to clean the glucometer with an alcohol swab every time between residents. It was his/her goal. 7. Review of Resident #5's face sheet showed the following: -admission date of 07/26/23; -Diagnoses that included type 2 diabetes mellitus with diabetic chronic kidney disease (kidneys are less likely to filter waste and fluid out of your body) and polyneuropathy (multiple peripheral nerves become damaged and problems with sensation, coordination and other body functions). Observation on 02/21/24, at 11:37 A.M., showed LPN P used hand sanitizer, put on gloves, and took the [NAME] Quintet AC glucometer without first sanitizing the glucometer, into the dining room at the resident's table, laid the glucometer on the resident's table without sanitizing the top of the table or putting a barrier down to lay the glucometer on, got the droplet of blood on the test strip, and placed into the glucometer. LPN P took the glucometer and placed it on top of the cart, removed his/her gloves, got an alcohol swab and cleaned the glucometer, but did not sanitize the glucometer, before placing it back in the top drawer of the cart. 8. Observation on 02/22/24, at 12:12 P.M. showed no disinfecting wipes on the nurses' cart for the 100-200 hall. 9. During an interview on 02/22/24, at 12:12 P.M., Licensed Practical Nurse (LPN) P said the procedure to do an accucheck was to look at the resident's chart, get supplies, use hand sanitizer and put on gloves, go into room and ask permission to check the resident's blood sugar. Then, he/she will use an alcohol wipe on the resident's finger, get a drop of blood and put it on the strip and then put into the monitor. It took five seconds to get a reading. Then go back to the cart, take off gloves, hand sanitize, and record blood sugar in the computer. Before putting the glucometer in the drawer, use an alcohol swab to wipe the glucometer. He/she only used an alcohol swab to clean the glucometer. There were no disinfecting wipes on the cart. During an interview on 02/22/24, at 12:40 P.M., the Corporate Nurse said they used the [NAME] Disposable Germicidal surface wipes to clean and disinfect the glucometers. During an interview on 02/26/24, at 11:03 A.M., the Director of Nursing (DON) said the following: -Staff were to wash and/or sanitize hands in between residents when doing accuchecks on residents; -Staff were to disinfect the glucometer in between residents and they were to wait approximately one to three minutes after disinfecting the glucometer before using it on the next resident; -Staff were to use a barrier on the dresser and/or bedside table when they go into the resident's room to do an accucheck for the glucometer and supplies. During an interview on 02/26/24, at 6:40 P.M., the Administrator said the staff were to clean and disinfect the glucometers between residents. 10. Review of the facility policy Handwashing/Hand Hygiene, revised August 2019, showed the following: -Hand hygiene is the primary means to prevent the spread of infection; -Wash hands with soap and water for when hands were visibly soiled and after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile; -Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively soap and water, before and after coming on duty; before and after direct contact with residents; before preparing or handling medications, handling an invasive device, donning sterile gloves, handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with resident's skin; after contact with blood or bodily fluids; after contact with objects such as medical equipment in the immediate vicinity of the resident; and after removing gloves; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 10/01/15; -Diagnoses include elevated white blood cell count, unspecified intestinal obstruction (a blockage that keeps food or liquid from passing through your small intestine or large intestine (colon)), personal history of transient ischemic attack (TIA-stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke), and aphasia (a language disorder that affects a person's ability to communicate). Review of the resident's care plan, last revised 06/26/2023, showed the following: -Resident requires a tube feeding related to diagnosis of dysphagia (difficulty swallowing) status post stroke. Resident has a history of gastronomy infection; -Resident's insertion site will be free of signs and symptoms of infection through the review date; -Provide treatment care to G-tube (gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach) site as ordered and observe for signs and symptoms of infection. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 02/02/24, showed the following: -Resident significantly cognitively impaired; -Completely dependent on staff for activities of daily living; -Receives tube feeding. Review of the resident's physician order, dated 02/19/24, showed the following: -J-tube site (tube feeding site), cleanse with wound cleanser pat dry, apply skin prep in two-three inch radius around tube insertion site and place Drawtex (used to control excessive wound exudate (drainage) and draws bacteria from the wound bed into the dressing) or equivalent cut to fit around tube, as needed for skin integrity. Observation on 02/26/24, at 8:20 A.M., showed Registered Nurse (RN) I went into the resident's room. The resident was lying in bed. He/she opened the resident's bedside dresser, removed a Drawtex dressing from the package and picked up the scissors from the drawer. The RN did not clean the scissors. The RN cut the dressing approximately two to three inches in the middle, and then laid the dressing on top of the dresser without cleaning the top of the dressing and/or putting a barrier down to lay the dressing. A shower aide came to the doorway and said they were going to give the resident a shower. RN left the dressing on the bedside dresser. Observation on 02/26/24, at 9:37 A.M., showed the resident was back in bed after the shower. The same Drawtex dressing lay on top of the resident's dresser top beside the bed. RN I came into the room, put on gloves, without washing hands, cleansed the wound and surrounding skin around the gastrostomy site with wound cleanser, then sprayed skin prep around the reddened wound and surrounding skin at the gastrostomy site, picked up the approximately Drawtex pre-cut dressing from the top of the dresser (left earlier) , and placed around the resident's gastrostomy tube opening. RN I, wearing the same gloves, took the water graduate container and pulled up water flushes with 55 milliliters (ml) of water with the syringe and flushed the water through the resident's gastrostomy tube, and then removed his/her gloves. Without washing and/or sanitizing hands, RN I went over to the resident's shelf and got a DVD and put this into the DVD player, and picked up the remote and turned this on for the resident. RN I picked up the water graduate container and rinsed the graduate at the sink. RN I picked up the packaged feeding and opened the package. Without washing and/or sanitizing hands, RN I put on a pair of gloves, and touched the IV pole to set the water flush on at 67 ml/hour (hr), and then poured the Jevity (nutrition formula for use with tube feeding) 1.5 feeding into the bag and set the rate to 45 ml/hr and then attached the tubing to the resident's gastrostomy tube. RN I removed his/her gloves, did not wash and/or sanitize hands, put the trash into the trash bag and removed this bag, the empty gallon water jug , and other supplies, went out of the room, down the hall to the soiled utility room to throw these away. During an interview on 02/26/24, at 10:00 A.M., RN I said he/she would have sanitized his/her hands before he/she left the resident's room, but he/she threw trash into the soiled utility room. He/she usually saw a paper towel laid on the bedside dresser for the dressing to lay on, but today it was not there. During an interview on 02/26/24, at 1:20 P.M., RN I said they were to wash hands or sanitize hands anytime before entering a resident's room. Sometimes he/she uses the and sanitizer that's on his/her cart. Most of the time, he/she would use the hand sanitizer unless it was a nasty wound, then he/she would probably wash his/her hands. He/she had taken off his/her gloves before leaving the resident's room and did not wash hands at the resident's sink since he/she was headed out of the resident's room anyway. During an interview on 02/26/24, at 3:10 P.M., Certified Nurse Assistant (CNA) A said staff should wash hands between gloving when providing care and wash hands again prior to leaving the room. During an interview on 02/26/24, at 3:39 P.M., CNA B said staff should use hand sanitizer or wash hands between providing care on residents and changing gloves, wash hands following the care. During an interview on 02/26/24, at 3:44 P.M., Licensed Practical Nurse (LPN) P said the following: -Staff should never place dressing for G-tubes on an unsterile surface without a barrier; -Staff should wash hands in between glove use, and wash hands again following care. During an interview on 02/26/24, at 6:28 P.M., the Director of Nursing (DON) and Administrator said the following: -Staff should wash hands prior to donning gloves, in between changing gloves to provide care and after removing gloves upon completion of providing care to a resident; -Staff should never place dressing for G-tubes on an unsterile surface without a barrier. During an interview on 02/26/24 at 11:03 A.M., the DON said the following: -Staff were to wash and/or sanitize hands when they go in and out of a resident's room, for any type of wound care such as applying or removing a dressing, when they remove their gloves and wash hands before applying gloves; -Staff were to use a barrier on the dresser and/or bedside table when they go into the resident's room to do a dressing change for any dressings. During interview on 02/26/24, at 6:40 P.M., the Administrator said the following: -Staff were to wash and/or sanitize hands when taking care of residents, before applying gloves and after removing gloves; -Staff were to apply a barrier on bedside tables or other places to do treatments and dressing changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents from misappropriation of property when four residents (Resident #1, Resident #2, Resident #3, and Resident #4) had medications go missing while in possession of the facility staff. The facility census was 54. Review of the facility's policy titled, Discarding and Destroying Medications, dated April 2019, showed the following: -All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of; -For unused, non-hazardous controlled substances that are not disposed of by an authorized collection, the Environmental Protection Agency (EPA) recommends destruction and disposal of the substance with other solid waste following the steps of taking the medication out of original containers, mix medication, either liquid solid, RX Destroyer, or with an undesirable substance, like sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage; -Dispose with the solid waste in the presence of two witnesses; -Document the disposal on the medication disposition record; -Include the signature(s) of at least two witnesses; -Destruction of a controlled substance must render it non-retrievable, meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted; -The medication disposition record will contain the following: the resident's name, date medication disposed, the name and strength of the medication, the name of the dispensing pharmacy, the quantity disposed, method of disposition, reason for disposition and signature of witnesses. Review of the facility's policy titled, Controlled Substances, dated April 2007, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances; -Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must made the count together. They must document and report any discrepancies to the Director of Nursing Services (DON) or Designee; -The DON or Designee shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. 1. Review of the facility's investigation, dated 08/23/23, showed the following: -On 8/23/23, at approximately 5:38 A.M., Registered Nurse (RN) A reported to the Assistant Director of Nursing (ADON) that RN B appeared to be lethargic and nodding off as he/she was leaning against the medication cart; -The ADON observed RN B leaning against the medication cart with a trash bag in his/her hand; -The ADON aroused RN B by touching his/her shoulder and RN B said he/she was tired; -RN B's purse was searched per his/her consent and facility medications were found; -Upon completion of the investigation, the facility was able to substantiate that RN B was attempting to divert narcotics from the facility. 2. Review of the Police Department Incident Report form, dated 8/23/23, showed the following: -On 8/23/23, at 7:31 A.M., an officer was dispatched to the facility in reference to a theft incident. The reporting party, the ADON, stated morphine (liquid pain medication) and Ativan (oral anxiety medication) were missing from the facility and believed to be in the possession of RN B; -Upon arrival, the officer contacted the ADON and RN A. The ADON said he/she was contacted by RN A due to RN B's unusual behavior last night and early this morning. RN B told RN A that he/she was tired. RN B went on break and went to his/her vehicle for a lengthy amount of time. When RN B came back inside the building, he/she was carrying a white hoodie that had a pink substance on it. RN B said it was vomit and went into the medication room to wash it out. RN A said RN B was in the medication room for a long amount of time. RN A checked on RN B and observed him/her dozing off at the sink. RN A advised RN B that it was time to pass medications; -After RN A and RN B completed their medication pass, RN B started wandering around the desk and medication carts while dozing off intermittently; -RN A contacted the ADON about RN B's unusual behavior. The ADON said when he/she arrived at the facility he/she observed RN B slumped over a medication cart with a trash bag in his/her hand; -While waiting to be picked up, RN B consented a search of her person and purse. The ADON located two 25 milligram (mg) promethazine (anti-nausea medication) pill packets, one empty 25 mg promethazine pill packet, and two 25 mg diphenhydramine (allergy medication) pill packets. The ADON said the medications located inside RN B's purse belonged to the facility and were prescribed for the facility residents. The ADON said RN B told him/her that he/she had taken one of the promethazine medication pills because he/she felt sick. The ADON said they searched the medication cart and found Ativan and morphine were missing. The ADON said RN B had possession of all four medicine carts, the keys to access the medicine carts and was he/she was the only one with access to the medicine carts during the shift. The ADON believed the missing Ativan and morphine were in RN B's vehicle and wanted the vehicle searched; -The officer contacted RN A, who said RN B had keys to access the medicine carts. RN A said RN B appeared lethargic, and was slumped over the medicine carts and took a very long amount of time on break. While RN B was on break, he/she went into his/her vehicle and was there for an extensive amount of time. RN A stated during their shift, RN B and RN A accessed morphine and other medications that needed to be destroyed per the facility policy and procedures; -The officer spoke with RN B and asked for consent to search his/her vehicle, in which he/she consented; -The officer searched RN B's purse and duffle bag. The officer located a syringe containing a purple liquid substance inside the syringe. RN B told the officer that he/she had taken it from the facility and that it was codeine cough medication. The officer also located an empty syringe labeled lidocaine hydrochloride jelly. RN B said the syringe had contained lidocaine in which he/she had taken for pain and had taken from the facility. The officer contacted the ADON and advised of findings. The ADON confirmed they were taken from the facility; -An officer searched the vehicle and located a syringe containing a purple gel like substance inside the center console of RN B's vehicle; -The officer showed the syringe to RN A, who advised the syringe was similar and consistent to the facility's prescribed morphine. The officer found a purse in the trunk portion of RN B's vehicle and located an empty vial labeled morphine inside the purse; -RN B was arrested for felony possession of controlled substance and stealing prescription medication. 3. Review of RN A's witness statement, dated 8/23/23, showed the following: -RN B counted the narcotic carts with the evening nurse's on 8/22/23, at 10:30 P.M.; -RN B seemed ok, however halfway through the shift he/she started to act tired and then lethargic; -Both RN A and RN B were out back vaping. RN A started to come back inside and RN B advised he/she was going to go to their car; -RN B was at his/her car for a good length of time and RN A looked and saw him/her moving around in his/her car; -When RN B came back inside, he/she had a white hoodie in his/her hands with a pink substance on it which RN B said was vomit; -RN B asked where he/she could wash his/her hoodie and RN A advised he/she could was in the medication room; -RN B went into the medication room and was in there for an extended amount of time. RN A observed RN B to be dozing off while standing up. RN A knocked on the door and advised RN B that it was time to pass synthroid medications; -RN B came out and kept stating how tired he/she was. RN B was wandering around the desk and carts dozing off intermittently; -RN A contacted the ADON about RN B's behavior. The ADON advised he/she was right outside the building and came in immediately; -The ADON told RN B that he/she needed to go home after RN B said he/she was just tired; -The ADON got the keys from RN B and gave them to RN A; -RN B took several minutes to gather his/her things and stated he/she had just a few things left to sign out of the narcotic book. RN B signed whatever he/she signed, grabbed his/her stuff, and headed toward the front entrance; -RN A advised the ADON that RN B's vehicle was in the back. The ADON got RN B and took him/her to the DON's office; -The ADON had RN A come in to witness RN B's bag search. The ADON found multiple packets of pills that belonged in the medication cart and a syringe with a pink water-like substance in it. The ADON called the Police. 4. Review of the ADON's Witness Statement, dated 8/23/23, showed the following: -On 8/23/23, at 5:38 A.M., the ADON arrived at the facility after receiving a call from RN A stating that RN B was acting lethargic and nodding off, leaning over against the medication cart and on walls; -Upon entering the facility, the ADON observed RN B slumped over the medication cart with a trash bag in his/her hand; -The ADON aroused RN B by touching his/her shoulder. RN B said he/she was just tired. The ADON requested/directed RN B to exit his/her shift due to safety issues; -RN B collected his/her belongings and started to ruffle though the medication books. The ADON again told RN B that he/she was relieved of their duties; -RN B headed to the front door, at which time RN A advised the ADON that RN B was parked out back; -The ADON directed RN B to an office and advised him/her to call someone to come pick him/her up; -RN B emptied her pockets, purse, and bag, and two promethazine HCL tablets 25 mg with another empty packet were located. RN B reported he/she took one of them because he/she felt sick; -Two diphenhydramine HCL tablets, 25 mg each were located, belonging to a resident; -At 6:12 A.M., the Administrator was notified and at 6:13 A.M., the Director of Nursing (DON) was notified; -The police were called to conduct a search due to missing Ativan and morphine from the facility nursing carts; -RN B had possession of all four sets of medication cart keys. RN B willingly turned over all keys to the ADON; -Only RN A and RN B had access to the two medication carts and two nursing carts during shift hours beginning on 8/22/23 at 10:30 P.M. 5. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of 05/24/23; -Diagnoses included dementia and malignant neoplasm (cancer) of unspecified part of bronchus or lung. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/05/23, showed the resident to have a significant cognitive deficit. Review of the resident's physician order sheet, dated August 2023, showed the following; -An order, dated 08/10/23, for Lorazepam Intensol Oral Concentrate (oral anxiety medication), 2 mg/ml (milligrams/milliliters), give .25 ml by mouth every 4 hours as needed for anxiety; -An order, dated 08/10/23, for Morphine Sulfate (Concentrate) Solution 20 mg/ml, give .25 ml by mouth every four hours as needed for pain/air hunger. Review of the electronic Medication Administration Record (MAR), dated August 2023, showed the following: -On 8/13/23, at 2:40 P.M., Morphine Sulfate (Concentrate) Solution, .25 ml was administered; -Staff did not document administration of Lorazepam Intensol Oral Concentrate. Review of the controlled Drug Receipt/Record/Disposition Form for Lorazepam Intensol Oral Concentrate, dated 8/11/23, showed the following: -On 08/12/23, at 3:15 P.M., .25 ml was administered leaving with 29.50 ml remaining in the bottle; -On 08/23/23, at 4:46 P.M., 29.25 ml was destroyed by the ADON and an RN. (Staff did not document the administration of the .25 ml of Lorazepam on 08/12/23 on the MAR. Between 8/12/23 and 08/23/23 .25 ml of Lorazepam was unaccounted for.) Review of the controlled Drug Receipt/Record/Disposition form for morphine sulfate (concentrate) solution, dated 8/11/23, showed the following: -On 08/12/23, at 3:15 P.M., morphine sulfate (concentrate) solution, .25 ml was administered; -On 08/13/23, at 3:00 P.M., morphine sulfate (concentrate) solution, .25 ml was administered. (Staff did not document the administration of the .25 ml of morphine on 08/12/23 on the MAR.) Review of the resident's nurses' notes, dated 08/15/23, showed the resident's passed away. During an interview on 08/25/23, at 2:05 P.M., RN A said the resident passed a week earlier and is unsure why his/her narcotics were not destroyed earlier. RN A said possibly there were not two RN's available. During an interview on 08/25/23, at 12:30 P.M., the ADON said he/she did not know why the resident's medications (morphine and Lorazepam) were not destroyed after he/she passed. 6. Review of Resident #2's face sheet showed the following information: -admission date of 03/09/22; -Diagnoses included Alzheimer's disease, type II diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)), and kidney disease. Review of the resident's significant change MDS, dated [DATE], showed the resident to have a significant cognitive deficit. Review of the resident's physician order sheet, dated August 2023, showed the following; -An order, dated 09/29/22, for Benadryl Allergy Tablet 25 mg, give 25 mg by mouth every eight hours as needed for pruritus (itchiness). Review of the resident's MAR, dated August 2023, showed staff did not document administration of Benadryl to the resident. During an interview on 08/25/23, at 12:30 P.M., the ADON said he/she located a non-narcotic medication (Benadryl) belonging to the resident in RN B's purse. 7. Review of Resident #3's face sheet showed the following information: -admission date of 06/29/23; -Diagnoses included encephalopathy (a broad term for any brain disease that alters brain function or structure), type II diabetes, and heart disease. Review of the resident's admission MDS, dated [DATE], showed the resident to be cognitively intact. Review of the resident's physician order sheet, dated August 2023, showed the following; -An order, dated 07/18/23, for promethazine tablet 25 mg, give 1 tablet by mouth every 8 hours as needed for nausea and vomiting. During an interview on 08/25/23, at 12:30 P.M., the ADON said he/she located a non-narcotic medication (promethazine) belonging to the resident in RN B's purse. 8. Review of Resident #4's face sheet showed the following information: -admission date of 08/04/22; -Diagnoses included heart failure, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), type II diabetes, atrial fibrillation (irregular heartbeat), and kidney disease. Review of the resident's significant change MDS, dated [DATE], showed the resident to be cognitively intact. Review of the resident's physician order sheet, dated August 2023, showed the following; -An order, dated 04/20/23, for oxycodone oral tablet, give 1 tablet by mouth every 6 hours as needed for pain. Record review of the MAR, dated August 2023, showed the following: -On 8/11/23, at 11:46 A.M., oxycodone 5 mg was administered; -On 8/19/23, at 4:59 P.M., oxycodone 5 mg was administered; -On 8/22/23, at 10:10 A.M., oxycodone 5 mg was administered. Review of the resident's Controlled Drug Receipt/Record/Disposition form for oxycodone 5 mg, dated 06/08/22, showed the following: -On 08/11/23, at 11:47 A.M., 5 mg was administered, with 14 pills remaining; -On 08/19/23, at 5:00 P.M., 5 mg was administered, with 13 pills remaining; -On 08/22/23, at 10:10 A.M., 5 mg was administered, with 12 pills remaining; -On 8/23/23, no time noted and no pills administered. The form showed a balance of 11 pills remaining, with two nurse's signatures. During an interview on 08/25/23, at 12:30 P.M., the ADON said he/she was not aware the resident was missing an oxycodone until today. During an interview on 08/25/23, at 1:15 P.M., Licensed Practical Nurse (LPN) D said he/she does not know why the resident's oxycodone narcotic sheet is marked out with a new number. During an interview on 08/25/23, at 1:50 P.M., RN E said he/she notified the ADON of the discrepancy with the resident's oxycodone. He/she does not know the circumstances surround the count being off. 9. During an interview on 08/25/23, at 2:05 P.M., RN A said the following: -RN A and RN B were working the overnight shift and RN A was helping with RN B's orientation; -When it was time to count, RN B asked to count because he/she wanted more training and wanted to do it by him/herself; -At 3:30 A.M., RN A noticed RN B was overly tired. RN A asked RN B if he/she was ok, and he/she said they were not used to nights; -Around this time, RN B said he/she was going to their car. After about 15 to 20 minutes, RN A went to check on RN B and observed him/her in his/her car. RN B did not return back inside for another 15 to 20 minutes; -When RN B returned inside, he/she was holding a white hooded sweatshirt. RN B said he/she had been sick and threw up on the shirt. RN A noticed there was pink on the hoodie. RN B asked where he/she could wash the shirt out at, and RN A said the medication room; -RN A said RN B was in the medication room for about 30 minutes, and was falling asleep standing up. RN A started tapping on the window, and RN B just nodded. RN B finally came out, to start to pass medications; -The ADON arrived and took RN B's keys. The ADON had RN conducted count on the medication carts; -RN A discovered the count was off, as there was Ativan and morphine missing; -RN A said earlier in the evening, he/she and RN B destroyed Resident #1's medications as he/she had passed; -RN A saw RN B hold up Resident #1's medications while he/she was standing at the nurse's desk before they went into the medication room, but RN A did not check the name on narcotic sheet, or check the bottles him/herself before destroying. After destroying the medications RN B told RN A to sign the narcotic sheets, which he/she did, but did not verify the resident's name on the sheet; -After the narcotic count was complete, RN A found out it was Resident #5's medications that had been destroyed; -Discontinued narcotic medications are continued to be counted as long as they are in the cart; -Narcotic medications are destroyed by two RN's, which need to be upper management. Once destroyed, the narcotic sheet is signed by both staff and removed from the narcotic book; -RN A said he/she thought it was ok that RN B was pulling discontinued narcotic medications as he/she was a staff at the facility, as RN A was an agency staff. ; -Administration of narcotic medications are documented in the MAR and on the narcotic sheet. 10. During an interview on 08/25/23, at 12:30 P.M., the ADON said the following: -On 08/23/23, at 5:38 A.M., as the ADON was pulling in the parking lot, he/she received a call from RN A; -RN A said RN B was having odd behavior; -The ADON entered the building and observed RN B leaning over the medication cart, holding an empty trash bag, and nodding off. The ADON had to tap RN B on the shoulder three times to arouse him/her; -RN B said he/she was tired as they were not used to working nights; -The ADON advised RN B that he/she could go. RN B started ruffling items on the medication cart and said he/she needed to sign the narcotic book. RN B came over to the nurses' station and dropped the book. The ADON told RN B that he/she did not need to count medications; -RN B started to walk toward the front door, but he/she was parked out back. The ADON suggested RN B call for a ride; -RN A notified the ADON that he/she conducted a narcotic count with the oncoming shift and narcotics were missing; -The ADON then asked to search RN B's property (a purse and bag); -The ADON located non-narcotic medications belonging to Resident #2 and Resident #3 in RN B's purse; -The ADON called the police, and they reported to the facility; -RN B gave consent to have his/her car searched. The police located a full syringe of a pink liquid; -When administering narcotic medications, staff should document in the MAR and on the narcotic sheet; -Narcotic medication counts are conducted at shift change. The oncoming shift is counting cards and medications, and the off going is documenting in the narcotic book; -If the count is off, staff should try to resolve, but if cannot be resolved, the staff cannot leave and the ADON and DON will be notified and a count will be conducted of all narcotic medications; -An investigation will be initiated, and the State will be notified within 24 hours; -Staff are not allowed to take resident medications because it is considered theft of property; -If a narcotic medication is discontinued, staff should notified the ADON or DON because the facility requires two RN's to destroy medications; -Staff should leave the discontinued narcotic in the cart and the medication will continued to be counted until removed from the cart and destroyed; -Discontinued narcotics should be pulled from the cart and destroyed on the same day, unless there are not two RN's available (like overnight shift); -When destroying medications, the two RN's should ensure the medications and the narcotic sheets match; -The RN's will both sign the narcotic sheet, and then sign the destruction log sheet. The narcotic sheet is then placed in the medical records bin. 11. During an interview on 08/25/23, at 11:30 A.M., Certified Medication Technician (CMT) C said the following: -The narcotic count is conducted at shift change by oncoming and off going staff; -The ongoing staff counts the cards and the individual pills in the cards, and the off going staff documents in the narcotic book; -If there is an issue with the narcotic count, staff report the issue to the ADON, DON, and/or charge nurse. The facility will start and investigation and report it to the state within 24 hours; -Staff cannot take resident medications as is misappropriation of property/abuse; -Discontinued narcotics are continued to be counted until they are removed from the cart; -If a medication is discontinued, CMT C will place a note on the medication that it needs to be destroyed. Staff can also notified the ADON or DON; -Mediations are destroyed by two RN's, and one has to be the ADON or DON; -There is not a set schedule when medications are destroyed. Narcotics are normally destroyed every week or two; -When administering narcotics, they are documented as given in the electronic MAR and on the narcotic sheet. 12. During an interview on 08/25/23, at 1:15 P.M., Licensed Practical Nurse (LPN) D said the following: -Narcotic counts are conducted at shift change. The oncoming staff counts the cards and pills and the off going staff documents in the narcotic book; -If the narcotic count is not right, the supervisor/DON is notified and no one leaves; -Staff cannot take resident medications because it is illegal as it is misappropriation; -Discontinued narcotic medications should not sit in the cart. Staff should notify the DON if a medication has been discontinued. If a discontinued medication is still in the cart, it should continue to be counted. Two RN's have to be present to destroy medications. LPN D believes carts are checked daily by the ADON or DON; -Staff administering narcotics should document in the MAR and in the narcotic book. 13. During an interview on 08/25/23, at 1:50 P.M., RN E said the following: -On 8/23/23, RN E worked the day shift. When he/she arrived at work, he/she was directed by the VP to count all narcotics and report any issues to him/her or the ADON; -At shift change, the oncoming and off going shift conduct the narcotic count. The oncoming shift counts the cards, pills, bottles, and patches, and the off going staff documents in the narcotic book; -Discontinued medications will be included in the count until they are removed from the cart; -If a count is off, staff will not sign the narcotic book, or accept the cart. The ADON and DON will be notified and an investigation will be initiated. The State will be notified; -Staff cannot take resident medications as it is misappropriation of property; -RN E will remove discontinued narcotic medications from the medication cart and destroy the medications with the ADON, as two RN's have to destroy narcotic medications. There is no set destruction schedule; -When destroying medications, staff verify the name on the narcotic, the narcotic medication, and the narcotic sheet to ensure they all match. Both staff will sign and date on the narcotic sheet after it is destroyed and place in the medical records basket. 14. During an interview on 08/25/23, at 2:39 P.M., the [NAME] President said the following: -Narcotic medication counts are conducted at shift change. Both nurses should be looking at cards and pills; -If a narcotic count is off, staff need to recount and then call the DON or on call staff. Staff need to remain in the building until management arrives. The facility will start an investigation and notify the State within 24 hours; -Staff cannot take resident medications as it is against the law and considered misappropriation of property; -Discontinued narcotics are continued to be counted as long as they are in the medication cart; -Narcotics should remain in the cart until they are destroyed; -Staff can notify the DON if there are narcotics in the cart that need to be destroyed; -Medications are destroyed by two RNs, which one has to be the DON or an RN designated by the DON. The RN's should pull the medication and the narcotic sheet. The RN's should verify the count, verify the narcotic medication against the resident name, and the narcotic sheet. Each RN signs the narcotic sheet and the destruction sheet; -When administering narcotic medications, staff should document in the MAR and on the narcotic sheet. MO00223430

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident rights for visitation were not restricted when staff did not allow a family member to visit Resident #1 inside the facility and did not communicate alternate visitation options. The facility census was 54. Record review of the facility's policy titled 'Resident Rights', revised December 2016, showed the following: -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -Communication with and access to people and services, both inside and outside the facility; -Visit and be visited by others from outside the facility; -Be informed of safety or clinical restriction or limitations of visitation. Record review of the facility's policy titled 'Visitation', revised February 2021, showed the following: -Our facility permits residents to receive visitor subject to the resident's wishes and the protection of the rights of other residents in the facility; -The facility does not restrict visitors based on the request of family members or the healthcare power of attorney. If a family member requests that a certain individual be denied access to resident based on safety or security concerns, the staff will protect resident safety while allowing visitor access until the allegations are investigated; -Incidents of any visitor's disruptive behavior are documented in the resident's medical record or other facility approved form. (The facility administration did not conduct an investigation of the allegations related to the visitor's behavior and did not document in the resident's medical record or provide a form related to the visitor's behavior) 1. Record review of Resident #1's face sheet showed the following: -Resident admitted to the facility on [DATE]; -Diagnoses of hemiplegia and hemiparesis (paralysis of one side of the body) following a stroke, diabetes mellitus type 2 (disease in which the body's ability to produce or respond to the hormone insulin is impaired), muscle wasting, muscle spasms, and pain. Record review of the resident's annual minimum data set (MDS, a federally-mandated comprehensive assessment tool completed by facility staff), dated 1/23/23, showed the following: -Moderate cognitive impairment; -Required extensive assistance of one staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Wheelchair for mobility device. Record review of the email from the administrator to the resident's family member, dated 3/9/23 at 11:16 A.M., showed the following: -At this time, we continue to ask you to not enter our facility. We have offered coordination of placement at any facility of your choice and we would assist with the move. If you would like to take the resident out of the building for a visit, we can accommodate that for you. (The email did not state specific details of 'out of the building' visit. Staff did not document in the resident's medical record of the visitation restrictions with his/her family member) During interviews on 3/16/23 at 9:39 A.M. and 3:26 P.M., the director of nursing (DON) said the following: -Facility administration staff discussed internally for the resident's family member to sit outside of the building or sit on the bench under the canopy in front of the facility for visits; -The chief executive officer (CEO) is out until 3/20/23 and instructed the facility staff to wait until she returned to clear the visitor's visitation plan; -She did not discuss the visitation plan with the resident's family member; -The resident's family member is belligerent, rude and threatening with her and called her a liar; -She did not interview residents or staff about the resident's family member's behaviors and if they were affected. During an interview on 3/16/23 at 10:01 A.M., certified nurse aide (CNA) A said the following: -The DON informed him/her the resident's family member is not allowed to visit due to rude and uncivilized behavior; -The DON said the resident's family member is not allowed to visit the resident and to contact her or the administrator if he/she sees the family member; -Residents and staff did not complain of being afraid of the resident's family member. During an interview on 3/16/23 at 10:10 A.M., the resident said his/her family member comes to visit him/her and he/she did not know if the family member is not able to visit him/her. During an interview on 3/16/23 at 10:15 A.M., CNA B said the following: -Licensed practical nurse (LPN) F informed him/her last week of the resident's family member not allowed in the facility and if the family member is at the facility to inform the nurses and DON; -He/she did not know the reason the resident's family member was not allowed to visit the resident; -Residents and staff did not complain of being afraid of the resident's family member. During an interview on 3/16/23 at 10:20 .A.M. CNA C said the following: -The DON informed him/her of the resident's family member not allowed at the facility; -The resident's family member asks weird questions such as Who has been caring for his/her family member?; -The resident's family member has not yelled or threatened him/her; -He/she observed the resident's family member ask nursing staff questions but did not hear what the family member talked about with the nursing staff; -He/she did not witness the family member talking to other residents or videoing in the facility; -Staff should report to the administrator and DON immediately if they observe the resident's family member on the premises; -The resident's family member is not allowed on the facility premises; -The visitor is not allowed because of getting upset with the administrator and nursing staff and took pictures of the nursing schedule. During an interview on 3/16/23 at 10:40 A.M., staff person D said he/she did not know of a visitor not allowed in the facility. During an interview on 3/16/23 at 10:49 A.M., CNA E did not know of a visitor not allowed to come to facility. He/she had not observed or heard of the resident's family member yell or threaten facility staff. During an interview on 3/16/23 at 10:55 A.M., LPN F said the following: -He/she showed this surveyor the note posted on the nurses' desk, dated 3/1/23, Resident #1's family member has been asked to leave the premises of the facility and not return. If the resident's family member is on premises, then you need to immediately call the administrator or DON; -The DON is the only staff person who stated she is afraid of the resident's family member; -He/she did not know of anything in past nursing reports the last three months of facility staff afraid of the resident's family member. During an interview on 3/16/23 at 11:51 A.M., staff person G said the following: -The resident's family member asked him/her a few weeks ago if Resident #2 had any family and he/she wanted to buy the resident some clothes; -The administrator came out of the office and said the resident's family member cannot ask about other residents and asked him/her to leave. The resident's family member raised his/her voice and was upset about other issues with his/her family member; -The administrator asked the resident's family member to leave the facility and not come back because he/she harassed the staff and asked questions. During an interview on 3/16/23 at 10:40 A.M., LPN H said the following: -He/she did not know of the resident's visitation plan with his/her family member; -The resident's family member asked Resident #2 if he/she had family one time; -Residents and staff did not report fear of the resident's family member. The DON is afraid of the resident's family member because he/she yelled at her and accused her of lying. During an interview on 3/16/23 at 12:36 P.M., the social service director (SSD) said the following: -She did not know if facility administration staff informed the resident's family member of reasons not to come to the facility; -She did not know if the resident was aware the family member was not allowed to come to the facility; -She did not know of the resident's family member's specific visitation plan. During a phone interview on 3/16/23 at 1:53 P.M. and 3:26 P.M. the administrator said the following: -She informed the resident's family member (in person) he/she harassed staff and to leave the facility premises and not return; -She emailed (3/9/23) the resident's family member that he/she could visit the resident outside the facility doors; -She said 'out of the building meant sitting out the front door or under the canopy; -She did not inform the resident's family member of the specific visitation plan due to he/she did not respond back to his/her email; -She did not inform the resident or resident's representative of the family member's visitation restrictions; -She did not document in the resident's medical record of the reason the family member cannot visit and the specific visitation plan; -She did not interview residents or staff about the resident's family member's behaviors and if they were affected. MO00215186

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident rights for visitation were not restricted when staff did not inform Resident #1 of his/her limitations of visits, the reasons for the restriction or limitation and to whom the restrictions applied when the facility did not allow the resident's family member in the facility for visits. The facility census was 54. Record review of the facility's policy titled 'Resident Rights', revised December 2016, showed the following: -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -Communication with and access to people and services, both inside and outside the facility; -Visit and be visited by others from outside the facility; -Be informed of safety or clinical restriction or limitations of visitation. Record review of the facility's policy titled 'Visitation', revised February 2021, showed the following: -Our facility permits residents to receive visitor subject to the resident's wishes and the protection of the rights of other residents in the facility; -The facility does not restrict visitors based on the request of family members or the healthcare power of attorney. If a family member requests that a certain individual be denied access to resident based on safety or security concerns, the staff will protect resident safety while allowing visitor access until the allegations are investigated; -Incidents of any visitor's disruptive behavior are documented in the resident's medical record or other facility approved form. (The facility administration did not conduct an investigation of the allegations related to the visitor's behavior and did not document in the resident's medical record or provide a form related to the visitor's behavior) 1. Record review of Resident #1's face sheet showed the following: -Resident admitted to the facility on [DATE]; -Diagnoses of hemiplegia and hemiparesis (paralysis of one side of the body) following a stroke, diabetes mellitus type 2 (disease in which the body's ability to produce or respond to the hormone insulin is impaired), muscle wasting, muscle spasms, and pain. Record review of the resident's annual minimum data set (MDS, a federally-mandated comprehensive assessment tool completed by facility staff), dated 1/23/23, showed the following: -Moderate cognitive impairment; -Required extensive assistance of one staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Wheelchair for mobility device. Record review of the email from the administrator to the resident's family member, dated 3/9/23 at 11:16 A.M., showed the following: -At this time, we continue to ask you to not enter our facility. We have offered coordination of placement at any facility of your choice and we would assist with the move. If you would like to take the resident out of the building for a visit, we can accommodate that for you; -The email did not state specific details of out of the building. Staff did not document in the resident's medical record of staff informing the resident of the family member's visitation restrictions and the reason for the restriction. During interviews on 3/16/23 at 9:39 A.M. and 3:26 P.M., the director of nursing (DON) said the following: -Facility administration staff discussed internally for the resident's family member to sit outside of the building or sit on the bench under the canopy in front of the facility for visits; -The chief executive officer (CEO) is out until 3/20/23 and instructed the facility staff to wait until she returned to clear the visitor's visitation plan; -She did not discuss the visitation plan with the resident's family member; -The resident's family member is belligerent, rude and threatening with her and called her a liar; -She did not interview residents or staff about the resident's family member's behaviors and if they were affected or afraid. During an interview on 3/16/23 at 10:01 A.M., certified nurse aide (CNA) A said the following: -The DON informed him/her that the resident's family member is not allowed to visit due to rude and uncivilized behavior; -The DON said the resident's family member is not allowed to visit the resident and to contact her or the administrator if he/she sees the family member; -Residents and staff did not complain of being afraid of the resident's family member. During an interview on 3/16/23 at 10:10 A.M., the resident said his/her family member comes to visit him/her and he/she did not know if the family member is not able to visit him/her. During an interview on 3/16/23 at 10:15 A.M., CNA B said the following: -Licensed practical nurse (LPN) F informed him/her last week of the resident's family member not allowed in the facility and if the family member is at the facility to inform the nurses and DON; -He/she did not know the reason the resident's family member was not allowed to visit the resident; -Residents and staff did not complain of being afraid of the resident's family member. During an interview on 3/16/23 at 10:20 A.M., CNA C said the following: -The DON informed him/her of the resident's family member not allowed at the facility; -The resident's family member asks weird questions such as Who has been caring for his/her family member?; -The resident's family member has not yelled or threatened him/her; -He/she observed the resident's family member ask nursing staff questions but did not hear what the family member talked about with the nursing staff; -He/she did not witness the family member talking to other residents or videoing in the facility; -Staff should report to the administrator and DON immediately if they observed the resident's family member on the facility premises; -The resident's family member is not allowed on the facility premises; -The visitor is not allowed because of getting upset with the administrator and nursing staff and taking pictures of the nursing schedule. During an interview on 3/16/23 at 10:40 A.M., staff person D said he/she did not know of a visitor not allowed in the facility. During an interview on 3/16/23 at 10:49 A.M., CNA E did not know of a visitor not allowed to come to facility. He/she had not observed or heard of the resident's family member yell or threaten facility staff. During an interview on 3/16/23 at 10:55 A.M., LPN F said the following: -He/she showed this surveyor the note posted on the nurses' desk, dated 3/1/23, Resident #1's family member has been asked to leave the premises of the facility and not return. If the resident's family member is on premises, then you need to immediately call the administrator or DON; -The DON is the only staff person who stated she is afraid of the resident's family member; -He/she did not know of anything in past nursing reports the last three months of facility staff afraid of the resident's family member. During an interview on 3/16/23 at 11:51 A.M., staff person G said the following: -The resident's family member asked him/her a few weeks ago if Resident #2 had any family and he/she wanted to buy the resident some clothes; -The administrator came out of the office and said the resident's family member cannot ask about other residents and asked him/her to leave. The resident's family member raised his/her voice and was upset about other issues with his/her family member; -The administrator asked the resident's family member to leave the facility and not come back because he/she harassed the staff and asked questions. During an interview on 3/16/23 at 10:40 A.M., LPN H said the following: -He/she did not know of the resident's visitation plan with his/her family member; -The resident's family member asked Resident #2 if he/she had family one time; -Residents and staff did not report fear of the resident's family member. The DON is afraid of the resident's family member because he/she yelled at her and accused her of lying. During an interview on 3/16/23 at 12:36 P.M., the social service director (SSD) said the following: -She did not know if facility administration staff informed the resident's family member of reasons not to come to the facility; -She did not know if the resident was aware of the family member not allowed to come to the facility; -She did not know of the resident's family member's specific visitation plan. During a phone interview on 3/16/23 at 1:53 P.M. and 3:26 P.M., the administrator said the following: -She informed the resident's family member in person he/she harassed staff and to leave the facility premises and not return; -She emailed (3/9/23) the resident's family member he/she could visit the resident outside the facility doors; -She said out of the building meant sitting out the front door or under the canopy; -She did not inform the resident's family member of the specific visitation plan due to he/she did not respond back to his/her email; -She did not inform the resident or resident's representative of the family member's visitation restrictions; -She did not document in the resident's medical record of the reason the family member cannot visit and the specific visitation plan; -She did not interview residents or staff about the resident's family member's behaviors and if they were affected or afraid. Record review of the resident's medical record showed staff did not document the reason for visitation restrictions for the family member, the visitation plan or that staff informed the resident of the family member's restricted visitation. MO00215186

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to timely report allegations of abuse to the state survey agency (DHSS) within the required two hour time frame when facility staff did not report allegations of staff to resident abuse involving one resident (Resident #1) and did not report allegations of resident to resident abuse involving 3 residents (Resident #1, Resident #3, and Resident #4) in a facility with a census of 53. Record review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, showed: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management; -Findings of all investigations are documented and reported; -Policy Interpretation and Implementation - Reporting Allegations to the Administrator and Authorities: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law;-The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility, the ombudsman; resident's representative; Adult protective services (where state law provides jurisdiction in long-term care); Law enforcement officials; The resident's attending physician; and The facility medical director; -Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. -Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents; -All allegations are thoroughly investigated. The administrator initiates investigations; -Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations; -The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation; -The administrator is responsible for keeping the resident and his/her representative informed of the progress of the investigation; -The administrator ensures that the resident and the person reporting the suspected violation are protected from retaliating or reprisal by the alleged perpetrator, or by anyone associated with the facility; -Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; The individual completing the investigation as a minimum: reviews the documentation and evidence, the medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his/her interactions with staff and other residents, interviews the persons reporting the incident, the witnesses, the resident or resident representative, the staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, the resident's roommate, family, and visitors, the physician (as needed), reviews all events leading up to the alleged incident, and documents the investigation completely and thoroughly; -Witness statements are obtained in writing, signed and dated. The witness may write a statement or the investigator may obtain a statement; -Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator; -Follow up report: Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The follow-up investigation report will provide as much information as possible at the time of submission of the report. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation; -Corrective Action: All relevant professional and licensing boards are notified when an employee is found to have committed abuse. If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated. Any allegations of abuse are filed in the accused employee's personnel record along with any statement by the employee disputing the allegation, if the employee chooses to make one. If the investigation reveals that the allegation(s) of abuse are unfounded, the employee(s) may be reinstated to his/her former position with back pay. Records concerning allegations that are determined to be unfounded are destroyed or archived per human resources policy. Corrective actions may include a full review of the incident(s) by the QAPI committee. 1. Record review of Resident #1's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of dementia with behavioral disturbances, muscle wasting and atrophy, depression, anxiety, edema, osteoarthritis, myalgia (muscle pain), and pain. Record review of Resident #1's quarterly minimum data set (MDS, a federally-mandated resident assessment tool completed by facility staff), dated 2/13/23, showed: -admitted to the facility on [DATE]; -Cognitively intact; -Required extensive assistance of two or more staff with bed mobility, transfers, toileting; -Required extensive assistance of one staff with dressing; -Used wheelchair for mobility device; -Frequently incontinent of bowel and bladder; -No limitations in range of motion; -No falls. Record review of the resident's progress note, dated 2/23/23 at 10:00 A.M., showed licensed practical nurse (LPN) L documented the following: -Resident complained of bruising on the right breast and under arm. Upon assessment red and purple bruising found located on the resident's right breast and underarm. Resident stated the bruising came from the sit-to-stand. Record review of the resident's progress note, dated 2/23/23 at 10:04 A.M., showed licensed practical nurse (LPN) A documented the following: -The resident complained the night shift aide was upset with him/her and the resident refused all cares last night; -The night shift attempted to get the resident both lifts and unsuccessful; -This morning, he/she had the day shift staff clean the resident up; -The resident cried because he/she wanted a certified medication technician (CMT) did not specify to run an errand and he/she had left ear pain; -The resident continued to sit at the nurse's station crying about all these topics. Other nurse investigated. Record review of the resident's progress note, dated 2/23/23 at 1:18 P.M., showed LPN I, the MDS/care plan coordinator, documented the following: -A CNA approached LPN I and reported that the resident stated that he/she could not reach his/her mouth with his/her hand. LPN I went with the Director of Rehabilitation (DOR) to evaluate the resident due to discussion earlier in the shift that therapy would see if the resident might need therapy services related to the use of the sit-to-stand versus the mechanical lift and the resident could not use the sit-to-stand but also did not want to sit on the mechanical lift pad. The MDS coordinator and therapist explained to the resident that if he/she agreed to get in bed, the sling could be removed, but the sling could not be removed in the chair. When the staff asked about the resident's right arm range of motion (ROM) the resident said he/she was bruised. The MDS nurse noted a large bruise under the resident's right armpit spreading across the resident's right breast. The MDS nurse stopped the discussion with the resident and brought the administrator and SSD into the room to determine the cause of the discoloration noted. Record review of the resident's progress note, dated 2/23/23 at 5:20 P.M., showed the Social Service Director (SSD) documented the following: -The SSD and the administrator visited with the resident's about the resident's concerns. Resident said that he/she had to lower self in sit-to-stand lift. Previous note at 10:30 A.M. this morning, showed resident stated the bruising came from the sit-to-stand. Resident is now stating will use the mechanical lift. The resident said, I will do anything I need to do. The resident agreed to laying down between meals and to allow use of the mechanical lift for transfers. The resident agreed to therapy for some possible strengthening. Record review of the hospital law enforcement documents, dated 2/28/23, showed: -The resident presented to the emergency room with significant amount of bruising noted to the right anterior (front) and posterior (back) upper torso. When asked, the resident told nurse that 5-6 days ago certified nurse assistant (CNA) F was rough with him/her. Resident stated while using a mobility device called a sit-to-stand, the resident told CNA F that he/she was in severe pain in the mobility device. The resident stated he/she told CNA F that he/she needed to sit down due to the pain. The resident reported that CNA F left the resident in the sit-to-stand for a while, he/she was unsure how long. Then CNA F came back in and helped. The resident mentioned multiple times that staff in the facility have seen the bruises, including that head lady but they are always trying to cover things up and make it go away. When asked if a physician had assessed the resident's injuries, the resident did not recall. The resident does not have any family or visitors that come to the facility. The resident said he/she felt safe at the facility. The resident did not want law enforcement contacted about the matter. The resident said he/she did not want them to retaliate -The resident affect: Quiet, sad, scared, anxious; -Frontal torso injury description: Extensive, dark, purple bruising with defined margins to the right breast, extending upward onto the chest, into the axilla (armpit), and down onto the abdomen. Skin sparing noted to the underside of the right breast, extending down onto the abdomen and to lateral side (towards the left hip). Purple bruise with blue/green surrounding the purple margins to the right medial mid chest, in line with the axilla- several centimeters above the bruising to the right breast. [NAME] bruising noted to entirety of right breast, extending onto upper chest and sternum (breastbone). Deep, dark purple bruising with defined margins noted to the right lateral side, extending onto both anterior and posterior surfaces, from axilla to mid abdomen. Streak of purple/red bruising extends from large bruise onto the right mid abdomen. Beneath the purple bruising on the right side, there is a green/yellow bruising extending into the lower abdomen. In the right axilla there is a section of green/yellow bruising in between areas of purple of the side and the arm. -Posterior torso injury description: Extensive, dark, deep, purple/black bruising noted to the right posterior torso. The majority of the bruising is solid in color, with scattered varying purple coloring to the upper portion of the bruise on the posterior shoulder and mid back. Extended on the left side of the posterior back. Green/yellow bruising noted below purple bruising, extending down onto the lower abdomen and waist. -Right upper extremity injury description: Circumferential (around the arm) dark purple bruising to the right upper arm, extending into the axilla and down onto the anterior forearm. Purple/green bruising noted to the right axilla, extending up to the anterior shoulder. Record review of the hospital law enforcement documented, dated 3/1/23, showed: -Resident still adamant not to notify the police department about bruising and states, CNA F has been rough with me for a while now and I just don't want it to get worse. I just can't live with it. Nurse asked for clarification. Resident states, CNA F is a night shift aide and he/she left me in a sit-to-stand. They will try to say that I fell but I didn't fall. He/she left me in it for a long time. During an interview on 3/1/23 at 12:15 P.M., the administrator said: -The facility has had no recent allegations of resident abuse; -The facility residents have had no suspicious injuries/bruises; -He/she and the SSD speak with the resident about his/her bruising on 2/23/23; -At that time, the resident claimed the bruising was caused by the sit-to-stand lift; -The resident did not complain of being left in the lift or of abuse; -The resident did not like the mechanial lift and at times would refuse cares. During an interview on 3/1/23 at 12:15 P.M., the director of nursing (DON) said: -Staff were using the sit-to-stand to assist the resident to transfer and she let go of the bar and she chicken winged (demonstrated by putting elbows up in the air with arms bent); -Resident #1 had a large bruise to his/her right side; -Therapy evaluated the resident and the facility changed the resident to a mechanical lift; -The resident admitted to purposely letting go of the sit to stand during the transfer; -On 2/23/23, the resident told the nurse, LPN A, that a night shift aide was upset with him/her (the resident); -Last night on 2/28/23, the resident told the DON he/she had soiled him/herself, but refused to be changed and said he/she would just sit in the stool and die, but would not use the mechanical lift. During interviews on 3/1/23 at 1:04 P.M. and on 3/6/23 at 1:50 P.M., LPN A said the following: -On 2/16/23, CNA B reported that Resident #1 was on the floor because the resident could not hold onto the sit-to-stand lift and had let go and staff lowered the resident to the floor; -The nurse assessed the resident for injuries and did not find any injuries and the resident denied pain; -The nurse said he/she did not notify the resident's physician of the 2/16/23 incident because staff lowered the resident to the floor; -Several days later, the resident complained of pain all over and an agency nurse assessed the resident and reported found bruising on the resident; -At one point, the night shift nurse, LPN J told LPN A the resident complained that CNA F was rough with the resident and mad at the resident, but CNA F was neither; -The resident complained to LPN A about how the night shift aide, CNA F, was mad at him/her because CNA A was throwing the sling around; -LPN A told the resident this was probably not true; -The resident reported to LPN A that CNA F caused the bruising and the nurse notified the DON; -After that, CNA F was not allowed to care for Resident #1; -The nurse said some types of abuse included physical and verbal; -If a resident alleged abuse, he/she would send the involved staff member home and would immediately notify the administrator and DON; -The facility should notify DHSS of an allegation of abuse within two hours. -LPN A never saw the bruises to the resident's right breast/underarm (Record review of the resident's treatment administration record showed the nurse initialed monitoring of the resident's breast and underarm bruises on 2/24/22, 2/25/22, 2/27/22, and 2/28/22); -The bruising should have definitely been monitored every day; -Nurses should have charted on the resident's bruises size and color in the progress notes so that other nurses would know if the resident's bruises were getting bigger; - LPN A did not realize the significance of the resident's bruises; -LPN A was confused about which lift to use to transfer the resident; -The DON told him/her to use the mechanical lift with no exceptions, but then the resident was refusing the mechanical lift and staff would continue to use the sit-to-stand lift and the nurse said that put the resident in jeopardy; -LPN A was unsure which staff were using the sit-to-stand lift, the aides would pass on in report to the next shift that the aides had used the sit-to-stand due to the resident's refusal to use the mechanical lift; LPN A said the DON was aware staff were continuing to use the sit-to-stand, and would reiterate that staff should be strictly using the mechanical lift with the resident. During an interview on 3/1/23 at 1:45 P.M., CNA B said the following: -The resident said someone from the night shift was rough with her while using the sit-to-stand lift; -The resident had black and blue bruising on his/her right chest, right shoulder, and right side (rib cage) and the resident kept saying someone from the night shift was rough with him/her; -When asked when the resident complained about the night shift, the CNA said last week; -The CNA said he/she notified the nurse about the resident's bruise and that the resident said staff was rough with him/her; -The CNA was unsure which nurse, he/she told; -The CNA said he/she thought the resident was speaking about CNA F, because CNA F was the only male aide on the night shift; -The resident complained about having to use the mechanical lift, but the resident no longer had the arm strength to hold him/herself up in the sit-to-stand lift; -The day the resident slid out of the sit-to-stand lift, the resident did not have the strength to hold on and slipped down through the sling; Types of abuse include neglect and rough staff; -If a resident alleged abuse, he/she would immediately notify his/her charge nurse and then it goes up the chain of command; -The aide said the facility had 24 hours to report an allegation of abuse to DHSS. During an interview on 3/1/23 at 2:17 P.M., CNA C said the following: -The resident had a bruise on the underside of his/her arm for approximately one or two weeks; -The CNA assisted the resident with a shower on 2/28/23 and the resident had dark purple bruising to the underside of his/her right upper arm, right arm pit, right shoulder, and right breast; -The CNA asked the resident about the bruising and the resident said the bruise occurred when CNA F lifted the resident up with the sit-to-stand lift. The resident said he/she told CNA F to stop lifting him/her, but he/she would not stop; -The CNA documented the bruising on the shower sheet and gave the shower sheet to the nurse LPN D on 2/24/23; -CNA C told CNA F that the resident said that the bruise was caused by CNA F. CNA F denied it and said the bruise was caused by a fall. CNA F said he/she was refusing to go back into the resident's room because the resident accused CNA F of causing the bruise; - CNA C did not report what the resident said about CNA F because CNA C assumed the staff already knew since CNA F was no longer taking care of the resident. During an interview on 3/1/23 at 3:05 P.M., LPN D said the following: -On 2/23/23, he/she was responsible for resident skin treatments and Resident #1 told the LPN about his/her bruising and said the bruising was from the sit-to-stand lift. The nurse did not assess the resident's bruises. LPN D told LPN L about the bruising and to assess the resident. During an interview on 3/1/23 at 4:02 P.M., CNA E said the following: -Approximately one week prior, the resident sat at the nurse's desk in his/her wheelchair and was crying; -The CNA asked the resident what was wrong and the resident said he/she had some bruising and pulled the side of his/her shirt up and showed his/her side (rib cage area). the resident's side looked dark purple; -The CNA asked the resident what happened and the resident said she did not remember, but the bruising was from CNA F and the sit-to-stand lift; -The CNA did not report the situation to anyone which was bad' on his/her part. During an interview on 3/1/23 at 4:45 P.M., the administrator said: -He/she did not recall the resident saying anything about CNA F causing the bruising; -The resident said the lift caused the bruising; -The administrator said he/she thought the resident said something about that CNA F was mad at the resident and having a bad night; -The administrator did not recall if he/she asked the resident what that meant; -The resident did not say CNA F hurt him/her of left the resident in the sling for a prolonged period of time; -The resident did complain of not being able to move his/her right arm, but later the administrator observed the resident move his/her arm. During a phone interview on 3/2/23 at 9:17 A.M., CNA F said: -If a resident required a sit-to-stand or mechanical lift for transfers, then he/she always used a second staff to assist with the transfer; -Resident #1 consistently refused cares and he/she notified the nurses; -The resident frequently refused the sit-to-stand and the mechanical lift; -The resident would frequently sit up all night in the recliner or wheelchair and would refuse to get in bed or have incontinent brief changed; -The resident had bruising on his/her right side and under his/her right arm; -The CNA said he/she believed the resident had the bruising when he/she moved to the hall from another part of the building, approximately 2-3 weeks prior; -He/she reported the bruising to LPN J and another LPN said the administrator was aware; -The CNA said he/she assisted the resident up with the sit-to-stand on only one occasion that he/she could recall; -The resident complained to him/her and to CNA G that the sit-to-stand lift hurt too much, so the staff member lowered the resident back down into his/her wheelchair; -On the morning of 2/24/23, one of the day nurses, LPN A, told CNA F the resident said that CNA F caused the bruising on the resident's side; -The CNA said he/she did not ask any questions, because he/she knew that the bruising was already there when the resident was moved to 200 hall; -Then that Friday evening, 2/24/23, when CNA G returned to work, CNA G told CNA F that the resident said he/she did not want CNA F to come into his/her room; -The aides then went and told LPN J about the resident's comments; -LPN J said he/she would notify the DON; -LPN J said the DON said to tell CNA F not to go back into Resident #1's room and the nurse had two female staff care for the resident; -The DON had an all staff meeting on Friday (3/24/23) of the past week over resident rights and abuse and also during the meeting the DON mentioned that Resident #1 should only be transferred with a mechanical lift; -That was the first time CNA F was told that Resident #1 needed to be only transfered by a mechanical lift; -Prior to that, the nurse LPN J said staff could use a mechanical lift or sit-to-stand to transfer the resident. During an interview on 3/2/23 at 2:14 P.M., CNA H said; -This past weekend, on Saturday 2/25/23, CNA H spoke with the resident; -The resident said three girls were rough with him/her. The resident said the staff were arguing with one another and not paying attention during Resident #1's transfer with a sit-to-stand transfer lift. The resident said he/she could no longer hold onto the sit-to-stand and staff had to lower the resident to the floor because he/she was slipping out of the lift harness. The resident did not say when this occurred; -When the CNA asked the resident what caused the bruising, the resident that night shift aide, CNA F caused the bruises on the resident with the sit-to-stand lift. The resident did not say when this occurred; -The resident had black and purple bruising to his/her entire right side and right breast; -The CNA said he/she reported this information to the nurse LPN A. During an interview on 3/2/23 at 2:40 P.M., the social service director (SSD) said: -On 2/23/23, the MDS nurse notified the administer and the SSD that he/she and the director of rehabilitation (DOR) were in the resident's room and found the resident to have bruising; -The MDS nurse, administrator and the SSD went to the resident's room; -Initially, the resident complained of a lot of pain to his/her right side and the MDS nurse tried to raise the resident's right arm, but the resident yelled out, so the MDS nurse lowered the resident's arm; -The SSD saw the resident's right arm pit and it was dark purple in color; -The SSD then stepped out to talk to the medication technician to see if the resident could have a pain pill and then returned to the room; -The resident said on the night of 2/22/22, he/she had lowered him/herself to the floor and kind of fell' on the sit-to-stand lift and that was what caused the bruising; -After the fall out of the sit-to-stand on 2/16/23, the MDS nurse changed the resident's care plan to show staff should only transfer the resident using a mechanical lift; -The resident was upset that he/she could not bend his/her right arm enough to feed him/herself and stated wanted assistance with lunch; -the resident was able to wipe his/her nose while the SSD was in the room with his/her right hand; -The resident said the CNA F was rough with him/her on the bed on the night shift; -The administrator asked the resident how CNA F was rough; -The resident said CNA F rolled the resident over onto his/her side to place a lift pad under the resident and was rough; -The SSD said he/she would consider a staff member being rough as an allegation of abuse; -The SSD said the different types of abuse included physical, verbal, sexual, and emotional; -The SSD said the administrator and the DON generally conduct the abuse investigations; -The SSD said if the facility suspected abuse, the facility calls the Department of Health and Senior Services (DHSS) hotline within 2 hours; -After talking about the situation with Resident #1, we did not feel there was a reason to hotline, because we went into room to figure out of the bruising was from abuse and gathered that the bruising was from the sit-to-stand lift; -The DON was out of the facility during this time, but the SSD thought the administrator called the DON about the situation -In this situation, the facility decided to look into the allegation first before deciding whether or not to call the allegation into DHSS; -The SSD said the facility was supposed to call in every allegation of abuse to DHSS. During an interview on 3/2/33 at 3:50 P.M., LPN I said: -The reason for the confusion on which lift the staff were supposed to use with the resident was a result of the resident adamantly refused the mechanical lift, but the resident was losing strength and had slid through the sit-to-stand lift and the aides had to lower the resident to the floor on 2/16/23, and therefore the resident needed to use the mechanical lift: -LPN care planned for staff to be able to use both types of lifts (sit-to-stand and mechanical) because although the resident agreed to use the mechanical lift, the LPN did not think the resident would use the mechanical lift; -The resident could bear some weight when he/she wanted to, making the best choice of lift difficult to determine; -On 2/23/23, one of the nurse aides informed the LPN that the resident was complaining that he/she was not able to use his/her right arm and wanted to be fed; -On 2/23/23 at approximately 12:30 P.M. or 1:00 P.M., the LPN and the director of rehabilitation (DOR) went to the resident's room to evaluate the resident; -The resident was very emotional and crying, but had no tears, the resident said he/she was unable to use his/her right arm and grimaced when staff attempted to raise the resident's arm. The DOR pulled the resident's shirt up on the right side, to expose right rib cage and below breast bruise, purple-blue in color and the approximate size of a football from what the LPN could see. The resident said, staff did it with the sit-to-stand sling; -The LPN then went and informed the administrator to come to the resident's room; -The LPN, administrator, and SSD went back to the resident's room. The resident then said, CNA F did it to her. CNA F did it at night in the bed. CNA F was rough with her. The resident said it occurred between 8:00 and 10:30 P.M., but CNA F was not in the facility during that time; -A nurse aide reported the resident did not have a transfer sling under him/her in the chair, earlier in the morning on 2/23/23, and therefore staff had attempted to use a sit-to-stand to transfer the resident back to bed, but the resident began flailing around, so staff lowered the resident and manually lifted the resident back to bed using three staff; -The LPN said he/she did not consider the resident's statements to be an allegation of abuse, because the resident had made false allegations in the past and he/she did not believe the resident's story; -However, The LPN said he/she immediately notified the administrator due to the resident's significant bruising and at that point it was the responsibility of the administrator to determine if abuse allegation. During an interview on 3/2/23 at 4:40 P.M., the DOR, a physical therapy assistant (PTA) said: -On 2/23/23 or 2/24/23, he/she and LPN I went to the residents room to discuss the need for the resident to use a mechanical lift for safe transfers because the resident was no longer strong enough to use the sit-to-stand lift, the resident did not like the mechanical lift, but agreed to allowing staff to use the mechanical lift for transfers; -The resident complained of right arm pain, the DOR and the LPN looked at the resident's arm and noted a bruise under the resident's right arm and over the resident's right lateral side. The resident complained of pain with range of motion to the right arm and sore when staff attempted to lift the resident's right arm. The resident said the bruise occurred during a sit-to-stand transfer when the resident's knees buckled and the resident slid down, the resident thought staff grabbed his/her arm and the resident thought that was what caused the resident's bruise. The resident said, He grabbed me around my arm. The resident said the arm was sore and hard to move. During a phone interview on 3/3/23 at 9:02 A.M., CNA G said: -He/she worked with CNA F on the night shift; -The resident told CNA G that the resident had to lower him/herself to the ground out of the sit to stand because he/she could not stand anymore; -On one occasion, CNA F asked for CNA G's help to transfer Resident #1 using a sit-to-stand to change the resident's clothing/incontinent brief; -CNA G assisted by putting the lift belt around the resident's waist and fastening securely in front, CNA F was running the controls and as we raised the resident, the resident complained that he/she was in pain and CNA F immediately lowered the resident back into his/her chair; -Last week, CNA G observed a dark bruise on the resident's side and underside of the resident's arm; -The resident said CNA F hurt him/her, the resident made it sound as if it happened during a transfer, but the aide was confused about exactly what the resident was trying to say; -He/she never saw CNA F do anything abusive; -CNA G reported this allegation immediately to LPN J and the nurse called the DON; -LPN J said the DON said it would be best if CNA F stayed out of the room; -After that, CNA F did not enter the resident's room; -Types of abuse include: physical, sexual, and verbal; -If a resident alleged abuse, he/she would report to the charge nurse immediately and then the charge nurse reports to the DON; -The facility has to report allegations of abuse to DHSS within 2 hours. During an interview on 3/6/23 at 5:00 P.M., the DON said: -Regarding the progr

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely conduct a staff to resident abuse allegation investigation involving one resident (Resident #1) and failed to timely conduct a resident to resident abuse investigation involving two residents (Resident #1 and Resident #3). The facility census was 53. Record review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, showed: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management; -Findings of all investigations are documented and reported; -Policy Interpretation and Implementation - Reporting Allegations to the Administrator and Authorities: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law; -The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility, the ombudsman; resident's representative; Adult protective services (where state law provides jurisdiction in long-term care); Law enforcement officials; The resident's attending physician; and The facility medical director; -Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. -Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents; -All allegations are thoroughly investigated. The administrator initiates investigations; -Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations; -The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation; -The administrator is responsible for keeping the resident and his/her representative informed of the progress of the investigation; -The administrator ensures that the resident and the person reporting the suspected violation are protected from retaliating or reprisal by the alleged perpetrator, or by anyone associated with the facility; -Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; The individual completing the investigation as a minimum: reviews the documentation and evidence, the medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observes the alleged victim, including his/her interactions with staff and other residents, interviews the persons reporting the incident, the witnesses, the resident or resident representative, the staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, the resident's roommate, family, and visitors, the physician (as needed), reviews all events leading up to the alleged incident, and documents the investigation completely and thoroughly; -Witness statements are obtained in writing, signed and dated. The witness may write a statement or the investigator may obtain a statement; -Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator; -Follow up report: Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The follow-up investigation report will provide as much information as possible at the time of submission of the report. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation; -Corrective Action: All relevant professional and licensing boards are notified when an employee is found to have committed abuse. If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) is terminated. Any allegations of abuse are filed in the accused employee's personnel record along with any statement by the employee disputing the allegation, if the employee chooses to make one. If the investigation reveals that the allegation(s) of abuse are unfounded, the employee(s) may be reinstated to his/her former position with back pay. Records concerning allegations that are determined to be unfounded are destroyed or archived per human resources policy. Corrective actions may include a full review of the incident(s) by the QAPI committee. 1. Record review of Resident #1's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of dementia with behavioral disturbances, muscle wasting and atrophy, depression, anxiety, edema, osteoarthritis, myalgia (muscle pain), and pain. Record review of the resident's quarterly minimum data set (MDS, a federally-mandated resident assessment tool completed by facility staff), dated 2/13/23, showed: -Entered the facility on 8/12/21; -Cognitively intact; -Required extensive assistance of 2 or more staff with bed mobility, transfers, toileting; -Required extensive assistance of one staff with dressing; -Used wheelchair for mobility device; -Frequently incontinent of bowel and bladder; -No limitations in range of motion; -No falls. Record review of the resident's care plan showed: -Resident required extensive assistance of two staff for bed mobility, toileting, and transfers and at times uses a sit to stand with one staff for transfers, revised on 2/15/23; -Resident required extensive assistance of two staff for bed mobility, toileting, and transfers with use of a Hoyer lift (a mechanical lift with a sling to lift and transfer residents) and at times used a sit to stand lift (a mechanical lift used by facility staff to help transfer a person, who can bear some body weight, from a seated to a standing position using a waist sling), with one staff for transfers, revised on 2/16/23; Record review of the resident's order summary report, showed: -An order, dated 2/22/23, Use Hoyer lift for transfers for safety. Record review of the resident's care plan showed: -Resident required extensive assistance of two staff for bed mobility, toileting, and transfers with use of a Hoyer lift for transfers. The resident had a fall out of the sit to stand lift and has demonstrated unsafe use of sit to stand, unable to hold on and slides down, revised on 2/22/23. Record review of the resident's progress note, dated 2/23/23 at 10:00 A.M., showed staff documented the following: -Resident complained of bruising on the right breast and under arm. Upon assessment, red and purple bruising found located on the resident's right breast and underarm. Resident stated the bruising came from the sit-to-stand. Record review of the resident's progress note, dated 2/23/23 at 10:04 A.M., showed licensed practical nurse (LPN) A documented the following: -The resident complained the night shift aide was upset with him/her and the resident refused all cares last night; -The night shift attempted to get the resident up using both both lifts and were unsuccessful; -This morning, the nurse had the day shift staff clean the resident up; -The resident was crying related to wanting the certified medication technician (CMT) to run an errand and the resident was crying related to left ear pain; -The resident continued to sit at the nurse's station crying about all these topics. Other nurse investigated. Record review of the resident's progress note, dated 2/23/23 at 1:18 P.M., showed LPN I, the MDS/ care plan coordinator, documented the following: -A Certified Nurse Aide (CNA) approached LPN I and reported that the resident stated that he/she could not reach his/her mouth with his/her hand. LPN I went with the director of rehabilitation (DOR) to evaluate the resident due to discussion earlier in the shift that therapy would see if the resident might need therapy services related to the use of the sit to stand versus the Hoyer lift and the resident could not use the sit to stand but also did not want to sit on the Hoyer pad. The MDS coordinator and therapist explained to the resident that if he/she agreed to get in bed, the sling could be removed, but the sling could not be removed in the chair. When the staff asked about the resident's right arm range of motion (ROM) the resident said he/she was bruised. The MDS nurse noted a large bruise under the resident's right armpit spreading across the resident's right breast. The MDS nurse stopped the discussion with the resident and brought the administrator and SSD into the room to determine the cause of the discoloration noted. Record review of the resident's interval exam form, dated 2/23/23, completed by the family nurse practitioner (FNP) showed: -Pneumonia - resolving clinically on Augmentin (an antibiotic), breathing comfortably, on oxygen, continue to monitor; -Ecchymosis - Right anterior (front) chest wall, no known significant trauma or respiratory compromise, will check chest X-Ray and complete blood work if persists or worsens, will schedule Ultram (a pain medication) 50 milligrams (mg) four times per day for 3 days, then as needed, to be administered with acetaminophen 500 mg four times per day for 3 days, then as needed; -Depression- tearful/anxious on exam, order for Lexapro (an antidepressant) 10 mg every day for 3 days, then increase to 20 mg every day; -Weakness - general decline, extensive assist with Hoyer lift/wheelchair. Record review of the resident's progress note, dated 2/23/23 at 5:20 P.M., showed the social service director (SSD) documented the following: -The SSD and the administrator visited with the resident's about the resident's concerns. Resident said that he/she had to lower self in sit to stand lift. Previous note at 10:30 A.M. this morning, showed resident stated the bruising came from the sit to stand. Resident is now stating will use the Hoyer lift. The resident said, I will do anything I need to do. The resident agreed to laying down between meals and to the allow use of the Hoyer lift for transfers. The resident agreed to therapy for some strengthening. Record review of the resident's care plan showed: -Resident had an activity of daily living (ADL) self-care performance deficit related to dementia requiring maximum assistance with most ADLs. The resident required use of a Hoyer lift due to limitations and safety concerns with sit to stand, revised on 2/24/23; Record review of the resident's shower sheet, dated 2/24/23, showed: -Staff documented a one (1) indicating bruising with circles on a body diagram circling the right breast, left shoulder and left scapula. Record review of the resident's physical therapy screen form, dated 2/24/23, showed: -Resident needs increased assistance with transfers; -Resident complain of bruising and soreness under the right arm since he/she slid down in the sit to stand lift with sling supporting him/her. The MDS coordinator and the therapist notes bruising to the resident's medial bicep/tricep (upper arm), and lateral inferior armpit/latissimus dorsi region (a part of the back from behind the arm to near midline of the back) appearing to be from the sit to stand sling when the resident's lower extremities buckled; -Recommend a Hoyer lift with all transfers; -Educated the resident that staff would be transferring him/her with a Hoyer lift. The resident was not happy with the therapist's decision because the resident preferred the sit to stand lift, but he/she agreed to allow use of the Hoyer lift. Record review of the resident's progress notes on 2/27/23 at 12:07 P.M., showed LPN I documented the following: -Medicare meeting held. The resident started physical, occupational, and speech therapy services. Evaluated by therapy on 2/24/23. On therapy services for transfers and strengthening, recently went from sit to stand to Hoyer due to sliding out of the sit to stand because he/she was unable to hold onto the bars or stand and was depending on the sling to hold his/her weight. Resident would state, No padding on sling. This writer explained sling was not supposed to support the resident's weight and resident would state he/she was unable to support his/her own weight; Record review of the resident's progress notes on 2/28/23 at 1:28 A.M., showed LPN J documented the following: -Two staff members went into the resident's room tonight to do rounds. The resident denied being incontinent of urine at that time and refused to be transferred via the Hoyer lift into bed for changing (incontinent care). The nurse went the room to change the resident's leg dressings and confirmed that the resident was soaked with urine. The nurse explained to the resident that he/she could not transfer without the Hoyer due to safety concerns. The resident refused to be changed. The nurse notified the director of nursing (DON) in regards to the lower extremities needed to be assessed by the wound clinic. Will continue to monitor behaviors. Record review of the resident's progress notes on 2/28/23 at 6:14 P.M., showed the DON documented the following: -Resident had call light on. Nurse assistant answered. Resident said he/she had soiled him/herself. Staff offered to change the resident's clothing. Resident refused the Hoyer lift and said would just sit in it. Staff reported to charge nurse and DON. Charge nurse will visit with resident. Record review of the resident's progress notes dated 2/28/23 at 9:23 P.M., showed staff sent the resident sent to the emergency room via ambulance at 7:55 P.M. due to respiratory issues; Record review of the hospital law enforcement documents, dated 2/28/23, showed: -The resident presented to the emergency room with significant amount of bruising noted to the right anterior and posterior upper torso. When asked, Resident told nurse that 5-6 days ago an aide named x was rough with him/her. Resident stated while using a mobility device called a sit to stand, the resident told the aide that he/she was in severe pain in the mobility device. The resident stated he/she told the aide that he/she needed to sit down due to pain. The resident reported that the aide left the resident in the sit to stand for a while, he/she was unsure how long. Then the aide came back in and helped. The resident mentioned multiple times that staff in the facility have seen the bruises, including that head lady but they are always trying to cover things up and make it go away. When asked if a physician had assessed the resident's injuries, the resident did not recall. The resident does not have any family or visitors that come to the facility. The resident said he/she felt safe at the facility. The resident did not want law enforcement contacted about the matter. The resident said he/she did not want them to retaliate. -The resident affect: Quiet, sad, scared, anxious; -Frontal torso (upper body) injury description: Extensive, dark, purple bruising with defined margins to the right breast, extending upward onto the chest, into the axilla (armpit), and down onto the abdomen. Skin sparing noted to the underside of the right breast, extending down onto the abdomen and to lateral (outer) side. Purple bruise with blue/green surrounding the purple margins to the right medial mid chest, in line with the axilla- several centimeters above the bruising to the right breast. [NAME] bruising noted to entirety of right breast, extending onto upper chest and sternum (breastbone). Deep, dark purple bruising with defined margins noted to the right lateral side, extending onto both anterior (front) and posterior (back) surfaces, from axilla to mid abdomen. Streak of purple/red bruising extends from large bruise onto the right mid abdomen. Beneath the purple bruising on the right side, there is a green/yellow bruising extending into the lower abdomen. In the right axilla there is a section of green/yellow bruising in between areas of purple of the side and the arm. -Posterior torso injury description: Extensive, dark, deep, purple/black bruising noted to the right posterior torso. The majority of the bruising is solid in color, with scattered varying purple coloring to the upper portion of the bruise on the posterior shoulder and mid back. Extended on the left side of the posterior back. Green/yellow bruising noted below purple bruising, extending down onto the lower abdomen and waist. -Right upper extremity injury description: Circumferential (around the arm) dark purple bruising to the right upper arm, extending into the axilla and down onto the anterior forearm. Purple/green bruising noted to the right axilla, extending up to the anterior shoulder. Record review of the hospital law enforcement documented, dated 3/1/23, showed: -Resident still adamant not to notify the police department about bruising and states, CNA F has been rough with me for a while now and I just don't want it to get worse. I just can't live with it. Nurse asked for clarification. Resident states, CNA F is a night shift aide and he/she left me in a sit to stand. They will try to say that I fell but I didn't fall. He/she left me in it for a long time. During an interview on 3/1/23 at 12:15 P.M., the administrator said: -The facility has had no recent allegations of resident abuse since the last incident reported to DHSS; -The facility residents have had no suspicious injuries/bruises; -He/she and the SSD spoke with the resident about his/her bruising on 2/23/23; -At that time, the resident claimed the bruising was caused by the sit to stand lift; -The resident did not complain of being left in the lift or of abuse; -The resident did not like the Hoyer lift and at times would refuse cares. During an interview on 3/1/23 at 12:15 P.M., the DON said: -Staff were using the sit to stand to assist the resident to transfer and he/she let go of the bar and he/she chicken winged (demonstrated by putting elbows up in the air with arms bent); -The resident had a large bruise to his/her right side; -Therapy evaluated the resident and the facility changed the resident to a Hoyer lift; -The resident admitted to purposely letting go of the sit to stand during the transfer; -On 2/23/23, the resident told the nurse, LPN A, that a night shift aide was upset with him/her (the resident); -Last night on 2/28/23, the resident told the DON he/she had soiled him/herself, but refused to be changed and said he/she would just sit in the stool and die, but would not use the Hoyer. During interviews on 3/1/23 at 1:04 P.M. and on 3/6/23 at 1:50 P.M., LPN A said the following: -On 2/16/23, CNA B reported that the resident was on the floor because he/she could not hold onto the sit-to-stand lift and had let go and staff lowered the resident to the floor; -The nurse assessed the resident for injuries and did not find any injuries and the resident denied pain; -The nurse said he/she did not notify the resident's physician of the 2/16/23 incident because staff lowered the resident to the floor; -Several days later, the resident complained of pain all over and an agency nurse assessed the resident and reported found bruising on the resident; -At one point, the night shift nurse, LPN J told LPN A the resident complained that CNA F was rough with the resident and mad at the resident, but CNA F was neither; -The resident complained to LPN A about how the night shift aide, CNA F, was mad at him/her because CNA A was throwing the sling around; -LPN A told the resident this was probably not true; -The resident reported to LPN A that CNA F caused the bruising and the nurse notified the DON; -After that, CNA F was not allowed to care for the resident; -The nurse said some types of abuse included physical and verbal; -If a resident alleged abuse, he/she would send the involved staff member home and would immediately notify the administrator and DON; -The facility should notify DHSS of an allegation of abuse within two hours. -LPN A never saw the bruises to the resident's right breast/underarm (Record review of the resident's treatment administration record showed the nurse initialed monitoring of the resident's breast and underarm bruises on 2/24/22, 2/25/22, 2/27/22, and 2/28/22); -The bruising should have definitely been monitored every day; -Nurses should have charted on the resident's bruises size and color in the progress notes so that other nurses would know if the resident's bruises were getting bigger; -The nurse did not realize the significance of the resident's bruises; -LPN A was confused about which lift to use to transfer the resident; -The DON told the nurse to use the Hoyer with no exceptions, but then the resident was refusing the Hoyer and staff would continue to use the sit to stand lift and the nurse said that put the resident in jeopardy; -LPN A was unsure which staff were using the sit to stand lift, the aides would pass on in report to the next shift that the aides had used the sit to stand due to the resident's refusal to use the Hoyer lift; LPN A said the DON was aware staff were continuing to use the sit to stand, and would reiterate that staff should be strictly using the Hoyer with the resident. During an interview on 3/1/23 at 1:45 P.M., CNA B said the following: -The resident said someone from the night shift was rough with him/her while using the sit to stand lift; -The resident had black and blue bruising on his/her right chest, right shoulder, and right side (rib cage) and the resident kept saying someone from the night shift was rough with him/her; -When asked when the resident complained about the night shift, the CNA said last week; -The CNA said he/she notified the nurse about the resident's bruise and that the resident said staff was rough with him/her; -The CNA was unsure which nurse, he/she told; -The CNA said he/she thought the resident was speaking about a night shift aide, CNA F, because the resident said it was a male aide on the night shift and CNA F was the only male aide on the night shift; -The resident complained about having to use the Hoyer lift, but the resident no longer had the arm strength to hold him/herself up in the sit to stand lift; -The day the resident slid out of the sit to stand lift, the resident did not have the strength to hold on and slipped down through the sling; Types of abuse include neglect and rough staff; -If a resident alleged abuse, he/she would immediately notify his/her charge nurse and then it goes up the chain of command; -The aide said the facility had 24 hours to report an allegation of abuse to DHSS. During an interview on 3/1/23 at 2:17 P.M., CNA C said the following: -The resident had a bruise on the underside of his/her arm for approximately one or two weeks; -The CNA assisted the resident with a shower on 2/28/23 and the resident had dark purple bruising to the underside of his/her right upper arm, right arm pit, right shoulder, and right breast; -The CNA asked the resident about the bruising and the resident said the bruise occurred when CNA F lifted the resident up with the sit to stand lift. The resident said he/she told CNA F to stop lifting him/her, but he/she would not stop; -The CNA documented the bruising on the shower sheet and gave the shower sheet to the nurse LPN D on 2/24/23; -CNA C told CNA F that the resident said that the bruise was caused by CNA F and CNA F denied it and said the bruise was caused by a fall. CNA F said he/she was refusing to go back into the resident's room because the resident accused CNA F of causing the bruise; -CNA C did not report what the resident said about CNA F because CNA C assumed the staff already knew since CNA F was no longer taking care of the resident. During an interview on 3/1/23 at 3:05 P.M., LPN D said the following: -On 2/23/23, he/she was responsible for resident skin treatments and the resident told the LPN about his/her bruising and said the bruising was from the sit to stand lift. The nurse did not assess the resident's bruises. LPN D told a nurse about the bruising and to assess the resident. During an interview on 3/1/23 at 4:02 P.M., CNA E said the following: -Approximately one week prior, the resident sat at the nurse's desk in his/her wheelchair and was crying; -The CNA asked the resident what was wrong and the resident said he/she had some bruising and pulled the side of his/her shirt up and showed his/her side (rib cage area). The resident's side looked dark purple; -The CNA asked the resident what happened and the resident said he/she did not remember, but the bruising was from CNA F and the sit to stand lift; -The CNA did not report the situation to anyone which was bad' on his/her part. During an interview on 3/1/23 at 4:45 P.M., the administrator said: -He/she did not recall the resident saying anything about CNA F causing the bruising; -The resident said the lift caused the bruising; -The administrator said he/she thought the resident said something about that CNA F was mad at the resident and having a bad night; -The administrator did not recall if he/she asked the resident what that meant; -The resident did not say CNA F hurt him/her or left the resident in the sling for a prolonged period of time; -The resident did complain of not being able to move his/her right arm, but later the administrator observed the resident move his/her arm. During a phone interview on 3/2/23 at 9:17 A.M., CNA F said: -If a resident required a sit-to stand or Hoyer lift for transfers, then he/she always used a second staff to assist with the transfer; -The resident consistently refused cares and he/she notified the nurses; -The resident frequently refused the sit to stand and the Hoyer lift; -The resident would frequently sit up all night in the recliner or wheelchair and would refuse to get in bed or have incontinent brief changed; -The resident had bruising on his/her right side and under his/her right arm; -The CNA said he/she believed the resident had the bruising when he/she moved to the hall from another part of the building, approximately 2-3 weeks prior; -He/she was unsure when he/she first saw the bruising, maybe one week after the resident's move to 200 hall; -He/she reported the bruising to LPN J and LPN J said the DON was aware; -The CNA said he/she assisted the resident up with the sit to stand on only one occasion that he/she could recall; -The resident complained to him/her and to CNA G that the sit to stand lift hurt too much, so the staff member lowered the resident back down into his/her wheelchair; -On the morning of 2/24/23, one of the day nurses, LPN A, told CNA F the resident said that CNA F caused the bruising on the resident's side; -The CNA said he/she did not ask any questions, because he/she knew that the bruising was already there when the resident was moved to 200 hall; -Then that Friday evening, 2/24/23, when the CNA G returned to work, CNA G told CNA F that the resident said he/she did not want CNA F to come into his/her room; -The aides then went and told LPN J about the resident's comments; -LPN J said he/she would notify the DON; -LPN J said the DON said to tell CNA F not to go back into the resident's room and the nurse had two female staff care for the resident; -The DON had an all staff meeting on Friday (3/24/23) of the past week over resident rights and abuse and also during the meeting the DON mentioned that the resident should only be transferred with a Hoyer lift; -That was the first time CNA F was told that the resident needed to be a Hoyer only; -Prior to that, the nurse LPN J said staff could use a Hoyer or sit to stand to transfer the resident. During an interview on 3/2/23 at 2:14 P.M., CNA H said; -This past weekend, on Saturday 2/25/23, CNA H spoke with the resident; -The resident said three girls were rough with him/her. The resident said the staff were arguing with one another and not paying attention during the resident's transfer with a sit to stand transfer lift. The resident said he/she could no longer hold onto the sit to stand and staff had to lower the resident to the floor because he/she was slipping out of the lift harness. The resident did not say when this occurred; -When the CNA asked the resident what caused the bruising, the resident said that night shift aide, CNA F caused the bruises on the resident with the sit-to stand lift. The resident did not say when this occurred; -The resident had black and purple bruising to his/her entire right side and right breast; -The CNA said he/she reported this information to the nurse, LPN A. During an interview on 3/2/23 at 2:40 P.M., the social service director (SSD) said: -On 2/23/23, the MDS nurse notified the administer and the SSD that he/she and the DOR were in the resident's room and found the resident to have bruising; -The MDS nurse, administrator and the SSD went to the resident's room; -Initially, the resident complained of a lot of pain to his/her right side and the MDS nurse tried to raise the resident's right arm, but the resident yelled out, so the MDS nurse lowered the resident's arm; -The SSD saw the resident's right arm pit and it was dark purple in color; -The SSD then stepped out to talk to the medication technician to see if the resident could have a pain pill and then returned to the room; -The resident said on the night of 2/22/22, he/she had lowered him/herself to the floor and kind of fell' on the sit to stand lift and that was what caused the bruising; -After the fall out of the sit to stand on 2/16/23, the MDS nurse changed the resident's care plan to show staff should only transfer the resident using a Hoyer lift; -The resident was upset that he/she could not bend his/her right arm enough to feed him/herself and stated wanted assistance with lunch; -The resident was able to wipe his/her nose while the SSD was in the room with his/her right hand; -The resident said the CNA F was rough with him/her on the bed on the night shift; -The resident said the CNA rolled the resident over onto his/her side to place a lift pad under the resident and was rough; -The SSD said he/she would consider a staff member being rough as an allegation of abuse; -The SSD said the different types of abuse included physical, verbal, sexual, and emotional; -The SSD said the administrator and the DON generally conduct the abuse investigations; -The SSD said if the facility suspected abuse, the facility calls the DHSS hotline within 2 hours; -After talking about the situation with the resident, we did not feel there was a reason to hotline, because we went into room to figure out if the bruising was from abuse and gathered that the bruising was from the sit to stand lift; -The DON was out of the facility during this time, but the SSD thought the administrator called the DON about the situation; -In this situation, the facility decided to look into the allegation first before deciding whether or not to call the allegation into DHSS; -The SSD said the facility was supposed to call in every allegation of abuse to DHSS. During an interview on 3/2/33 at 3:50 P.M., LPN I said: -The reason for the confusion on which

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care according to professional standards when staff failed to monitor one resident's (Resident #1's) injury to the right upper body and arm resulting from a fall which occurred when staff attempted to transfer the resident with a sit to stand lift (mechanical lift which requires a resident to bear weight and hold onto handles during the transfer). The facility had a census of 53. Record review of the facility policy titled, Charting and Documentation, revised July 2017, showed: -All services provided to the resident, progress toward the care plan goals, or changed in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care; -The following information is to be documented in the resident's medical record: Objective observations, medications administered, treatments or services performed, changes in the resident's condition, events, incidents, or accidents involving the resident. Record review of Resident #1's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of dementia with behavioral disturbances, muscle wasting and atrophy, depression, anxiety, edema, osteoarthritis, myalgia (muscle pain), and pain. Record review of the resident's quarterly minimum data set (MDS, a federally-mandated resident assessment tool completed by facility staff), dated 2/13/23, showed: -Entered the facility on 8/12/21; -Cognitively intact; -Required extensive assistance of 2 or more staff with bed mobility, transfers, toileting; -Required extensive assistance of one staff with dressing; -Used wheelchair for mobility device; -Frequently incontinent of bowel and bladder; -No limitations in range of motion; -No falls. Record review of the resident's care plan, revised 2/15/23, showed: -Resident required extensive assistance of two staff for bed mobility, toileting, and transfers and at times uses a sit to stand lift with one staff for transfers, revised on 2/15/23; -Resident required extensive assistance of two staff for bed mobility, toileting, and transfers with use of a Hoyer lift (a mechanical lift with a sling to lift and transfer residents) and at times used a sit to stand lift with one staff for transfers, revised on 2/16/23. Record review of the resident's shower sheet, dated 2/16/23, showed: -Staff did not document any bruising to the resident's body. Record review of the resident's order summary report, showed: -An order, dated 2/22/23, Use Hoyer lift for transfers for safety. Record review of the resident's care plan, revised 2/22/23, showed: -Resident required extensive assistance of two staff for bed mobility, toileting, and transfers with use of a Hoyer lift for transfers. The resident had a fall out of the sit to stand lift and has demonstrated unsafe use of sit to stand, unable to hold on and slides down, revised on 2/22/23. Record review of the resident's progress note, dated 2/23/23 at 10:00 A.M., showed staff documented the following: -Resident complained of bruising on the right breast and under arm. Upon assessment red and purple bruising found located on the resident's right breast and underarm. Resident stated the bruising came from the sit-to-stand lift. Record review of the resident's progress note, dated 2/23/23 at 10:04 A.M., showed licensed practical nurse (LPN) A documented the following: -The night shift attempted to get the resident up with both lifts, unsuccessfully; -This morning, the nurse had the day shift staff clean the resident up. Record review of the resident's progress note, dated 2/23/23 at 1:18 P.M., showed LPN I, the MDS/care plan coordinator, documented the following: -A CNA approached LPN I and reported that the resident stated that he/she could not reach his/her mouth with his/her hand. LPN I went with the director of rehabilitation (DOR) to evaluate the resident due to discussion earlier in the shift that therapy would see if the resident might need therapy services related to the use of the sit to stand versus the Hoyer lift, and the resident could not use the sit to stand but also did not want to sit on the Hoyer pad. The MDS coordinator and therapist explained to the resident that if he/she agreed to get in bed, the sling could be removed, but the sling could not be removed in the chair. When the staff asked about the resident's right arm range of motion (ROM) the resident said he/she was bruised. The MDS nurse noted a large bruise under the resident's right armpit spreading across the resident's right breast. The MDS nurse stopped the discussion with the resident and brought the administrator and social services director (SSD) into the room to determine the cause of the discoloration noted. Record review of the resident's interval exam form, dated 2/23/23, completed by the family nurse practitioner (FNP) showed: -Ecchymosis - Right anterior (front) chest wall, no known significant trauma or respiratory compromise, will check chest X-Ray and complete blood work (CBC) if persists or worsens, will schedule Ultram (a pain medication) 50 milligrams (mg) four times per day for 3 days, then as needed, to be administered with acetaminophen 500 mg four times per day for 3 days, then as needed; -Weakness - general decline, extensive assist with Hoyer lift/wheelchair. Record review of the resident's physician order, dated 2/23/23, showed instructions for staff to monitor red and purple bruising found on the resident's right breast and underarm, until resolved, every shift. Record review of the resident's February 2023 treatment administration record (TAR), showed: -An order dated 2/23/23, Staff to monitor red and purple bruising found on the resident's right breast and underarm until resolved; -Staff initialed completion from 2/23/23-2/28/23. Record review of the resident's progress note, dated 2/23/23 at 3:34 P.M., showed LPN I documented the following: -The nurse practitioner in and new orders received and noted. Resident notified. Record review of the resident's progress note, dated 2/23/23 at 5:20 P.M., showed the SSD documented the following: -The SSD and the administrator visited with the resident about the resident's concerns. Resident said that he/she had to lower self in sit to stand lift. Previous note at 10:30 A.M. this morning, showed resident stated the bruising came from the sit to stand. Resident is now stating he/she will use the Hoyer lift. The resident said, I will do anything I need to do. The resident agreed to laying down between meals and to allow the use of the Hoyer lift for transfers. The resident agreed to therapy for some strengthening. Record review of the resident's progress note, dated 2/23/23 at 10:07 P.M., showed staff did not document any information related to the resident's bruising. Record review of the resident's progress note, dated 2/24/23 at 1:14 A.M., showed staff did not document any information related to the resident's bruising. Record review of the resident's progress note, dated 2/24/23 at 10:38 A.M., showed staff did not document any information related to the resident's bruising. Record review of the resident's progress note, dated 2/24/23 at 5:37 P.M., showed staff did not document any information related to the resident's bruising. Record review of the resident's care plan, revised 2/24/23, showed: -Resident had an activity of daily living (ADL) self-care performance deficit related to dementia requiring maximum assistance with most ADLs. The resident required use of a Hoyer lift due to limitations and safety concerns with sit to stand, revised on 2/24/23; Record review of the resident's shower sheet, dated 2/24/23, showed: -Staff documented a one (1) indicating bruising with circles on a body diagram circling the right breast, left shoulder and left scapula (shoulder blade). Record review of the resident's physical therapy screen form, dated 2/24/23, showed: -Resident complain of bruising and soreness under the right arm since he/she slid down in the sit to stand lift with sling supporting him/her. The MDS coordinator and the therapist notes bruising to the resident's medial bicep/tricep (upper arm), and lateral inferior armpit/latissimus dorsi region (a part of the back from behind the arm to near midline of the back) appearing to be from the sit to stand sling when the resident's lower extremities buckled. Record review of the resident's progress notes showed no entries for 2/25/23 or 2/26/23. Record review of the resident's progress note, dated 2/27/23 at 12:07 P.M., showed LPN I did not document any information related to the resident's bruising. Record review of the resident's progress note, dated 2/28/23 at 1:28 A.M., showed LPN J did not document any information related to the resident's bruising. Record review of the resident's progress note, dated 2/28/23 at 3:39 A.M., showed LPN J did not document any information related to the resident's bruising. Record review of the resident's progress note, dated 2/28/23 at 10:55 A.M., showed LPN A documented the following skin evaluation note: -Skin warm and dry, skin color within normal limits (WNL), mucous membranes moist, turgor normal. Resident has current skin issues; -The note did not mention the resident's bruising. Record review of the resident's progress note, dated 2/28/23 at 6:14 P.M., showed the DON did not document any information related to the resident's bruising. Record review of the hospital law enforcement documents, dated 2/28/23, showed: -The resident presented to the emergency room with significant amount of bruising noted to the right anterior and posterior upper torso; -Frontal torso (upper body) injury description: Extensive, dark, purple bruising with defined margins to the right breast, extending upward onto the chest, into the axilla (armpit), and down onto the abdomen. Skin sparing noted to the underside of the right breast, extending down onto the abdomen and to lateral (outer) side. Purple bruise with blue/green surrounding the purple margins to the right medial mid chest, in line with the axilla- several centimeters above the bruising to the right breast. [NAME] bruising noted to entirety of right breast, extending onto upper chest and sternum (breastbone). Deep, dark purple bruising with defined margins noted to the right lateral side, extending onto both anterior (front) and posterior (back) surfaces, from axilla to mid abdomen. Streak of purple/red bruising extends from large bruise onto the right mid abdomen. Beneath the purple bruising on the right side, there is a green/yellow bruising extending into the lower abdomen. In the right axilla there is a section of green/yellow bruising in between areas of purple of the side and the arm; -Posterior torso injury description: Extensive, dark, deep, purple/black bruising noted to the right posterior torso. The majority of the bruising is solid in color, with scattered varying purple coloring to the upper portion of the bruise on the posterior shoulder and mid back. Extended on the left side of the posterior back. Green/yellow bruising noted below purple bruising, extending down onto the lower abdomen and waist; -Right upper extremity injury description: Circumferential (around the arm) dark purple bruising to the right upper arm, extending into the axilla and down onto the anterior forearm. Purple/green bruising noted to the right axilla, extending up to the anterior shoulder. During an interview on 3/1/23 at 12:15 P.M., the administrator said: -The facility residents have had no suspicious injuries/bruises; -He/She and the SSD spoke with the resident about his/her bruising on 2/23/23; -At that time, the resident claimed the bruising was caused by the sit to stand lift. During an interview on 3/1/23 at 12:15 P.M., the director of nursing (DON) said: -Staff were using the sit to stand to assist the resident to transfer and he/she let go of the bar and he/she chicken winged (demonstrated by putting elbows up in the air with arms bent); -The resident had a large bruise to his/her right side. During interviews on 3/1/23 at 1:04 P.M. and on 3/6/23 at 1:50 P.M., licensed practical nurse (LPN) A said the following: -On 2/16/23, certified nurse assistant certified nurse assistant (CNA) B reported that the resident was on the floor because the resident could not hold onto the sit-to-stand lift and had let go and staff lowered the resident to the floor; -The nurse assessed the resident for injuries and did not find any injuries and the resident denied pain; -The nurse said he/she did not notify the resident's physician of the 2/16/23 incident because staff lowered the resident to the floor; -Several days later, the resident complained of pain all over and an agency nurse assessed the resident and reported he/she found bruising on the resident; -LPN A never saw the bruises to the resident's right breast/underarm (Record review of the resident's treatment administration record showed the nurse initialed monitoring of the resident's breast and underarm bruises on 2/24/22, 2/25/22, 2/27/22, and 2/28/22); -The bruising should have definitely been monitored every day; -Nurses should have charted on the resident's bruises size and color in the progress notes so that other nurses would know if the resident's bruises were getting bigger; -The nurse did not realize the significance of the resident's bruises. During an interview on 3/1/23 at 1:45 P.M., CNA B said the following: -The resident had black and blue bruising on his/her right chest, right shoulder, and right side (rib cage); -The CNA said he/she notified the nurse about the resident's bruise; -The day the resident slid out of the sit to stand lift, the resident did not have the strength to hold on and slipped down through the sling. During an interview on 3/1/23 at 2:17 P.M., CNA C said the following: -The resident had a bruise on the underside of his/her arm for approximately one or two weeks; -The CNA assisted the resident with a shower on 2/28/23 and the resident had dark purple bruising to the underside of his/her right upper arm, right arm pit, right shoulder, and right breast; -The CNA documented the bruising on the shower sheet and gave the shower sheet to the nurse LPN D on 2/24/23. During an interview on 3/1/23 at 3:05 P.M., LPN D said the following: -On 2/23/23, he/she was responsible for resident skin treatments and the resident told the LPN about his/her bruising and said the bruising was from the sit to stand lift. The nurse did not assess the resident's bruises. LPN D told the charge nurse (LPN L) about the bruising and to assess the resident. During an interview on 3/1/23 at 4:02 P.M., CNA E said the following: -Approximately one week prior, the resident sat at the nurse's desk in his/her wheelchair and was crying; -CNA E asked the resident what was wrong and the resident said he/she had some bruising and pulled the side of his/her shirt up and showed his/her side (rib cage area). The resident's side looked dark purple. During an interview on 3/1/23 at 4:45 P.M., the administrator said: -The resident said the lift caused the bruising; -The resident did complain of not being able to move his/her right arm, but later the administrator observed the resident move his/her arm. During a phone interview on 3/2/23 at 9:17 A.M., CNA F said: -The resident had bruising on his/her right side and under his/her right arm; -The CNA said he/she believed the resident had the bruising when he/she moved to the hall from another part of the building, approximately 2-3 weeks prior; -He/she was unsure when he/she first saw the bruising, maybe one week after the move to 200 hall; -He/She reported the bruising to LPN J and LPN J said the DON was aware; During an interview on 3/2/23 at 2:14 P.M., CNA H said: -The resident had black and purple bruising to his/her entire right side and right breast; -The CNA said he/she reported this information to the nurse LPN A. During an interview on 3/2/23 at 2:40 P.M., the social service director (SSD) said: -On 2/23/23, the MDS nurse notified the administrator and the SSD that he/she and the DOR were in the resident's room and found the resident to have bruising; -The MDS nurse, administrator and the SSD went to the resident's room; -Initially, the resident complained of a lot of pain to his/her right side and the MDS nurse tried to raise the resident's right arm, but the resident yelled out, so the MDS nurse lowered the resident's arm; -The SSD saw the resident's right arm pit and it was dark purple in color; -The SSD then stepped out to talk to the certified medication technician (CMT) to see if the resident could have a pain pill and then returned to the room; -The resident was upset that he/she could not bend his/her right arm enough to feed him/herself and wanted assistance with lunch; -The SSD said the resident was able to wipe his/her nose while the SSD was in the room with his her right hand. During an interview on 3/2/33 at 3:50 P.M., LPN I said: -On 2/23/23, one of the nurse aides informed the LPN that the resident was complaining that he/she was not able to use his/her right arm and wanted to be fed; -On 2/23/23 at approximately 12:30 P.M. or 1:00 P.M., the LPN and the director of rehabilitation (DOR) went to the resident's room to evaluate the resident; -The resident was very emotional and crying, but had no tears, the resident said he/she was unable to use his/her right arm and grimaced when staff attempted to raise the resident's arm. The DOR pulled the resident's shirt up on the right side, to expose right rib cage and below breast bruise, purple-blue in color and the approximate size of a football from what the LPN could see. The resident said, staff did it with the sit to stand sling. During an interview on 3/2/23 at 4:40 P.M., the director of rehabilitation (DOR), said: -On 2/23/23 or 2/24/23, he/she and LPN I went to the residents room; -The resident complained of right arm pain, the DOR and the LPN looked at the resident's arm and noted a bruise under the resident's right arm and over the resident's right lateral (outer) side. The resident complained of pain with range of motion to the right arm and soreness when staff attempted to lift the resident's right arm.The resident said the arm was sore and hard to move. During a phone interview on 3/3/23 at 9:02 A.M., CNA G said: -Last week, CNA G observed a dark bruise on the resident's side and underside of the resident's arm. During an interview on 3/6/23 at 5:00 P.M., the DON said: -Regarding the progress note on 2/16/23, the nurse should notify the DON and physician of all falls; -Staff should complete and document a head to toe assessment and should monitor the resident daily per the facility policy; -LPN I called the DON late on the evening of 2/23/23 and informed the DON that the resident had bruising from the sit to stand lift or Hoyer, the DON was unsure which one; -Staff should have monitored the resident's bruise every shift and documented approximate size in the progress notes due to the significant size of the bruise; -When the resident's bruise increased in size, the DON expected the nurses to notify the resident's physician or FNP; -On 2/25/23 and 2/26/23, staff should have charted on the resident's bruise and pain every shift in the progress notes. During an interview on 3/6/23 at 5:53 P.M., the administrator said: -On 2/23/23, LPN I told the SSD and administrator of the resident's bruising and they went to the resident's room and tried to look at the bruises; -The resident said the bruise was from the sit to stand lift and from sliding down in the harness; -If a resident had a bruise, the nurse should monitor the bruise every shift to make sure the bruise was healing; -If the bruise increased in size, the nurse should notify the physician or nurse practitioner, but the administrator would ask the DON what to do in that situation. During a phone interview on 3/7/23 at 7:57 A.M., LPN J said: -If a resident had a fall, the nurse should monitor the resident for injuries and do fall follow-up charting for three days every shift; -If a resident had a bruise, staff should monitor the bruise; -He/She did not know anything about the resident's bruising; -He/She never saw the resident's skin; -The nurse was unsure if he/she documented a fall follow-up on the resident. MO00214742

Based on interview and record review, the facility failed to ensure staff utilized appropriate transfer assistance for one resident (Resident #1), resulting in the resident falling from the sit to stand lift (a mechanical lift used by facility staff to help transfer a person, who can bear some body weight, from a seated to a standing position using a waist sling) and sustaining significant bruising to the right side of his/her body. The facility census was 53. Record review of the facility policy titled, Lifting Machine, Using a Mechanical, revised July 2017, showed the following: -The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions; -At least two nursing assistants are needed to safely move a resident with a mechanical lift. Record review of the facility's policy titled, Charting and Documentation, revised July 2017, showed the following: -All services provided to the resident, progress toward the care plan goals, or changed in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care; -Documentation in the medical record may be electronic, manual, or a combination; -The following information is to be documented in the resident's medical record: Objective observations, medications administered, treatments or services performed, changes in the resident's condition, events, incidents, or accidents involving the resident, and progress toward or changes in the care plan goals and objectives; -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Record review of Resident #1's face sheet showed: -admission date of 8/12/21; -Diagnoses included dementia with behavioral disturbances, muscle wasting and atrophy (loss of muscle tissue), depression, anxiety, edema (swelling caused by excess fluids trapped in the body's tissues), osteoarthritis, myalgia (muscle pain), and pain. Record review of the resident's quarterly Minimum Data Set (MDS - a federally-mandated resident assessment tool completed by facility staff), dated 2/13/23, showed the following: -Cognitively intact; -Required extensive assistance of two or more staff with bed mobility, transfers, and toileting; -Required extensive assistance of one staff with dressing; -Used a wheelchair for mobility; -Frequently incontinent of bowel and bladder; -No limitations in range of motion; -No falls. Record review of the resident's care plan showed the following: -Revised 2/15/23, resident required extensive assistance of two staff for bed mobility, toileting, and transfers and at times uses a sit to stand with one staff for transfers; -Revised 2/16/23, resident required extensive assistance of two staff for bed mobility, toileting, and transfers with use of a Hoyer lift (a mechanical lift with a sling to lift and transfer residents) and at times used a sit to stand lift with one staff for transfers. Record review of the resident's shower sheet, dated 2/16/23, showed the following: -Staff did not document bruising to the resident's body. Record review of the resident's progress note dated 2/16/23, at 8:00 A.M., showed Licensed Practical Nurse (LPN) A documented the following: -The CNA reported the resident was on the floor. With three staff and a Hoyer lift, staff assisted the resident off the floor and back into the recliner. Staff assessed the resident for injuries, but none found; -The resident complained of shortness of air and the resident's oxygen was placed on until the resident calmed down and breathing returned to normal. Vital signs charted and will continue to monitor. Record review of the resident's progress note, dated 2/16/23 at 3:06 P.M., showed LPN I documented the following: -Spoke with the resident regarding use of the sit to stand lift and the resident's inability to hold his/her weight when using the sit to stand lift. The resident acknowledged he/she was depending on the sling to hold his/her weight. LPN I explained to the resident that the sling was not meant to hold the resident's weight and the resident had to bear weight and hold onto the sides of the sit to stand and that area under the arms is tender and could be damaged if the resident tried to hang onto the sit to stand or resident could have another fall from slipping out of the sling if he/she does not bear his/her own weight. The resident acknowledged inability to hold own weight or stand and resident acknowledged that he/she does not want to hurt self or anyone else. Resident agreed to the use of the Hoyer and stated he/she did not like the idea, but would agree. The LPN brought the SSD into the room and the conversation was reiterated and the resident once again agreed to use of the Hoyer. The resident requested a room change which would assist with the use of the Hoyer lift due to roommate chair impeding staff from getting to the resident's recliner. The resident wishes to sleep in the recliner instead of the bed. Record review of the resident's progress note, dated 2/17/23 at 5:03 A.M., showed LPN J documented the following: -Per staff members, the resident was changed to the Hoyer lift on 2/15/23 due to not properly holding onto the bar and fell to the floor. The resident refused the Hoyer lift this morning. The resident said he/she would only use the sit to stand lift to be changed; -The nurse notified the Director of Nursing (DON). Record review of the resident's progress note, dated 2/17/23 at 4:42 P.M., showed LPN A documented the following: -The resident refused to have staff use the Hoyer lift to be able to change the resident and as of 2/16/23, the resident was changed to a Hoyer lift due to his/her inability to hang on to the sit to stand. The resident was moved to a private room to accommodate the use of the Hoyer. Staff re-educated the resident on the use of the Hoyer and agreed to the staff being able to use the Hoyer as long as staff could place the resident on the toilet. Two staff assisted the resident with the Hoyer and a toileting sling and placed the resident on the toilet at this time. Record review of the resident's order summary report showed an order, dated 2/22/23, for use of Hoyer lift for transfers for safety. Record review of the resident's care plan showed the following: -Revised 2/22/23, resident required extensive assistance of two staff for bed mobility, toileting, and transfers with use of a Hoyer lift for transfers. The resident had a fall out of the sit to stand lift and has demonstrated unsafe use of sit to stand. Resident unable to hold on and slides down. Record review of the resident's progress note, dated 2/23/23 at 6:24 A.M., showed LPN J documented the following: -Resident refuses the use of the Hoyer and the sit to stand lift tonight. The resident said he/she was unable to hold him/herself up with the sit to stand. The resident had stool and urine in his/her brief. The resident continues to refuse cares on a daily basis. Record review of the resident's progress note, dated 2/23/23 at 10:00 A.M., showed staff documented the following: -Resident complained of bruising on the right breast and under arm. Upon assessment red and purple bruising found located on the resident's right breast and underarm. Resident stated the bruising came from the sit-to-stand. Record review of the resident's progress note, dated 2/23/23 at 10:04 A.M., showed LPN A documented the following: -The resident complained the night shift aide was upset with her and the resident refused all cares last night; -The night shift attempted to get the resident up using both lifts and were unsuccessful; -This morning, the nurse had the day shift staff clean the resident up; -The resident was crying related to wanting the certified medication technician (CMT) to run an errand and the resident was crying related to left ear pain; -The resident continued to sit at the nurses' station crying about all these topics. Other nurse investigated. Record review of the resident's progress note, dated 2/23/23 at 1:18 P.M., showed LPN I (MDS/Care Plan Coordinator) documented the following: -A CNA approached LPN I and reported that the resident stated that he/she could not reach his/her mouth with his/her hand. LPN I went with the Director of Rehabilitation (DOR) to evaluate the resident due to discussion earlier in the shift that therapy would see if the resident might need therapy services related to the use of the sit to stand versus the Hoyer lift and the resident could not use the sit to stand, but also did not want to sit on the Hoyer pad. The MDS coordinator and therapist explained to the resident that if he/she agreed to get in bed, the sling could be removed, but the sling could not be removed in the chair. When the staff asked about the resident's right arm range of motion (ROM) the resident said he/she was bruised. The MDS nurse noted a large bruise under the resident's right armpit spreading across the resident's right breast. The MDS nurse stopped the discussion with the resident and brought the Administrator and Social Services Director (SSD) into the room to determine the cause of the discoloration noted. Record review of the resident's Interval Exam Form, dated 2/23/23, completed by the family nurse practitioner (FNP) showed the following: -Weakness with general decline, extensive assist with Hoyer lift/wheelchair. Record review of the resident's order summary report showed the following: -An order, dated 2/23/23, to monitor red and purple bruising found on the resident's right breast and underarm, until resolved, every shift. Record review of the resident's February 2023 Treatment Administration Record (TAR) showed the following: -An order, dated 2/23/23, for staff to monitor red and purple bruising found on the resident's right breast and underarm until resolved; -Staff initialed completion from 2/23/23 to 2/28/23. Record review of the resident's progress note, dated 2/23/23 at 3:34 P.M., showed LPN I documented the nurse practitioner was in and new orders received and noted. Resident notified. Record review of the resident's progress note, dated 2/23/23 at 5:20 P.M., showed the SSD documented the following: -The SSD and the administrator visited with the resident about the resident's concerns. Resident said that he/she had to lower self in sit to stand lift. Previous note at 10:30 A.M. this morning, showed resident stated the bruising came from the sit to stand. Resident is now stating will use the Hoyer lift. The resident said, I will do anything I need to do. The resident agreed to laying down between meals and to the allow use of the Hoyer lift for transfers. The resident agreed to therapy for some strengthening. Record review of the resident's care plan showed: -Resident had an activity of daily living (ADL) self-care performance deficit related to dementia requiring maximum assistance with most ADLs. The resident required use of a Hoyer lift due to limitations and safety concerns with sit to stand, revised on 2/24/23. Record review of the resident's shower sheet, dated 2/24/23, showed: -Staff documented a one (1) indicating bruising with circles on a body diagram circling the right breast, left shoulder and left scapula. Record review of the resident's physical therapy screen form, dated 2/24/23, showed: -Resident needs increased assistance with transfers; -Resident complain of bruising and soreness under the right arm since he/she slid down in the sit to stand lift with sling supporting him/her. The MDS coordinator and the therapist noted bruising to the resident's medial bicep/tricep, and lateral inferior armpit/latissimus dorsi region (a part of the back from behind the arm to near midline of the back) appearing to be from the sit to stand sling when the resident's lower extremities buckled; -Recommend a Hoyer lift with all transfers; -Educated the resident that staff would be transferring him/her with a Hoyer lift. The resident was not happy with the therapist's decision because the resident preferred the sit to stand lift, but he/she agreed to allow use of the Hoyer lift. Record review of the resident's progress note, dated 2/27/23 at 12:07 P.M., showed LPN I documented the following: -Medicare meeting held. The resident started physical, occupational, and speech therapy services. Evaluated by therapy on 2/24/23. On therapy services for transfers and strengthening, recently went from sit to stand to Hoyer due to sliding out of the sit to stand because she was unable to hold onto the bars or stand and was depending on the sling to hold his/her weight. Resident would state, No padding on sling. This writer explained sling was not supposed to support the resident's weight and resident stated he/she was unable to support his/her own weight; -The note did not mention assessment of the resident's bruising. Record review of the resident's progress note, dated 2/28/23 at 1:28 A.M., showed LPN J documented the following: -Two staff members went into the resident's room tonight to do rounds. The resident denied being incontinent of urine at that time and refused to be transferred via the Hoyer lift into bed for changing (incontinent care). The nurse went the room to change the resident's leg dressings and confirmed that the resident was soaked with urine. The nurse explained to the resident that he/she could not transfer without the Hoyer due to safety concerns. The resident refused to be changed. The nurse notified the director of nursing (DON) in regards to the lower extremities needed to be assessed by the wound clinic. Will continue to monitor behaviors. -The note did not mention assessment of the resident's bruising. Record review of the resident's progress note, dated 2/28/23 at 6:14 P.M., the DON documented the following: -Resident had call light on. Nurse assistant answered. Resident said he/she had soiled him/herself. Staff offered to change the resident's clothing. Resident refused the Hoyer lift and said would just sit in it. Staff reported to charge nurse and DON. Charge nurse will visit with resident. Record review of the resident's progress note, dated 2/28/23 at 9:23 P.M., showed staff documented they sent the resident to the emergency room via ambulance at 7:55 P.M. due to respiratory issues; -No mention of the resident's bruising. Record review of the hospital law enforcement documents, dated 2/28/23, showed: -The resident presented to the emergency room with significant amount of bruising noted to the right anterior and posterior upper torso. When asked, resident told nurse that 5-6 days ago an aide was rough with him/her. Resident stated while using a mobility device called a sit to stand, the resident told the aide that she was in severe pain in the mobility device. The resident stated he/she told the aide that he/she needed to sit down due to pain. The resident reported that the aide left the resident in the sit to stand for a while, he/she was unsure how long. Then the aide came back in and helped. The resident mentioned multiple times that staff in the facility have seen the bruises, including that head lady but they are always trying to cover things up and make it go away. When asked if a physician had assessed the resident's injuries, the resident did not recall. The resident does not have any family or visitors that come to the facility. The resident said he/she felt safe at the facility. The resident did not want law enforcement contacted about the matter. The resident said he/she did not want them to retaliate -The resident affect: Quiet, sad, scared, anxious; -Frontal torso injury description: Extensive, dark, purple bruising with defined margins to the right breast, extending upward onto the chest, into the axilla, and down onto the abdomen. Skin sparing noted to the underside of the right breast, extending down onto the abdomen and to lateral side. Purple bruise with blue/green surrounding the purple margins to the right medial mid chest, in line with the axilla- several centimeters above the bruising to the right breast. [NAME] bruising noted to entirety of right breast, extending onto upper chest and sternum. Deep, dark purple bruising with defined margins noted to the right lateral side, extending onto both anterior and posterior surfaces, from axilla to mid abdomen. Streak of purple/red bruising extends from large bruise onto the right mid abdomen. Beneath the purple bruising on the right side, there is a green/yellow bruising extending into the lower abdomen. In the right axilla there is a section of green/yellow bruising in between areas of purple of the side and the arm; -Posterior torso injury description: Extensive, dark, deep, purple/black bruising noted to the right posterior torso. The majority of the bruising is solid in color, with scattered varying purple coloring to the upper portion of the bruise on the posterior shoulder and mid back. Extended on the left side of the posterior back. Green/yellow bruising noted below purple bruising, extending down onto the lower abdomen and waist. -Right upper extremity injury description: Circumferential dark purple bruising to the right upper arm, extending into the axilla and down onto the anterior forearm. Purple/green bruising noted to the right axilla, extending up to the anterior shoulder. Record review of the hospital law enforcement documented, dated 3/1/23, showed: -Resident still adamant not to notify the police department about bruising and states, Certified Nurses Aide (CNA) F has been rough with me for a while now and I just don't want it to get worse. I just can't live with it. Nurse asked for clarification. Resident states, CNA F is a night shift aide and he/she left me in a sit to stand. They will try to say that I fell but I didn't fall. He/she left me in it for a long time. During an interview on 3/1/23 at 12:15 P.M., the administrator said: -The facility has had no recent allegations of resident abuse since the last incident reported to DHSS; -The facility residents have had no suspicious injuries/bruises; -He/she and the SSD spoke with the resident about his/her bruising on 2/23/23; -At that time, the resident claimed the bruising was caused by the sit to stand lift; -The resident did not complain of being left in the lift or of abuse; -The resident did not like the Hoyer lift and at times would refuse cares. During an interview on 3/1/23 at 12:15 P.M., the DON said: -Staff were using the sit to stand to assist the resident to transfer and she let go of the bar and she chicken winged (demonstrated by putting elbows up in the air with arms bent); -Resident #1 had a large bruise to his/her right side; -Therapy evaluated the resident and the facility changed the resident to a Hoyer lift; -The resident admitted to purposely letting go of the sit to stand during the transfer; -On 2/23/23, the resident told the nurse, LPN A, that a night shift aide was upset with him/her (the resident); -Last night on 2/28/23, the resident told the DON he/she had soiled him/herself, but refused to be changed and said he/she would just sit in the stool and die, but would not use the Hoyer. During interviews on 3/1/23 at 1:04 P.M. and 3/6/23 at 1:50 P.M., LPN A said the following: -On 2/16/23, CNA B reported that Resident #1 was on the floor because the resident could not hold onto the sit-to-stand lift and had let go and staff lowered the resident to the floor; -The nurse assessed the resident for injuries and did not find any injuries and the resident denied pain; -The nurse said he/she did not notify the resident's physician of the 2/16/23 incident because staff lowered the resident to the floor; -Several days later, the resident complained of pain all over and an agency nurse assessed the resident and found bruising on the resident; -At one point, the night shift nurse, LPN J told LPN A the resident complained that CNA F was rough with the resident and mad at the resident, but CNA F was neither; -The resident complained to LPN A about how the night shift aide, CNA F, was mad at him/her because CNA A was throwing the sling around; -LPN A told the resident this was probably not true; -The resident reported to LPN A that CNA F caused the bruising and the nurse notified the DON; -After that, CNA F was not allowed to care for Resident #1; -LPN A never saw the bruises to the resident's right breast/underarm (Record review of the resident's treatment administration record showed the nurse initialed monitoring of the resident's breast and underarm bruises on 2/24/22, 2/25/22, 2/27/22, and 2/28/22); -The bruising should have definitely been monitored every day; -Nurses should have charted on the size and color of the bruises in the progress notes so that other nurses would know if the resident's bruises were getting bigger; -The nurse did not realize the significance of the resident's bruises; -LPN A was confused about which lift to use to transfer the resident; -The DON told the nurse to use the Hoyer with no exceptions, but then the resident was refusing the Hoyer and staff would continue to use the sit to stand lift and the nurse said that put the resident in jeopardy; -LPN A was unsure which staff were using the sit to stand lift, the aides would pass on in report to the next shift that the aides had used the sit to stand due to the resident's refusal to use the Hoyer lift; -LPN A said the DON was aware staff were continuing to use the sit to stand, and would reiterate that staff should be strictly using the Hoyer with the resident. During an interview on 3/1/23 at 1:45 P.M., CNA B said the following: -The resident said someone from the night shift was rough with her while using the sit to stand lift; -The resident had black and blue bruising on his/her right chest, right shoulder, and right side (rib cage) and the resident kept saying someone from the night shift was rough with him/her; -The resident complained about the night shift last week; -CNA B said he/she notified the nurse about the resident's bruise and that the resident said staff was rough with him/her; -CNA B was unsure which nurse, he/she told; -CNA B said he/she thought the resident was speaking about a night shift aide because the resident said it was a male aide on the night shift and CNA F was the only male aide on the night shift; -The resident complained about having to use the Hoyer lift, but the resident no longer had the arm strength to hold him/herself up in the sit to stand lift; -The day the resident slid out of the sit to stand lift, the resident did not have the strength to hold on and slipped down through the sling. During an interview on 3/1/23 at 2:17 P.M., CNA C said the following: -The resident had a bruise on the underside of his/her arm for approximately one or two weeks; -CNA C assisted the resident with a shower on 2/28/23 and the resident had dark purple bruising to the underside of his/her right upper arm, right arm pit, right shoulder, and right breast; -CNA C asked the resident about the bruising and the resident said the bruise occurred when CNA F lifted the resident up with the sit to stand lift. The resident said he/she told CNA F to stop lifting him/her, but he/she would not stop; -CNA C documented the bruising on the shower sheet and gave the shower sheet to the nurse LPN D on 2/24/23; -CNA C told CNA F that the resident said that the bruise was caused by CNA F and CNA F denied it and said the bruise was caused by a fall. CNA F said he/she was refusing to go back into the resident's room because the resident accused CNA F of causing the bruise; -CNA C did not report what the resident said about CNA F because CNA C assumed the staff already knew since CNA F was no longer taking care of the resident. During an interview on 3/1/23 at 3:05 P.M., LPN D said the following: -On 2/23/23, he/she was responsible for resident skin treatments and Resident #1 told LPN D about his/her bruising and said the bruising was from the sit to stand lift. LPN D did not assess the resident's bruises. LPN D told a nurse about the bruising and to assess the resident. During an interview on 3/1/23 at 4:02 P.M., CNA E said the following: -Approximately one week prior, the resident sat at the nurse's desk in his/her wheelchair and was crying; -CNA E asked the resident what was wrong and the resident said he/she had some bruising and pulled the side of his/her shirt up and showed his/her side (rib cage area). the resident's side looked dark purple; -CNA E asked the resident what happened and the resident said she did not remember, but the bruising was from CNA F and the sit to stand lift. During an interview on 3/1/23 at 4:45 P.M., the administrator said: -He/she did not recall the resident saying anything about CNA F causing the bruising; -The resident said the lift caused the bruising; -The administrator said he/she thought the resident said something about that CNA F was mad at the resident and having a bad night; -The administrator did not recall if he/she asked the resident what that meant; -The resident did not say CNA F hurt him/her of left the resident in the sling for a prolonged period of time; -The resident did complain of not being able to move his/her right arm, but later the administrator observed the resident move his/her arm. During a phone interview on 3/2/23 at 9:17 A.M., CNA F said: -If a resident required a sit-to stand or Hoyer lift for transfers, then he/she always used a second staff to assist with the transfer; -Resident #1 consistently refused cares and he/she notified the nurses; -The resident frequently refused the sit to stand and the Hoyer lift; -The resident would frequently sit up all night in the recliner or wheelchair and would refuse to get in bed or have incontinent brief changed; -The resident had bruising on his/her right side and under his/her right arm; -He/she believed the resident had the bruising when he/she moved to the hall from another part of the building, approximately 2-3 weeks prior; -He/she was unsure when first saw the bruising, maybe one week after moving to 200 hall; -He/she reported the bruising to LPN J and LPN J said the DON was aware; -He/she assisted the resident up with the sit to stand on only one occasion that he/she could recall; -The resident complained to him/her and to CNA G that the sit to stand lift hurt too much, so the staff member lowered the resident back down into his/her wheelchair; -On the morning of 2/24/23, one of the day nurses, LPN A, told CNA F the resident said that CNA F caused the bruising on the resident's side; -He/she did not ask any questions because he/she knew that the bruising was already there when the resident was moved to 200 hall; -Then that Friday evening, 2/24/23, when the CNA G returned to work, CNA G told CNA F that the resident said he/she did not want CNA F to come into his/her room; -The aides then went and told LPN J about the resident's comments; -LPN J said he/she would notify the DON; -LPN J said the DON said to tell CNA F not to go back into Resident #1's room and the nurse had two female staff care for the resident; -The DON had an all staff meeting on Friday (3/24/23) of the past week over resident rights and abuse and also during the meeting the DON mentioned that Resident #1 should only be transferred with a Hoyer lift; -That was the first time CNA F was told that Resident #1 needed to be a Hoyer only; -Prior to that, LPN J said staff could use a Hoyer or sit to stand to transfer the resident. During an interview on 3/2/23 at 2:14 P.M., CNA H said; -This past weekend, on Saturday 2/25/23, CNA H spoke with the resident; -The resident said three girls were rough with him/her. The resident said the staff were arguing with one another and not paying attention during Resident #1's transfer with a sit to stand transfer lift. The resident said he/she could no longer hold onto the sit to stand and staff had to lower the resident to the floor because he/she was slipping out of the lift harness. The resident did not say when this occurred; -When CNA H asked the resident what caused the bruising, the resident that night shift aide, CNA F caused the bruises on the resident with the sit-to stand lift. The resident did not say when this occurred; -The resident had black and purple bruising to his/her entire right side and right breast; -CNA H reported this information to the nurse LPN A. During an interview on 3/2/23 at 2:40 P.M., the social service director (SSD) said: -On 2/23/23, the MDS nurse notified the administer and the SSD that he/she and the director of rehabilitation (DOR) were in the resident's room and found the resident to have bruising; -The MDS nurse, administrator and the SSD went to the resident's room; -Initially, the resident complained of a lot of pain to his/her right side and the MDS nurse tried to raise the resident's right arm, but the resident yelled out, so the MDS nurse lowered the resident's arm; -The SSD saw the resident's right arm pit and it was dark purple in color; -The SSD then stepped out to talk to the medication technician to see if the resident could have a pain pill and then returned to the room; -The resident said on the night of 2/22/22, he/she had lowered him/herself to the floor and kind of fell' on the sit to stand lift and that was what caused the bruising; -After the fall out of the sit to stand on 2/16/23, the MDS nurse changed the resident's care plan to show staff should only transfer the resident using a Hoyer lift; -The resident was upset that he/she could not bend his/her right arm enough to feed him/herself and stated he/she wanted assistance with lunch; -The resident was able to wipe his/her nose while the SSD was in the room with his her right hand; -The resident said CNA F was rough with him/her on the bed on the night shift; -The resident said the CNA rolled the resident over onto his/her side to place a lift pad under the resident and was rough; -After talking about the situation with Resident #1, we did not feel there was a reason to hotline, because we went into room to figure out if the bruising was from abuse and gathered that the bruising was from the sit to stand lift; -The DON was out of the facility during this time, but the SSD thought the administrator called the DON about the situation During an interview on 3/2/33 at 3:50 P.M., LPN I said: -The reason for the confusion on which lift the staff were supposed to use with the resident was a result of the resident adamantly refusing the Hoyer lift; -The resident was losing strength and had slid through the sit to stand lift and the aides had to lower the resident to the floor on 2/16/23, and therefore the resident needed to use the Hoyer lift; -He/she care planned for staff to be able to use both types of lifts (sit to stand and Hoyer) because although the resident agreed to use the Hoyer lift, the LPN did not think the resident would use the Hoyer; -The resident could bear some weight when he/she wanted to, making the best choice of lift difficult to determine; -On 2/23/23, one of the nurse aides informed LPN I that the resident was complaining that he/she was not able to use his/her right arm and wanted to be fed; -On 2/23/23 at approximately 12:30 P.M. or 1:00 P.M., LPN I and the DOR went to the resident's room to evaluate the resident; -The resident was very emotional and crying, but had no tears, the resident said he/she was unable to use his/her right arm and grimaced when staff attempted to raise the resident's arm. The DOR pulled the resident's shirt up on the right side, to expose right rib cage and below breast bruise, purple-blue in color and the approx

Based on record review and interview, the facility failed to properly document one resident's (Resident #2's) pain medication administration. The facility census was 53. 1. Record review of the facility policy titled, Controlled Substances, revised April 2019, showed the following: -The facility complies with all laws, regulations, and other requirement related to handling, storage, disposal, and documentation of controlled medications; -Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; -Upon administration, the nurse is responsible for recording the name of the resident, the name, strength, and dose of medication, time of administration, method of administration, quantity of the medication remaining, and signature of staff administering the medication. Record review of the facility policy titled Pain Assessment and Management, dated July 2017, showed the following: -The purposes of this procedure are to help identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management; -Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals; -Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain; Recognizing the presence of pain; Identifying the characteristics of pain; Addressing the underlying causes of the pain; Developing and implementing approaches to pain management; Identifying and using specific strategies for different levels and sources of pain; Monitoring for the effectiveness of interventions; and Modifying approaches as necessary; -Cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain. Comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain; -Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained; -For stable chronic pain the resident's pain and consequences of pain are assessed at least weekly; -Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain; -Possible Behavioral Signs of Pain, including: Verbal expressions such as groaning, crying, screaming; Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; Changes in gait, skin color and vital signs; -Behavior such as resisting care, irritability, depression, decreased participation in usual activities; Limitations in his or her level of activity due to the presence of pain; Guarding, rubbing or favoring a particular part of the body; Difficulty eating or loss of appetite; Insomnia; and Evidence of depression, anxiety, fear of hopelessness; -Possible Physiological Signs of Pain, including: Increased blood pressure; Tachycardia; Increased respirations; Diaphoresis; Anorexia; or Somnolence; -Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling; -Review the medication administration record to determine how often the individual requests and receives PRN pain medication, and to what extent the administered medications relieve the resident's pain; -Re-asses the resident's pain and consequences of pain at least each shift for acute pain or significant change in the levels of chronic pain and at least weekly in stable chronic pain; -Monitor the resident's response to interventions and level of comfort over time. The status of the underlying cause of pain. The presence of adverse consequences to treatment; -Document the resident's reported level of pain with adequate detail in as necessary and in accordance with the pain management program; -Record the resident's pain assessment in the resident's medical record. Record review of Resident #2's face sheet showed: -admission date of 1/20/22; -Diagnoses included hemiplegia (paralysis of one side of the body) following a stroke, diabetes mellitus type 2 (a condition in which the body cannot regulate blood sugar), muscle wasting, muscle spasms, and pain. Record review of the resident's annual Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 1/23/23, showed the following: -admission date of 1/20/22 with a readmission date of 2/15/22; -Moderate cognitive impairment; -Required extensive assistance of one staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Wheelchair for mobility device; -Diagnoses of stroke, diabetes mellitus type 2, and depression; -On scheduled and as needed pain medication with no pain noted present at time of assessment. Record review of the resident's February 2023 Medication Administration Record (MAR) showed the following: -An order, start date of 6/21/22, for Tramadol Hydrochloride (HCL) (an opioid pain medication) tablet 50 milligrams (mg), staff to give one tablet by mouth every eight hours as needed for pain; -On 2/1/23, staff initialed administration of the pain medication twice, at 7:44 A.M. and at 8:48 P.M. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form (the form used to account for each dose of a controlled substance), showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/1/23, staff documented administration of one tablet at 8:40 A.M.; -On 2/1/23, staff did not document administration of the resident's P.M. dose note on the MAR. Record review of the resident's February 2023 MAR showed the following: -An order, start date of 6/21/22, for Tramadol HCL tablet 50 mg, staff to give one tablet by mouth every eight hours as needed for pain; -On 2/5/23, staff did not document administration of the resident's pain medication. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/5/23, staff documented administration of one tablet at 8:10 A.M. and one tablet at 7:40 P.M. Record review of the resident's February 2023 MAR showed the following: -An order, start date of 6/21/22, for Tramadol HCL tablet 50 mg, staff to give one tablet by mouth every eight hours as needed for pain; -On 2/7/23, staff did not document administration of the resident's pain medication. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/7/23, staff documented administration of one tablet at 7:08 A.M. Record review of the resident's February 2023 MAR showed the following: -An order, start date of 6/21/22, for Tramadol HCL tablet 50 mg, staff to give one tablet by mouth every eight hours as needed for pain; -On 2/10/23, staff did not document administration of the resident's pain medication. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/10/23, staff documented administration of one tablet at 9:30 A.M. Record review of the resident's February 2023 MAR showed the following: -An order, start date of 6/21/22, for Tramadol HCL tablet 50 mg, staff to give one tablet by mouth every eight hours as needed for pain; -On 2/11/23, staff did not document administration of the resident's pain medication. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/11/23, staff documented administration of one tablet at 9:10 A.M. and one tablet at 7:30 P.M. Record review of the resident's February 2023 MAR showed the following: -An order, start date of 6/21/22, for Tramadol HCL tablet 50 mg, staff to give one tablet by mouth every eight hours as needed for pain; -On 2/12/23, staff did not document administration of the resident's pain medication; -Pain monitoring, assess for pain every shift, showed no pain on all shifts on 2/12/23. Record review of the resident's progress notes showed no progress note dated 2/12/23. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form, showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/12/23, staff documented administration of one tablet at 8:30 P.M. Record review of the resident's progress note dated 2/13/23, at 5:51 A.M., showed the following: -Resident has been showing signs and symptoms of behaviors the last 12 hours alleging the certified medication technician (CMT) did not pass the resident's evening and bed time medications; -Resident said at evening time on 2/12/23, the CMT did not give the resident his/her medications; -CMT witnessed by numerous staff members giving the resident medications; -Resident continued to hit the call light and demand medications; -At 8:30 P.M., the nurse, CMT, and certified nurse assistant (CNA) prepared and administered as needed medications to the resident trying to satisfy the resident; -Resident educated during the medication administration that all medications were received in front of three witnesses; -Resident again called at 9:00 P.M. on 2/12/23 and said, I never received any medications for the night; -Two staff members tried to redirect the resident; -The resident started yelling at the staff, I did not! I never received any medications. Staff were unable to redirect the resident; -The resident then got up into his/her wheelchair and had staff push the resident to the nurses' desk to continue his/her rant. This nurse, the CMT, and a CNA informed the resident that all medications were given per witness by multiple staff. Resident stated he/she would be reporting the nurse in the A.M. to management. The nurse gave the resident his/her name on a piece of paper; -All cares were done in pairs (two staff) related to the resident's behaviors this entire shift; -At 5:00 A.M., the resident again started making accusations against staff members; -The nurse notified the DON of the resident's behaviors and accusations; -Will continue to monitor and perform cares in pairs at this time. Record review of the resident's February 2023 MAR showed the following: -An order, start date of 6/21/22, for Tramadol HCL tablet 50 mg, staff to give one tablet by mouth every eight hours as needed for pain; -On 2/14/23, staff documented administration of one dose at 7:42 A.M. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form, showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/14/23, staff documented administration of two doses, one at 7:42 A.M. and one at 7:40 P.M. Record review of the resident's February 2023 MAR showed the following: -An order, start date of 6/21/22, for Tramadol HCL tablet 50 mg, staff to give one tablet by mouth every eight hours as needed for pain; -On 2/19/23, staff documented administration of one dose at 6:11 P.M. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form, showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/19/23, staff documented administration of two doses, one at 8:40 A.M. and one at 7:20 P.M. Record review of the resident's February 2023 MAR showed the following: -An order, start date of 6/21/22, for Tramadol HCL tablet 50 mg, staff to give one tablet by mouth every eight hours as needed for pain; -On 2/26/23, staff did not document administration of the resident's Tramadol. Record review of the resident's Controlled Drug Receipt/Record/Disposition Form, showed the following: -Staff to administer Tramadol 50 mg. Give one tablet by mouth every eight hours as needed; -On 2/26/23, staff documented administration of one dose at 7:30 P.M. During an interview on 3/1/23 at 1:04 P.M., Licensed Practical Nurse (LPN) A said the resident was generally pleasant and friendly. The resident did not complaint of pain nor of not getting pain medications. The resident did not appear oversedated. During an interview on 3/1/23 at 1:45 P.M., Certified Nurse Assistant (CNA) B said the resident did not complain of pain and did not appear oversedated. During an interview on 3/1/23 at 3:05 P.M., LPN D said the resident did not complain of uncontrolled pain or issues with pain medication administration The resident did not appear oversedated. During an interview on 3/6/23, at 2:42 P.M., Certified Medication Technician (CMT) K said the following: -The facility had some issues with documentation of as needed medications on the MAR; -The resident had not complained of issues with pain control and did not appear over sedated. During an interview on 3/2/23, at 5:30 P.M., the Director of Nursing (DON) said the following: -On the evening of 2/12/23, the nurse administered the resident's Tramadol and signed out on the controlled drug form, but failed to sign out on the MAR; -The nurse called the DON that evening and said the resident was claiming he/she did not receive his/her evening medications from the CMT; -The nurse said he/she gave the resident all of his/her ordered medications; -The nurse later said in a written statement that the CMT gave all routine medications and the LPN gave all the as needed medications (PRNs); -The CMT worked for a contracted agency and no longer worked at the facility; -The nurse said he/she forgot to sign the MAR for the dose of Tramadol he/she gave the resident; -The nurse no longer works at the facility; -Staff should sign pain medications on the MAR and the controlled drug form; -The DON in-serviced all nursing staff on medication administration and pain medication administration and documentation. During an interview on 3/1/23, at 12:15 P.M., the Administrator said the following: -Staff administered the resident's medications as ordered, as far as the administrator knew; -The resident's family asked why the resident was on Tramadol. MO00214386

Based on observation, interview, and record review, the facility failed to obtain a valid physician's order indicating where and when the resident was to go for dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) treatment and failed to provide thorough assessments and on-going monitoring for one resident (Resident # 19) The facility had a census of 52. Record review of the Nursing Guidelines Manual, dated March 2015, regarding dialysis showed the following: -Care of the shunt/fistula/graft/port (an entry into the body used for dialysis): keep the area clean and dry; feel for the thrill sensation (a vibrating sensation that can be felt) daily; inspect the access site for redness, swelling or warmth; avoid excessive pressure to the puncture site; watch for bleeding after dialysis; and monitor for signs of infection. Record review of the Nation Kidney Foundation's form, Hemodialysis Access: What You Need to Know, dated 2006, showed the following: -Protect the arm with the access port; -Do not let measure blood pressure on the access arm. The other arm should be used instead. Record review of the facility's policy titled, Care of a Resident with End-Stage Renal Disease (ESRD), dated September 2010, showed the following: -Residents with ESRD will be cared for according to currently recognized standards of care; -Staff caring for residents with ESRD, including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents; -Education and training of staff includes the following the nature and clinical management of ESRD (including infection prevention and nutritional needs; the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; signs and symptoms of worsening condition and/or complications of ESRD; how to recognize and intervene in medical emergencies such as hemorrhages and septic infections; how to recognize and manage equipment failure or complications (according to the type of equipment used in the facility); timing and administration of medications, particularly those before and after dialysis; the care of grafts and fistulas; and the handling of waste; -Education and training of staff in the care of ESRD/dialysis residents may be managed by the contracted dialysis facility or by the clinician with training in ESRD and dialysis care; -Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed including how the care plan will be monitored and implemented; how information will be exchanged between the facilities; and responsibility of waste handling, sterilization and disinfection of the equipment; -The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. 1. Record review of Resident # 19's face sheet (a document that gives the resident's information at a quick glance) showed the following: -admission date of 8/15/16 -Diagnoses included ESRD, chronic kidney disease, dependence on renal dialysis, and diabetes. Record review of the resident's care plan, dated 8/23/16, showed the following: -Dialysis thee times weekly on Monday, Wednesday and Friday; -Assess thrills and bruits ( a swishing sound to indicate blood flow and potency (unobstructed or blocked)) daily. (Staff did not care plan the time of day for dialysis, the location of the fistula, the types of complications to monitor for, or guidance for obtaining blood pressure.) Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/1/21, showed the following: -Cognitively intact; -Required extensive assistance with hygiene, dressing, and transfers; -Received dialysis. Observation and interview of the resident on 1/7/22, at 8:20 A.M., showed the resident sitting on the side of the bed. A fistula was observed on the resident's left arm. The resident's said the following -He/she goes to dialysis three times a week on Monday, Wednesday, and Friday; -Staff look at his/her arm in the morning; -Staff take vital signs occasionally, but not daily; -Staff do not monitor the site, take vital signs, or check on him/her on return from dialysis; -The resident cares for the access site; -The resident has been receiving dialysis for several years. Record review of the resident's November 2021 vital sign record showed the following: -On 11/23/21, staff obtained a blood pressure in the resident's left arm (the dialysis access arm); -On 11/27/21, staff obtained a blood pressure in the resident's left arm (the dialysis access arm); -On 11/28/21, staff obtained a blood pressure in the resident's left arm (the dialysis access arm); -On 11/30/21, staff obtained a blood pressure in the resident's left arm (the dialysis access arm). Record review of the resident's physician's order sheet (POS), dated 1/5/22, showed the following: -An order, dated 12/10/19, directing staff to monitor the resident's fistula daily. (The POS did not have orders for dialysis including where to send the resident for dialysis and what days the resident was scheduled for dialysis.) Record review of the resident's December 2021 vital sign record showed the following: -On 12/11/21, staff obtained a blood pressure in the residents left arm (the dialysis access arm); -On 12/25/21, staff obtained a blood pressure in the resident's left arm (the dialysis access arm); -On 12/26/21, staff obtained a blood pressure in the resident's left arm (the dialysis access arm). Record review of the resident's January 2022 vital sign record showed the following: -On 1/2/22, staff obtained a blood pressure in the resident's left arm (the dialysis access arm); -On 1/8/22, Staff obtained a blood pressure in the resident's left arm (the dialysis access arm). Record review of the resident's medical record show the staff did not document daily assessment of the access site or assessment of the resident following dialysis. During an interview on 1/7/22, at 8:35 A.M., Certified Nurse Assistant (CNA) A said the following: -The resident goes to dialysis on Monday, Wednesday, and Friday; -Has received no specific guidelines or education on how to care for a resident receiving dialysis; -Does not know if the resident has a fistula; -Takes blood pressure in the left arm for all residents as it is closer to the heart. During an interview on 1/7/22, at 8:42 A.M., Licensed Practical Nurse (LPN) E said the following: -The resident has dialysis three times weekly; -A physician's order should be obtained for resident's receiving dialysis; -Staff monitor for thrills and bruits daily, first thing in the morning before the resident leaves for dialysis; -Blood pressure should not be taken in the arm with the fistula; -The resident does not require assessment on return; - He/she is alert and can let staff know if there is a problem. During an interview on 1/10/22, at 9:00 A.M., the MDS Coordinator said all resident's receiving dialysis should have a care plan to show where they receive dialysis, when they receive dialysis, and a phone number to the dialysis facility. There should be a physician order for the dialysis. She would not care plan interventions for potential complications unless the resident actually had some complications, and then she would add interventions. She does not include interventions for CNA's on the care plan. The CNA's should get information needed in daily report from the nurses. She is not aware of any inservices or training's offered by the facility for the care of dialysis residents. During an interview on 1/10/12, at 9:17 A.M., the Director of Nursing (DON) and the administrator said the following: -There should be a physician's order for all residents receiving dialysis to include how many times weekly; -Expects staff to monitor thrills and bruits daily; -The resident should have a full set on vitals taken on return from dialysis; -Blood pressure should be obtained in the arm opposite the fistula; -Staff should monitor the resident for bleeding on return from dialysis; -CNA's should be aware of the fistula site location; -Dialysis care interventions should be addressed in the residents care plan; -Not aware that in-services or training has been provided to staff for the care of dialysis residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed-hold policy for two residents (Residents #28 and #41) who transferred/discharged to the hospital. A sample of 22 residents was selected for review in a facility with a census of 71. Record review of the facility's policy titled, Preparing a Resident for Transfer or Discharge, revised date December 2008, showed the following: -The business office will be responsible for informing the resident of the facility's bed-hold policy before discharge from the facility. 1. Record review of Resident #28's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 8/15/16; -Diagnoses included diabetes (condition which affects the way the body processes blood sugar (glucose)), chronic (longstanding) kidney disease, and repeated falls; -Resident listed as responsible party. Record review of the resident's discharge Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/27/19, showed the following: -On 1/27/19, resident discharged with return anticipated; -Cognitively intact. Record review of the resident's physician's note, dated 1/31/19, showed the following: -Resident discharged to the hospital on 1/27/19 and returned to the facility on 1/30/19. Record review showed staff did not have documentation of written bed-hold information provided to the resident at discharge. 2. Record review of Resident #41's face sheet showed the following: -On 1/28/19, admitted from the hospital; -Resident listed as responsible party; -Diagnoses included encephalopathy (broad term for any brain disease that alters brain function or structure), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and cognitive communication deficit (disorder in which a person has difficulty communicating because of injury to the brain that controls the ability to think). Record review of the resident's discharge assessment MDS, dated [DATE], showed the following: -On 2/18/19, resident discharged with return anticipated; -Cognitively intact. Record review of the facility's discharge report showed the resident was discharged from the facility to the hospital on 2/18/19 and returned to the facility on 2/21/19. Record review showed staff did not have documentation of written bed-hold information provided to the resident at discharge. 3. During an interview on 5/7/19, at 11:41 A.M., the Social Services Designee (SSD) said the following: -He/She is responsible for providing the bed hold policy upon residents' admission to the facility and giving a notification of discharge to residents and residents' representatives; -He/She is not providing a bed-hold policy to the residents or the residents' representatives whenever residents discharge to the hospital. He/She was not aware it was a requirement. 4. During an interview on 5/7/19, at 1:28 P.M., the Director of Nursing (DON) said the following: -Residents are given the bed hold policy upon admission, but not when they are discharged to the hospital. 5. During an interview on 5/8/19, at 10:28 A.M., the administrator said the following: -He was not aware a bed hold policy should be provided to the residents upon discharge to the hospital; -The facility does not currently provide residents with bed hold information when discharged to the hospital.

Based on interview and record review, the facility failed to ensure the required quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, was completed within the required timeframe for two residents (Resident #4 and #6) out of a sample of 22 residents. The facility census was 71. Record review of the facility's policy titled MDS Completion and Submission Timeframes, dated 2001 and revised October 2010, showed the following: -The facility will conduct and submit resident assessments in accordance with current federal and state submission timeframe's; -The Assessment Coordinator or designee shall be responsible for ensuring resident assessments (admission, annual, significant change, quarterly review) are submitted to Centers for Medicare/Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 1. Record review of Resident #4's MDS assessments showed the following: -Staff completed a quarterly MDS with an assessment reference date of 11/28/18; -Staff did not complete the required quarterly MDS for February 2019. 2. Record review of Resident #6's MDS assessments showed the following: -Staff completed a quarterly MDS with an assessment reference date of 12/13/18; -Staff did not complete the required quarterly MDS for March 2019. 3. During an interview on 5/8/19, at 12:30 P.M., the MDS Coordinator said Resident #4 and Resident #6 should have had a quarterly MDS assessments in March. She had been on unexpected leave and some MDS assessments were missed. 4. During an interview on 5/8/19, at 1:30 P.M., the Director of Nursing (DON) said sometimes there are alerts built into the MDS program if an assessment is due. She would expect that assessments would not be overdue. 5. During an interview on 4/8/19, at 2:33 P.M., the administrator said he expected staff would complete the MDS assessments on time. The current MDS Coordinator was on leave recently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the required Preadmission Screening and Resident Review (PASRR) Level I screening (identifies residents with a mental illness (MI), intellectual disability (ID) or a related condition) for one resident (Resident #54) prior to or upon admission to determine if a PASRR Level II (an in-depth evaluation and determination is needed to ensure residents identified receive care and services in the most integrated setting appropriate to their needs. The facility census was 71. Record review of the facility's undated policy titled, Medicaid Forms Timeline, showed the following: -The PASRR Level I screening should be completed on every admission within 14 days. 1. Record review of Resident #54's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted on [DATE]; -Diagnoses including schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs); -Listed medicaid as the primary payer source. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/29/19, showed the following staff assessment of the resident: -The resident was admitted from the hospital; -Staff documented no, indicating the resident did not have a serious MI and/or ID or related condition for the PASRR; -Diagnoses including depression, manic depression (also known as bipolar disorder), and schizophrenia. Record review of the resident's May 2019 physician order sheet (POS) showed the resident's physician directed staff to administer the following: -Escitalopram (medication used to treat depression and anxiety), 10 milligrams (mg) one time a day; -Seroquel (an anti-psychotic medication used to treat mental/mood conditions (such as schizophrenia, bipolar disorder)), 25 mg, two times daily. Record review of the resident's care plan, dated 4/3/19, showed direction for the following: -The resident has episodes of aggressive/combative behaviors; -He/She has diagnoses of schizophrenia and bipolar disorder and receives an anti-depressant and anti-psychotic medication. Record review of the resident's record showed staff did not complete a Level I screening for the resident. During an interview on 5/3/19, at 1:56 P.M., the Social Services Designee said the following: -He/She could not locate a PASRR Level I screening for the resident; -The hospital generally completes the PASRR Level I screening and sends it to the facility with the admission paperwork. He/She did not get it from the hospital. During an interview on 5/7/19, at 2:18 P.M., the Director of Nursing (DON) said the following: -She completes the initial screening portion of the PASRR; -The PASRR Level I should be completed for all residents and she would expect it to be in the residents' charts; -She was not sure why a PASRR Level I screening was not completed or requested from the hospital. During an interview on 5/8/19, at 10:28 A.M., the administrator said the following:: -A PASRR Level I screening should have been filled out for resident; -The facility staff should request the PASRR I screening from the previous facility or hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide assistance to prevent potential accidents when staff did not remove a nasal cannula (device used to deliver supplemental oxygen, consisting of tube with prongs which are placed in the nostrils) and oxygen tank when one resident (Resident #41) smoked. The facility's census as 71. Record review of the facility's policy titled, Resident Smoking Policy, dated 11/19/18, showed direction for staff to supervise residents at all times during smoke breaks. Staff will not be allowed to leave the smoke area until conclusion of the smoke break. Record review of the facility's policy titled, Oxygen Administration, revised date 2010, showed direction for staff to remove all potentially flammable items (smoking articles) from the immediate area where oxygen is to be administrated. 1. Record review of Resident #41's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted on [DATE] from the hospital; -Diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe), respiratory failure, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder, bipolar disorder (disorder with episodes of mood swings ranging from depressive lows to manic highs), and cognitive communication deficit (disorder in which a person has difficulty communicating because of injury to the brain that controls the ability to think). Record review of the resident's nursing admission assessment, dated 1/28/19, showed the following: -Use of oxygen; -Independent with smoking. Record review of the resident's care plan, dated 2/15/19, showed direction for staff to do the following: -Assist the resident to the smoking area upon request; -Check for burns; -Keep matches/lighters at the nurse's station. Record review of the resident's admission Minimum Data Sheet (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 2/18/19 showed the following: -Cognitively intact; -Limited staff assistance required with transfers; -Oxygen therapy received; -Wheelchair used for mobility. Record review of the resident's physicians order sheet, dated May 2019, showed direction to provide supplemental oxygen through nasal cannula, set on two liters per minute. Observations on 5/3/19, at 10:54 A.M., showed Resident #41 and another resident smoking outside on the patio. The housekeeping supervisor sat close by. Resident #41 had a nasal cannula in his/her nose and an oxygen tank hanging on the back of the wheelchair. The oxygen tank regulator was turned off. During an interview on 5/3/19, at 11:54 A.M., the resident said the following: -He/She turns off the oxygen when he/she goes outside to smoke; -The facility staff never take the oxygen cannula off his/her face or remove the oxygen tank from the back of the wheelchair before lighting the his/her cigarette or while smoking; -The facility staff always supervise the residents when they go outside to smoke; -The facility staff light the resident's cigarettes. During an interview on 5/3/19, at 12:06 P.M., the Housekeeping Supervisor said the following; -The residents always have supervision while smoking; -He/She or another housekeeper supervise the residents when they smoke at 10:30 A.M.; -The resident usually turns the oxygen regulator off, and facility staff make sure the oxygen tank is turned off; -He/She does not remove the oxygen tank from the resident's wheelchair prior to going outside to smoke or lighting the cigarette; -The resident usually takes his/her own nasal cannula off prior to smoking; -Oxygen tanks should be stored 50 feet away from anything flammable or an open flame; -He/She thinks staff should remove the resident's oxygen tank from the wheelchair and leave it inside when the resident smokes to ensure the residents safety. During an interview on 5/3/19, at 12:21 P.M., the maintenance supervisor said the following: -Oxygen should always be turned off whenever a resident is smoking and generally, the oxygen tubing is removed from the resident's nose; -The oxygen tank is left on the resident's wheelchair when he/she goes outside to smoke; -An oxygen tank should not be within 50 feet of an open flame or a lit cigarette; -The facility staff should probably be removing the oxygen tank from the back of the resident's wheelchair prior to going outside to smoke. During an interview on 5/7/19, at 1:28 P.M., with the administrator said the oxygen tanks should stay in the building when the resident goes outside to smoke even if the tank is turned off. During an interview on 5/7/19, at 1:29 P.M., the Director of Nursing (DON) said the following: -Oxygen tanks should never be around an open flame or a lit cigarette even if the oxygen tank is turned off; -The facility staff should be removing the oxygen tank from the resident's wheelchair and leaving it in the building in a secure location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician order for hydration for one resident (Resident #53 with an abnormal lab value; failed to contact the physician with a change in condition and obtain an order for supplemental oxygen for one resident (Resident #67); and failed to ensure one resident (Resident #74) had a follow-up appointment with an ophthalmologist (physician who specializes in eye and vision care). A sample of 22 residents was selected for review in a facility with a census of 71. Record review of the facility's policy titled, Charting and Documentation, dated January 2017 showed the following: -All observations, medications administered, services performed, etc., must be documented in the resident's clinical records; -All incidents, accidents or changes in the resident's condition must be recorded; -Documentation shall include notification of the physician. 1. Record review of the facility's policy titled Enteral Nutrition, dated December 2008, showed the following: -Fluids to be provided will be calculated by the dietitian and referred to the physician for an order; -The dietitian will recommend bolus flushes with consideration of fluid content of feeding product, resident weight, diagnosis, and fluid, electrolyte, and nutritional status. Record review of Resident #53's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 10/1/15; -Diagnoses included cerebrovascular disease (damage to the brain from interruption of the blood supply), hemiplegia (paralysis of one side of the body), aphasia (a language disorder that affects a person's ability to communicate), epilepsy (seizure disorder), disorder of white blood cells (cells in blood that fight infection) and dysphagia (difficulty swallowing). Record review of the resident's physician order, dated 10/1/15, showed the resident's physician directed staff to flush the resident's gastrostomy (also called a G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) tube five times a day with 250 milliliters (ml) of water. Record review of the resident's care plan, dated 8/1/16, showed direction for the following: -Nothing by mouth (NPO); -Provide nutrition and hydration through a gastrostomy tube due to dysphagia; -Identified a risk for aspiration (when food, liquid, or some other material enters your airway or lungs by accident, which can cause serious health problems, such as pneumonia); -Notify dietitian of any complications such as weight loss/gain, hydration status, or skin issues; -Flush gastrostomy tube as ordered by the physician. Record review of the residents' laboratory results, dated 2/5/19, showed the resident's sodium level to be below normal limits. Record review of a dietitian recommendation, dated 3/6/19, to the resident's physician showed the following: -Staff administer 250 ml of water five times daily per gastrostomy tube; -The resident's sodium level was low; -Recommended to repeat a Basic Metabolic Profile (BMP-a blood test to check fluid balance in the body). If the BMP remains low, recommend reducing the gastrostomy tube flushes to 250 ml four times a day; -The physician signed the order on 3/15/19 and agreed to the recommendations; -A nurse noted and initialed the physician order. Record review of the resident's laboratory results, dated 3/19/19, showed the resident's sodium level to be low. Record review of the resident's physician's evaluation form, dated 3/21/19, showed a diagnosis of hyponatremia (a condition that occurs when the level of the sodium in the blood is too low). Record review of the resident's March 2019 treatment administration records (TAR) showed staff administered the 250 ml water flushes through the resident's gastrostomy tube five times a day. Record review of the resident's quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/01/19, showed the following: -Severely impaired cognition; -Required total staff assistance for eating; -Received intake through a feeding tube. Record review of the residents' TARs, dated 4/1/19 through 5/7/19, showed staff administered the 250 ml water flushes through the resident's gastrostomy tube five times a day. Observation and interview on 5/3/19, at 1:15 P.M., showed Licensed Practical Nurse (LPN) E flushed the resident's gastrostomy tube with 250 ml of water. The nurse said the resident receives five flushes of 250 ml daily. During an interview on 5/8/19, at 9:25 A.M., LPN A said when the dietitian writes a recommendation and the physician agrees and signs the recommendation form it is considered an order and should be followed. When the nurse notes the order and the change should be transcribed (transfers a physician's prescription order to a medication administration record (MAR). The transcriber must ensure accuracy and compliance onto the MAR or the TAR. During an interview on 5/8/19, at 11:20 A.M., the Director of Nursing (DON) said if the physician agrees with the dietitian's recommendation and signs the form it is considered an order. She would expect staff to follow the new order and it should be reflected on the resident's MAR or TAR. A resident with a low sodium level that receives too much fluid is at risk for potential health issues. 2. Record review of the facility's policy titled, Oxygen Administration, dated October 2010, showed the following: -Verify the physician's order for oxygen; -The reason for administration, rate of oxygen flow, and route should be documented in the medical record. Record review of Resident #67's face sheet showed the following: -admitted on [DATE]; -Diagnosis included heart disease, dementia (decline in memory or thinking and social symptoms that interferes with daily functioning), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), and nausea with vomiting. Record review of the resident's April 2019 POS showed no order for oxygen. Record review of the resident's MDS, dated [DATE], showed the following staff assessment of the resident: -Cognitively intact; -No shortness of breath experienced; -Oxygen therapy not used during the seven day look-back period. Record review of the resident's progress note dated 4/28/19, at 12:59 A.M., showed LPN C documented the following: -He/She checked the resident's oxygen saturation level and it was 80%; -Facility staff administered oxygen via nasal cannula (device used to deliver supplemental oxygen, consisting of tube with prongs which are placed in the nostrils) and set to two liters. The resident's oxygen saturation level increased to 91% after two hours of continuous therapy. Record review of the resident's progress note dated 4/28/19, at 1:00 P.M., showed LPN D documented the resident's supplemental oxygen was taken off at 7:00 A.M. Staff checked the resident's oxygen saturation level and noted a level of 97%. He/She will continue to monitor. Record review of the resident's progress note dated 4/29/19, at 2:51 A.M., showed LPN C documented the resident's oxygen saturation went down to 88% while on two liters of oxygen. He/She will recheck for improvement. Record review of the resident's progress notes dated 5/1/19, at 1:54 P.M., showed LPN A documented the resident was wearing continuous oxygen because the resident thought he/she was supposed to. The resident's oxygen saturation was 95%. He/She educated the resident about the use of oxygen only as needed. Record review of the resident's progress note dated 5/4/19, at 2:31 P.M., showed LPN D documented the resident's oxygen saturation went down to 82% last night. Staff administered two liters of oxygen via nasal cannula. Record review of the resident's medical record showed staff did not notify the physician about the resident's change in condition. During an interview on 5/1/19, at 10:02 A.M., the resident said the following: -He/She just started wearing oxygen on 4/28/19 due to not feeling well; -He/She was given nausea medication and ever since he/she has felt weak and dizzy. During an interview on 5/6/19, at 10:04 P.M., LPN A said the following: -The resident has recently required supplemental oxygen to keep his/her oxygen saturation at the appropriate level; -The resident has not needed oxygen in the past; -When a resident has a change in condition then staff should contact the physician or send a referral with an update on the resident's condition. During an interview on 5/6/19, at 4:20 P.M., Registered Nurse (RN) B said the following: -He/She was surprised to see the resident on oxygen earlier in the week due to the resident not using oxygen in the past; -He/She would consider the need for oxygen a change in condition and he/she would contact the physician; -He/She would expect the nurse to get an order from the physician for the oxygen. During an interview on 5/7/19, at 7:42 A.M., LPN C said the following: -The resident had a decreased oxygen level and reported feeling dizzy and ill; -He/She checked the resident's vital signs and put two liters of oxygen on the resident via nasal cannula; -The resident's decreased oxygen saturation became a pattern; -He/She did not call the physician; -He/She thought they had put the physician's referral in the computer, but was not sure; -The physician would see the referral the next time he/she was in the building. It could be a week or so; -He/She was not sure if the resident has to have an order for oxygen; -He/She only calls the physician if he/she feels the resident needs to go to the hospital. During an interview on 5/7/19, at 7:42 A.M., the DON said the following: -There should have been a physician referral about resident's change in condition; -He/She considered a resident needing oxygen who has not needed it before, a change in condition; -The nurse should have gotten an order for the continued use of the oxygen. During an interview on 5/7/19, at 7:42 A.M., the administrator said the following: -Staff should contact the physician when a resident has a change in condition; -The DON or Assistant Director of Nursing (ADON) should also be contacted about a resident's change in condition; -An order should have been put in the medical record for the use of oxygen. 3. Record review of Resident #74's face sheet showed the following: -admitted on [DATE]; -Diagnoses included obesity, osteoarthritis (a type of arthritis), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder. Record review of the resident's admission MDS, dated [DATE], showed the following staff assessment of the resident: -Cognitively intact; -Independent with transfers and activities of daily living; -Use of a wheelchair. Record review of the resident's physician note, dated 3/29/19, showed direction for the following: -Apply a warm compress to see if the tear duct will unclog; -The resident is to see an ophthalmologist. Record review of the residents' physician's note, dated 4/4/19, showed the following: -The resident asked again about what to do with his/her right eye; -The resident has a right inner eye cyst and is awaiting an ophthalmologist appointment for possible drainage. Observation on 5/1/19, at 10:12 A.M., showed the resident with a swollen area between his/her eye and the bridge of his/her nose. During an interview on 5/1/19, at 10:18 A.M., the resident said the following: -He/She has had a clogged tear duct since he/she was admitted to the facility; -He/She thought the facility's physician ordered an eye specialist follow-up; -He/She has been asking staff about the appointment for about a month and nobody seems to know anything about it; -He/She decided to call an Ophthalmologist him/her self. During an interview on 5/6/19, at 10:18 A.M., LPN A said the following: -The ADON processes the residents' referrals for other physicians outside of the facility; -The transportation person makes the appointments. During an interview on 5/6/19, at 11:30 A.M., the DON said the following: -The resident should have had an appointment made, but it must have been overlooked; -He/She was not aware the resident needed a follow-up appointment; -There is a lack of communication due to not having a consistent person transporting residents; -He/she has recently been in charge of transport. During an interview on 5/6/19, at 7:54 P.M., the ADON said the following; -He/she enters the physician referral orders into the computer and passes the information on to the transport person; -The transportation person schedules the residents' appointments; -The previous transportation person should have had the referral and scheduled the resident's ophthalmologist appointment. During an interview on 5/8/19, at 10:28 A.M., the administrator said the following: -It has been difficult to keep the transportation position filled; -He/she was not aware the resident's physician had written an order to have a follow-up appointment with an ophthalmologist; -Staff should have made an appointment and followed up on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a medication regimen free from unnecessary medication when the facility failed to implement gradual dose reductions (GDR - a step-wise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) or provide a reason it would be contraindicated for one resident (Resident #16) and failed to provide rationale to continue an as needed (PRN) psychotropic medication past 14 days for four residents (Resident #39, #41, #53, and #64) in a selected sample of 22 residents. The facility census was 71. Record review of the facility's undated policy titled GDR Process showed direction for the following: -The physician will address the recommendation, and sign and date the request; -The request or recommendation is then considered an order. 1. Record review of Resident #16's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 2/29/16; -Diagnoses included vascular dementia (memory and judgment problems caused by brain damage from impaired blood flow to your brain) without behavioral disturbance, schizoaffective disorder (mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized anxiety disorder, and insomnia. Record review of the resident's physician order, dated 2/3/17, showed the resident's physician directed staff to administer Trazodone (a sedative and anti-depressant), 100 milligrams (mg), one time a day, for insomnia. Record review of the resident's annual GDR review, dated 3/8/18, showed the following: -No recommendation for a change to the Trazodone 100 mg one time a day order (more than 13 months after the original order); -No physician rationale to continue the Trazodone 100 mg one time a day order. Record review of the resident's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/19, showed the following: -Severely impaired cognition; -Extensive staff assistance required for bed mobility, transfer, dressing, eating, toilet use, and hygiene; -Dependent for bathing. Record review of the resident's annual GDR review, dated 2/10/19, showed: -No recommendation for a change to the Trazodone 100 mg at bedtime order (two years after the original order); -No physician rationale to continue the Trazodone 100 mg at bedtime order. Record review of the resident's physician orders, dated 2/14/19, showed the resident's physician directed staff to administer Lexapro (an anti-depressant) 10 mg, one time a day. Record review of the resident's nurse's note, dated 2/14/19, showed staff documented the following: -The physician reviewed the resident's pharmacy recommendations; -A new order to decrease the Lexapro dosage; -No documentation regarding the physician rationale for the continued order of Trazadone. Record review of the resident's care plan, dated 10/3/17 and review date 2/20/19, showed direction to staff for the following: -The resident takes psychotropic medication for diagnoses of depression, schizophrenia and insomnia; -Interventions included a monthly pharmacist and physician review of medications: -Instruction to use the lowest effective dose of medication, and provide gradual dose reductions as ordered. During an interview on 5/7/19, at 11:46 A.M., the Pharmacy Consultant said the following: -The pharmacy reviews all psychotropic medications twice during the first year ordered and then annually; -The pharmacy sends the physician the GDR for review; -The pharmacy provides recommendations to change a medication order as well as a box the physician could mark to not change the current therapy; -The pharmacy considers the GDR reviewed if the physician signs it, even if the box is not marked, indicating no changes recommended; -The physician may provide rationale during rounds at the facility and the nurse would document. During an interview on 5/8/19, at 1:30 P.M., DON said she assumed the physician did not want to change the order for a medication if there were no rationale documented for a change. 2. Record review of Resident #39's face sheet showed the following: -admission date of 6/30/17; -Diagnoses included congestive heart failure (CHF- a condition in which the heart does not pump blood as well as it should), cerebral infarction (damage to tissue in the brain due to a lack of oxygen to the area), shortness of breath, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), diabetes mellitus (a group of diseases that affects the way the body processes blood sugar (glucose)), and history of pneumonia (infection that inflames air sacs in one or both lungs), depressive disorder and anxiety disorder. Record review of the resident care plan, dated 7/26/17, showed direction for staff to administer anti-anxiety mediation as ordered and instructed. Record review of the resident's physician order sheet (POS) showed the resident's physician directed staff to administer Ativan (an anti-anxiety medication) 0.5 mg every six hours as needed (PRN) for anxiety with a start date of 10/24/18 and duration of lifetime due to hospice. Record review of the resident's November 2018 medication administration records (MAR) showed the following: -On 11/9/18, staff administered the resident's PRN Ativan every six hours; -On 11/14/18, staff administered the resident's PRN Ativan every six hours; -On 11/23/18, staff administered the resident's PRN Ativan every six hours; -On 11/24/18, staff administered the resident's PRN Ativan every six hours; -On 11/27/18, staff administered the resident's PRN Ativan every six hours; -On 11/29/18, staff administered the resident's PRN Ativan two times; -On 11/30/18, staff administered the resident's PRN Ativan two times. Record review of the resident's December 2018 MAR showed on 12/27/18, staff administered the resident's PRN Ativan every six hours. Record review of the resident's January 2019 MAR showed the following: -On 1/8/19, staff administered the resident's PRN Ativan every six hours; -On 1/11/19, staff administered the resident's PRN Ativan every six hours. Record review of the resident's MAR dated February 2019 showed the following: -On 2/4/19, staff administered the resident's PRN Ativan every six hours; -On 2/5/19, staff administered the resident's PRN Ativan every six hours. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Received anti-anxiety medication seven out of the previous seven days; -Received anti-depressant medication seven out of the previous seven days. Record review of the resident's March 2019 MAR showed the following: -On 3/2/19, staff administered the resident's PRN Ativan every six hours; -On 3/5/19, staff administered the resident's PRN Ativan every six hours; -On 3/7/19, staff administered the resident's PRN Ativan every six hours; -On 3/14/19, staff administered the resident's PRN Ativan every six hours; -On 3/15/19, staff administered the resident's PRN Ativan every six hours; -On 3/18/19, staff administered the resident's PRN Ativan every six hours; -On 3/30/19, staff administered the resident's PRN Ativan every six hours. Record review of the resident's pharmacist's medication regimen review, dated 4/1/19, showed the following: -All as needed (PRN) psychoactive orders should be ordered for 14 days or less unless other wise noted by the physician; -Hospice status is not considered an exemption to the 14 day requirement; -No recommendations for the resident. Record review of the resident's April 2019 MAR showed the following: -On 4/1/19, staff administered the resident's PRN Ativan every six hours; -On 4/22/19, staff administered the resident's PRN Ativan every six hours. 3. Record review of Resident #53's face sheet showed the following: -admission date of 10/1/15; -Diagnoses included cerebrovascular disease (group of conditions, such as stoke that can lead to a cerebrovascular event. These events affect the blood vessels and blood supply to the brain), hemiplegia (paralysis of one side of the body), aphasia (a language disorder that affects a person's ability to communicate), epilepsy (seizure disorder), disorder of white blood cells (cells in blood that fight infection), dysphagia (difficulty swallowing), and generalized anxiety disorder. Record review of the resident's care plan, dated 8/1/16, showed direction for staff to do the following: -Assess the need for a PRN anti-anxiety medication; -Physician and pharmacist to review medications for gradual dose reductions. Record review of the resident's May 2019 POS showed the resident's physician directed staff to administer Alprazolam (an anti-anxiety medication) 1.0 mg PRN every six hours for anxiety with a start date of 11/8/18. The Alprazolam did not have a stop date. Record review of the resident's November 2018 MAR showed the following: -On 11/28/18, staff administered the resident's PRN Alprazolam every six hours; -On 11/30/18, staff administered the resident's PRN Alprazolam every six hours. Record review of the resident's December 2018 MAR showed the following: -On 12/3/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/5/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/7/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/8/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/9/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/10/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/13/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/14/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/15/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/16/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/17/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/18/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/20/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/21/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/23/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/24/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/25/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/26/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/27/18, staff administered the resident's PRN Alprazolam every six hours; -On 12/31/18, staff administered the resident's PRN Alprazolam every six hours. Record review of the resident's January 2019 MAR showed the following: -On 1/1/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/2/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/4/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/7/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/8/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/9/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/11/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/14/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/16/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/18/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/21/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/23/19, staff administered the resident's PRN Alprazolam every six hours; -On 1/25/19, staff administered the resident's PRN Alprazolam every six hours. Record review of the resident's February 2019 MAR showed the following: -On 2/3/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/4/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/6/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/8/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/10/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/11/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/13/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/14/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/18/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/19/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/20/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/20/19, staff administered the resident's PRN Alprazolam every six hours; -On 2/22/19, staff administered the resident's PRN Alprazolam every six hours. Record review of the resident's March 2019 MAR showed the following: -On 3/3/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/4/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/5/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/7/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/9/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/12/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/14/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/15/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/17/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/18/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/19/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/20/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/22/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/25/19, staff administered the resident's PRN Alprazolam every six hours; -On 3/28/19, staff administered the resident's PRN Alprazolam every six hours. Record review of the resident's quarterly MDS dated [DATE], showed the following: -Severely impaired cognition; -Received anti-anxiety medication five out of the previous seven days; -Received anti-depressant medication seven out of the previous seven days. Record review of the resident's pharmacist's medication regimen review, dated 4/1/19, showed the pharmacist did not make a recommendation for the resident. Record review of the resident's April 2019 MAR showed the following: -On 4/1/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/4/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/5/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/13/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/15/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/16/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/17/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/18/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/19/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/23/19, staff administered the resident's PRN Alprazolam every six hours; -On 4/28/19, staff administered the resident's PRN Alprazolam every six hours. Record review of the resident's May 2019 MAR showed the following: -On 5/1/19, staff administered the resident's PRN Alprazolam every six hours; -On 5/2/19, staff administered the resident's PRN Alprazolam every six hours; -On 5/3/19, staff administered the resident's PRN Alprazolam every six hours; -On 5/6/19, staff administered the resident's PRN Alprazolam every six hours; -On 5/7/19, staff administered the resident's PRN Alprazolam every six hours. Record review of the resident's medical record showed the physician did not document a rationale for the continued use of the PRN Alprazolam. 4. Record review of Resident #64's face sheet showed the following: -admission date of 11/11/16; -Diagnoses included depressive disorder and generalized anxiety disorder. Record review of the resident's care plan, dated 11/17/17, showed direction for staff for the following: -Provide medications as ordered; -Physician and pharmacist to review medications; -Attempt GDR as indicated. Record review of the resident's physician order, dated 11/1/18, showed the resident' physician directed staff to administer Alprazolam 0.5 mg every four hours PRN for anxiety. The Alprazolam did not have a stop date. Record review of the resident's November 2018 MAR showed the following: -On 11/16/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/17/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/18/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/20/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/21/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/22/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/23/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/26/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/27/18, staff administered the resident's PRN Alprazolam every four hours; -On 11/29/18, staff administered the resident's PRN Alprazolam every four hours. Record review of the resident's December 2018 MAR showed the following: -On 12/3/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/6/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/11/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/13/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/18/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/19/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/20/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/21/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/22/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/26/18, staff administered the resident's PRN Alprazolam every four hours; -On 12/27/18, staff administered the resident's PRN Alprazolam every four hours. Record review of the resident's January 2019 MAR showed the following: -On 1/1/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/3/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/4/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/6/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/8/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/9/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/11/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/14/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/15/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/19/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/21/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/23/19, staff administered the resident's PRN Alprazolam every four hours; -On 1/29/19, staff administered the resident's PRN Alprazolam every four hours. Record review of the resident's February 2019 MAR showed the following: -On 2/6/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/7/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/8/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/10/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/11/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/12/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/13/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/14/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/16/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/17/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/19/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/22/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/23/19, staff administered the resident's PRN Alprazolam every four hours; -On 2/27/19, staff administered the resident's PRN Alprazolam every four hours. Record review of the resident's March 2019 MAR showed the following: -On 3/1/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/5/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/8/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/9/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/10/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/12/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/17/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/18/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/23/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/24/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/28/19, staff administered the resident's PRN Alprazolam every four hours; -On 3/30/19, staff administered the resident's PRN Alprazolam every four hours. Record review of the resident's pharmacist's medication regimen review, dated 4/1/19, showed no recommendation for the resident. Record review of the resident's April 2019 MAR showed the following: -On 4/10/19, staff administered the resident's PRN Alprazolam every four hours; -On 4/11/19, staff administered the resident's PRN Alprazolam every four hours; Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Received anti-anxiety medication three out of the previous seven days. Record review of the resident's April 2019 MAR showed the following: -On 4/16/19, staff administered the resident's PRN Alprazolam every four hours; -On 4/20/19, staff administered the resident's PRN Alprazolam every four hours; -On 4/23/19, staff administered the resident's PRN Alprazolam every four hours; -On 4/24/19, staff administered the resident's PRN Alprazolam every four hours; -On 4/25/19, staff administered the resident's PRN Alprazolam every four hours; -On 4/27/19, staff administered the resident's PRN Alprazolam every four hours. Record review of the resident's May 2019 MAR showed the following: -On 5/6/19, staff administered the resident's PRN Alprazolam every four hours; -On 5/7/19, staff administered the resident's PRN Alprazolam every four hours; -On 5/8/19, staff administered the resident's PRN Alprazolam every four hours. Record review of the resident's medical record showed the physician's did not document a rationale for the continued use of the PRN Alprazolam. 5. Record review of Resident #41's face sheet showed the following: -admitted on [DATE] from the hospital; -Diagnoses included encephalopathy (broad term for any brain disease that alters brain function or structure), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and cognitive communication deficit (disorder in which a person has difficulty communicating because of injury to the brain that controls the ability to think). Record review of the resident's admission Minimum Data Sheet (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 2/18/19, showed the following: -admitted from the hospital; -Cognitively intact; -Depression diagnosis; -The mood interview indicated severe depression. Record review of the resident's physician order, dated 3/28/19, showed the resident's physician directed staff to administer Alprazolam (an anti-anxiety medication) 1.0 mg as needed one time daily for generalized anxiety disorder. Record review of the resident's pharmacist review, dated 4/3/19, showed the pharmacy consultant documented a request for the duration of therapy from the physician for the Alprazolam as needed use. Record review of the resident's April 2019 MAR showed the following: -On 4/16/19, staff administered the resident's PRN Alprazolam one time; -On 4/17/19, staff administered the resident's PRN Alprazolam one time; -On 4/18/19, staff administered the resident's PRN Alprazolam one time; -On 4/19/19, staff administered the resident's PRN Alprazolam one time; -On 4/22/19, staff administered the resident's PRN Alprazolam one time; -On 4/23/19, staff administered the resident's PRN Alprazolam one time; -On 4/25/19, staff administered the resident's PRN Alprazolam one time; -On 4/26/19, staff administered the resident's PRN Alprazolam one time; -On 4/29/19, staff administered the resident's PRN Alprazolam one time; -On 4/30/19, staff administered the resident's PRN Alprazolam one time. Record review of the resident's May 2019 MAR showed the following: -On 5/1/19, staff administered the resident's PRN Alprazolam one time. Record review of the resident's medical record showed no documentation of the physician's rational for the continued use of the PRN Alprazolam. During an interview on 5/7/19, at 12:50 P.M., the Pharmacy Consultant said the following: -He/She requested a stop date for the resident's Alprazolam due to it being a psychotropic medication; -Psychotropic medications should not be used longer than 14 days without a rational given; -There was not rational given for the continued use of the resident's Alprazolam. 6. During an interview on 5/7/19, at 11:32 A.M., the pharmacist said the following: -All PRN psychotropic medications should have a stop date of 14 days or less; -Anti-anxiety medications ordered on an as needed basis should be reviewed by the physician. If the anti-anxiety medication needs to be continued, the physician should document a rationale, and a new stop date should be indicated on the order; -The pharmacist should be notified if the order is continued and the rationale. 7. During an interview on 5/8/19, at 9:00 A.M., Certified Medication Technician (CMT) F said he/she is not aware of stop dates for PRN anti-anxiety medications. 8. During an interview on 5/8/19, at 9:25 A.M., Licensed Practical Nurse (LPN) A said PRN anti-anxiety medications are generally on-going without stop dates. The PRN medications should be re-evaluated by a physician. 9. During an interview on 5/8/19, at 9:55 A.M., the Assistant Director of Nursing (ADON) said PRN anti-anxiety medications should be written for 14 days. The physician reviews and writes an order for six months if the resident needs the medication. The physician should write a rationale to why the medication is needed. 10. During an interview on 5/8/19, at 11:20 A.M., the Director of Nursing (DON) said a resident's order for PRN anti-anxiety medications should show a stop date. If the medication is needed past 14 days, the physician should re-evaluate and write a rationale of why the medication is needed. The ball has been dropped with allowing PRN anti-anxiety medication to continue past 14 days without the physicians re-evaluating and writing a rationale indicating the reason the medication is to be continued.

Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%) when staff made three errors out of 25 opportunities, resulting in an error rate of 8%, affecting three residents (Resident #53, #66 and #73). The facility census was 71. 1. Record review of the Novolog (brand name of a rapid-acting insulin) insulin manufacturer's insert showed the following: -Novolog starts acting fast; -A meal should be eaten within five to ten minutes of taking a dose of Novolog; -Dosage adjustments may be needed in regards to timing of food intake. Record review of Medscape website (medical reference website for clinicians) showed the following: -This medication can cause hypoglycemia (low blood sugar). This may occur when enough calories are not consumed after taking the insulin within the time frame; -Older adults may be more sensitive to the side effects of low blood sugar from Novolog insulin. Record review of the facility's policy titled Insulin Administration, dated October 2018, showed the following: -Rapid acting insulin has an onset of 10 to 15 minutes. 2. Record review of Resident #73's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 3/26/19; -Diagnosis of insulin dependent diabetes mellitus (a chronic condition in which the body does not produce enough insulin). Record review of the the resident's physician's orders showed the following: -Dated 4/8/19, administer Novolog insulin eight units three times a day; -Administer additional Novolog insulin according to the sliding scale (progressive increase in the pre-meal insulin dose, based on pre-defined blood glucose ranges): -If blood sugar level is 131-180 milligrams/deciliter (mg/dL) administer 4 units; -If blood sugar level is 181-240 mg/dl, administer eight units; -If blood sugar level is 241-300 mg/dl, administer 10 units; -If blood sugar level is 301-350 mg/dl, administer 12 units; -If blood sugar level is 351-400 mg/dl, administer 16 units; -If blood sugar level is 401-450 mg/dl administer 25 units; -If blood sugar level is 451-500 mg/dl administer 30 units. Observation on 5/2/19, at 11:05 A.M., showed Licensed Practical Nurse (LPN) A administered 33 units of Novolog insulin (8 units of the scheduled routine dose plus the additional 25 units according to the sliding scale dose based on an blood sugar level of 408) to the resident. The resident remained in his/her room. Observation on 5/2/19, at 12:20 P.M., showed staff served the resident his/her lunch. The resident began eating 75 minutes after he/she received the Novolog insulin injection. 3. Record review of Resident #66's face sheet showed the following: -admission date of 9/28/18; -Diagnosis of insulin dependent diabetes mellitus. Record review of the resident's physician's order, dated 3/16/19, showed the physician directed staff to administer Novolog insulin 23 units, three times a day with meals. Observation on 5/2/19 showed the following: -At 11:22 A.M., LPN A administered the resident's 23 units of Novolog insulin. The resident lay in bed; -At 12:32 P.M., staff served the resident his/her lunch. The resident began eating 65 minutes after he/she received the Novolog insulin injection. 4. During an interview on 5/8/19 at 9:25 A.M., LPN A said the following: -He/She starts the noon insulin's at 11:00 A.M.; -The noon meal starts at 12:00 P.M.; -The rapid-acting insulin should be given within 15 minutes of eating. 5. During an interview on 5/8/19, at 11:20 A.M., the Director of Nursing (DON) said residents receiving fast-acting insulin, such as Novolog, should eat within 15 minutes after receiving the insulin. The nurse should not give the insulin until 10 to 15 minutes before the meal is served. If the meal is going to be longer than 15 minutes she would expect staff to provide the resident a snack. If the resident does not eat within 15 minutes after receiving a fast-acting insulin they are at risk for their blood sugar dropping to a low level and could cause complications. 6. Record review of the facility's policy titled Administering Medications Through an Enteral Tube, dated October 2010, showed direction for facility staff for the following: -Always check with the pharmacy or medication insert for special dilution instructions prior to administering the medication; -Always position the resident with the head of the bed elevated to at least 30 degree elevation during administration of medication per enteral tube (a tube to the stomach). Record review of Resident #53's face sheet showed the following: -admission date of 10/1/15; -Diagnoses included cerebrovascular disease (group of conditions, such as stoke that can lead to a cerebrovascular event. These events affect the blood vessels and blood supply to the brain), hemiplegia (paralysis of one side of the body), aphasia (a language disorder that affects a person's ability to communicate), epilepsy (seizure disorder), disorder of white blood cells (cells in blood that fight infection), dysphagia (difficulty swallowing), and generalized anxiety disorder. Record review of the resident's POS showed the physician directed staff for the following: -Dated 10/1/15, flush gastrostomy tube (also called a G-tube, is a tube inserted through the abdomen that delivers nutrition, hydration or medications directly to the stomach) five times a day with 250 ml of water; -Dated 11/12/18, administer 5.0 milliliters(ml) of carbamazepine suspension (liquid form of an anti-seizure medication) through the gastrostomy tube three times a day. Record review of the manufacturer's insert for carbamazepine suspension showed the following: -Shake the suspension well prior to use; -To minimize the loss of the drug, dilute the suspension with an equal volume of water prior to administration through gastrostomy tube. Observations on 5/3/19, at 1:15 P.M., showed LPN E poured 5.0 ml's of carbamazepine suspension from a bottle. A label on the bottle of suspension showed a bright orange sticker with directions to shake well. The nurse did not shake the suspension. The resident lay flat in bed without the head of the bed elevated. The nurse checked the tube for placement and administered the carbamazepine suspension full strength into the gastrostomy tube. The nurse did not dilute the suspension. The nurse flushed the tube with 250 ml's of water. The nurse did not elevate resident's head of bed. The nurse left the room. The resident continued to lay in a flat position in the bed. 7. During an interview on 5/8/19 at 9:25 A.M., LPN A said the following: -The carbamazepine should be mixed thoroughly before using. Follow the medication recommendations and dilute if recommended; -A resident receiving medications through a gastrostomy tube should always be in an elevated position and should never lay flat during the medication administration or flushes. 8. During an interview on 5/8/19, at 11:20 A.M., the Director of Nursing (DON) said she would expect nurses to follow the manufactures directions on preparing medications. Residents receiving medications and fluids through a gastrostomy tube should always have their head elevated. If the resident is in a flat positron it puts the resident at risk for aspiration (when food, liquid, or some other material enters your airway or lungs by accident, which can cause serious health problems, such as pneumonia). MO00155213

Based on observation, interview, and record review, the facility failed to ensure residents remained free of significant medication errors when staff administered two resident's (Resident #66 and #73) rapid-acting insulin without ensuring the resident's received food timely after the insulin administration and failed to ensure staff followed acceptable standards of practice when administering enteral medication for one resident (Resident #53). The facility census was 71. 1. Record review of the Novolog (brand name of a rapid-acting insulin) insulin manufacturer's insert, showed Novolog starts acting fast. A meal should be eaten within five to ten minutes of taking a dose of Novolog. Dosage adjustments may be needed in regards to timing of food intake. Record review of Medscape website (medical reference website for clinicians) showed the following: -This medication can cause hypoglycemia (low blood sugar). This may occur when enough calories are not consumed after taking the insulin within the time frame. Hypoglycemia can lead to seizures, may be life threatening, or cause death; -Older adults may be more sensitive to the side effects of low blood sugar from Novolog insulin. Record review of the facility's policy titled Insulin Administration dated October, 2018 showed direction for facility staff for the following: -Rapid acting insulin has an onset of 10 to 15 minutes. 2. Record review of Resident #73's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 3/26/19; -Diagnosis of insulin dependent diabetes mellitus (a chronic condition in which the body does not produce enough insulin). Record review of the the resident's physician's orders showed the following: -Dated 4/8/19, administer Novolog insulin eight units three times a day; -Administer additional Novolog insulin according to the sliding scale (progressive increase in the pre-meal insulin dose, based on pre-defined blood glucose ranges): -If blood sugar level is 131-180 milligrams/deciliter (mg/dL) administer 4 units; -If blood sugar level is 181-240 mg/dl, administer eight units; -If blood sugar level is 241-300 mg/dl, administer 10 units; -If blood sugar level is 301-350 mg/dl, administer 12 units; -If blood sugar level is 351-400 mg/dl, administer 16 units; -If blood sugar level is 401-450 mg/dl administer 25 units; -If blood sugar level is 451-500 mg/dl administer 30 units. Observation on 5/2/19 at 11:05 A.M. showed Licensed Practical Nurse (LPN) A administered 33 units of Novolog insulin (8 units of the scheduled routine dose plus the additional 25 units according to the sliding scale dose based on an blood sugar level of 408) to the resident. The resident remained in his/her room. Observation on 5/2/19 at 12:20 P.M., showed staff served the resident his/her lunch. The resident began eating 75 minutes after he/she received the Novolog insulin injection. 3. Record review of Resident #66's face sheet showed the following: -admission date of 9/28/18; -Diagnosis of insulin dependent diabetes mellitus. Record review of the resident's physician's order, dated 3/16/19, showed the physician directed staff to administer Novolog insulin 23 units, three times a day with meals. Observation on 5/2/19 showed the following: -At 11:22 A.M., LPN A administered the residents' 23 units of Novolog insulin. The resident lay in bed; -At 12:32 P.M., staff served the resident his/her lunch. The resident began eating 65 minutes after he/she received the Novolog insulin injection. 4. During an interview on 5/8/19 at 9:25 A.M., LPN A said the following: -He/She starts the noon insulin's at 11:00 A.M.; -The noon meal starts at 12:00 P.M.; -The rapid-acting insulin should be given within 15 minutes of eating. 5. During an interview on 5/8/19 at 11:20 A.M., the Director of Nursing (DON) said residents receiving fast-acting insulin, such as Novolog, should eat within 15 minutes after receiving the insulin. The nurse should not give the insulin until 10 to 15 minutes before the meal is served. If the meal is going to be longer than 15 minutes she would expect staff to provide the resident a snack. If the resident does not eat within 15 minutes after receiving a fast-acting insulin they are at risk for their blood sugar dropping to a low level and could cause complications. 6. Record review of the facility's policy titled Administering Medications Through an Enteral Tube, dated October 2010 showed direction for facility staff for the following: -Always check with the pharmacy or medication insert for special dilution instructions prior to administering the medication; -Always position the resident with the head of the bed elevated to at least 30 degree elevation during administration of medication per enteral tube (tube to the stomach). Record review of Resident #53's face sheet showed the following: -admission date of 10/1/15; -Diagnoses included cerebrovascular disease (group of conditions, such as stoke that can lead to a cerebrovascular event. These events affect the blood vessels and blood supply to the brain), hemiplegia (paralysis of one side of the body), aphasia (a language disorder that affects a person's ability to communicate), epilepsy (seizure disorder), disorder of white blood cells (cells in blood that fight infection), dysphagia (difficulty swallowing) and generalized anxiety disorder. Record review of the resident's POS showed the physician directed staff for the following: -Dated 10/1/15, flush gastrostomy tube (also called a G-tube, is a tube inserted through the abdomen that delivers nutrition, hydration or medications directly to the stomach) five times a day with 250 ml of water; -Dated 11/12/18, administer 5.0 milliliters(ml) of carbamazepine suspension (liquid form of an anti-seizure medication) through the gastrostomy tube three times a day. Record review of the manufacturer's insert for carbamazepine suspension showed the following: -Shake the suspension well prior to use; -To minimize the loss of the drug, dilute the suspension with an equal volume of water prior to administration through gastrostomy tube. Observations on 5/3/19 at 1:15 P.M., showed LPN E poured 5.0 ml's of carbamazepine suspension from a bottle. A label on the bottle of suspension showed a bright orange sticker with directions to shake well. The nurse did not shake the suspension. The resident lay flat in bed without the head of the bed elevated. The nurse checked the tube for placement and administered the carbamazepine suspension full strength into the gastrostomy tube. The nurse did not dilute the suspension. The nurse flushed the tube with 250 ml's of water. The nurse did not elevate resident's head of bed. The nurse left the room. The resident continued to lay in a flat position in the bed. 7. During an interview on 5/8/19 at 9:25 A.M., LPN A said the following: -The carbamazepine should be mixed thoroughly before using. Follow the medication recommendations and dilute if recommended; -A resident receiving medications through a gastrostomy tube should always be in an elevated position and should never lay flat during the medication administration or flushes. 8. During an interview on 5/8/19 at 11:20 A.M., the Director of Nursing (DON) said she would expect nurses to follow the manufactures directions on preparing medications. Residents receiving medications and fluids through a gastrostomy tube should always have their head elevated. If the resident is in a flat positron it puts the resident at risk for aspiration (when food, liquid, or some other material enters your airway or lungs by accident, which can cause serious health problems, such as pneumonia). MO00155213

Based on interview and record review, the facility failed to implement a complete and effective system for monitoring and tracking residents' infections. The facility census was 71. 1. Record review of the facility's policy titled General Infection Control Guidelines for All Nursing Staff and Nursing Procedures, dated January 2017, showed the following: -The facility will review all infections to determine cause, if it was preventable, if there is exposure concerns, and if there was an appropriate treatment plan; -The Director of Nursing (DON) will identify communicable diseases and infections as they arise before they have an opportunity to spread to other persons within the facility. Record review the facility's antibiotic medication report, dated 1/1/19 through 1/31/19, showed a total of five residents names and the prescribed antibiotics. The report did not show the type of infection, identified organism, or location facility-wise (room/hall) of the infection. Record review of the facility's untitled document provided by facility staff, dated 1/1/19 to 1/31/19, showed the following: -Residents' names, prescribed antibiotic, and room number; -A total of five residents receiving antibiotic. -The type of infection and identified organism for one of the five residents; -The document did not show a summary and analysis for the type of infections developed. Record review the facility's antibiotic medication report, dated 2/1/19 through 2/28/19, showed a total of nine residents names and the prescribed antibiotics. The report did not show the type of infection, identified organism, or location facility-wise (room/hall) of the infection. Record review of the facility's untitled document provided by facility staff, dated 2/1/19 through 2/18/19, showed the following: -Residents' names, prescribed antibiotic, and room number; -A total of nine residents receiving antibiotic; -The document did not show organisms identified; -The document did not show a summary and analysis of the type of infections developed. Record review the facility's antibiotic medication report, dated 3/1/19 through 3/31/19, showed a total eight residents names and the prescribed antibiotics. The report did not show the type of infection, identified organism, or location facility-wise (room/hall) of the infection. Record review the facility's antibiotic medication report, dated 4/1/19 through 4/30/19, showed a total of three residents names and the prescribed antibiotics. The report did not show the type of infection, identified organism, or location facility-wise (room/hall) of the infection. Record review the facility's antibiotic medication report, dated 5/1/19 through 5/7/19, showed a total of five residents names and the prescribed antibiotics. The report did not show the type of infection, identified organism or location facility-wise (room/hall) of the infection. During an interview on 5/8/19, at 9:25 A.M., Licensed Practical Nurse (LPN) A said he/she is not aware of a tracking process for antibiotic stewardship. Infections should be tracked to identify trends. There has been no education provided on antibiotic stewardship or infections tracking. During an interview on 5/8/19, at 9:50 A.M., the Assistant Director of Nursing (ADON) said the Director of Nursing (DON) is responsible for tracking infections. She is not aware of how the infection rates are being tracked. She is not involved in the process. Some residents have had infections requiring transmission based precautions. During an interview on 5/8/19, at 11:20 A.M., the DON said the following: -The facility has a sample policy that has not been updated or adapted to the facility; -She logs anyone taking an antibiotic but does not document trends or infections rates; -She is not sure what role the pharmacist should have in the Antibiotic Stewardship program; -There was a binder containing infection tracking information, but the binder was misplaced approximately two months ago; -The infections rates have been low so there was no reason to track and trend and no actions have been necessary to reduce the use of antibiotic use; -Staff education would be provided if and when a need arose.

Based on interview and record review, the facility failed to establish an antibiotic stewardship programs (ASP - a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves resident outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) that included antibiotic use protocols and a system to monitor antibiotic use. This deficient practice had the potential to affect all residents in the facility. The facility census was 71. 1. Record review showed the facility did not have documentation of an Antibiotic Stewardship Program. During an interview on 5/8/19, at 9:25 A.M., Licensed Practical Nurse (LPN) A said he/she is not aware of an antibiotic tracking process for antibiotic stewardship. Infections should be tracked to identify trends. No education has been provided on antibiotic stewardship. During an interview on 5/8/19, at 9:50 A.M., the Assistant Director of Nursing (ADON) said the Director of Nursing (DON) is responsible for tracking infections. She is not aware of how the infection rates are being tracked. She is not involved in the process. During an interview on 5/8/19, at 11:20 A.M., the DON said the following: -The facility has a sample policy that has not been updated or adapted to the facility; -She logs anyone taking an antibiotic, but does not document trends or infections rates; -She is not sure what role the pharmacist should have in the Antibiotic Stewardship program; -There was a binder containing infection tracking information but the binder was misplaced approximately two months ago; -The infections rates have been low so there was no reason to track and trend and no actions have been necessary to reduce the use of antibiotic use; -Staff education would be provided if and when a need arose. During an interview on 5/8/19, at 11:45 A.M., the DON said she was not aware the facility corporate office had an Antibiotic Stewardship Policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer the pneumococcal vaccine (vaccines used to prevent some cases of pneumonia, meningitis (swelling of brain and spinal cord membranes, typically caused by an infection), and sepsis (potentially life-threatening complication of an infection)) to four residents (Resident #30, #39, #53, and #55) following the residents' admission to the facility. The facility census was 71. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines are recommended for adults; -CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people 19 through 64 years with certain medical conditions, including chronic (ongoing) conditions; -CDC recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax23) for all adults 65 years or older regardless of previous history of vaccinations with pneumococcal vaccines, and people 19 to [AGE] years old with certain medical conditions including chronic medical condition. Record review of the facility's policy titled Pneumococcal Vaccine, dated March 2019, showed the following: -Prior to or upon admission, residents will be offered the PCV13 or PPSV23 in accordance with CDC recommendations for vaccines; -The resident will be offered the first vaccination within thirty days of admission to the facility unless medically contraindicated or if the resident has previously been vaccinated; -Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission; -Before receiving the pneumococcal vaccinations, the resident or the legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccines; -Provision of offered vaccinations and education shall be documented in the resident's medical record; -Refusal or offered vaccinations will be documented in the resident's medical record. 1. Record review of Resident #30's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 12/30/16; -Diagnoses included chronic obstructive pulmonary disease (COPD-a lung disease that blocks airflow and makes it difficult to breathe), dementia (mental decline that interferes with daily functioning), and chronic kidney disease (long standing disease of the kidneys leading to renal failure). Record review of the resident's hospital discharge record, dated 12/30/16, showed the following: -On 11/23/98, the resident received a Pneumovax23; -Staff did not document the resident was offered, educated, or received a PCV13. 2. Record review of Resident #39's face sheet showed the following: -admission date of 6/30/17; -Diagnoses included congestive heart failure (CHF- a condition in which the heart does not pump blood as well as it should), cerebral infarction (damage to tissue in the brain due to a lack of oxygen to the area), shortness of breath, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), diabetes mellitus (a group of diseases that affects the way the body processes blood sugar (glucose)), and history of pneumonia (infection that inflames air sacs in one or both lungs). Record review of the resident's hospital discharge record, dated 8/21/18, showed the following: -On 10/15/15, the resident received a Pneumovax23 (prior to admission); -Staff did not document the resident was offered, educated or received a PCV13. During an interview on 5/8/19, at 9:10 A.M., the resident said staff had not talked to him/her regarding pneumonia vaccines. He/she received one vaccine prior to admitting to the facility. He/she was not offered or educated on receiving any additional pneumonia vaccine. He/she would have wanted to receive any pneumonia vaccines recommended. 3. Record review of Resident #53's face sheet showed the following: -admission date of 10/1/15; -Diagnoses included cerebrovascular disease (group of conditions, such as stoke that can lead to a cerebrovascular event. These events affect the blood vessels and blood supply to the brain), hemiplegia (paralysis of one side of the body), aphasia (a language disorder that affects a person's ability to communicate), epilepsy (seizure disorder), and disorder of white blood cells (cells in blood that fight infection). Record review of the resident's immunization record showed the following: -On 6/11/16, the resident received a pneumonia vaccine; -Staff did not document the type of pneumonia vaccine received or needed; -Staff did not document the resident was offered, educated, or received any further pneumonia vaccinations. 4. Record review of Resident #55's face sheet showed the following: -admission date of 4/24/17; -Diagnoses included Down syndrome (a genetic disorder causing developmental and intellectual delays), Alzheimer's (memory loss and other cognitive abilities serious enough to interfere with daily life) Disease, dysphagia oropharyngeal phase (difficulty swallowing possibly resulting in regurgitation (bringing up swallowed food through the mouth or nose) and aspiration (when food, liquid, or some other material enters your airway or lungs by accident, which can cause serious health problems, such as pneumonia). Record review of the resident's immunization record showed the following: -On 11/26/18, staff administered a Pneumovax23; -Staff did not document the resident was offered, educated, or received a PCV13. 5. During an interview on 5/8/19, at 9:25 A.M., Licensed Practical Nurse (LPN) A said staff nurses do not give the pneumonia vaccines. The Assistant Director of Nursing (ADON) is responsible for providing and tracking the pneumonia vaccines. 6. During an interview on 5/8/19, at 9:50 A.M., the ADON said residents should be offered pneumonia vaccines and provided education on the risks and benefits of receiving the vaccines. The resident or representative should sign a consent or refusal form that should be should be maintained in the residents' medical record. She does not know if pneumonia vaccines are being offered. She is not tracking pneumonia vaccines. 7. During an interview on 5/8/19, at 11:20 A.M., the Director of Nursing (DON) said the facility follows the CDC guidelines for pneumonia vaccines. The residents should be offered both vaccines as outlined by the CDC. She is not sure how the vaccines are being given or tracked. She needs to look at all resident's immunization records and offer the vaccines to anyone who needs them. 8. During an interview on 5/8/19, at 12:45 P.M., the Information Technology (IT - computer support specialist) support staff said there was no records of Resident's #30, #39, 53, and #55's pneumonia consents or refusals forms.