Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility's census was 87. Review of the facility's policy titled, Shower Room, undated, showed: - Maintaining a clean and sanitary shower room in skilled nursing facilities is crucial for infection control and resident safety; - Shower rooms should be cleaned and disinfected daily, with increased frequency based on usage and facility needs; - High-touch surfaces and any visibly soiled areas should be cleaned and disinfected immediately after each use; - Remove any waste or disposable items from the area; - Apply detergent to all surfaces, including walls, floors, fixtures, and equipment; - Scrub surfaces to remove dirt and biofilm. Observations on 03/10/25 between 10:05 A.M. and 10:48 A.M. showed: - The A wing shower room between hallway 200 and 300 had two, 2 inch (in.) diameter piles of fecal material about 1 in. near the shower drain and the caulking around the shower perimeter, where the wall meets the floor, was covered with a black substance; - The B wing B7 shower room: - Had the shower stall's caulking around the perimeter, where the wall meets the floor, was covered in a black substance; - Had 16, 1 in by 1 in. ceramic tiles missing to the entrance of the shower, exposing the floor beneath; - Had 1 foot (ft.) by 1 ft. section of floor tiles with a black substance between the 1-in. by 1-in. shower floor tiles; - The locked unit B6 shower room caulking around the perimeter, where the wall meets the floor, was covered in a black substance and three missing 4-in. by 4-in. ceramic wall tiles near the floor on the separation wall between the toilet and the sink. During an interview on 03/10/25 at 9:53 A.M., Resident #238 said the A wing shower room has a black substance in the floor. He/she would prefer the shower to look and feel clean. During an interview on 03/12/25 at 3:38 P.M., Resident #15 said the shower floor on B wing has a black substance and he/she would prefer it to look and feel clean. During an interview on 03/10/25 at 10:08 A.M., Housekeeper O said cleaning is done early every morning. He/she had cleaned this morning in the A wing shower room around 8:00 A.M. He/she also cleans the showers as needed, but usually it is only when someone tells him/her there is a problem. He/she wasn't told about any problems today in the A wing shower room. During an interview on 03/10/25 at 10:11 A.M., Housekeeper P said he/she usually cleans showers every morning. He/she has cleaned showers this morning. During an interview on 03/10/25 at 10:45 A.M., Housekeeper Q said he/she has scrubbed the black substance in the showers on the locked unit and on B wing but it doesn't come up. The former maintenance director was aware of the problem with the showers. It is unknown if the new maintenance director was told about the shower problems, including tile damage. During an interview on 03/12/25 at 12:50 P.M., the Administrator said the shower rooms should be kept clean and not have a black substance build up or feces in the floor. If the housekeepers can't remove the black substance, the caulk can be removed and replaced. Tiles should be kept intact on the floor and walls and the missing tiles will be replaced. During an interview on 03/12/25 at 2:16 P.M., the Maintenance Director said the showers should not have black build up in the corners, the caulk will be removed and replaced so housekeeping can scrub away black substance easily. The floor and wall tiles should be kept intact and the grout with black build up can be grinded out and replaced. Complaint #MO00250186

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the ombudsman of all transfers to the hospital and failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for four residents (Resident #29, #57, #76, #83) out of 18 sampled residents and one resident (Resident #87) outside the sample. The facility's census was 87. The facility did not provide a policy. 1. Review of Resident #29's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer; - Hospital transfer on 01/30/25 not included on the monthly list sent to the ombudsman. 2. Review of Resident #57's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 3. Review of Resident #76's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer; - Hospital transfer on 01/28/25 not included on the monthly list sent to the ombudsman. 4. Review of Resident #83's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 5. Review of Resident #87's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. During an interview on 03/12/25 at 10:54 A.M., the Social Services Designee said she sends the list to the ombudsman monthly. She does not send them if residents go out and come right back in the same day. She will add them to the list if they are a true discharge, meaning out overnight. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect transfer notifications to be given in writing to the resident and/or resident's representative upon discharge or transfer. They would also expect all transfers, including emergent transfers, to be included on the monthly list sent to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for five residents (Resident #29, #36, #57, #76, #83) out of 18 sampled residents and one resident (Resident #87) outside the sample. The facility's census was 87. Review of the facility's policy, Bed Holds and Returns, revised March 2017, showed: - Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy; - Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: the rights and limitations of the resident regarding bed holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and the details of the transfer (per the Notice of Transfer). 1. Review of Resident #29's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 2. Review of Resident #36's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 3. Review of Resident #57's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 4. Review of Resident #76's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 01/28/25; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 5. Review of Resident #83's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 6. Review of Resident #87's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. During an interview on 03/12/25 at 8:25 A.M., the Director or Nursing (DON) said that family and responsible parties are notified verbally of transfers to the hospital. He/she was unaware bed holds had to be sent out on every hospital transfer, he/she thought they were only to be sent if the resident was in the hospital past midnight. During an interview on 03/12/25 at 6:25 P.M., the Administrator and DON said they would expect bed hold policies to be given in writing to the resident and/or the resident's representative when discharging or transferring to the hospital.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility) within the required time frames for seven residents (Resident #29, #31, #36, #49, #52, #68, and #83) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on completion of MDS assessments. Record review of the Resident Assessment Instrument (RAI) Manual showed: - For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600); - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment; - For the admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later than than 13 days after the Entry Date (A1600); - For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300). 1. Review of Resident #29's medical record showed: - An admission date of 11/15/24; - A comprehensive admission MDS assessment with CAA completion date of 12/12/24, and MDS completion date of 12/12/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 2. Review of Resident #31's medical record showed: - An admission date of 03/01/24; - A comprehensive admission MDS assessment with CAA completion date of 03/29/24, and MDS completion date of 03/29/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 3. Review of Resident #36's medical record showed: - An admission date of 01/30/24; - A comprehensive admission MDS assessment with CAA completion date of 03/17/24, and MDS completion date of 03/17/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 4. Review of Resident #49's medical record showed: - An admission date of 11/27/24; - A comprehensive admission MDS assessment with CAA completion date of 12/18/24, and MDS completion date of 12/18/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 5. Review of Resident #52's medical record showed: - An admission date of 10/04/24; - A comprehensive admission MDS assessment with CAA completion date of 11/01/24, and MDS completion date of 11/01/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 6. Review of Resident #68's medical record showed: - An admission date of 06/17/24; - A comprehensive admission MDS assessment with CAA completion date of 07/10/24, and MDS completion date of 07/10/24; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. 7. Review of Resident #83's medical record showed: - An admission date of 12/27/24; - A comprehensive admission MDS assessment with CAA completion date of 01/14/25, and MDS completion date of 01/14/25; - No CAAs completed within 14 days of admission; - No comprehensive admission MDS assessment completed within 14 calendar days of admission. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect MDS assessments to be completed in a timely manner per the RAI manual.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for two residents (Resident #52 and #56) out of 18 sampled residents and one resident (Resident #33) outside the sample. The facility's census was 87. The facility did not provide a policy that addressed the timely completion of significant change MDS assessments. Review of the Resident Assessment Instrument (RAI) Manual, revised October 2024, showed: - A significant change in status (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident; - A SCSA is required to be completed by the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). 1. Review of Resident #33's medical record showed: - A quarterly MDS assessment with an ARD of 10/10/24 and a completion date of 10/15/24; - An opened, but incomplete significant change MDS assessment with an ARD of 01/11/25; - The facility failed to complete a significant change assessment within 14 days. 2. Review of Resident #52's medical record showed: - An admission date of 10/27/24 to hospice services; - A significant change MDS assessment with an ARD of 01/14/25 and a completion date of 02/05/25; - The facility failed to complete a significant change MDS assessment within 14 days of hospice admission. 3. Review of Resident #56's medical record showed: - An admission date of 10/12/24 to hospice services; - A significant change MDS assessment with an ARD of 12/04/24 and a completion date of 12/30/24; - The facility failed to complete a significant change MDS assessment within 14 days of hospice admission. During an interview on 03/12/25 at 5:56 P.M., the MDS Coordinator said he/she would expect a significant change assessment to be completed for a resident admitted to hospice, or any other thing that would warrant a significant change, within 14 days. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect a significant change MDS to be completed per the RAI Manual.

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 one resident (Resident #52) out of 18 sampled residents and one resident (Resident #86) outside the sample. The facility's census was 87. Review of the facility's policy, Certifying Accuracy of the Resident Assessment, revised December 2009, showed all personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section O0110K1, Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions; - Section A1805: Enter the two-digit code that best describes the setting the resident was in immediately preceding this admission/entry or reentry; - Section A1805: Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was admitted from a hospital that is contracted with Medicare to provide acute inpatient care and accepts a predetermined rate as payment in full. 1. Review of Resident #52's medical record showed: - An admission date of 10/04/24; - Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), alcoholic cirrhosis of the liver (a chronic liver disease caused by long-term excessive alcohol consumption), insomnia (persistent problems falling and staying asleep), and pain; - admitted to hospice on 10/27/24; - A significant change MDS assessment with an ARD of 01/14/25 with Section O0110K1 marked no for hospice care. 2. Review of Resident #86's medical record showed: - An admission date of 01/21/25; - Diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), dementia, and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy); - A progress note dated 02/28/25. Resident readmitted to the facility after a hospital stay. Hospital stay dates 02/23/25-02/28/25; - A Death in Facility MDS tracking record dated 03/03/25, with Section A1805 marked entered from a nursing home (long-term care facility). During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing said they would expect MDS assessments to be coded accurately.

Based on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for two residents (Residents #138 and #289) out of 18 sampled residents. The facility's census was 87. Review of the facility's policy, Care Plans-Baseline, undated, showed: - A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; - The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medication, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs, including but not limited to: initial goals based on admission orders; physician orders; dietary orders; therapy services; social services; Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) recommendations, if applicable; - The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; - The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: initial goals of the resident, a summary of the resident's medication and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan, as necessary. 1. Review of Resident #138's medical record showed: - An admission date of 02/28/25; - Diagnoses of fractured (broken) right humerus (the long bone in upper arm), epilepsy (a disorder that causes seizures) and depression; - No baseline care plan. Observation on 03/10/25 at 2:36 P.M. showed the resident with a sling on his/her right arm, hand was swollen and resting on leg. 2. Review of Resident #289's medical record showed: - An admission date of 03/07/25; - Diagnoses of dementia (a decline in cognitive function that cannot be attributed to a specific known cause), cirrhosis of the liver (a condition in which the liver is scarred but the specific cause of the scarring is unknown), constipation, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), essential primary hypertension (a chronic cardiovascular disease that causes abnormally high blood pressure for unknown reasons), and chronic viral hepatitis C (a liver infection caused by the hepatitis C virus (HCV) that persists more than six months); - A baseline care plan, dated 03/10/25, three days after being admitted to the facility. During an interview on 03/12/25 at 9:00 A.M., the MDS (Minimum Data Set) Coordinator said the admitting nurse should fill out a baseline care plan on newly admitted residents upon arrival. He/She will be doing them from now on. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect baseline care plans to be completed within the required time frame.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions to meet the highest practicable physical, mental, and psychosocial well-being for four residents (Residents #29, #47, #49, and #79) out of 18 sampled residents and one resident (Resident #86) outside the sample. The facility's census was 87. The facility did not provide a policy. 1. Review of Resident #29's medical record showed: - admission date of 11/15/24; - Diagnoses of muscle weakness, morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), pain, and osteoarthritis of both hips (a chronic, degenerative joint disease that causes pain, stiffness, and loss of function in the affected joints); - On 11/16/24, a Bed Rail Assessment was completed with no side rails or assist bars indicated; - An order for horse shoe rails for positioning, dated 11/27/24; - An order for the audiologist to evaluate and treat, dated 2/27/25; - A quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility) assessment, dated 02/24/25, with B0200 marked for moderate difficulty with hearing; - Care plan did not address the use of side rails/grab bars or hearing difficulty. During an interview on 03/09/25 at 12:54 P.M., the resident said he/she has had hearing loss since living here. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail. 2. Review of Resident #47's medical record showed: - admission date of 06/17/24; - Diagnoses of morbid obesity, aphasia (a language disorder that affects a person's ability to communicate, functional quadriplegia (a condition where someone is unable to move limbs due to a medical condition, not spinal cord damage), post traumatic seizures (seizures that occur after a traumatic brain injury) and hypertension (high blood pressure); - Nurses Note, dated 6/21/24, showed the resident found on floor next to lowered bed, no injuries; - Side Rail assessment, dated 02/11/25, did not indicate need for bed rails; - Care plan did not address falls, grab bar, or fall mat. Observation on 03/10/25 at 10:30 A.M. showed the resident lay in a low rise bed with a floor mat and a grab bar on the left side of the bed. 3. Review of Resident #49's medical record showed: - admission date of 11/27/24; - Diagnoses of type 2 diabetes (a condition in which the body has trouble controlling blood sugar and using it for energy), pressure ulcer of the sacral region (area just above the buttocks and the base of the spine), and paraplegia (a condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body); -A Physician's order dated, 01/22/25, low concentrated sweets (LCS) diet, regular texture, regular/thin consistency; - Care plan did not address the use of cigarettes and supervised smoking status or the need for a LCS diet. During an interview on 03/09/25 at 11: 00 A.M., Resident #49 said he/she is a smoker and was unhappy that the facility changed the policy and now all residents are supervised smokers. 4. Review of Resident #79's medical record showed: - admission date of 10/15/24; - Diagnoses of spinal stenosis (spaces inside the bones of spine are too small and may cause, pain, tingling or weakness in an arm, hand, arm foot or leg) and chronic pain; - A smoking assessment, dated 10/16/24, showed safe to smoke without supervision; - Care plan did not address smoking. 5. Review of Resident #86's medical record showed: - An admission date of 01/21/25; - Diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), dementia, and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy); - admitted to hospice on 02/28/25; - Care plan did not address hospice. During an interview on 03/12/25 at 9:00 A.M., the MDS (Minimum Data Set, a mandatory assessment completed by the facility) Coordinator said that each department puts in their part of the care plan; it is a team effort. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect care plans to accurately reflect the condition of the residents and to be updated as needed.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #29) out of one sampled resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility's census was 87. Review of the facility's policy, Pain Assessment and Management, revised March 2015, showed: - The purposes of this procedure are to help the staff 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 resident comfort; - Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 1. Review of Resident #29's medical record showed: - admission date of 11/15/24; - Diagnoses of muscle weakness, morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), pain, and osteoarthritis of both hips (a chronic, degenerative joint disease that causes pain, stiffness, and loss of function in the affected joints). Review of the resident's Physician's Order Sheet (POS), dated 03/11/25, showed: - Pain Scale twice daily every day and night shift for pain assessment, dated 11/15/24 and discontinued 12/28/24; - Pain Scale twice daily every day and night shift for pain assessment, dated 12/28/24; - Out of bed in chair daily, every shift, dated 11/15/24 and discontinued 12/01/24; - Out of bed in chair daily, every day shift, dated 12/01/24 and discontinued 01/22/25; - MS Contin Oral Tablet Extended Release (opioid pain medication) 30 mg, give 45 mg by mouth two times a day related to pain. Give with 15 mg tablet totaling 45 mg, dated 11/15/24 and discontinued 11/20/24; - MS Contin Oral Tablet Extended Release 15 mg, give 15 mg by mouth two times a day related to pain, dated 11/15/24 and discontinued 11/20/24; - MS Contin Oral Tablet Extended Release 15 mg, give 15 mg by mouth every morning and at bedtime related to pain, dated 11/21/24 and discontinued 02/26/25; - MS Contin Oral Tablet Extended Release 30 mg, give 45 mg by mouth every morning and at bedtime related to pain. Give with 15 mg tablet totaling 45 mg, dated 11/21/24 and discontinued 02/26/25; - MS Contin Oral Tablet Extended Release 15 mg, give 15 mg by mouth every morning and at bedtime related to pain, dated 02/26/25; - MS Contin Oral Tablet Extended Release 30 mg, give 45 mg by mouth every morning and at bedtime related to pain, dated 02/26/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 02/24/25, showed: - No cognitive impairment; - Total dependence on staff for bed mobility, sitting to lying, personal hygiene, upper and lower body dressing, chair/bed to chair transfer, toilet transfer and hygiene, tub/shower transfer, and showering/bathing; - Pressure reducing device for bed; - Almost constant pain that affects sleep frequently and affects day-to-day activities almost constantly. Review of the resident's care plan, revised 02/21/25, showed: - The resident has abdominal pain and right hip pain related to arthritis; - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; - Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects, and impact on function; - The resident will not have an interruption in normal activities due to pain through the review date; - The resident will not have discomfort related to side effects of analgesia through the review date. Review of the resident's Medication Administration Record (MAR), dated 11/15/24 through 03/12/25, showed: - In November, the resident missed five doses of MS Contin 15 mg out of 30 opportunities; - In November, the resident missed six doses of MS Contin 30 mg out of 30 opportunities; - In December, the resident missed three doses of MS Contin 15 mg out of 62 opportunities; - In December, the resident missed three doses of MS Contin 30 mg out of 62 opportunities; - In January, the resident missed four doses of MS Contin 15 mg out of 62 opportunities; - In January, the resident missed four doses of MS Contin 30 mg out of 6 opportunities; - In February, the resident missed 14 doses of MS Contin 15 mg out of 56 opportunities; - In February, the resident missed 10 doses of MS Contin 30 mg out of 56 opportunities; - In March, the resident missed three doses of MS Contin 15 mg out of 24 opportunities; - In March, the resident missed one dose of MS Contin 30 mg out of 24 opportunities. Review of the resident's progress notes showed: - On 11/17/24 at 5:44 P.M., medication (MS Contin 15 mg) not available; - On 11/29/24 at 9:02 A.M., awaiting medicine (MS Contin 30 mg) from pharmacy; - On 12/23/24 at 7:59 P.M., resident out of Morphine (MS Contin) 30 mg; - On 12/24/24 at 6:41 P.M., medication (MS Contin 30 mg) on order; - On 12/26/24 at 9:50 P.M., medication (MS Contin 15 mg) not available; - On 12/31/24 at 8:11 A.M., (MS Contin 30 mg) not available; - On 12/31/24 at 8:11 A.M., (MS Contin 15 mg) not available; - On 01/31/25 at 11:36 P.M., medication (MS Contin 30 mg) not available; - On 01/31/25 at 11:36 P.M., medication (MS Contin 15 mg) not available; - On 02/01/25 at 10:28 A.M., waiting for medication (MS Contin 30 mg) to be dispensed from the pharmacy. It is supposed to arrive today; - On 02/01/25 at 10:29 A.M., waiting for medication (MS Contin 15 mg) to be dispensed from the pharmacy. It is supposed to arrive today; - On 02/02/25 at 7:39 A.M., MS Contin 30 mg only given - 15 mg cap unavailable; - On 02/02/25 at 7:40 A.M., MS Contin 30 mg only given - 15 mg cap unavailable; - On 02/02/25 at 9:17 P.M., MS Contin 15 mg pill unavailable; - On 02/02/25 at 9:18 P.M., medication (MS Contin 15 mg) unavailable; - On 02/03/25 at 9:12 P.M., waiting for medication (MS Contin 15 mg) from pharmacy; - On 02/04/25 at 1:03 P.M., MS Contin 30 mg not available from pharmacy. Pharmacy called; - On 02/04/25 at 1:05 P.M., MS Contin 15 mg not available from pharmacy. Pharmacy called; - On 02/04/25 at 8:32 P.M., medication (MS Contin 15 mg) unavailable; - On 02/18/25 at 8:32 A.M., medication (MS Contin 30 mg) unavailable; - On 02/23/25 at 11:39 A.M., MS Contin 30 mg unavailable. Awaiting signed script; - On 02/23/25 at 7:43 P.M., MS Contin 30 mg not available; - On 02/24/25 at 8:00 P.M., resident requested hydrocodone-acetaminophen 10-325 mg. Resident out of morphine; - On 02/25/25 at 10:45 P.M., medication (MS Contin 15 mg) not available; - On 02/25/25 at 10:47 P.M., medication (MS Contin 30 mg) not available; - On 02/26/25 at 9:15 A.M., medication (MS Contin 15 mg) unavailable; - On 02/26/25 at 9:16 A.M., medication (MS Contin 30 mg) unavailable; - On 02/27/25 at 9:28 A.M., MS Contin 15 mg unavailable; - On 02/27/25 at 8:42 P.M., MS Contin 15 mg not available; - On 02/28/25 at 7:23 A.M., medication (MS Contin 15 mg) not available; - On 03/04/25 at 9:25 P.M., medication (MS Contin 15 mg) is on order; - On 03/05/25 at 9:20 A.M., medication (MS Contin 30 mg) is not available; - On 03/06/25 at 7:24 A.M., medication (MS Contin 15 mg) not available. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/12/25 at 2:45 P.M., up in his/her motorized scooter in the hall. During an interview on 03/09/25 at 12:54 P.M., the resident said he/she has a lot of pain and the facility has run out of his/her pain medication, MS Contin, a few times since he/she moved here in November. He/She is unable to give a pain rating that would be acceptable. His/Her goal is to get up in the motorized scooter three to four days a week. He/She can tolerate about an hour now. During an interview on 03/12/25 at 6:25 P.M., the Director of Nursing said she would expect residents to get their pain medication as ordered and for their pain to be managed at an acceptable level to the resident. During an interview on 03/20/25 at 2:20 P.M., the DON said one of the doctors was out sick and could not sign scripts, and the facility wasn't aware for about two to three weeks. They do have another doctor that covers. Staff would look at alternatives in the Emergency Kit (E-kit) and get approval from the doctor to give that if a medication was not available. They would try to get as close to the ordered medication as possible. There were days that the pharmacy could not make deliveries due to the winter weather. The facility just got a new pharmacy system in place this week, and it should make things go much more smoothly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to appropriately assess residents for the use of side rails prior to installation or use, the facility failed to obtain informed consent from the resident or resident's representative, and the facility failed to provide on-going monitoring, supervision, and routine maintenance of the beds with side rails in use for two residents (Resident #29 and #47) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on side rails. 1. Review of Resident #29's medical record showed: - admission date of 11/15/24; - Diagnoses of muscle weakness, morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), pain, and osteoarthritis of both hips (a chronic, degenerative joint disease that causes pain, stiffness, and loss of function in the affected joints); - On 11/16/24, a Bed Rail Assessment was completed with no side rails or assist bars indicated; - An order for horse shoe rails for positioning, dated 11/27/24; - Resident was not assessed for risk of entrapment; - No signed informed consent that explained risks and benefits for side rail use. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment completed by the facility), dated 02/24/25, showed dependent on staff for bed mobility. Review of the resident's care plan, revised 02/24/25, did not address the use of side rails/grab bars. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail. 2. Review of Resident #47's medical record showed: - admitted on [DATE]; - Diagnoses of morbid obesity (excessive amount of body fat), aphasia (a language disorder that affects a person's ability to communicate, functional quadriplegia (a condition where someone is unable to move limbs due to a medical condition, not spinal cord damage), post traumatic seizures (seizures that occur after a traumatic brain injury) and hypertension (high blood pressure); - On 02/11/25, a Bed Rail Assessment was completed with no side rails or assist bars indicated; - Resident was not assessed for risk of entrapment; - No order for side rails; - No signed informed consent that explained risks and benefits for side rail use. Review of the resident's quarterly MDS, dated [DATE], showed requires maximum assistance with bed mobility. Review of the resident's undated care plan did not address the use of side rails/grab bars. Observations of the resident showed: - On 03/10/25 at 10:30 A.M., resident lay in bed, grab bar up on left side of bed, right side of bed against the wall; - On 03/12/25 at 10:34 A.M., resident lay in bed, grab bar up on left side of bed, right side of bed against the wall. During an interview on 03/12/25 at 4:57 P.M., the Director of Nursing (DON) said if a resident assessment showed not indicated for side rails, he/she would not expect the resident to have them. If the resident wanted to use side rails as an enabler, another assessment should be completed. During an interview on 03/12/25 at 5:00 P.M., the Maintenance Director said he/she has not done any assessments for side rails/grab bars and they are working on a policy for that. During an interview on 03/12/25 at 6:25 P.M., the Administrator and DON said they would expect residents to have a signed consent for the use of side rails and/or grab bars. They would also expect maintenance to complete a bed rail/entrapment assessment.

Based on interview and record review, the facility failed to ensure that three nursing assistants (NAs) completed a nursing assistant training program within four months of his/her employment at the facility. This deficient practice had the potential to affect all residents. The facility's census was 87. Review of the facility's policy, Nurse Aide Training Program, Purpose of, last revised December 2006, showed: - The primary purpose of the nurse aide training program is to prepare the individual for employment in a long-term care facility; - Provide each individual presently employed in the long-term care facility with an in-depth training program; - Provide each student with instructions on how to perform basic long-term care nursing procedures; - The policy did not address time frame in which NAs must become certified. 1. Review of Nursing Assistant H's personnel file and schedule showed: - Hire date of 09/11/24; - Not currently enrolled in a Certified Nursing Assistant (CNA) class; - Scheduled to work day shift on 03/01/25, 03/02/25, 03/05/35, 03/07/25, 03/10/25, 03/11/25, 03/12/25, 03/15/25, 03/16/25, 03/19/25, 03/21/25, 03/24/25, 03/25/24, 03/26/25, 03/29/25 and 03/30/25; - The facility failed to ensure the NA was certified within four months of his/her employment. 2. Review of Nursing Assistant I's personnel file and schedule showed: - Hire date of 10/24/23; - Not currently enrolled in a CNA class; - Scheduled to work day shift on 03/03/25, 03/04/25, 03/08/25, 03/09/25, 03/12/25, 03/14/25, 03/17/25, 03/18/25, 03/19/25, 03/22/25, 03/23/25, 03/26/25, 03/28/25 and 03/31/25; - The facility failed to ensure the NA was certified within four months of his/her employment. 3. Review of Nursing Assistant J's personnel file and schedule showed: - Hire date of 08/23/24; - Not currently enrolled in a CNA class; - Scheduled to work day shift on 03/01/25, 03/02/25, 03/04/25, 03/06/25, 03/08/25, 03/09/25, 03/11/25, 03/13/35, 03/15/25, 03/16/25, 03/18/25 and 03/20/25; - The facility failed to ensure the NA was certified within four months of his/her employment. During an interview on 03/12/25 at 4:30 P.M., the Director of Nursing (DON) said the facility is currently not able to have Certified Nursing Assistant (CNA) classes, but they were having them prior to getting a citation. All non-certified NAs are still working on the floor. During an interview on 03/12/25 at 6:25 P.M., the Administrator and DON said they would expect NAs to be certified within four months of being hired and, if not certified within that time frame, the employee(s) should be moved to a department that doesn't have direct resident contact.

Based on interview and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, and reconciled for one resident (Resident #29) of 18 sampled residents and failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and end of each shift. The facility failed to document the total number of narcotic drug cards counted for two of three narcotic count books checked. The facility's census was 87. Review of the facility's policy titled, Controlled Substances, revised December 2012, showed: - 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; - Nursing staff must count controlled medications 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; - The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties, and shall give the Administrator a written report of such findings. 1. Observation of Resident #29's medication cards showed: - On 03/12/25 at 3:20 P.M., MS Contin (opioid pain medication) 30 milligram (mg) card showed one tablet in the card; - On 03/12/25 at 3:22 P.M., MS Contin 15 mg card showed 16 tablets in the card. Review of Resident #29's Controlled Substance Accountability Sheets showed: - On 03/12/25 at 3:20 P.M., MS Contin 30 mg with a count of two; - On 03/12/25 at 3:22 P.M., MS Contin 15 mg with a count of 15. During an interview on 03/12/25 at 3:20 P.M., Registered Nurse (RN) N said he/she gave the resident MS Contin 30 mg this morning and forgot to sign it out. He/She signed out MS Contin 15 mg and gave it to the resident this morning at 8:00 A.M., but he/she did not make the entry with no signature on the line just above it that showed on 03/11/25 at 8:00 A.M. that the count was 17 and one was given for an ending count of 16. He/She should sign medications out when they are given. 2. Review of the Nurses Controlled Substance Shift Change Record, dated 01/01/25 through 03/12/25, showed: - Signing indicates Package Quantity matches Package Log and Tablets remaining match Medication Administration Count Sheet; - A Hall oncoming and offgoing nurses missed a total of 103 out of 141 opportunities; - B Hall oncoming and offgoing nurses missed a total of 134 out of 147 opportunities. Review of the Certified Medication Technician (CMT) Controlled Substance Shift Change Record, dated 01/01/25 through 03/12/25, showed: - Signing indicates Package Quantity matches Package Log and Tablets remaining match Medication Administration Count Sheet; - 100/200 Hall oncoming and offgoing CMTs missed a total of 38 out of 57 opportunities in February with the facility unable to provide count sheets for January and March; - 300/400 Hall oncoming and offgoing CMTs missed a total of 18 out of 56 opportunities in February with the facility unable to provide count sheets for January and March; - B Hall oncoming and offgoing CMTs missed a total of 51 out of 62 opportunities with the facility unable to provide count sheets for February and March; - B Hall Unit oncoming and offgoing CMTs missed a total of 50 out of 62 opportunities with the facility unable to provide count sheets for February and March. During an interview on 03/12/25 at 3:47 P.M., Licensed Practical Nurse (LPN) G said he/she isn't sure why they don't count cards. Different facilities do different things. During an interview on 03/12/25 at 4:07 P.M., the Director of Nursing (DON) said offgoing and oncoming staff should be counting cards together with each shift change. Staff should sign out medications at the time they give them. During an interview on 03/20/25 at 2:20 P.M., the DON said the Shift Change Record indicates that both the oncoming and offgoing nurses have counted each resident's total number of pills on each narcotic card as well as total cards for each shift. The facility has two nurse narcotic carts and four CMT narcotic carts.

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. This had the potential to affect all residents. The facility's census was 87. Review of the facility's policy titled, Cleaning Rotation, dated 2011, showed: - Equipment and utensils will be cleaned according to the following guidelines or manufacturer's instructions; - Items cleaned daily: stove top, grill, exterior and large appliances, kitchen and dining room floors; - Items cleaned weekly: hoods, filters, storerooms. Review of the facility's policy titled, Steam Table Serving Temperatures for Hot and Cold Foods, dated 2011, showed: - Staff will follow the guidelines below when serving hot and cold beverages and food; - Foods will be served at the following temperatures to ensure a safe and appetizing dining experience; - Meat and casseroles at 135 degrees Fahrenheit (F) to 170 degrees F; - Dairy products 41 degrees F or below. 1. Observation on 03/09/25 at 9:58 A.M. and 03/12/25 at 12:40 P.M. of the kitchen showed: - No cleaning logs; - Scattered debris below the food preparation table; - Range with food debris on the floor beneath, black grime buildup and oily film on the griddle; - Range hood with an oily film build up on interior and exterior surfaces; - The dishwasher with a white build up on the interior surfaces; - Ice machine with a white build up on the exterior surfaces; - Two 12 inch (in.) ceiling diffusers (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces and between the ventilation louvers; - One light fixture without a plastic cover; - One light fixture with a damaged plastic cover. 2. Observation on 03/09/25 at 10:05 A.M. of the walk-in freezer showed: - The interior door frame near the ceiling with an approximately 1 in. by 3-foot (ft.) section of ice build up; - Door gasket with a black substance. 3. Observation on 03/09/25 at 10:15 A.M. of the walk-in refrigerator showed: - One cracked shell egg lay in an unlabeled, undated cardboard tray with 29 whole shell eggs; - One 12 in. by 12 in. foil topped metal container labeled brats, dated 2/19/25, with six cooked bratwurst sausages with onion bits; - One 12 in. by 12 in. metal container partially full and covered with foil, labeled sausage sauce, dated 01/19/25; - One 12 in. by 12 in. metal container partially full of a yellow food, unlabeled and undated; - One 18 in. by 10 in. metal pan with white pureed food half full, unlabeled, dated 03/06/25; - One 6 in. round plastic bowl with a brown food, unlabeled, dated 02/11/25; - One 4 liter clear pitcher with a clear plastic package of undated, unlabeled liquid egg opened and partially full. 4. Observation on 03/09/25 at 10:20 A.M. and 03/12/25 at 12:35 P.M. of the dry food storage room showed: - An opened closet door with a 2 ft. by 1 ft. vent with dust buildup and a brown substance on the front exterior surfaces and between the ventilation louvers; - Two 24 count boxes of 24 ounce (oz.) chocolate flavored syrup, dated best by 07/11/24; - One 6 pound 5 oz. can of cut green beans stored in the floor of the dry storage beside the rack, dated received on 2/12/25. 5. Observation of the dining room on 03/10/25 at 11:30 A.M. showed: - Beef tips in steam table bin at 190 degrees F; - Shepherd's pie in steam table bin at 200 degrees F; - Metal steam table bin container lay on the serving area counter with six bologna and cheese sandwiches at 55 degrees F, dated 03/10/25. During an interview on 03/09/25 at 10:14 A.M., Dietary Aide (DA) L said liquid scrambled eggs are being served and new orders of shell eggs are on hold due to the egg shortage. He/she wasn't aware they had shell eggs and said they must be left over. The shell eggs should have been stored in a box with labels to indicate the expiration date and type of egg, and the cracked egg shouldn't have been in storage. During an interview on 03/09/25 at 10:42 A.M., the Assistant Dietary Manager (DM) said that food should not have been stored in the walk-in refrigerator without being properly labeled. The brown food wrapped in the round bowl should have been labeled and thrown out a long time ago since it was dated 02/11/25. Leftover food should not be stored in those types of containers in the refrigerator. The eggs should have been in a box with labels to indicate the expiration date and type of egg. During an interview on 03/09/25 at 10:45 A.M., DA K said food should have been stored in a different type of container with a lid and labeled. The food in the small round bowl is unidentifiable, but smelled like it could be chili or taco meat. It should have been thrown out a long time ago since it has a label dated 02/11/25. We should throw food out after three days if it isn't used. The eggs should have been in a box with labels to indicate the expiration date and type of egg, and we should not store cracked eggs. During an interview on 03/12/25 at 12:46 P.M., the DM said no shell eggs are served due to an egg shortage, and the eggs should not have been stored if they are cracked. Opened and leftover foods should be stored with dated labels and discarded after three days; expired foods should be thrown out. A company comes in to clean the vent hood, but staff wash the filters in the dishwasher weekly. The dishwasher should not have white build up inside. The stove and appliances should be cleaned, but there are no cleaning logs yet, as the DA crew is new. Canned food should not be stored in the floor in the dry storage. Vents should be clean, and lighting should be intact. Foods should be held for serving at appropriate temperatures according to facility policy. During an interview on 03/12/25 at 12:50 P.M., the Administrator said stored food should be labeled in the refrigerator and in the dry storage. The vents should be clean and light fixtures should be intact. Appliances should be kept clean, and the floors and walls should be cleaned underneath. There should be cleaning logs. The eggs should have been in a box with labels to indicate the expiration date and type of egg, and expired food should be thrown out. Foods should be held at safe temperatures and dietary staff should follow facility policy. During an interview on 03/12/25 at 2:16 P.M., the Maintenance Director said the walk-in freezer should not have ice build-up above the door. It may need a new gasket, and it should not have black build up. The vents in the kitchen ceiling should be clean and they will be repaired or replaced. The lighting should be intact, and it will be replaced in the kitchen. Repair parts and replacements get delayed due to shipping.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for ten residents (Resident #6, #14, #19, #37, #38, #57, #70, #72, #78, and #79) out of the 14 sampled residents. The facility's census was 87. Review of the facility's policy titled, Hand Hygiene Policy and Procedure, dated 2025, showed: - The purpose is to establish clear and standardized hand hygiene practices for all staff to prevent the spread of infections, maintain a safe environment, and comply with CMS (Centers for Medicare and Medicaid Services, CDC (Centers for Disease Control), and state infection control guidelines. This policy includes specific hand hygiene practices related to peri care (the cleaning of the the genitals and anal area) to minimize the risk of urinary tract infections (UTIs) and other infections; - This policy applies to all facility staff, including nurses, Certified Nurse Aides (CNAs), therapists, dietary staff, housekeeping, and any personnel with direct or indirect resident contact; - All staff must perform hand hygiene correctly and consistently before, during, and after resident care activities, including peri care, to prevent the transmission of infections; - Indications for hand hygiene-Staff must perform hand hygiene at the following times: Before and after direct contact with a resident, before performing an aseptic (being free from, or designed to prevent the presence of, disease-causing microorganisms) task, after contact with blood, body fluids, secretions, excretions, or contaminated surfaces, before and after wearing gloves; - Hand hygiene methods: Alcohol-based hand rub (preferred method), use alcohol-based hand rub with at least 60 percent (%) alcohol when hands are not visibly soiled; Hand washing with soap and water (required in certain circumstances); - Glove use and hand hygiene: Gloves do not replace hand hygiene, perform hand hygiene before putting on gloves and immediately after removing them. Change gloves when moving from a dirty to clean task, gloves become damaged or visibly contaminated, switching between different body areas. The facility did not provide a policy for Medication Administration. 1. Observation on 03/11/25 at 11:00 A.M. showed: - Certified Medication Technician (CMT) M administered medications to Resident #72; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration; - CMT M used a glucometer (a device used to check blood sugar level) to obtain a blood sugar level for Resident #72. CMT M did not wear gloves or wash/sanitize his/her hands prior to or after using the glucometer; - CMT M placed the glucometer on top of the medication cart without a barrier and without sanitizing the glucometer. 2. Observation on 03/11/25 at 11:05 A.M. showed: - CMT M administered medications to Resident #78; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 3. Observation on 03/11/25 at 11:13 A.M. showed: - CMT M administered medications to Resident #19; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 4. Observation on 03/11/25 at 11:15 A.M. showed: - CMT M administered medications to Resident #70; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 5. Observation on 03/11/25 at 11:20 A.M. showed: - CMT M administered medications to Resident #57; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 6. Observation on 03/11/15 at 11:25 A.M. showed: - CMT M administered medications to Resident #79; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 7. Observation on 03/11/25 at 11:32 A.M. showed: - CMT M administered medications to Resident #14; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 8. Observation on 03/11/25 at 11:35 A.M. showed: - CMT M administered medications to Resident #6; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 9. Observation on 03/11/25 at 11:45 A.M. showed: - CMT M administered medications to Resident #38; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. 10. Observation on 03/11/25 at 11:48 A.M. showed: - CMT M administered medications to Resident #37; - CMT M failed to wash his/her hands or use hand sanitizer before and after medication administration. During an interview on 03/11/25 at 2:00 P.M., CMT M said that he/she should sanitize his/her hands between every resident when administering medications. He/She should wear gloves when administering ointments and when dealing with blood. During an interview on 03/12/25 at 6:25 P.M., the Administrator and Director of Nursing (DON) said they would expect CMTs to utilize proper hand sanitization and glove use while administering medications and obtaining blood sugar checks.

Based on interview and record review, the facility failed to document pertinent education provided to the resident or the resident's representative regarding benefits, side effects, or warnings of the influenza (a viral respiratory infection) and/or the pneumococcal (an infectious lung disease) vaccine for two residents (Residents #36 and #47) out of five sampled residents. The facility's census was 87. The facility did not provide a policy regarding influenza or pneumococcal vaccination. 1. Review of Resident #36's medical record showed: - admission date of 04/24/20; - No documentation the facility provided information and education for influenza or pneumococcal vaccinations; - No documentation of consent or refusal; - No documentation the influenza or the pneumococcal vaccinations had been administered. 2. Review of Resident #47's medical record showed: - admission date of 06/17/24; - An incomplete Pneumococcal and Influenza Immunization consent form, signed by the representative on 06/17/24, that did not state whether or not the resident was to receive vaccinations; - No documentation that the influenza or pneumococcal vaccinations had been administered. During an interview on 03/12/25 at 2:09 P.M., the Minimum Data Set (MDS-a mandatory assessment tool to be filled out by facility staff) Coordinator said he/she could not find any more information for the residents that were missing vaccinations, but the facility does offer all vaccinations. During an interview on 03/12/25 at 4:03 P.M., the Director of Nursing (DON) said the facility is doing a complete audit of all vaccinations for all residents now.

Based on interview and record review, the facility failed to ensure the Covid-19 (an infectious disease caused by a virus that could cause some people to become seriously ill and require medical attention) vaccination was offered, administered, or refused by the resident and/or resident's representative for three residents (Resident #36, #47 and #56) out of five sampled residents. The facility's census was 87. Review of the facility's Immunization Policy, undated, showed: - The Centers for Medicare and Medicaid Services (CMS) mandates that all long term care facilities develop and implement policies to ensure that all staff are fully vaccinated against Covid-19. This includes educating residents and staff about benefits and potential side effects of the Covid-19 vaccine and offering the vaccine to them; - Facilities are expected to have processes in place to track and securely document the vaccination status of all staff and residents. 1. Review of Resident #36's medical record showed: - admission date of 04/24/20; - Diagnoses of schizoaffective disorder (a condition that includes delusions, hallucinations, depressed episodes and manic periods of high energy), morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), borderline intellectual functioning (below average cognitive ability) and hypertension (high blood pressure); - No documentation the education of Covid-19 vaccination was provided; - No documentation the Covid-19 vaccination was provided or refused. 2. Review of Resident #47's medical record showed: - admission date of 06/17/24; - Diagnoses of morbid obesity, aphasia (a language disorder that affects a person's ability to communicate), functional quadriplegia (a condition where someone is unable to move limbs due to a medical condition, not spinal cord damage), post traumatic seizures (seizures that occur after a traumatic brain injury) and hypertension (high blood pressure); - No documentation the education of Covid-19 vaccination was provided; - No documentation the Covid-19 vaccination was provided or refused. 3. Review of Resident #56's medical record showed: - admission date of 08/22/24; - Diagnoses of rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in hands and feet), paraplegia (paralysis that affects all or parts of the trunk, legs and pelvic organs, Kienbocks disease (a rare, progressive bone disorder that disrupts blood flow to the small wrist bones) and pressure ulcer of the coccyx (tailbone); - No documentation the education of Covid-19 vaccination was provided; - No documentation the Covid-19 vaccination was provided or refused. During an interview on 03/12/25 at 2:09 P.M., the Minimum Data Set (MDS-a mandatory assessment tool to be filled out by facility staff) Coordinator said he/she could not find any more information for the residents that were missing vaccinations, but the facility offers all vaccinations. During an interview on 03/12/25 at 4:03 P.M., the Director of Nursing (DON) said the facility is doing a complete audit of all vaccinations for all residents now.

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for two residents (Residents #29 and #47) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on inspection of side rails. 1. Review of Resident #29's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail. 2. Review of Resident #47's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 03/10/25 at 10:30 A.M., Resident lay in bed, grab bar up on left side of bed, right side of bed against the wall; - On 03/11/25 at 2:40 P.M., Resident out of room, grab bar up on left side of bed, right side of bed against the wall; - On 03/12/25 at 10:34 A.M., Resident lay in bed, grab bar up on left side of bed, right side of bed against the wall. During an interview on 03/12/25 at 5:00 P.M., the Maintenance Director said he had not done any inspections/assessments for side rails and grab bars. They are working on a policy for that. During an interview on 03/12/25 at 6:25 P.M., the Director of Nursing (DON) said she would expect the Maintenance Director to do side rail inspections.

Based on interview and record review, the facility failed to provide the required annual competency training for dementia care (care of a resident with an impaired ability to remember, think, or make decisions) and/or have staff attend at least twelve hours of in-service education per year for two of three sampled Certified Nursing Assistants (CNAs). This deficient practice had the potential to affect all residents. The facility's census was 87. The facility did not provide a policy. 1. Review of CNA E's in-service record showed: - A hire date of 07/12/89; - A total of twelve hours of annual in-services for March 2024 through February 2025; - No documented annual dementia care training. 2. Review of CNA F's in-service record showed: - A hire date of 03/28/23; - A total of four hours of annual in-services for March 2024 through February 2025; - No documented annual dementia care training. During an interview on 03/12/25 at 3:50 P.M., the Director of Nursing (DON) said she provides some in-service videos on the staff's communication app. There are no written in-services on dementia care. During an interview on 03/12/25 at 6:25 P.M., the Administrator and DON said they would expect in-services to be documented and include annual dementia care training and training on residents with cognitive impairments.

Based on interview and record review, the facility failed to ensure the required members attended Quality Assurance & Performance Improvement (QAPI) meetings at least quarterly. The facility's census was 87. The facility did not provide a policy. 1. Review of the monthly QAPI Meeting sign in sheets, dated August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, and February 2025, provided by the Administrator, showed the following required members attended each meeting: - Administrator; - Director of Nursing; - Infection Preventionist; - At least two other staff members; - No record of the Medical Director attending any meetings. During an interview on 03/12/25 at 4:36 P.M., the Director of Nursing (DON) said the Medical Director is invited, but he does not come to the meetings. During an interview on 03/12/25 at 4:30 P.M., the Administrator said the Medical Director should be coming to the meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1) out of five sampled residents was free of misappropriation of his/her property when Housekeeper A utilized the resident's bank card for his/her own personal use. The facility census was 62. The administrator was notified of the Past Non-Compliance (PNC) on 08/23/24. The PNC started on 07/28/24 and was removed on 07/30/24, when the incident was reported to the Administrator who immediately began an investigation and removed the housekeeper from the facility then completed the facility policy and procedure on misapprorpiation, reporting and retraining staff The PNC was removed on 07/30/24. Review of the facility's policy titled, Standards of Conduct, dated May 2023, showed violation of the Conduct Standards include, but are not limited to: stealing from a resident, visitor, other employee of facility showed the first offense to be a discharge. 1. Review of Resident #1's face sheet showed: - admitted on [DATE]; - Diagnoses of Buerger's Disease (rare condition that causes blood vessel inflammation and blockage in the hands and feet) and alcohol abuse with withdrawal. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the staff), dated 07/17/24, showed the resident to be cognitively intact. Review of the facility's investigation dated, 08/01/24, showed: - On 07/30/24, Resident #1 notified the facility he/she believed his/her bank card had been compromised. He/She had given the card to the Activities Director (AD) to buy him/her cigarettes, and after checked the bank account balance which was zero, but he/she knew there was at least $90.00 in the account; - The Social Service Designee (SSD) called the resident's family to verify the card was active and if there were charges made on the card that were not made by the resident or a family member. The family said no one else had access to the account or made the charges; - The SSD and the Business Office Manager (BOM) went to the businesses where the card was used and confirmed the purchases against the card number; - One business had surveillance video of the person who used the card to purchase the items, but was only able to share with law enforcement; - On 08/01/24, law enforcement notified the facility they had a suspect and requested the phone number for the Housekeeper A; - Housekeeper A was placed on suspension pending the outcome of the investigation. Review of the information obtained form the resident's bank and receipts from the businesses where the card was used dated, 07/28/24 through 07/29/24, showed: - On 07/28/24, vending machine transactions for $1.70, $1.35, and $1.85; - On 07/28/24, a restaurant transaction for $18.00; - On 07/28/24, a business transaction for for $42.39; - On 07/29/24, a business transaction for $30.21. Review of Housekeeper A's personnel file showed the Abuse and Neglect Policy Presentation signed on 01/20/99. During an interview on 08/06/24 at 9:20 A.M., the AD said the resident had given him/her the bank card on 07/26/24, to buy cigarettes. The purchase was for two cartons of cigarettes for $68.58, and three packs of cigarettes for $9.63, for a total of $85.42. By the time the AD returned to the facility, the resident was sent out to the hospital. He/She put the resident's cigarettes, bank card, and receipt in a locked activity cabinet in the locked activity room for the weekend. On the morning of 07/29/24, the resident came to the activity room and the AD gave him/her the bank card and the cigarettes. The resident told the AD there was no more money and there were purchases on the account. The AD notified the BOM of what the resident reported. During an interview on 08/06/24 at 10:40 A.M., Certified Medication Technician (CMT) B said he/she went to the resident's room to give him/her medication on 07/29/24 at 2:00 P.M., and the resident said to hang on because he/she was on the phone with the bank. He/She placed the bank on hold and told CMT B about the bank card. He/She said the AD had the card and brought it to him/her later. During an interview on 08/06/24 at 1:10 P.M., the SSD said the BOM asked if he/she would speak to the resident about what was going on with his/her bank card on 07/30/24. The resident thought the AD had used his/her bank card because he/she had given it to the AD on 07/26/24, to buy cigarettes. The resident showed the BOM the purchases online. The SSD said he/she verified with the resident's family the bank card was active and only Residnet #1 had access. The SSD said once the amounts and businesses were known, the SSD and the BOM went to the businesses, verified the purchases, and obtained copies of the receipts. The SSD said once they verified the purchases were made by someone other than Resident #1 and one of the businesses had video of that person, they contacted law enforcement who later asked for Housekeeper A's contact information. During an interview on 08/08/24 at 1:25 P.M., the Administrator said she would expect all staff to follow policies on abuse, neglect, exploitation and misappropriation. The bank refunded the resident's money and Housekeeper A was terminated. The police department was pursuing charges on the theft. During an interview on 08/20/24 at 11:07 A.M., Housekeeper A said, I worked at the facility for 29 years. This was the first time I ever used a resident's bank card. It came through the laundry in his/her clothes. It was a dumb mistake, and I wasn't thinking. It was stupidity. Housekeeper A said he/she had been educated in the past on abuse, neglect and misappropriation. Complaint #MO239942

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility staff) for three residents (Resident #23, #45 and #48) out of 16 sampled residents. The facility census was 65. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, undated, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Review of the Residents' Smoking List, dated 10/11/23, showed: - Resident #23 smoked while supervised by staff. - Resident #45 and #48 smoked while unsupervised by staff. 1. Review of Resident #23's annual MDS, dated [DATE], showed: - admission date of 03/28/22; - The resident did not smoke. Observations on 10/26/23 at 9:35 A.M., and 3:30 P.M., showed the resident sat in his/her wheelchair outside in the designated smoking area and smoked while supervised by two staff. 2. Review of Resident #45's annual MDS, dated [DATE], showed: - admission date of 10/29/21; - The resident did not smoke. Observations on 10/24/23 at 9:21 A.M., and 10/25/23 at 4:05 P.M., showed the resident sat in the designated smoking area and smoked without supervision. During an interview on 10/26/23 at 8:10 A.M., the resident said he/she was a smoker and used tobacco upon admission. 3. Review of Resident #48's admission MDS, dated [DATE], showed: - admission date of 04/19/23; - The resident did not smoke. Observations on 10/24/23 at 9:21 A.M. and 10/25/23 at 4:05 P.M., showed the resident sat in the designated smoking area and smoked without supervision. During an interview on 10/26/23 at 8:35 A.M., the resident said he/she had smoked since the age of [AGE] years old. The facility was aware he/she was a smoker upon admission. During an interview on 10/27/23 at 1:15 P.M., the MDS Coordinator said if a resident smoked, then the resident's MDS should be marked as a smoker. During an interview on 10/27/23 at 1:56 P.M., the Administrator said the MDS should reflect the resident's care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs of three residents (Resident #15, #45, and #48) out of 16 sampled residents and one resident (Resident #35) outside the sample. The facility census was 65. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, undated, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 1. Review of Resident 15's medical record showed: - admission date of 10/25/21; - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypertension (HTN) (high blood pressure) and anxiety disorder (persistent worry and fear about everyday situations). Review of the resident's revised comprehensive care plan, dated 07/21/23, showed no individualized interventions for smoking. Observations on 10/26/23 at 9:35 A.M., and at 3:35 P.M., showed the resident sat in his/her wheelchair in a designated smoke area smoking with staff supervision. Review of Resident #35's medical record showed: - admission date of 04/28/21; - Diagnoses of COPD and Type II diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar). Review of the resident's revised comprehensive care plan, dated 04/28/23, showed no individualized interventions for smoking. Observations on 10/24/23 at 10:56 A.M., and 10/25/23 at 3:29 P.M., showed the resident sat in his/her wheelchair in a designated smoke area smoking with staff supervision. During an interview on 10/24/23 at 10:10 A.M., the resident said he/she was a smoker. Review of Resident #45's medical record showed: - admission date of 10/29/21; - Diagnoses of bipolar disorder (a mental disorder that causes unusual shifts in mood) and anxiety disorder. Review of the resident's revised comprehensive care plan, dated 07/18/23, showed no individualized interventions for smoking. Observations on 10/24/23 at 9:21 A.M., and 10/25/23 at 4:05 P.M., showed the resident sat in a designated smoke area smoking without staff supervision. During an interview on 10/26/23 at 8:10 A.M., the resident said he/she was a smoker and used tobacco upon admission. Review of Resident #48's medical record showed: - admission date of 04/19/23; - Diagnoses include HTN and COPD. Review of the resident's revised comprehensive care plan, dated 09/14/23, showed no individualized interventions for smoking. Observations on 10/24/23 at 9:21 A.M., and 10/25/23 at 4:05 P.M., showed the resident sat in a designated smoke area smoking without staff supervision. During an interview on 10/26/23 at 8:35 A.M., the resident said he/she has smoked since the age of [AGE] years old. The facility was aware he/she was a smoker upon admission. During an interview on 10/27/23 at 1:23 P.M., the Care Plan Coordinator said smoking assessments were completed quarterly or if there was a change in a resident. If a resident smoked, then there should be interventions on the care plan. During an interview on 10/27/23 at 2:00 P.M., the Administrator said the care plan should be updated and revised as needed. She said anyone should be able to look at a care plan and know what was going on with the resident. She said the care plan should reflect the resident.

Based on interview and record review, the facility failed to obtain physician's orders for one resident (Resident #2) out 16 sampled residents. The facility census was 65. Review of the facility's policy titled, Physician's Orders, undated, showed: - Our facility shall promptly obtain physician orders for accident, discovery of injuries of an unknown source, an incident involving the resident and specific instruction to notify the physician of changes in the resident's condition; - Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider; - The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status; - The policy did not address a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) and/or urostomy (a surgical procedure that creates an opening for the urinary system) care. Review of Resident #2's medical record showed: - admission date of 07/20/23; - Diagnoses of hypertension (HTN) (high blood pressure), Type II diabetes mellitis (DM) (a condition that affects the way the body processes blood sugar), and spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly). Review of the resident's Physician Order Sheet (POS), dated October 2023, showed: - No order for colostomy or care of the colostomy; - No order for urostomy or care of the urostomy. During an interview on 10/27/23 at 12:30 P.M., the resident said he/she had a colostomy and urostomy. The staff come took care of it and assisted him/her. The supplies were kept in the resident's room in the closet. During an interview on 10/27/23 at 1:20 P.M., the Director of Nursing (DON) said if a resident had a colostomy or urostomy, there should be orders and how to care for them. During an interview on 10/27/23 at 1:25 P.M., the Administrator said if a resident had a colostomy or urostomy, then there should be orders and how to care for them.

Based on observation, interview and record review, the facility failed to maintain infection control practices during incontinent care for one resident (Resident #38) out of six sampled residents, and for the disinfection of a glucometer (a device for measuring the concentration of glucose in the blood) used for glucose (the main type of sugar in the blood) monitoring for three residents (Resident #24, #30, and #47) out of three sampled residents. The facility census was 65. Review of the facility's policy, titled, Handwashing/Hand Hygiene, dated 10/11/22 showed: - The facility considers hand hygiene the primary means to prevent the spread of infection; - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents; before moving from a contaminated body site to a clean body site during resident care; and after removing gloves. 1. Observation of peri care for Resident #38 on 10/24/23 at 12:36 P.M., showed: - The resident lay in bed; - Certified Nurse Aide (CNA) E sanitized hands and put on gloves; - CNA E removed the resident's urine soiled pants and brief; - Wearing the same soiled gloves, CNA E retrieved a clean wet wipe cloth, rolled the resident to his/her left side and cleaned the resident's buttocks and hips with visible fecal material on the wipe; - Wearing the same soiled gloves, CNA E placed a clean brief under the resident, rolled the resident to his/her back, cleaned the resident's front peri area, fastened the resident's brief and the resident's pants; - CNA E removed his/her gloves before transferring the resident from the bed to the Broda (a chair that traditionally offers tilt-in-space positioning, which prevents skin breakdown) chair and didn't perform hand hygiene; - CNA E failed to perform hand hygiene between dirty and clean care, and before transferring the resident from the bed to the Broda chair. During an interview on 10/27/23 at 12:45 P.M., CNA F said he/she would change gloves after doing the front peri area and after doing the back peri area. If the gloves got dirty, then he/she would change them also. Staff should always remove their gloves when completely done with care, and before touching any bed linens, the resident's clothes or anything else. During an interview on 10/27/23 at 1:25 P.M., the Director of Nursing (DON) said she expected staff to put on gloves after washing their hands, before care was done, and between dirty and clean care. Staff should always wash their hands after care was completed before touching anything else. Review of the facility's policy titled, Cleaning and Disinfection for Resident-Care Items and Equipment, undated, showed: - Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Blood borne Pathogens Standard; - Reusable resident care equipment will be decontaminated and/or sterilized between residents according to the manufacturers instructions. Review of the PDI Super Sani Cloths Manufacturer's Disinfection Directions showed: - If present use a wipe to remove visible soil prior to disinfecting; - Unfold a clean wipe and thoroughly wet surface; - Allow treated surface to remain wet for two minutes - Allow to air dry; - Dispose of the wipe after a single use. 2. Observation of the blood glucose monitoring on 10/26/23 showed: - At 10:58 A.M., Certified Medication Technician (CMT) A performed blood glucose monitoring with the glucometer for Resident #47; - At 11:09 A.M., CMT A placed the glucometer on a PDI Super Sani Cloth and folded the wipe over the top of the glucometer. The wipe did not make contact with all surfaces of the glucometer, and the glucometer was not wiped with the PDI Super Sani Cloth; - At 11:12 A.M., CMT A performed blood glucose monitoring for Resident #30, using the same glucometer; - At 11:14 A.M., CMT A placed the glucometer on a PDI Super Sani Cloth and folded the wipe over the top of the glucometer; - At 11:34 A.M., CMT A performed blood glucose monitoring for Resident #24, using the same glucometer; - At 11:36 A.M., CMT A placed the glucometer on a PDI Super Sani Cloth and folded the wipe over the top of the glucometer; - CMT A failed to disinfect the glucometer for two minutes between each resident use. During an interview on 10/26/23 at 10:55 A.M., CMT A said that he/she usually just wrapped the glucometer in a germicidal wipe and allowed it to sit for a few minutes between each resident use. During an interview on 10/27/23 at 12:51 P.M., the DON said that she would expect the glucometer cleaning to include disinfecting the glucometer with a PDI Super Sani Cloth for the time recommended by the manufacturer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 65. Review of the facility's policy titled, Quality of Life - Homelike Environment, undated, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary and orderly environment. Observations of room [ROOM NUMBER] showed: - On 10/24/23 at 11:59 A.M., the top right corner of the heating and air unit pulled away from the wall with daylight showing through a one inch (in.) open crack across the corner; - On 10/26/23 at 9:20 A.M., the bed rolled a few in. across the floor as the resident tried to sit on the edge of it. During an interview on 10/26/23 at 9:20 A.M., the resident in room [ROOM NUMBER] said the brakes on the bed had not worked since he/she had moved there. He/She had told staff about it, but no one had tried to fix it. Observation on 10/24/23 at 12:53 P.M., of room [ROOM NUMBER] showed: - The blinds on the window had three broken slats that did not close shut to provide privacy; - The crank bar under the bed next to the window was broken and hung to the floor; - The resident in the bed next to the window had his/her television stored away in his/her closet. During an interview on 10/24/23 at 12:53 P.M., the resident in room [ROOM NUMBER] said the staff broke the window blinds when they closed the window during a drill. The crank bar under the bed had been broken for over a month and the head of the bed couldn't be adjusted, and the cable for the TV did not work on his/her side of the room, so the tv was stored in the closet since he/she could not watch it. Observation on 10/24/23 at 3:03 P.M., of room [ROOM NUMBER] showed the top right corner of the heating and air unit pulled away from the wall with daylight showing through a two in. open crack across the corner and down the right side. Observation on 10/26/23 at 1:30 P.M., of room [ROOM NUMBER] showed an electrical outlet next to the heating and air conditioner unit with a broken outlet cover. Observation on 10/26/23 at 4:10 P.M., showed in the A wing shower room between 300 and 400 hallway, a shower chair with the mesh material back support, head rest, foot rest, and seat, tattered and torn. Observation on 10/27/23 at 4:10 P.M., showed Resident #22 sat in his/her power chair with the right side arm rest cover completely peeled away and the padding exposed. During an interview on 10/25/23 at 9:05 A.M., the Maintenance Assistant said staff tell him/her verbally if something needed to be repaired. He/She was aware of a maintenance log that staff could write concerns or repairs on, but they rarely used it. He/She checked it several times daily and this was his/her first week on this job. During an interview on 10/25/23 at 9:51 A.M., Housekeeper G said there was a maintenance repair log on the maintenance door that was supposed to be filled out with any needed repairs or concerns. He/She verbally told the maintenance department when something needed to be fixed most of the time. During an interview on 10/27/23 at 10:33 A.M., Certified Nurse Aide (CNA) F said staff should report repairs to maintenance. He/She had only worked at the facility for three days and was not sure if there was a maintenance log to be filled out or not. If staff saw things that need to be repaired, it should be reported. During an interview on 10/27/23 at 1:15 P.M., CNA B said there was a maintenance repair log book by the employee lounge, and if the staff reported a needed repair, it usually got fixed. During an interview on 10/27/23 at 1:20 P.M., Registered Nurse (RN) D said there was a maintenance request book where the staff could report items that needed to be fixed, and the new maintenance staff was good about fixing stuff that he/she knew about. During an interview on 10/27/23 at 1:35 P.M., Housekeeper C said there was a maintenance request log on a clipboard on the Maintenance Office door that could be filled out for anything that needed to be fixed, and that was where he/she reported anything that needed to be repaired. The new maintenance staff seemed to be trying to get that caught up. During an interview on 10/27/23 at 1:50 P.M., the Administrator said she would expect all staff to report any needed repairs they saw to the maintenance department on the repair log sheet so that it could get fixed in a timely manner.

Based on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from verbal abuse when Registered Nurse (RN) C yelled, cursed, and threatened to withhold cigarettes from the resident in order to force the resident's compliance with incontinence care. The facility census was 64. The Administration was notified on 09/12/23 of the Past Non-Compliance citation on 09/06/23. On 09/06/23, facility staff took appropriate corrective actions as confirmed by survey staff during the onsite visit. The facility started an investigation, and assessed Resident #1. The facility started an in-service that covered abuse and neglect. The deficiency was corrected on 09/06/23. Review of the facility's policy titled, Resident Freedom from Misappropriation of Property and Exploitation and Procedure, not dated, showed: - Enable any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others working for the facility to do all that is within their power to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.; - The facility shall not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; - The facility shall develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. 1. Review of Resident #1's medical record showed: - An admission date of 05/21/21; - Diagnoses of anxiety (a feeling of fear, dread, and uneasiness), major depressive disorder (a mental health disorder characterized by persistently depressed mood), and unspecified symptoms and signs involving cognitive functions (cognitive impairment). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 08/08/23, showed: - Moderate cognitive impairment; - Short term memory problems; - Long term memory problems; - Extensive assistance of at least two staff for toileting; - Always incontinent of bladder and bowel. Review of the resident's care plan, revised on 09/14/23, showed: - Resident with impaired cognition and communication problems. Staff will give the resident the opportunity to make decisions about his/her daily care, needs and wants; - Resident with impaired communication related to cognitive deficit. Staff will approach in a calm manner and explain all procedures prior to beginning. Provide care in a relaxed, unhurried and a non-judgmental manner; - Resident with behavioral symptoms related to cognitive deficit with a history of slapping at staff. The resident gets annoyed, short-tempered easily. Soda and chips help calm the resident. Staff will approach the resident in a calm and unhurried manner while explaining the procedures prior to beginning. Staff will attempt to refocus the resident's behaviors to something positive. Staff will speak in a reassuring voice and be supportive of the resident's feelings; - Resident with impaired cognitive function and thought processes. Staff will identify self at each interaction; face the resident and make eye contact; staff will reduce distractions; the resident understands consistent, simple, and direct sentences; staff will provide the resident with necessary cues; and staff will stop and return if the resident becomes agitated. Review of the facility's investigation, dated 09/06/23, showed: - RN C yelled, cursed, and threatened Resident #1 due to the resident refused incontinent care on 09/06/23; - Certified Nurse Aide (CNA) A heard RN C loudly tell Resident #1 there was only one fucking aide in the facility, he/she was not dealing with the resident's shit tonight, and the resident would not receive any more cigarettes if he/she didn't comply; - Nurse Aide (NA) B heard RN C loudly tell the resident he/she didn't have fucking time for this tonight and and threatened to take the resident's cigarettes away from him/her; - RN C was removed from the facility; - Resident #1 was assessed and had no injuries and or behavior changes; - RN C was terminated. During an interview on 09/12/23 at 9:45 A.M., the Administrator said during the shift change on 09/06/23 around 9:30 P.M., CNA A and NA B were discussing Resident #1 being uncooperative with incontinent care in front of RN C. RN C entered the resident's room, cursed at the resident and threatened to withhold the resident's cigarettes if he/she would not comply with the care. RN C noticed CNA A and NA B standing nearby, so he/she exited the room. CNA A was on the phone with a member of the regional human resources office, who overheard part of the incident of RN C yelling at Resident #1. CNA A notified the regional human resource officer of the entire incident after RN C exited the resident's room. The regional human resource officer contacted the Administrator of the incident. RN C was terminated and staff were inserviced on abuse and neglect. Review of RN C's written statement, dated 09/06/23, showed he/she was asked by staff to go into Resident #1's room to attempt to get the resident to agree to incontinent care. RN C was very overwhelmed and snapped at Resident #1 telling the resident the facility was very understaffed right then. RN C continued to tell the resident if he/she didn't allow the staff to provide incontinent care, the resident would have to sit in his/her own shit and no one wanted that. During an interview on 09/12/23 at 12:39 P.M., CNA A said on 09/06/23 around shift change, he/she heard RN C and NA B discussing Resident #1 being uncooperative with incontinent care. CNA A said neither he/she or NA B asked RN C to intervene, but RN C took it upon him/herself to intervene, went into Resident #1's room yelled, cursed and threatened the resident to comply with incontinent care or lose his/her cigarette breaks. RN C yelled, You need to be changed right now, I only have one other fucking aide in the facility. I'm not dealing with your shit tonight. No more cigarettes for you, you are done! at Resident #1. CNA A said he/she immediately reported the incident to a member of the regional human resources team, who he/she was on the phone with at the time of the incident. The resident was tearful, but calmed down after being comforted and given a snack and a drink. During an interview on 09/12/23 at 10:38 A.M., NA B said he/she heard RN C go into Resident #1's room and started getting loud towards the resident. RN C yelled, I don't have fucking time for this tonight! He/She overheard RN C threaten to take away the resident's cigarettes. RN C left the room when he/she noticed NA B and CNA A standing nearby. The resident was tearful, but calmed down after being comforted. Complaint #MO224086

Based on observation, interview, and record review, facility staff failed to follow physician orders for two residents (Resident #8 and #9) out of five sampled residents. The facility census was 66. 1. Review of Resident #8's medical record showed: - An admission date of 12/2/22; - Diagnoses of quadriplegia (paralysis that affects all of a person's limbs and body from the neck down) and a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral (pertaining to the large, triangle-shaped bone in the lower spine that forms part of the pelvis) region. Record review of Resident #8's Physician Order Summary (POS), dated 2/23/23, showed: - An order to clean the suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) site and change the drainage sponge (a dressing) every day and night shift, dated 12/2/22; - An order to clean the groin (where the abdomen transitions into the lower body and legs) wound with wound cleanser, apply hydrogel (a type of wound dressing), cover with an abdominal (ABD) pad (an extra thick dressing) daily and as needed (PRN), dated 12/8/22; - An order to clean the coccyx with wound cleanser, apply hydrogel, and cover with an ABD pad every day shift, dated 12/15/22; - An order to clean the left hip with wound cleanser, apply calcium alginate (a type of wound dressing), and cover with a border dressing every day shift, dated 1/27/23; - An order to apply skin prep (a dressing that forms a protective film) to the left inner heel every day and night shift, dated 1/27/23; - An order to cleanse the right buttock with wound cleanser, protect the peri-wound (skin around the wound) with skin prep, apply hydrogel to the wound bed, apply an ABD pad, and change the dressing daily and PRN, dated 12/20/22. Record review of the resident's Treatment Administration Record (TAR), dated February 2023, showed: - No documentation of the resident's wound care being completed on 2/14/23 and 2/18/23; - No documentation of the resident's suprapubic catheter site being cleaned and the drainage sponge being changed for the day shift on 2/2/23 and 2/14/23, and the night shift on 2/12/23; - No documentation the skin prep applied to the resident's left inner heel for the day shift on 2/2/23, 2/14/23, and 2/18/23 and the night shift on 2/12/23. Record review of the resident's care plan, revised on 2/23/23, showed: - The resident with a pressure ulcer; - Administer treatments as ordered and monitor for effectiveness; - Follow facility policies/protocols for the prevention/treatment of skin breakdown; - The resident with skin impairment to his/her right groin and coccyx (tailbone) areas. Observation on 2/23/23 at 10:28 A.M., of Resident #8's treatments showed: - Registered Nurse (RN) A cleansed the wound to the groin area with wound cleanser and applied calcium alginate instead of hydrogel per the physician's order; - With no drainage sponge covering the suprapubic catheter site prior to the treatment, RN A cleansed the suprapubic catheter site with wound cleanser and a four inch by four inch gauze (a dressing); - RN A cleaned the resident's coccyx, left hip, and right buttock wounds with wound cleanser and blotted each with a four inch by four inch gauze; - RN A placed calcium alginate into the left hip wound and applied a foam border dressing over the site; - RN A applied skin prep to the right heel instead of the left heel; - RN A failed to apply a drainage sponge to the suprapubic catheter site after cleansing it; - RN A failed to apply hydrogel and an ABD pad to the groin wound; - RN A failed to apply hydrogel to the coccyx wound; - RN A failed to apply the skin prep to the left heel. 2. Record review of Resident #9's medical record showed: - An admission date of 2/22/23; - Diagnoses of non-pressure chronic ulcer to the right ankle and cellulitis (common and potentially serious bacterial skin infection) to the right lower limb. Record review of the resident's POS, dated 2/23/23, showed: - An order to cleanse the right ankle with normal saline or wound cleanser, dry, apply a thin layer of silver sulfadiazine cream (a topical antibiotic) to the wound base, cover with Mepilex (a foam dressing that absorbs drainage and maintains a moist wound environment), and secure with Kerlix (a white gauze dressing) two times a day for seven days for wound care, dated 2/23/23. Record review of Resident #9's care plan, undated, showed: - The resident with skin impairment to his/her right lateral ankle related to venous (pertaining to the veins) insufficiency; - Keep skin clean and dry, and provide treatments per the physician's order; - Wound care consultant to follow and treat as indicated. Observation on 2/23/23 at 2:08 P.M., of Resident #9 treatment showed: - RN A removed the undated dressing from the right lateral ankle wound; - RN A cleansed the right lateral ankle wound with wound cleanser; - RN A applied silver sulfadiazine to the right lateral ankle wound with a cotton-tipped applicator and left the wound open to air with no dressing; - RN A failed to apply the Mepilex dressing and the Kerlix wrap to the wound. During an interview on 2/23/23 at 3:00 P.M., RN A said he/she was a psychiatric nurse and not a wound nurse. Wounds were new to him/her. Physician orders were supposed to be followed for wound treatments. During an interview on 2/23/23 at 4:00 P.M., the Administrator said they had a new process improvement plan (PIP) in place for recognizing new skin issues, but it did not address the wound care process itself, such as performing wound care treatments per physician orders. The wound nurse was new to the position, and will be following the wound care consultant nurse practitioner next week for training. She would expect staff to follow facility policy, physician orders, and proper infection control practices. During an interview on 2/23/23 at 4:30 P.M., the Director of Nursing (DON) said he would expect staff to follow physician orders, and they should not be putting anything on a wound that was not ordered. He would expect there to be a drain sponge on a suprapubic catheter site. The facility did not provide a policy for not following physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide evidence for a facility- initiated discharge for four of four residents sampled (Residents #1, #5, #6 and #7) who were issued an immediate discharge notice and transferred to an acute care facility. The facility also failed to follow appropriate discharge practices when they discharged Resident #1 to the hospital and refused to allow the resident to return to the facility even after the appeal hearings unit gave a ruling to throw out the discharge notice. The facility census was 66. Record review of the facility's Transfer or Discharge, Emergency policy, undated, showed residents will not be transferred unless: - The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; - The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; - The health of individuals in the facility would otherwise be endangered; - If a resident exercises his or her right to appeal a transfer or discharge notice, he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility; - If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented; - Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: - Notify the resident's attending physician; - Notify the receiving facility that the transfer is being made; - Prepare the resident for transfer; - Notify the representative (sponsor) or other family member; - Assist in obtaining transportation; - Other interventions as deemed appropriate or as necessary to meet needs of discharging resident; The policy did not address the physician needs to document the reasons for discharge. 1. Review of Resident #1's medical chart showed: - admitted to the facility on [DATE]; - Diagnoses included schizophrenia (a thought disorder marked by delusions, hallucinations, and disorganized speech and behaviors); bipolar disorder (a mental disorder with periods of elevated moods and depression); autistic disorder (a developmental condition causing an inability to relate to everyday life and adjust socially); conversion disorder (a mental health condition that cause physical symptoms); anxiety (a mental health condition that causes excessive worry); - Had a legal guardian (court appointed person who has the authority to make decisions for a person); - The resident's baseline care plan showed the resident alert and cognitively intact. Record review of the resident's progress notes showed: - On 2/13/23, resident became physically aggressive. Staff instructed all patients to go into their rooms for safety. Staff stayed 1:1 with resident for safety. Resident began to break items and hit staff. De-escalation attempted but failed. Doctor notified and order received to send to hospital for evaluation. Resident returned to facility on 2/14/23. - On 2/14/23, the resident placed hands on another resident. Education provided to the resident. Resident #1 walked to the dining room and tried to grab another resident's hat then tried to pick up a dining room chair. Resident paced hallway and tried to take fire extinguisher and air humidifier off the wall. Resident hard to redirect. He/she tried to remove Director of Nursing (DON) mask multiple times. Resident continued aggressive behaviors. 911 called; police and ambulance arrived. Immediate discharge given and resident left facility; - On 2/16/23, spoke with hospital case management regarding resident discharged due to violent, aggressive behaviors. The unidentifiable triggers keep him/her in a heightened state of aggression. Explained due to aggression and inability to successfully redirect, he/she puts staff and residents in safety risk. - On 2/17/23, Administrator received dismissal of immediate discharge notice from the state hearings office. Facility issued another immediate discharge notice with all required information. Immediate discharge issued to resident at the hospital in person. Ombudsman (an agency that advocates for residents in long-term care facilities) and guardian sent a copy of the letter; - No documentation of attempts to contact the resident's physician or legal guardian. Review of the resident's medical record showed: - No documentation from the physician regarding the resident being a safety risk to other residents; - No documentation from the physician regarding the specific needs or services the current facility cannot meet; - No documentation from the physician of the efforts the facility has attempted in meeting those needs; - No documentation from the physician of the specific services the receiving facility will provide that the current facility cannot. Record review of the resident's immediate notice of discharge/emergency discharge, dated 2/14/23, addressed to the resident and legal guardian showed: - Pursuant to regulatory requirements, we are hereby notifying you that on an emergency basis, effective immediately you are being discharged from the facility; - discharged to the hospital; - Your discharge is being made on an emergency basis which permits discharge if the safety of individuals in the facility would be endangered; - The specific fact relied upon by the facility to support your immediate discharge on immediate basis are: Resident is becoming aggressive. He/she is throwing objects, going into other residents' rooms and throwing their personal items on the floor. He/she placed hands on multiple other residents and staff. Needing to provide 1:1 with resident. He/she is putting all residents at risk for their safety. Record review of the resident's appeals unit letter dated 2/16/23, showed the Respondent's discharge did not met the requirements for appropriate notice to discharge to Petitioner, therefore, Respondent's discharge is dismissed. During an interview on 2/23/23 at 2:45 P.M., the Administrator (Adm) said: - The facility was not going to take the resident back due to concerns regarding the safety of others because the resident laid hands on other residents; - The resident grabbed one resident by the arms and another by the shoulders. Neither resident had any injuries; - The Adm said she received the dismissal letter and they contacted the facility's corporate lawyer to ask for further guidance; - Their lawyer contacted the appeals unit to ask for a stay on the dismissal because they cannot meet the resident's needs; - They issued a second immediate discharge notice with the required information. 2. Record review of Resident #5's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of schizophrenia, anxiety, auditory and visual hallucinations, and attention deficit hyperactivity disorder (chronic condition including attention difficulty, hyperactivity, and impulsiveness); - Had a legal guardian. Record review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 10/26/22, showed: - Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact); - Other behavioral symptoms not directed toward others. Record review of the resident's progress notes on 1/17/23 showed: - Resident and male neighbor were in a physical altercation. The resident went into another resident's room and attacked the resident; - Resident given copy of immediate discharge due to altercation this morning. Resident's immediate discharge sent to social worker at hospital, guardian, and Ombudsman. Review of the resident's medical record showed: - No documentation from the physician regarding the resident being a safety risk to other residents; - No documentation from the physician regarding the specific needs or services the current facility cannot meet; - No documentation from the physician of the efforts the facility has attempted in meeting those needs; - No documentation from the physician of the specific services the receiving facility will provide that the current facility cannot. Record review of the resident's immediate notice of discharge/emergency discharge, dated 1/17/23, addressed to the resident and guardian showed: - Pursuant to regulatory requirements, we are hereby notifying you that on an emergency basis, effective immediately you are being discharged from the facility; - discharged to the hospital; - Your discharge is being made on an emergency basis which permits discharge if the safety of individuals in the facility would be endangered; - The specific fact relied upon by the facility to support your immediate discharge on immediate basis are: Resident physically hit another resident causing injury. 3. Record review of Resident #6's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of anxiety, depression, autistic disorder, and speech development disorder; - Had legal guardian. Record review of the resident's Quarterly MDS, dated [DATE], showed: - Severely impaired decision making; - Behaviors: physical behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, rejection of care, and wandering. Record review of the resident's progress notes showed: - On 12/29/22, resident has been having increased behaviors. Wandering excessively and not easily redirected. He/she is undressing in inappropriate places and is aggressive toward others. This is upsetting other residents and they attempt to avoid her when she is coming their way. When trying to communicate he/she screams very loudly all hours of the day and night and goes into other residents' rooms scaring them; - On 12/29/22, resident has had aggressive behaviors and unable to redirect. The safety of other individuals in the nursing home is threatened by resident's continued presence of pitching, scratching, grabbing, and choking staff. Resident placed on 1:1 to ensure safety of residents. Interventions tried such as toileting, snacks, nap, walking holding hands, music, TV, and much more. Call placed to physician with orders to send out to hospital with immediate discharge. Copy signed by cop and EMT. Ombudsman notified; - On 12/30/22, social worker informed by Administrator that immediate discharge notice given and that she had spoken to guardian. Copy sent to Ombudsman. Review of the resident's medical record showed: - No documentation from the physician regarding the resident being a safety risk to other residents; - No documentation from the physician regarding the specific needs or services the current facility cannot meet; - No documentation from the physician of the efforts the facility has attempted in meeting those needs; - No documentation from the physician of the specific services the receiving facility will provide that the current facility cannot. Record review of the resident's immediate notice of discharge/emergency discharge, dated 12/29/22, addressed to the resident and legal guardian showed: - Pursuant to regulatory requirements, we are hereby notifying you that on an emergency basis, effective immediately you are being discharged from the facility; - discharged to the hospital; - Your discharge is being made on an emergency basis which permits discharge if the safety of individuals in the facility would be endangered; - The specific fact relied upon by the facility to support your immediate discharge on immediate basis are: pinching, hitting, aggressive toward other, individuals in the nursing home is threatened by resident, continued presence of pitching and scratching toward staff. 4. Record review of Resident #7's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of Huntington's disease (a condition in which nerve cells in the brain break down over time); Parkinson's disease (a disorder of the central nervous system that affects movement); unspecified psychosis (a mental disorder characterized by a disconnection from reality); and mood disorder; - Had a legal guardian. Record review of the resident's Quarterly MDS, dated [DATE], showed: - BIMS score of 7 (severe cognitive impairment); - Behaviors: physical behavioral symptoms directed toward others, rejection of care, and wandering. Review of the resident's progress note showed: - On 9/28/22, resident started yelling at housekeeper and Certified Nurse Aide (CNA). Resident hit the housekeeper on the side of the face and hit the CNA on the back of the head. Social worker was helping move other resident out of the area for safety. Resident chased the social worker into the front office. Resident was put on 1:1; - On 9/29/22, resident sitting in dining room. Resident got up and came at the Certified Medication Technician (CMT). Started hitting CMT in the arms and hands. When CNA came to help redirect resident, the resident started hitting the CNA in the side of the face. Resident 1:1 until EMT and police arrived. Transfer to hospital. Immediate discharge faxed to guardian, social worker at hospital, and Ombudsman. Review of the resident's medical record showed: - No documentation from the physician regarding the resident being a safety risk to other residents; - No documentation from the physician regarding the specific needs or services the current facility cannot meet; - No documentation from the physician of the efforts the facility has attempted in meeting those needs; - No documentation from the physician of the specific services the receiving facility will provide that the current facility cannot. Record review of the resident's immediate notice of discharge/emergency discharge, dated 09/29/22, addressed to the resident and legal guardian showed: - Pursuant to regulatory requirements, we are hereby notifying you that on an emergency basis, effective immediately you are being discharged from the facility; - discharged to the hospital; - Your discharge is being made on an emergency basis which permits discharge if the safety of individuals in the facility would be endangered; - The specific fact relied upon by the facility to support your immediate discharge on immediate basis are: physically and verbally attacked others with no successful interventions. During an interview on 2/23/23 at 2:45 P.M., The Administrator said: - She did not realize until recently that the facility's discharge notice did not contain all the required information; - The physician has not document in the resident's medical chart the reason for the immediate discharge, the resident's needs that the facility cannot meet, attempts made to meet the resident's needs, or the services available at the receiving facility/hospital that can meet the resident's needs. MO00214109 MO00214203

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide complete and accurate discharge notices with required information to residents and legal guardians for four residents (Resident #1, #5, #6, and #7) out of four sampled residents for discharge notices. Facility census was 66. Record review of the facility's Transfer or Discharge, Emergency policy, undated, showed residents will not be transferred unless: - The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; - The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; - The health of individuals in the facility would otherwise be endangered; - If a resident exercises his or her right to appeal a transfer or discharge notice, he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility; - If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented; - Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: - Notify the resident's attending physician; - Notify the receiving facility that the transfer is being made; - Prepare the resident for transfer; - Notify the representative (sponsor) or other family member; - Assist in obtaining transportation; - Other interventions as deemed appropriate or as necessary to meet needs of discharging resident. The facility did not provide a policy regarding immediate/emergency discharge notices. 1. Record review of Resident #1's medical chart showed: - admitted to the facility on [DATE]; - Diagnoses of schizophrenia (a thought disorder marked by delusions, hallucinations, and disorganized speech and behaviors); bipolar disorder (a mental disorder with periods of elevated moods and depression); autistic disorder (a developmental condition causing an inability to relate to everyday life and adjust socially); conversion disorder (a mental health condition that cause physical symptoms); anxiety (a mental health condition that causes excessive worry); - Had a legal guardian (court appointed person who has the authority to make decisions for a person); - On 2/14/23, the resident's behaviors escalated and the facility issued an immediate discharge letter and sent him/her to the hospital. Review of the resident's immediate notice of discharge/emergency discharge letter, dated 2/14/23, addressed to the resident and legal guardian showed: - No documentation regarding the specific needs or services the current facility cannot meet, the efforts made to meet those needs, or why the hospital could meet them. (As required by F622); - No documentation the notice was provided to the resident in a language and manner reasonably calculated to be understood by the resident and sent to any legally authorized representative of the resident; - No documentation of the resident's right to appeal the transfer or discharge notice to the director of DHSS or his/her designated hearing official within thirty days of the receipt of notice; - Incorrect appeal address, email, and phone number; - No contact information for the Ombudsman office as required; - No contact information for the agencies that are responsible for protection and advocacy of individuals with intellectual, developmental, or mental disorders. Record review showed hospital staff assisted Resident #1 with an appeal of the discharge. The resident's appeal decision letter, dated 2/16/23, showed the facility's discharge notice did not meet the requirements for appropriate notice to discharge to Petitioner (Resident #1), therefore, Respondent's discharge is dismissed. The following were the reasons given by the Appeals Hearing Office to dismiss the letter: - No documentation the notice was provided to the resident in a language and manner reasonably calculated to be understood by the resident. Sent to any legally authorized representative of the resident and to at least one family member; - The resident's right to appeal the transfer or discharge notice to the director of Department of Health and Senior Services (DHSS) or his/her designated hearing official within thirty days of the receipt of notice; - The correct appeal address, email, and phone number; - That filing an appeal will allow a resident to remain in the facility until the hearing is held unless a hearing official finds otherwise; - The location to which the resident is being transferred or discharged ; - The name, address, and telephone number of the designated regional long-term care ombudsman office; - For Medicare and Medicaid certified facility residents with developmental disabilities, the mailing address and telephone number of the Missouri Protection and Advocacy Agency. 2. Record review of Resident #5's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of schizophrenia, anxiety, auditory and visual hallucinations, and attention deficit hyperactivity disorder (chronic condition including attention difficulty, hyperactivity, and impulsiveness); - Had a legal guardian. Record review of the resident's progress notes showed on 1/17/23: - Resident and male neighbor were in a physical altercation. The resident went into another resident's room and attacked the resident; -Resident given copy of immediate discharge due to altercation this morning. Resident's immediate discharge sent to social worker (SW) at hospital, guardian, and Ombudsman. Record review of the resident's immediate notice of discharge/emergency discharge, dated 1/17/23, addressed to the resident and guardian showed: - The same form used for Resident #1's dismissed appeal; - The notice did not contain the following required information: - No documentation regarding the specific needs or services the current facility cannot meet, the efforts made to meet those needs, or why the hospital could meet them. (As required by F622); - No documentation the notice was provided to the resident in a language and manner reasonably calculated to be understood by the resident and sent to any legally authorized representative of the resident; - The resident's right to appeal the transfer or discharge notice to the director of DHSS or his/her designated hearing official within thirty days of the receipt of notice; - The correct appeal address, email, and phone number; - Did not provide Ombudsman office contact information; - Did not provide contact information for the agencies that are responsible for protection and advocacy of individuals with intellectual, developmental, or mental disorders. 3. Record review of Resident #6's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of anxiety, depression, autistic disorder, and speech development disorder; - Had a legal guardian. Record review of the resident's progress notes showed: - On 12/29/23, resident has had aggressive behaviors and unable to redirect. The safety of other individuals in the nursing home is threatened by resident's continued presence of pitching, scratching, grabbing, and choking staff. Resident placed on 1:1 to ensure safety of residents. Interventions tried such as toileting, snacks, nap, walking holding hands, music, TV, and much more. Call placed to physician with orders to send out to hospital with immediate discharge. Copy signed by cop and EMT. Ombudsman notified. - On 12/30/22, social worker informed by Administrator that immediate discharge notice given and that she had spoken to guardian. Copy sent to Ombudsman. Record review of the resident's immediate notice of discharge/emergency discharge, dated 12/29/22, addressed to the resident and legal guardian showed: - The same form used for Resident #1's dismissed appeal; - The notice did not contain the following required information: - No documentation regarding the specific needs or services the current facility cannot meet, the efforts made to meet those needs, or why the hospital could meet them. (As required by F622); - No documentation the notice was provided to the resident in a language and manner reasonably calculated to be understood by the resident and sent to any legally authorized representative of the resident; - The resident's right to appeal the transfer or discharge notice to the director of DHSS or his/her designated hearing official within thirty days of the receipt of notice; - The correct appeal address, email, and phone number; - Did not provide Ombudsman office contact information; - Did not provide contact information for the agencies that are responsible for protection and advocacy of individuals with intellectual, developmental, or mental disorders. 4. Record review of Resident #7's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of Huntington's disease (a condition in which nerve cells in the brain break down over time); Parkinson's disease (a disorder of the central nervous system that affects movement); unspecified psychosis (a mental disorder characterized by a disconnection from reality); and mood disorder; - Had a legal guardian. Review of the resident's progress note showed: - On 9/29/22, resident sitting in dining room. Resident got up and came at the Certified Medication Technician (CMT). Started hitting CMT in the arms and hands. When CNA came to help redirect resident, the resident started hitting the CNA in the side of the face. Resident 1:1 until EMT and police arrived. Transfer to hospital. Immediate discharge faxed to guardian, social worker at hospital, and Ombudsman. Record review of the resident's immediate notice of discharge/emergency discharge, dated 09/29/22, addressed to the resident and legal guardian showed: - The same form used for Resident #1's dismissed appeal; - The notice did not contain the following required information: - No documentation regarding the specific needs or services the current facility cannot meet, the efforts made to meet those needs, or why the hospital could meet them. (As required by F622); - No documentation the notice was provided to the resident in a language and manner reasonably calculated to be understood by the resident and sent to any legally authorized representative of the resident; - The resident's right to appeal the transfer or discharge notice to the director of DHSS or his/her designated hearing official within thirty days of the receipt of notice; - The correct appeal address, email, and phone number; - Did not provide Ombudsman office contact information; - Did not provide contact information for the agencies that are responsible for protection and advocacy of individuals with intellectual, developmental, or mental disorders. During an interview on 2/23/23 at 2:45 P.M., the Administrator said the letter she initially sent with Resident #1 is the form letter she had always used. She found out after Resident #1's discharge that the information in the letter was incorrect and insufficient. The Administrator or Assistant Administrator fills out the letter then a copy is given to the resident at the time of transfer and they try to give a copy to EMT but not always will they accept. The SW will call the responsible party. The responsible party can get a copy of the discharge notice from the hospital or will send to responsible party on request. The Administrator was not aware a written copy always needed to be provided to the resident's guardian. During a telephone interview on 2/24/23 at 9:28 A.M., Resident #1's guardian said he/she never received a written discharge notice from the facility. MO00214109 MO00214203

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices when the staff failed to clean/sanitize or provide barriers between wound treatment supplies and the work surface, keep clean treatment supplies separated from contaminated supplies, and perform hand hygiene, to prevent the development and transmission of infections for five residents (Resident #4, #8, #9, #11 and #12) out of five sampled residents during wound treatments. The facility's census was 66. Record review of the facility's Infection Control policy, undated, showed: - The facility's infection control policies and practices will facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections; - The objectives of the infection control policies and practices will be to prevent, detect, investigate, and control infections in the facility; maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; establish guidelines for implementing isolation precautions, including standard and transmission-based precautions; and provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment; - All personnel will be educated on the infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Record review of the facility's Handwashing policy, dated 7/19, showed: - Hand hygiene shall be the primary means to prevent the spread of infection; - The use of gloves does not replace proper hand washing; - Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: when coming on duty, when hands visibly soiled (handwashing with soap and water), before and after direct resident contact (for which hand hygiene indicated by acceptable professional practice), before and after changing a dressing, after removing gloves or aprons, and after completing duty. Record review of the facility's Personal Protective Equipment - Gloves policy, undated, showed: - Gloves must be worn when handling blood, bodily fluids, secretions, excretions, mucous membranes, and/or non-intact skin; - Wash hands after removing gloves; - Employees must receive training relative to the use of gloves and other protective equipment prior to being assigned tasks that involve potential exposure to blood or body fluids. 1. Observation on 2/23/23 at 10:28 A.M., of Resident #8 showed: - RN A removed the calcium alginate (a wound dressing) from the treatment cart and sat it on top of the unclean/unsanitized treatment cart without a barrier; - RN A then took the calcium alginate into the resident's room and placed it on the overbed table where the wound cleanser, the unpackaged and individualized pieces of four inch by four inch gauze, and abdominal (ABD) pads (extra thick dressing for draining wounds) already sat on the resident's overbed table without a barrier. RN A did not clean/sanitize the overbed table prior to the wound care; - RN A did not wash/sanitize his/her hands and put on gloves; - RN A cleansed the groin wound with the wound cleanser and a four inch by four inch gauze; - RN A opened and applied the calcium alginate to the groin wound with the same gloves; - RN A cleansed the suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) site with the wound cleanser and a gauze with the same gloves; - RN A sprayed the wounds on the coccyx, the right buttock, and the left hip with the wound cleanser and blotted all the wounds with the same piece of gauze and wearing the same gloves; - RN A placed three ABD pads on the coccyx and the right buttock wounds with the same gloves; - RN A retrieved a pair of scissors from his/her pants pocket with the same gloves, cut the calcium alginate, then returned the scissors to his/her pants pocket without sanitizing the scissors before or after use; - RN A applied the calcium alginate to the left hip wound and covered it with the border foam dressing while wearing the same gloves; - RN A removed the gloves and put on clean gloves without washing/sanitizing his/her hands; - RN A applied skin prep (a dressing that forms a protective film) to the resident's right heel; - RN A removed the gloves and washed his/her hands; - RN A placed an extra unopened calcium alginate dressing from the resident's uncleaned/unsanitized overbed table on top of the unclean/unsanitized treatment cart without a barrier, then retrieved the unpackaged and individualized four inch by four inch pieces of gauze for Resident #11's wound treatment and sat it on top of the unopened calcium alginate dressing that came from Resident #8's uncleaned/unsanitized overbed table; - RN A put the wound cleanser bottle, which is used for multiple residents, into the treatment cart. RN A did not clean/sanitize the wound cleanser bottle before returning it to the treatment cart. - RN A did not clean/sanitize the overbed table or the treatment cart after the resident's treatment. 2. Observation on 2/23/23 at 11:00 A.M., of Resident #11 showed: - RN A entered Resident #11's room and sat the border foam dressing, the soiled wound cleanser bottle, and the unpackaged and individualized pieces of four inch by four inch gauze, which was removed from Resident #8's uncleaned/unsanitized overbed table without a barrier, and placed directly on Resident #11's nightstand without cleaning/sanitizing it or using a barrier; - RN A washed his/her hands and put on clean gloves; - RN A removed the wound dressing from the resident's back; - RN A cleansed the wound with the wound cleanser and a piece of gauze; - RN A applied the dressing to the wound with the same gloves; - RN A removed the gloves and washed his/her hands; - RN A did not change gloves and wash/sanitize his/her hands between dirty and clean care; - RN A did not clean/sanitize the soiled wound cleanser bottle before returning it to the treatment cart. - RN A did not clean/sanitize the nightstand or the treatment cart after the resident's treatment. 3. Observation on 2/23/23 at 11:20 A.M., of Resident #4 showed: - RN A removed two unpackaged foam border dressings, unidentified and dated 2/10/23, in marker on top of each dressing from the top drawer of the treatment cart and lay them on top of the cart and then placed the unpackaged and individualized pieces of four inch by four inch gauze, from an opened package in the treatment cart, on top of the unpackaged foam border dressings; - RN A retrieved the same wound cleanser bottle from the treatment cart which was used for Resident #8 and Resident #11's treatments, put a clean glove on his/her right hand, and carried the wound cleanser bottle and the gauze together, so they touched each other, in his/her right hand into Resident #4's room; - RN A entered the resident's room and sat the wound cleanser bottle and the gauze on the overbed table, without cleaning/sanitizing it or using a barrier. He/She left the room to go to the storage room to look for a foam dressing; -RN A removed the glove, but did not perform hand hygiene after removing the glove or when re-entering the resident's room; - RN A entered the resident's room with the foam dressing and placed it on the overbed table; - RN A put on clean gloves without washing/sanitizing his/her hands; - RN A removed the dressing from the coccyx (tailbone) wound; - RN A cleansed the coccyx wound with the wound cleanser and gauze wearing the same gloves; - RN A applied the foam dressing to the wound with the same gloves; - RN A removed the gloves and washed his/her hands; - RN A did not clean/sanitize the wound cleanser bottle before returning it to the treatment cart. - RN A did not clean/sanitize the overbed table or the treatment cart after the resident's treatment. 4. Observation on 2/23/23 at 2:08 P.M., of Resident #9 showed: - RN A removed the wound cleanser bottle, cotton tipped applicators, and unpackaged and individualized pieces of four inch by four inch gauze from the treatment cart and sat them onto the unclean/unsanitized treatment cart while holding the cotton tipped applicators in his/her left hand; - RN A entered the resident's room and sat the wound cleanser bottle, the cotton tipped applicators, and the gauze on Resident #9's dresser without cleaning/sanitizing or using a barrier and left the room to find gloves; - RN A returned to the room and put on clean gloves without washing/sanitizing his/her hands; - RN A removed a silver sulfadiazine (a wound treatment) jar from the resident's nightstand, opened it, and sat it on the resident's dresser; - RN A removed the dressing from the right ankle wound; - RN A cleansed the wound with the wound cleanser and the gauze with the same gloves; - RN A retrieved a cotton tipped applicator lying directly on the resident's dresser with the same gloves and inserted it into the container of silver sulfadiazine, then applied it to the wound; - RN A removed the gloves; - RN A did not wash/sanitize his/her hands prior to exiting the resident's room; - RN A did not clean/sanitize the wound cleanser bottle before returning it to the treatment cart. 5. Observation on 2/23/23 at 2:18 P.M., of Resident #12 showed: - RN A removed the unpackaged and individualized pieces of four inch by four inch gauze, tape, the wound cleanser bottle used for multiple treatments without cleansing/sanitizing the bottle, the calcium alginate, and an ABD pad from the treatment cart and sat them on top of the unclean/unsanitized treatment cart with no barrier; - RN A entered the resident's room and sat the gauze, the tape, the wound cleanser bottle, the calcium alginate, and the ABD pad onto the resident's unclean/unsanitized countertop; - RN A washed his/her hands, put on clean gloves, and then touched the room divider curtain to move it out of the way; - RN A opened the calcium alginate onto the resident's countertop along with the ABD pads; - RN A cleansed the right hip wound with the wound cleanser and a piece of gauze; - RN A retrieved the calcium alginate and an ABD pad from the countertop and applied them to the wound and taped the ABD pad in place with the same gloves; - RN A removed his/her gloves and washed his/her hands; - RN A did not clean/sanitize the soiled wound cleanser bottle before returning it to the treatment cart. During an interview on 2/23/23 at 3:00 P.M., RN A said his/her hands should be washed before and after wound care or if soiled. He/she was unsure if the opened and unused dressings, dated 2/10/23, in the top drawer of the treatment cart should be used since they were opened, even though they appeared unused. A barrier should have been used for the wound care supplies and the surfaces sanitized. Gloves should have been changed going from one wound to another. He/she said the scissors should have been cleaned every time they were used. During an interview on 2/23/23 at 4:00 P.M., the Administrator said she would expect staff to follow facility policy and proper infection control practices. During an interview on 2/23/23 at 4:30 P.M., the Director of Nursing said he would expect staff to use a barrier for wound care supplies and would expect the surface to be sanitized before laying wound care supplies down, but he prefers a barrier. Hands should be washed/sanitized before and after resident care, if hands were visibly soiled, and between each wound. Gloves should be changed when visibly soiled, between wounds and residents, and after washing. Staff should wash before changing gloves. Scissors should be sanitized between residents and as necessary. He also believes they should be sanitized between wounds so as not to cross-contaminate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individualized needs for three residents (Residents #33, #51, and #40) out of 16 sampled residents. The facility census was 64. 1. Record review of Resident #33's Face sheet, showed: - admission date 4/14/2015; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD) a group of lung diseases that block air flow making it difficult to breathe, tracheostomy (trach, tube surgically inserted into the trachea for breathing) . Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/21 showed: - Section O, special treatment for tracheostomy care while a resident marked. Review of Resident #33's Physician's Order Sheet (POS), dated November 2021, showed: - An order to clean tracheostomy and change inner cannula every two days. Review of the resident's comprehensive care plan, last reviewed 9/20/21, showed: - Change inner cannula daily; - Clean trach as ordered daily by physician; - Care plan has not been revised to address the physicians orders. 2. Review of Resident #51's medical record, showed: -An admission face sheet, showed an admission date of 9/18/19 and readmission date of 9/30/21; -Diagnoses included congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs); -POS, dated 10/1/21 through 10/31/21, an order dated 10/6/21, to admit to hospice for diagnosis of CHF; -Hospice form signed/dated 10/6/21, for start of hospice care services. Review of the resident's significant change MDS, dated [DATE], showed: -Alert and oriented; -Required extensive to total assistance from one to two staff for activities of daily living (ADLs); -Prognosis for life expectancy of less than six months; -Hospice care. Review of the resident's hospice company coordinated care plan, dated 10/6/21, showed hospice Registered Nurse (RN) visits scheduled twice a week for feeding, bathing, oral care, monitoring and assessments. Review of the resident's facility comprehensive care plan, dated 9/30/21 and revision dated 10/3/21, showed hospice care services not identified and no interventions and/or goals addressed on the care plan to meet the hospice care needs for the resident. 3. Review of Resident #40's medical record, showed: -An admission face sheet, showed an admission date of 2/16/21 and readmission date of 10/15/21; -Diagnoses included acute kidney failure (a condition in which the kidneys suddenly can't filter waste products from the blood) and dependence on renal (kidney) dialysis (process of purifying the blood of a person whose kidneys aren't working normally). Review of the resident's comprehensive care plan, dated 8/19/21 and in use during the survey, showed no problem identified for the resident receiving dialysis treatments and no specific interventions and/or goals addressed on the care plan to meet the resident's care needs for dialysis. Review of the resident's POS, dated 11/1/21 through 11/30/21, showed an undated order for dialysis treatments three times a week on Monday, Wednesday and Friday. Observation on 11/3/21 at 11:50 A.M., showed the resident sat in the wheelchair with an undated, dry dressing covered his/her dialysis access port in his/her right upper chest. 4. During an interview on 11/5/21 at 2:45 P.M., the Director of Nurses (DON) said the MDS Coordinator is responsible for reviewing and updating the resident's care plan with specific care needs regarding hospice, dialysis, tracheostomy care, falls and/or weight loss with updated interventions/goals to reflect and meet the care needs of the each resident. The facility did not provide a policy on updating or revising care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to follow physician orders for two residents (Resident #22 and #214) out 16 sampled residents. The facility census was 64. 1. Record review of Resident #22's medical record, showed: -An admission face sheet, admission date of 2/22/17; -Diagnoses included morbid obesity due to excess calories and major depression (a serious medical illness that negatively affects how you feel, the way you think and how you act). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/13/21, showed: -Alert and oriented; -No behaviors for rejection of care; -Required extensive to total assistance from one to two staff for activities of daily living (ADLs); -Non-ambulatory; -No impaired range of motion affecting upper/lower extremities. Review of the resident's Physician Order Sheet (POS), dated October 2021, showed: -An order dated 10/5/21, for physical therapy to evaluate the resident one time to set the resident up for restorative therapy (RT) program; -No order to discontinue the RT program and/or RT services. Review of the RT program binder, showed: -On 10/5/21, physical therapy documented the completed RT evaluation form with RT plan of care for the resident to receive bilateral lower extremity exercises at least three to five times a week for restorative/functional maintenance; -No documented RT services provided for the resident in October and/or November 2021. Review of the facility's RT Aide list, provided by the facility on 11/4/21, showed: -RT C, last day worked at the facility dated 10/5/21, then resigned; -RT D, days worked 10/8/21 and 10/20/21, then resigned; -RT E, scheduled to start work as RT aide on 11/8/21. During an interview on 11/2/21 at 11:52 P.M., the resident said physical therapy department provided an evaluation on him/her sometime during the first part of October and should be receiving RT services, but has not received any RT services in October or November 2021. During an interview on 11/4/21 at 4:16 P.M., the administrator said the facility did have a RT aide until approximately two weeks ago, then hired another RT aide who only worked for two days then quit and now the facility has hired another RT aide who is scheduled to start work on Monday, 11/8/21. The administrator verified the resident did not receive RT services as ordered. During an interview on 11/4/21 at 4:52 P.M., Physical Therapist (PT) F said he/she provided the resident with an evaluation regarding RT program on 10/5/21 and recommended the resident to start RT exercises three to five times a week. The physical therapist said the resident's completed evaluation form is maintained in the RT binder for the RT aide to follow. The resident's RT sessions should be documented in the RT binder which is maintained in the therapy department. During an interview on 11/5/21 at 2:45 P.M., the Director of Nurses (DON) said residents with RT program orders should have their RT services/sessions documented in the RT binder and verified Resident #22 had not received his/her RT services as ordered. The DON said she expected all nursing staff to follow physician's orders for the continuity of care for all residents. 2. Record review of Resident #214's POS, dated 10/22/21 through 10/31/21 showed: - admitted [DATE]; - Diagnosis of Necrotizing Fasciitis (a serious bacterial infection that destroys tissue under the skin) of the right lower leg and foot; - An order for Daptomycin (an antibiotic used to treat serious bacterial infections) 950 milligrams (mg) to infuse via Peripherally Inserted Central Catheter (PICC) line, once daily times six weeks, with start date 10/7/21; - An order for sodium chloride 0.9% injection, administer 5-20 milliliters (ml) into PICC line every 12 hours; Review of the resident's Medication Administration Record (MAR) showed: - An order for sodium chloride 0.9% injection, administer 5-20 milliliters (ml) into PICC line every 12 hours; - October 2021, 10 administrations missed out of 20 opportunities; - November 2021, 7 administrations missed out of 8 opportunities. During an interview on 11/04/21 at 12:17 P.M. Licensed Practical Nurse (LPN) B, said she is not certified to flush the PICC line, and one of the other nurses comes and flushes it. It is scheduled to be done twice a day. During an interview on 11/05/21 at 12:05 P.M. the DON, I would expect all orders to be followed, an order for twice a day should be twice a day and it should be documented. Review of the facility's policy Midline Catheter Flushing, dated 5/1/2020, showed: - Verify physician order, flushing agent and frequency; - Flush orders must be documented; - Flushing is performed to ensure and maintain catheter patency and to prevent mixing of incompatible medication solutions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain adequate grooming, bathing and nail care had been completed for three residents (Resident #21, #22, and #38) out of 16 sampled residents. The facility census was 64. 1. Record review of the facility's Shower/Tub Bath Policy/Procedure, dated October 2020, showed: -Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the residents and to observe the condition of the resident's skin; -Documentation: The following information should be recorded in the resident's ADL record and/or in the resident's medical record; 1. The date and time the shower/tub bath was performed. 2. The name and title of the individuals who assisted the resident with the shower/tub bath; 3. All assessment data (any redness and/or sore on the resident's skin) obtained during the shower/tub bath; 4. How the resident tolerated the shower/tub bath; 5. If the resident refused the shower/tub bath, reasons why and the intervention taken; 6. The signature and title of the person recording the data. 2. Record review of Resident #21's medical record, showed: - An admission face sheet, with admission date of 1/30/20; - Diagnoses of Cerebral Vascular Accident (CVA) (stroke, damage to the brain from interrupted blood supply) and Parkinson's disease (a disease of the central nervous system that affects movements, often including tremors), gastrostomy tube placement (g-tube) (a tube placed in the stomach to receive food or medication) and dementia. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/8/21 showed: - Required extensive assistance of two staff for bed mobility and transfers; - Required total assistance of two staff for dressing and toilet use; - Required total assistance of one staff for personal hygiene. Record review of the resident's care plan, dated 1/30/21, revised 8/21/21 showed: - Required extensive assist of two staff to total assist with his ADL's due to recent CVA, Parkinson's, dementia and g-tube; - Resident will have his needs met by staff; - Provide a shower and shampoo at least two times a week. Record review of the shower schedule for A wing, showed the resident to receive his/her showers on Tuesday and Thursday of each week. Review of the resident's CNA shower sheets, provided by the facility, showed: - On 9/5/21, staff documented resident received a shower with fingernails, toenails cleaned and trimmed; - On 9/21/21, staff documented resident received a shower without fingernails/toenails cleaned and/or trimmed; - No other documented showers/baths provided and/or completed for the resident. Observation of the resident on 11/3/21 at 2:30 P.M., showed the resident lay in the bed with his/her fingernails long, dirty and hair long and greasy. Observation of the resident on 11/4/21 at 8:15 A.M., showed the resident sat in his/her geri-chair, with fingernails long dirty and hair long and greasy. During an interview on 11/4/21 at 3:05 P.M., Licensed Practical Nurse (LPN) B said staff should be completing showers as scheduled, staff should be giving at least 2 out of the 3 scheduled. During an interview on 11/4/21 at 3:15 P.M. CNA K said staff gives showers on a regular basis for the residents. He/she said today, we did not do any showers, not sure what happened today. During an interview on 11/4/21 at 3:18 P.M. CNA H said staff gives the residents at least two showers a week, shower list has some on days and some on nights and staff follow the list. He/she said one shower was given today and the other two residents showered themselves. 3. Review of Resident #38's medical record, showed: -An admission face sheet, with admission date of 4/28/20; -Diagnoses included hemiplegia (paralysis of one side of the body), multiple sclerosis (MS) (a disease of central nervous system resulting in muscle weakness and loss of coordination), CVA and Parkinson's disease. Review of Resident #38's annual MDS, dated [DATE], showed: -Alert and oriented; -No behaviors for rejection of care; -Required total assistance from one to two staff for bed mobility, transfers, dressing, personal hygiene and toilet use; -Required extensive assistance from one staff for bathing. Review of the resident's comprehensive care plan, dated 10/30/15 and revision dated 11/7/21 and in use during the survey, showed: -Problem: Resident requires extensive assistance with ADLs related to stroke causing hemiplegia, weakness and Parkinson's disease; -Goal: Resident will continue to actively participate in ADLs to the best of his/her ability through next review (revision dated 11/7/21); -Approach: Provide a shower/shampoo at least two times a week, resident prefers four to [NAME] times a week with staff assistance of one staff, give the resident a wash cloth and cue the resident to wash as much as possible and complete task as needed (PRN). Review of the shower schedule book for B wing, showed the resident listed to receive his/her showers on Tuesday and Thursday of each week. Review of the resident's CNA shower sheets, provided by the facility, showed: -On 9/16/21, staff documented resident received a shower with fingernails/toenails cleaned; -On 9/23/21, staff documented resident received a shower with fingernails/toenails cleaned; -On 9/25/21, staff documented resident received a bed bath without fingernails/toenails cleaned; -On 10/9/21, staff documented resident received a shower with fingernails/toenails cleaned and trimmed; -On 10/14/21, staff documented resident received a shower with fingernails/toenails cleaned; -On 11/2/21, staff documented resident received a shower without fingernails/toenails cleaned and/or trimmed; -No other documented showers/baths provided and/or completed for the resident. Review of the completed shower sheets provided by the facility on 11/4/21, showed no further shower/bath sheets completed for the resident. Observation on 11/3/21 at 11:05 A.M., showed the resident lay in the bed with his/her fingernails long, untrimmed/dirty and hair greasy. The resident said he/she has not received a shower and/or bed bath at least twice a week in over two months and denied he/she refused staff to provide his/her shower/bath. Observation on 11/4/21 at 8:00 A.M. and 2:00 P.M., showed the resident lay in the bed with his/her fingernails long, untrimmed/dirty and hair greasy. At 2:00 P.M., on 11/4/21, the Director of Nurses (DON) present in the resident's room verified the resident appeared unclean and fingernails dirty. 4. Review of Resident #22's medical record, showed: -An admission face sheet, admission date of 2/22/17; -Diagnoses included morbid obesity due to excessive calories and major depression (a serious medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident #22's annual MDS, dated [DATE], showed: -Alert and oriented; -No behaviors for rejection of care; -Required total assistance from one to two staff for transfers, dressing, toilet use and bathing; -No limited range of motion affecting upper/lower extremities. Review of the resident's care plan, dated 3/9/17 and revision dated 11/7/21 and in use during the survey, showed: -Problem: Resident requires extensive to maximum assistance with ADLs related to morbid obesity and weakness; -Goal: Resident will increase her participation with his/her ADLs through next review; -Approaches: Offer resident shower/shampoo two times a week and PRN. Review of the shower schedule book for B wing, showed the resident listed to receive his/her showers on Monday and Wednesday of each week. Review of the resident's CNA shower sheets, provided by the facility, showed: -On 9/10/21, staff documented resident shaved, no shower/bath and/or fingernails/toenails cleaned; -On 9/15/21, staff documented resident received his/her shower with fingernails/toenails cleaned; -On 9/27/21, staff documented resident refused his/her shower/bath and wanted to wait until 9/28/21, to receive his/her shower; -No documented shower/bath sheet completed dated 9/28/21 for the resident; -On 10/8/21, staff documented resident received a bed bath with fingernails/toenails cleaned and trimmed; -No other documented showers/baths provided and/or completed for the resident. Review of the completed shower sheets provided by the facility on 11/4/21, showed no further shower/bath sheets completed for the resident. During an interview on 11/2/21 at 11:48 P.M., the resident said he/she has not received a shower for over two weeks due to lack of sufficient staff to provide him/her with a shower. The resident denied refusal of staff providing him/her with showers. 4. During an interview on 11/5/21 at 2:45 P.M., the DON said she expected the CNAs to provide every resident's showers/baths at least twice a week and/or PRN. The CNAs should document the resident's showers/baths on a shower/bath sheet with the resident's name, room number and sign the shower/bath sheets even when the resident refused his/her shower/bath. The DON said she expected nursing staff to document when the resident refused his/her shower/bath and report to the charge nurse when a resident refused his/her shower/bath. The DON said nursing staff should attempt to offer and/or provide the resident a shower/bath on a different day/time when the resident refused. She expected nursing staff to follow the facility's policy regarding shower/bath and expected each resident to have a documented shower/bath sheet when shower/baths are provided by the nursing staff. MO00192422

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to recognize, evaluate and address the nutritional needs of one resident (Resident #3) out of 16 sampled residents. The facility's census was 64. Record review of the facility's policy titled Weight Assessment and Intervention, dated September 2008, showed: - The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter; - Each weight will be recorded in each unit's Weight Record chart; - Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; - The Dietician will respond within 24 hours of receipt of notification; - The Dietician will review the Weight Record by the 15 th of the month to follow individual weight trends; - Negative trends will be evaluated by the treatment team to determine if criteria for significant weight change has been met; - The threshold for significant weight weight loss is based on the following; - 1 month - 5% weight loss is significant; greater than 5% is severe; - 3 months - 7.5% weight loss is significant; greater than 7.5% is severe; - 6 months - 10% weight loss is significant; greater than 10% is severe; - Assessment information will be analyzed by the multidisciplinary team and conclusions made regarding the; - Resident's target weight range; - Approximate calorie, protein and other nutrient needs compared with the resident's current intake; - The current medical condition or clinical situation and recent fluctuations in weight; - Whether and to what extent weight stabilization or improvement can be anticipated; - The care plan will be individualized to identify causes of weight loss; The goals and benchmarks for improvement; The time frames and parameters for monitoring and reassessment; - Interventions for undesirable weight loss shall be based on careful consideration of; - The resident's choice and preferences; - Nutrition and hydration needs; - Functional factors that may inhibit independent eating; - Environmental factors; - Chewing and swallowing abnormalities; - Medications; - The use of supplements; - End of life decisions. Record review of Resident #3's Physician's Order Sheet (POS), dated November 2021, showed: - admitted on [DATE]; - Diagnoses of throat cancer, muscle weakness, dysphagia (difficulty or discomfort in swallowing), mild intellectual disabilities; - An order for a regular diet with fortified foods at all meals, house supplement three times a day with medication pass. Record review of the Weight Variance report dated 5/1/21 through 10/31/21, showed; - On 5/10/21, weight 119.6 pounds (lb); - On 6/1/21, weight 122 lb, 2.4 lb gain; - On 7/1/21, weight 117.4 lb, 4.6 lb loss; - No weight for August 2021; - No weight for September 2021; - October weight 106 lb, 11.4 lb or 10.3% weight loss in 3 month; - November weight 103.6 lb, 2.4 lb or 4.4% weight loss in 1 month. Record record review of the most current progress note from the Registered Dietician (RD), dated 4/26/21, showed: - Weight gain 7.5% over 3 months; - Weight gain greater than 10% over 6 months; - Interventions unchanged and remain appropriate; - Continue current interventions to support weight maintenance; - No further documentation. Record review of the Dietary Managers (DM) notes, showed: - On 6/7/21, the resident is on a regular diet; - Eats 50% to 70% of meals; - Tolerated diet well. - Weight for May 119.6 lb, weight for June 122 lb; - On 9/7/21, the resident is on a regular diet; - Likes grilled cheese or peanut butter and jelly; - July weight 117.4 lb; - Will continue current plan of care; - No documentation regarding August or September weights; - No documentation of meal consumption. Observations of the resident showed: - On 11/4/21 at 11:40 A.M., resident lay in bed with eyes closed, lunch tray on bedside table containing a chicken salad sandwich, beets, a slice of cake and milk; - On 11/4/21 at 5:07 P.M., the resident sat bedside eating supper, mashed potatoes, gravy, mixed vegetables, sliced ham and milk, consumed approximately 40%. During an interview on 11/04/21 at 2:22 P.M., Nurse Aide (NA) L, said the resident ate close to half his/her lunch today. During an interview on 11/04/21 at 2:36 P.M., the DM said there was a while where they didn't have any weights. The weight sheet is given to the RD when they come in and recommendations are made at that time if needed. During an interview on 11/4/21 at 2:40 P.M., the Administrator said they went for a while without weights due to not being able to keep a restorative aide and that is who usually does the weights. The nursing department is now responsible for getting the weights. During a telephone interview on 11/04/21 at 3:09 P.M., the RD said the last time she was at the facility was in October. She did not get the normal weight sheet that she usually gets. It was hand written and some weights were missing. If his/her weight wasn't there, there was nothing to alert her to see him/her for a high risk assessment. She said she will contact the facility and do a high risk assessment. During an interview on 11/05/21 at 12:01 P.M. the Director of Nursing (DON) said she would expect the resident's to be weighed at least monthly. If the weights are off they should be re-weighed. If there if a significant difference the RD should be notified immediately. Weights should be completed and on matrix by the 2nd week of the month as the RD is usually here by the 3rd week. If a weight is missing it should be obtained once she is here.

Based on interview, and record review the facility failed to provide tracheostomy (trach, tube surgically inserted into the trachea for breathing) care consistent with professional standards of practice by failing to change the inner cannula (IC) every other day as ordered by the physician for one resident (Resident #33) out of one sampled resident. The facility census was 64. 1. Record review of Resident #33's Face sheet, showed: - admission date 4/14/2015; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block air flow making it difficult to breathe) and Tracheostomy. Record review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/21 showed: - Section O, special treatment for tracheostomy care. Record review of Resident #33's Physician's Order Sheet (POS), dated November 2021, showed: - An order to clean tracheostomy and change the IC every two days. Record review of the resident's Treatment Administration Record (TAR), showed: - The September 2021 TAR showed out of 16 opportunities - five opportunities missed, for changing the IC; - The October 2021 TAR showed out of 16 opportunities - five opportunities missed, for changing the IC, last date marked as completed 10/29/21; - The November 2021 TAR showed every three days highlighted for changing the IC, and marked as completed on 11/3/21, out of two opportunities one opportunity missed. During an interview on 11/04/21 at 10:10 A.M. Licensed Practical Nurse (LPN) B said the resident's IC was changed on the 3rd, was not due to be changed until the 6th. It was previously changed every other day but the TAR has been highlighted every three days. Normally if an order was noticed to be different he/she would look at the physicians orders to clarify a change had been made but he/she had not checked this on yet. During an interview on 11/05/21 at 12:05 P.M. The Director of Nursing said she would expect the physician's orders to be followed and if the order said to change the IC every other day it should be changed and documented. The DON said she thought it was most likely done and staff failed to document it. Record review of the facility's policy titled Tracheostomy Care, dated August 2013, showed: - Tracheostomy care should be provided as often as needed; - At least once daily for old established tracheotomies.

Based on observation, interview and record review, the facility failed to provide thorough assessments, orders, monitoring and on-going communication with dialysis (process for removal of waste and excess water from the blood due to kidney failure) center for one resident (Resident #40) out of a sample of two residents receiving dialysis treatments. The facility census was 64. Review of the facility's Dialysis-General Guidelines and Management Policy/Procedure, dated May 2017, showed: -Policy: -It is the policy of this home that dialysis residents will receive services as per physician's orders and will be monitored accordingly; -Hemo-Dialysis involves shunting the resident's blood from the body through a dialyzer (machine used in dialysis treatments) in which diffusion and ultrafiltration occur and back into the resident's circulation. To perform hemo-dialysis there must be access to the resident's blood, a mechanism to transport the blood to and from the dialyzer, and a dialyzer (area in which the exchange of fluid electrolytes and waste products occurs). This dialysis access is usually in the form of a graft/shunt (device aids the connection from the dialysis access point to a major artery) placed in the arm or Central Line Intravenous catheter access; -Potential complications after Hemo-Dialysis: -Headache; -Nausea and vomiting; -Postural hypotension (positional low blood pressure); -Dizziness and fainting; -Nursing intervention: -1. Avoid taking blood pressure and or wearing constrictive clothing of limb containing access; -2. Monitor for signs/symptoms of access site for infection or occlusion by bruit (loud swishing noise heard with a stethoscope/thrill (vibration sound over the dialysis access site) observations or central line observations of possible swelling or redness to the area; -3. Dialysis center to complete labs and administer medications as needed (PRN); -4. Monitor for signs and symptoms of bleeding from access site; -5. Keep open communication with dialysis center and facility physician and nursing staff. Review of Resident #40's medical record, showed: -An admission face sheet, an admission date of 2/16/21 and readmission date of 10/15/21; -Diagnoses included acute kidney failure (a condition in which the kidneys suddenly can't filter waste products from the blood) and dependence on renal (kidney) dialysis. Review of the resident's physician's order sheet (POS), dated 11/1/21 through 11/30/21, showed: -An undated order, for dialysis three times a week on Monday, Wednesday and Friday; -No order for location and/or name of the dialysis center; -No orders to assess and monitor the dialysis access site for signs/symptoms of infection and/or bleeding; -No order to assess the resident's dialysis access site for bruit/thrill every shift; -No orders to assess and monitor the resident's condition/status before and after dialysis. Review of the resident's medication administration record (MAR) and treatment administration record (TAR), dated 10/15/21 through 10/31/21 and 11/1/21 through 11/30/21, showed no documentation by nursing staff for assessments and/or monitoring the resident's dialysis access site for signs/symptoms of bleeding, infection, redness and/or swelling before and after dialysis. No documentation of the resident's condition/status before/after dialysis treatments. No assessments of checking the resident's dialysis access site for bruit/thrill every shift. Review of the resident's nurse's notes/progress notes, dated 10/1/21 through 11/5/21, showed no on-going, thorough assessments and monitoring of the resident's dialysis access site for signs/symptoms of infections, bleeding, redness, warmth or swelling every shift. No documentation of the resident's condition before/after dialysis treatments. No on-going communication between the dialysis center and facility regarding the resident's dialysis treatments every Monday, Wednesday and Friday of each week. Review of the dialysis communication binder, maintained at the B Wing nurse's station, for resident's on 500 and 600 Halls, showed no communication sheets completed for the resident between the facility and dialysis center. Observation on 11/3/21 at 11:50 A.M., showed the resident sat in the wheelchair with an undated, dry dressing covered his/her dialysis access site/port in his/her right upper chest area. The resident said he/she receives dialysis treatments every Monday, Wednesday and Friday. The resident said nursing staff does not assess and/or monitor his/her dialysis access site and does not receive any communication forms to take to his/her dialysis treatments from the facility. The resident said the dialysis center does the dressing changes on his/her dialysis access port every week. During an interview on 11/5/21 at 2:45 P.M., the Director of Nurses (DON) said residents receiving dialysis should have complete physician's orders for dialysis, how often to receive dialysis, location of the dialysis center, assess/monitor the resident's dialysis access site for signs/symptoms of infection, bleeding, bruit/thrill every shift and assess/monitor the resident before and after dialysis treatments. The DON said nursing staff should document the residents assessments/monitoring in the nurse's notes/progress notes and/or TAR. She expected on-going communication between the facility and dialysis center to be documented on the resident's dialysis communication forms and/or in the nurse's notes/progress notes. The DON said dialysis is a very invasive procedure and nursing staff should complete a thorough, on-going assessment/monitoring of all residents who receive dialysis treatments.

Based on observation and interview, the facility failed to ensure staff dated insulin vials and Flexpens (prefilled injectable insulin) once they were opened and discard outdated insulin vials for two of two medication carts checked and failed to store all drugs under proper temperature controls in the medication refrigerator on the B hall. The facility census was 64. 1. Review of the facility's Insulin Administration Policy, dated September 2014, showed: -Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes mellitus (DM, condition that affects the way the body processes blood sugar); -Preparation: The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to use; -Steps in the procedure (insulin injections); -Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record the expiration date and time on the vial (follow manufacturer recommendations for expiration after opening); -The facility's policy did not address staff to date the insulin vial and/or flexpens with the date when opened; -The facility's policy did not address for staff to discard opened, outdated insulin vials and/or flexpens. 2. Observation on 11/2/21 at 10:16 P.M., of the nurse's medication cart for 500, 600, 700, and 800 Halls, showed: -One Lantus (long acting) insulin vial opened without a date written when opened; -One Humalog (fast acting) insulin vial opened without a date written when opened; -One Novolog (fast acting) insulin vial opened and dated 7/28/21; -One Novolog insulin vial opened and dated 7/29/21; -One Novolog insulin flexpen opened without a date written when opened. During an interview on 11/2/21 at 10:16 P.M., Licensed Practical Nurse (LPN) A said all the opened insulin vials and flexpens are in use on the residents on the 500, 600, 700, and 800 Halls. LPN A verified the one Lantus and one Humalog insulin vials were opened/not dated when opened, one Novolog insulin flexpen was opened/not dated when opened, one Novolog insulin vial was opened/dated 7/28/21 and one Novolog insulin vial was opened/dated 7/29/21. The LPN said nursing staff should date the insulin vials/flexpens with the date when opened and should administer for up to 30 days from the date when opened due to the stability of the insulin. 3. Observation on 11/2/21 at 11:10 P.M. of the nurse's medication cart for 100, 200 , 300, and 400 halls showed: -One flexpen (injectable insulin), opened and dated with an expiration date of 7/28/21. During an interview on 11/2/21 at 11:12 P.M. the LPN I said he/she did not realize the flexpen was out of date. LPN I said he/she said the flexpen should be discarded after 28 days of use and he/she would replace it. During an interview on 11/5/21 at 2:45 P.M., the Director of Nurses (DON) said nursing staff should date the resident's insulin vial and/or flexpen with the date when opened and should administer the insulin for up to 28 days from date when opened. The charges nurses are responsible to check the insulin vials/flexpens for the date when opened before they administer the insulin. The DON said nursing staff should discard opened, outdated insulin vials/flexpens, notify the pharmacy and/or pull a new insulin vial/flexpen from the emergency kit for all opened, outdated insulin. The DON said she expected nursing staff to follow the facility's insulin administration policy. 4. Record review of the facility's policy on Refrigerators and Freezers, dated December 2014 showed: -The facility will ensure safe refrigerator and freezer maintenance, and temperatures; -Acceptable temperature ranges are 35 degrees (°) Fahrenheit (F) to 40 °F for refrigerators; -Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures; -The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. Record review of the Medication Refrigerator Temperature and Care Log, dated October 2021 showed: - Temperatures not checked nine times out of 31 opportunities. Record review of the Medication Refrigerator Temperature and Care Log, dated November 2021 showed: - On November 1, 2021, defrosting; - On November 2, 2021, 28 °F; - On November 3, 2021, 27 °F; - On November 4, 2021, 25 °F. Observation on 11/5/21 at 11:15 A.M. of the refrigerator in the nurses medication room on the 500, 600, 700, and 800 hall showed: - Unopened insulin(used to treat diabetes) included the following: - 10 Lantus pens; - 3 Levemir (long acting) flex touch pens; - 1 Lantus 10 milliliter (ml) bottle; - 1 Humulin (fast acting) R 3 ml bottle; - 1 Humulin N 3 ml bottle; - 1 Humulin 70/30 3 ml bottle; - 1 Humalog 3 ml bottle; - 5 Lispro (fast acting) bottles; - 7 Novolog pens. During an interview on 11/5/21 at 11:35 A.M. LPN J said the refrigerator temperatures should be about 34 °F or so, the night shift nurse is responsible for checking and documenting the temperatures of the medication room refrigerators. During an interview on 11/5/21 at 2:55 P.M., the DON said the maintenance staff had defrosted and repaired this particular refrigerator earlier this week. It may need to be replaced if we cannot get the temperatures corrected. The DON said the night nurse is responsible for checking the temperatures of the refrigerators that are in the medications rooms. She also said she had contacted the pharmacy that supplies the facility with their medications and was told the temperatures of the refrigerators should be kept between 36 °F and 46 °F for storage of the medications. The DON also said the all of the medications were discarded and will be replaced.