**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Resident #40 and #51) out of 15 sampled residents. The facility census was 60. Review of the facility's policy, Resident Assessment Instrument (RAI) General Guidelines, undated, showed: - Completion of the RAI process: Accurate and timely completion of MDS and Care Area Assessments (CAA) areas as assigned; - Accurate completion requires resident interviews, staff interviews, resident assessment, review of the clinical record including physician notes, and observation of the resident in the nursing home environment. Review of the RAI Manual, revised October 2023, showed: - A1805: Enter the two-digit code that best describes the setting the resident was in immediately preceding this admission/entry or reentry. 1. Review of Resident #40's medical record showed: - An admission date of 04/14/22; - Diagnoses of chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), presence of cardiac defibrillator (a device that gives an electric charge to restore a normal heartbeat), and history of myocardial infarction (when blood flow to the heart muscle is blocked); - An order for Eliquis (blood thinner medication that reduces blood clotting) five milligrams(mg) twice a day, dated 03/12/24. Review of the resident's quarterly MDS, dated [DATE], showed anticoagulant not marked on section N of the assessment. 2. Review of Resident #51's medical record showed: - An admission date of 02/23/24; - The latest admission on [DATE] from the hospital; - Diagnoses of cerebral infarction (stroke), type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), and muscle weakness. Review of the resident's MDS assessments showed: - An entry tracking record, dated 04/26/24; - A significant change MDS assessment, dated 05/03/24; - Resident entered from home/community recorded on entry tracking record and significant change MDS; - The facility failed to complete the MDS entry tracking record and significant change MDS with correct entry location (A1805). During an interview on 05/23/24 at 11:01 A.M., the MDS Coordinator said she would expect the MDS assessments to accurately reflect the current condition of the resident. Medications should be reflected correctly. She follows the RAI Manual for MDS assessment accuracy. During an interview on 05/23/24 at 12:15 P.M., the Administrator and Director of Nursing (DON) said they would expect the MDS assessments to be completed accurately per the RAI Manual.

Based on interview and record review, the facility failed to follow physician's orders for four residents (Resident #3, #21, #34, and #36) out of 15 sampled residents and one resident (Resident #174) outside the sample. The facility's census was 60. The facility did not provide a policy regarding following physician orders. 1. Review of Resident #3's medical record showed: - An admission date of 10/12/22; - Diagnoses of dysphagia (difficulty swallowing foods or liquids), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations); - An order for biotin (B vitamin) 10 milligrams (mg), one tablet daily, dated 01/25/24; - An order for Namzaric (dementia medication) 28-10 mg, one capsule daily at bedtime, dated 01/25/24; - An order for pantoprazole (reflux medication) 40 mg, one packet daily, dated 02/08/24; - An order for Vitamin D3, 125 micrograms (mcg), one daily, dated 01/25/24. Review of the resident's Medication Administration Record (MAR), dated April 2024, showed: - Biotin not administered due to being unavailable on 04/14, 04/17, 04/18, 04/19, 04/20, 04/24, 04/25, 04/26, 04/28, 04/29, and 04/30, for a total of 11 missed doses out of 30 opportunities; - Namzaric not administered due to being unavailable on 04/03, for a total of one missed dose of 30 opportunities; - Pantoprazole not administered due to being unavailable on 04/02, 04/17, 04/23, 04/24, 04/28, and 04/29, for a total of six missed doses out of 30 opportunities. Review of the resident's MAR, dated 05/01/24 - 05/23/24, showed: - Biotin not administered due to being unavailable on 05/01 through 05/23, for a total of 23 missed doses out of 23 opportunities; - Pantoprazole not administered due to being unavailable on 05/11, for a total of one missed dose out of 23 opportunities; - Vitamin D3 not administered due to being unavailable on 05/12, 05/13, 05/14, 05/15, 05/16, 05/21, 05/22, and 05/23, for a total of eight missed doses out of 23 opportunities. 2. Review of Resident #21's medical record showed: - An admission date of 08/25/16; - Diagnoses of type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), muscle weakness, and dementia; - An order for Lexapro (antidepressant) 20 mg, one tablet daily, dated 09/15/23; - An order for Xarelto (medication used to prevent blood clots) 10 mg, two tablets daily, dated 05/19/22; - An order for Dyazide (water pill) 37.5-25 mg, one capsule daily, dated 07/19/18; - An order for Vitamin D3, 25 mcg, one capsule daily, dated 05/07/20. Review of the resident's MAR, dated April 2024, showed: - Lexapro not administered due to being unavailable on 04/21, for a total of one missed dose out of 30 opportunities; - Xarelto not administered due to being unavailable on 04/06, for a total of one missed dose out of 30 opportunities. Review of the resident's MAR, dated 05/01/24 - 05/23/24, showed: - Dyazide not administered due to being unavailable on 05/21, 05/22, and 05/23, for a total of three missed doses out of 23 opportunities; - Vitamin D3 not administered due to being unavailable on 05/11, 05/12, 05/13, 05/14, 05/15, and 05/16, for a total of six missed doses out of 23 opportunities. 3. Review of Resident #34's medical record showed: - An admission date of 04/22/24; - Diagnoses of chronic kidney disease (a gradual loss of kidney function over time), major depressive disorder, and hypertension (high blood pressure); - An order for atenolol (blood pressure medication), 25 mg, 1/2 tablet twice daily, dated 04/18/24; - An order for brimonidine 0.2 % (eye drop for glaucoma - an eye disease that can cause vision loss and blindness ), one drop in both eyes twice daily, dated 04/22/24; - An order for Creon (pancreatic enzymes) 6,000-19,000-30,000 international units (IU), one capsule three times daily, dated 04/18/24; - An order for Eliquis (medication to help prevent blood clots) 2.5 mg, one tablet twice daily, dated 04/18/24; - An order for Flomax (medication for an enlarged prostate) 0.4 mg, daily at bedtime, dated 04/18/24; - An order for hydroxyzine (medication used for itching or anxiety) 25 mg, one tablet twice daily, dated 04/22/24; - An order for pravastatin (cholesterol medication) 80 mg, one tablet daily at bedtime, dated 04/18/24; - An order for Remeron (antidepressant) 30 mg, one tablet daily at bedtime, dated 04/18/24; - An order for Azo Bladder Control, 300 mg, one capsule three times daily, dated 05/04/24 and discontinued 05/17/24; - An order for Miralax (laxative) 17 grams, twice daily, dated 04/18/24; - An order for spironolactone (water pill), 25 mg, one tablet daily, dated 04/22/24. Review of the resident's MAR, dated April 2024, showed: - Atenolol not administered due to being unavailable on 04/22, for a total of one missed dose out of 17 opportunities; - Brimonidine not administered due to being unavailable on 04/22, for a total of one missed dose out of 17 opportunities; - Creon not administered due to being unavailable on 04/22 and 04/23, for a total of two missed doses out of 25 opportunities; - Eliquis not administered due to being unavailable on 04/22, for a total of one missed dose out of 17 opportunities; - Flomax not administered due to being unavailable on 04/22, for a total of one missed dose out of nine opportunities; - Hydroxyzine not administered due to being unavailable on 04/22, for a total of one missed dose out of 17 opportunities; - Pravastatin not administered due to being unavailable on 04/22, for a total of one missed dose out of nine opportunities; - Remeron not administered due to being unavailable on 04/22, for a total of one missed dose out of nine opportunities. Review of the resident's MAR, dated 05/01/24 - 05/23/24, showed: - Azo Bladder Control not administered due to being unavailable on 05/04, 05/05, 05/06, 05/07, and 05/08, for a total of 13 missed doses out of 42 opportunities; - Creon not administered due to being unavailable on 05/06 and 05/17, for a total of four missed doses out of 67 opportunities; - Miralax not administered due to being unavailable on 05/18, 05/19, 05/20, 05/21, and 05/22, for a total of eight missed doses out of 45 opportunities; - Spironolactone not administered due to being unavailable on 05/21, 05/22, and 05/23, for a total of three missed doses out of 23 opportunities. 4. Review of Resident #36's medical record showed: - An admission date of 07/31/23; - Diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dysphagia, and pain; - An order for Paxil (antidepressant) 30 mg, one tablet daily, dated 04/04/24; - An order for Protonix (reflux medication) granules, 40 mg, one packet daily, dated 09/06/23 and discontinued 04/04/24; - An order for Protonix (reflux medication) granules, 40 mg, one packet daily, dated 04/04/24; - An order for Tramadol (pain medication) 50 mg, one tablet every six hours, dated 04/08/24. Review of the resident's MAR, dated April 2024, showed: - Paxil not administered due to being unavailable on 04/19 and 04/20, for a total of two missed doses out of 26 opportunities; - Protonix not administered due to being unavailable on 04/01, 04/05, 04/06, 04/07, 04/09, 04/10, 04/11, 04/12, 04/13, 04/14, 04/15, 04/16, 04/18, 04/19, and 04/20, for a total of 15 missed doses out of 21 opportunities; - Tramadol not administered due to being unavailable on 04/08, 04/09, 04/10, and 04/12, for a total of seven missed doses out of 88 opportunities. 5. Review of Resident #174's medical record showed: - An admission date of 01/05/24; - Diagnoses of chronic kidney disease, type II diabetes mellitus, and weakness; - An order for erythromycin (antibiotic) ointment 0.5%, administer one drop to left eye, daily at bedtime, dated 01/08/24 and discontinued 01/09/24; - An order for erythromycin ointment 0.5%, administer one drop to left eye, daily at bedtime, dated 01/23/24 and discontinued 01/24/24; - A order for Flonase Allergy Relief spray, 50 mcg/actuation, one spray nasally daily at bedtime, dated 01/05/24 and discontinued 01/23/24; - A order for Flonase Allergy Relief spray, 50 mcg/actuation, two sprays nasally daily at bedtime, dated 01/23/24; - An order for levothyroxine (thyroid hormone) 125 mcg, one tablet daily at bedtime, dated 01/05/24 and discontinued 01/23/24; - An order for levothyroxine, 125 mcg, one tablet daily at bedtime, dated 01/23/24; - An order for moxifloxacin (antibiotic) drops 0.5%, one drop to left eye every two hours, dated 01/23/24 and discontinued 01/24/24; - An order for nortriptyline (antidepressant) 50 mg, one tablet three times daily, dated 01/05/24 and discontinued 01/23/24; - An order for pregabalin (nerve pain medication) 50 mg, one capsule three times daily, dated 01/05/24 and discontinued 01/23/24; - An order for pyridoxine (Vitamin B6) 100 mg, one tablet daily, dated 01/23/24; - An order for simvastatin (cholesterol medication) 20 mg, one tablet daily at bedtime, dated 01/05/24 and discontinued 01/24/24; - An order for Systane (lubricant) drops 0.4-0.3%, two drops per eye twice daily, dated 01/10/24 and discontinued 01/23/24; - An order for Systane drops 0.4-0.3%, two drops per eye twice daily, dated 01/23/24; - An order for vancomycin (antibiotic), 125 mg, one capsule every six hours, dated 01/05/24 and discontinued 01/07/24; - An order for Temovate (a cream to treat skin conditions) 0.05%, apply to affected area twice daily, dated 01/23/24. Review of the resident's MAR, dated January 2024, showed: - Erythromycin not administered due to being unavailable on 01/08 and 01/23/24, for a total of two missed doses out of two opportunities; - Flonase not administered due to being unavailable on 01/05, 01/07, 01/10, and 01/23, for a total of four missed doses out of 14 opportunities (resident hospitalized 01/16 to 01/23); - Levothyroxine not administered due to being unavailable on 01/05, 01/09, and 01/23, for a total of three missed doses out of 14 opportunities (resident hospitalized 01/16 to 01/23); - Moxifloxacin not administered due to being unavailable on 01/23 and 01/24, for a total of five missed doses out of eight opportunities; - Nortriptyline not administered due to being unavailable on 01/05 and 01/06, for a total of two missed doses out of 30 opportunities (resident hospitalized 01/16 to 01/23); - Pregabalin not administered due to being unavailable on 01/05 and 01/06, for a total of three missed doses out of 30 opportunities (resident hospitalized 01/16 to 01/23); - Pyridoxine not administered due to being unavailable on 01/24, for a total of one missed dose out of one opportunity; - Simvastatin not administered due to being unavailable on 01/05, for a total of one missed dose out of 11 opportunities; - Systane not administered due to being unavailable on 01/10, 01/11, 01/12, 01/13, 01/14, 01/15, 01/23, and 01/24, for a total of 12 missed doses out of 12 opportunities (resident hospitalized 01/16 to 01/23); - Vancomycin not administered due to being unavailable on 01/05, not administered due to being too close together on 01/06, and not administered due to resident being asleep on 01/07, for a total of three missed doses out of eight opportunities; - Temovate not administered due to being unavailable on 01/23 and 01/24, for a total of two missed doses out of three opportunities. During an interview on 05/22/24 at 11:00 A.M., Certified Medication Technician (CMT) F said that Licensed Practical Nurse (LPN) D checks medication carts and stock rooms for expired medications often, and pharmacy was just here to check our carts. During an interview on 05/22/24 at 11:30 A.M., Registered Nurse (RN) E said when medications are not available, they send a fax to pharmacy, and if it's something that's needed right away, he/she will call the pharmacy. They can also use meds out of the emergency kit (E-kit). The pharmacy typically gets medications to the facility the same day as ordered; they do an 8:00 P.M. run. During an interview on 05/22/24 at 11:35 P.M., the Administrator said if a medication is a stock medication and they don't have it, they can run to a local pharmacy to get the medication. The electronic medical record system will be linked with the pharmacy starting in June or July. During an interview on 05/23/24 at 12:15 P.M., the Director of Nursing (DON) said CMTs and nurses will notify the charge nurse if they are getting low or are out of a medication. The charge nurse will then notify the pharmacy, and they can get those medications on the same day. If it's an over-the-counter medication, they can use stock medication or staff will drive to one of the local pharmacies and purchase it. There is no reason for a resident to go several days without receiving their medication unless it's a specialty medication or prior authorization is needed. During an interview on 05/29/24 at 2:44 P.M., the Administrator said staff have been told that they can access most medications out of the Stat Safe but if medication is not in there, there is always a pharmacist on call. There should not be any reason that a resident would not receive their medication. Cmp #MO00236261

Based on observation and interview, the facility failed to maintain proper infection control practices during perineal care (washing the genital and rectal areas of the body) for two residents (Resident #14 and Resident #46) outside of the 15 sampled residents. The facility's census was 60. Review of the facility's policy, Gloves, dated March 2015, showed: - Wear gloves when anticipating that hands will be in contact with mucous membranes, non-intact skin, and body substances such as blood, urine, feces, drainage, oral secretions, vomit, or items soiled with these substances; - Gloves must be changed between residents and between contact with different body sites of same resident; - Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to skin; - Handling medical equipment and devices with contaminated gloves is not acceptable. Review of the facility's policy, Perineal Care, dated March 2015, showed to remove gloves and wash hands after providing care. Review of the facility's policy, Handwashing, dated March 2015, showed handwashing is to be done to reduce transmission of organisms. 1. Observation of perineal care for Resident #14 on 05/23/24 at 9:16 A.M., showed: - Certified Nursing Assistant (CNA) A washed hands and donned gloves; - CNA A obtained a washcloth, sprayed perineal cleanser onto cloth, placed spray bottle onto bedside table without a barrier, and provided perineal care for the resident; - Wearing the same soiled gloves, CNA A picked up cleanser from bedside table, sprayed onto a different part of the washcloth, and returned cleanser to bedside table without barrier; - Wearing the same soiled gloves, CNA A picked up cleanser again, sprayed onto back of the washcloth, and placed back onto bedside table without barrier; - Wearing the same soiled gloves, CNA A placed a clean brief on the resident, removed gloves, and did not wash hands; - With soiled hands, CNA A obtained pants from the closet and placed on the resident; - With soiled hands, CNA A placed oxygen via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) under the resident's nose, placed call light in reach, and pulled the blanket over the resident; - With soiled hands, CNA A gave the resident a drink and placed water container onto the bedside table beside the soiled perineal cleanser spray bottle; - With soiled hands, CNA A placed dirty clothes into a bag and left the room without washing hands. During an interview on 5/23/24 at 9:40 A.M., CNA A said he/she should have washed hands between dirty and clean, after removing gloves, before touching clean blankets and call light, and before leaving the room. 2. Observation of perineal/catheter care for Resident #46 on 05/22/24 at 1:35 P.M. showed: - CNA B washed his/her hands and donned gloves; - CNA B provided perineal care and catheter care; - Wearing the same soiled gloves, CNA B placed a clean bed pad under the resident and pulled blankets over the resident; - CNA B removed gloves and washed hands. During an interview on 5/23/24 at 12:50 P.M., CNA B said he/she should have washed his/her hands when going from dirty to clean and before touching the resident's clean blanket. During an interview on 5/23/24 at 12:15 P.M., the Director of Nursing (DON) said staff should absolutely wash their hands between dirty and clean as well as prior to leaving a room, and supplies should not be placed directly onto a bedside table. During an interview on 5/23/24 at 12:26 P.M., the Administrator said staff should wash hands and change gloves between dirty and clean, and a barrier should be placed when using a bedside table for supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS), a federal mandated assessment to be completed by the facility for two residents (Resident #22 and #45) out of 16 sampled residents. The facility's census was 63. The facility did not provide an MDS policy. 1. Record review of Resident #22's medical record showed: - An admission date of 12/19/19; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and shortness of breath; - An order for oxygen two to four liters per minute per nasal cannula continuous during hours of sleep, dated 11/29/22; - An order for oxygen two to four liters per minute per nasal cannula as needed for shortness of breath, dated 12/19/2019; - A Treatment Administration History report, including dates of 11/28/22 through 12/15/22, showing staff initialed completion of the order for oxygen two to four liters per minute per nasal cannula continuous at bedtime. Record review of the resident's comprehensive annual MDS assessment, dated 12/16/22, showed: - Oxygen use was not marked on Section O of the assessment. During an interview on 12/13/22 at 2:36 P.M., Resident #22 said she wears oxygen every night for shortness of breath. 2. Record review of Resident #45's Physician Order Sheet (POS) showed: - On 10/10/2021, an order for Cefdinir (an antibiotic) 300 milligrams, one capsule by mouth, twice daily for seven days for pneumonia (an infection that inflames the air sacs of the lungs, which may fill with fluid); - On 10/10/21, an order for ipratropium-albuteral (a breathing treatment used to treat air flow blockage) four times daily for diagnosis of pneumonia; - On 5/31/2022, an order for a chest X-ray to rule out aspiration pneumonia (an infection in the lungs caused by inhaling saliva, food or liquid). Results of chest X-ray on 5/31/22 showed no pneumonia. Record review of the Resident's Comprehensive MDS, dated [DATE], showed pneumonia not marked on section I for Active Diagnosis Infections. Record review of the Resident's Quarterly MDS, dated [DATE], showed pneumonia marked on section I for Active Diagnosis. During an interview on 12/16/22 at 09:52 A.M., the Assistant Director of Nursing (ADON) and MDS Coordinator said she normally would look through the chart to see if a resident had a certain diagnosis. Pneumonia could have been missed as far as unchecking it for Resident #45. Normally, she would look at the orders to see if the resident had a prescribed antibiotic and/or chest x-ray. During an interview on 12/16/22 at 10:00 A.M., the Director of Nursing (DON) said if a resident is on oxygen, it would be documented on the Treatment Administration Record (TAR) that the order was completed. During an interview on 12/16/22 at 11:39 A.M., the ADON/MDS Coordinator said she looks at the monthly summary, observations, events, and nurses notes in the resident's medical record to complete an MDS assessment. She will also look at the TAR for oxygen use. Active diagnoses come from the face sheet, and they don't change for most people, except for diagnoses like pneumonia and urinary tract infections. During an interview on 12/16/22 at 11:56 A.M., the DON said Resident #45 had not had any respiratory infections this year. During an interview on 12/16/22 at 12:35 P.M., the Administrator said the facility does not have an MDS policy. The MDS Coordinator should follow the RAI Manual.

Based on record review and interview, the facility failed to include the infection preventionist in quarterly quality assessment and assurance (QAA) meetings. The facility's census was 63. 1. Record review of the first quarter QAA Committee sign in sheet, dated 4/13/22, and the second Quarter QAA Committee sign in sheet, dated 7/27/22 showed the following members attended: - Administrator; - Medical Director; - Director of Nurses (DON); - Assistant Director of Nurses (ADON); - Social Services Director (SSD). Record review of the third quarter QAA Committee sign in sheet, dated 10/12/22, showed the following members attended: - Administrator; - Medical Director; - Director of Nursing; - Assistant Director of Nursing. During an interview on 12/16/22 at 11:09 A.M., the Administrator said QAA meets every three months and the DON, ADON, Administrator, and Medical Director attend the meetings. The Infection Preventionist does not attend QAA meetings, and the Administrator was not aware that he/she was supposed to be there. During an interview on 12/16/22 at 11:24 A.M., the DON said QAA meetings are held quarterly, and the Medical Director, DON, Administrator, ADON, and SSD attend the meetings. The Infection Preventionist attends only if they are going to be talking about infection control. The dietician does not attend meetings and they do not keep minutes. The facility did not provide a policy.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility's census was 63. Record review of the facility's Receiving and Storage of Food policy, dated April 2006, showed: -The dietary manager is responsible for receiving and storing food and nonfood items; - A table of safe temperatures for refrigerators and freezers (frozen food should be kept at -10 to 0 degrees Fahrenheit); -The policy did not address freezer cleaning/maintenance. Record review of the dietician's monthly kitchen recommendations showed: -On 8/22/22, door to freezer continues to not fully close due to significant ice build up; -On 9/15/22, door to freezer continues to not fully close due to significant ice build up; -On 11/07/22, freezer door continues to not shut, build up of ice on edge of door; -On 12/12/22, freezer door continues to not shut, build up of ice on edge of door. Observations of the kitchen on 12/13/22 at 2:00 P.M., on 12/14/22 at 1:30 P.M., on 12/15/22 at 9:50 A.M., and on 12/16/22 at 9:00 A.M. showed: - A build-up of ice, one inch thick on the top right door seal of the walk in freezer, as well as the right side door seal; - The walk in freezer door did not close completely at the top right corner and top right side of the door. During an interview on 12/15/22 at 10:00 A.M. , the Dietary Manager (DM) said the freezer door has been an issue and the door may have to be replaced. The DM said the Administrator and Maintenance Manager are aware of the issue and he/she believes there is a plan in place. The freezer door appears to have settled and the new closure latch and new seals have not helped. During an interview on 12/15/22 at 2:00 P.M., the Maintenance Manager said the freezer is old and the door has had a new closure latch and seal kit replaced on 7/25/22 due to the door not shutting and ice build up. The Maintenance Manager said he/she would have to schedule the refrigerator/freezer maintenance company to come back and assess the door again and see if a new door is required or if a hinge kit should be tried first. During an interview on 12/15/22 at 1:00 P.M., the Administrator said she was not aware there was still an issue with the freezer door not closing and having ice build up. She said she will have the refrigerator/freezer maintenance company come out to assess the freezer again and see if it is going to require a replacement door, which will be costly.