Based on observation, interview, and record review, the facility failed to follow standards of practice and ensure proper administration of physician ordered insulin (medication used to treat diabetes) via an insulin pen for one resident (Resident #6), in a review of 14 sampled residents. Staff failed to hold the insulin pen in place for the appropriate amount of time during administration per policy and per the manufacturer's instructions. Failure to follow this procedure for administration results in residents not receiving the ordered dose of insulin. The facility census was 37. Review of the facility's policy, Insulin Administration, dated 6/14/23, showed to depress the plunger and remove the needle after approximately five seconds. Review of the Novolog (fast acting insulin) Flex Pen manufacturer instructions, last revised February 2023, showed the following: -Put the needle into the skin all the way; -Keep the button pressed and slowly count to ten before taking the needle out of the skin. 1. Review of Resident #6's Continuity of Care Document (CCD) showed the resident's diagnoses included Type 2 diabetes mellitus with hyperglycemia (blood sugar elevated to potentially dangerous levels). Review of the resident's physician orders, dated December 2023, showed the following: -Novolog FlexPen U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/mL (3 mL); amount: 5 units; subcutaneous. Give 5 units three times a day (TID) with meals with additional sliding scale; -Novolog Flex Pen U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/mL (3 mL); amount: per sliding scale TID; -If blood sugar is 150-200, give 2 units; -If blood sugar is 201 to 250, give 4 units; -If blood sugar is 251 to 300, give 6 units; -If blood sugar is 301 to 350, give 8 units; -If blood sugar is 351 to 400, give 10 units; -If blood sugar is greater than 400, call physician. Observation on 12/12/23 at 7:10 A.M. showed Licensed Practical Nurse (LPN) J dialed the insulin Novolog FlexPen to 7 units and administered the insulin into the resident's arm. LPN J removed the pen (needle) from the resident's skin immediately after injecting the insulin. LPN J did not wait ten seconds before taking the needle out of the resident's skin. During an interview on 12/12/23 at 7:10 A.M., LPN J said he/she never holds the needle in the skin when he/she administers insulin. During an interview on 12/13/23 at 6:00 P.M., the Director of Nursing (DON) said she expected staff to follow manufacturer's recommendations for insulin administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff safely transferred one resident (Resident #12), who had left side weakness and required two staff assistance for transfers, in a review of 14 sampled residents. The facility failed to ensure staff transported two residents (Resident #14 and #18) safely in wheelchairs with foot rests/pedals. During staff transport of Resident #18, his/her feet touched the floor and he/she fell forward, out of the wheelchair, striking his/her forehead on the floor. During staff transport of Resident #14, his/her feet drug the ground and caused the resident to jolt forward in his/her wheelchair. The facility census was 37. Review of the facility's undated policy, Wheelchair Pedals, showed the following: -All residents who require staff to propel them in a wheelchair are to have bilateral pedals on; -This is to ensure the resident's safety; -If a resident is refusing pedals, education needs to be provided to that resident and their person; -A progress note needs to be made that the education has been provided and the resident is still refusing to utilize the pedals; -The resident or person needs to sign a copy of our wheelchair policy stating they know the risks associated with no pedals and still do not want them; -It will then be care planned to not have the pedals. Review of the undated facility policy, Mandatory Gait Belt, showed the following: -All nursing staff will keep a gait belt on them at all times. It is part of the certified nurse assistant (CNA) uniform, available for immediate use. Gait belts will be used with one and two person transfers; -If the resident is refusing to allow staff to use a gait belt, education needs to be provided to the resident related to the importance of its use and risks for not using. If the resident continues to refuse, a progress note needs to be made each time there is a refusal. Need to work on getting itcare planned. A real reason needs to be noted, not just I don't like it; -Gait belts will be provided in every one room, for every resident. They will be hung on the closet door. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/19/23, showed the following: -Cognitively intact; -Lower and upper extremity functional limitation in range of motion on one side; -Dependent on staff for sit to stand and chair/bed to chair transfer; -Weight 267 pounds. Review of the resident's care plan, dated 11/14/23, showed the resident required assistance from two staff for transfers due to his/her left hemiplegia (paralysis on one side of the body). Observation on 12/12/23 at 5:28 A.M. showed the following: -The resident lay awake in bed; -A gait belt hung on the wall behind the bathroom door; -Licensed Practical Nurse (LPN) G and Certified Nurse Assistant (CNA) H entered the resident's room; -LPN G and CNA H assisted the resident to a sitting position on the side of the bed; -Without the use of a gait belt or a second staff member to assist, CNA H placed his/her left arm under the resident's left arm and assisted the resident to stand; -The resident placed his/her right hand on the mobility bar to steady himself/herself while he/she stood; -The resident was incontinent of a small amount of feces; -LPN G provided perineal care while the resident stood at the side of the bed; -CNA H held the resident in a standing position by holding under the resident's left arm as LPN G provided pericare; -LPN G applied a clean incontinence brief and pulled up the resident's pants; -CNA H assisted the resident to pivot to the wheelchair. During an interview on 12/12/23 at 5:46 A.M., CNA H said he/she doesn't usually use a gait belt to transfer the resident because the resident does pretty good with transfers. During an interview on 12/12/23 at 6:35 A.M., LPN G said the resident will often refuse to let staff use the gait belt with transfers, but the staff should offer use of the gait belt each time. During an interview on 12/13/23 at 9:04 A.M., Occupational Therapist F said the following: -The resident was discharged from skilled therapy as staff assist of two for transfers; -If staff have to transfer a resident who requires hands-on assistance, staff should use a gait belt for safety; -A gait belt gives staff something to hold onto in case the resident becomes unsteady. 2. Review of Resident #18's Continuity of Care Document (CCD) showed the resident's diagnoses included disorientation, age-related physical debility, muscle weakness (generalized), weakness, unsteadiness on feet, and unspecified fall. Review of the resident's nurse's note, dated 10/23/23 at 11:57 A.M., showed at 8:15 A.M. it was reported to the nurse that the resident fell forward out of his/her wheelchair while staff attempted to push the resident's wheelchair without the use of foot pedals. Record review of Certified Medication Technician (CMT) P's witness statement, dated 10/23/23, showed he/she was passing medications when CNA B came out of the resident's room with the resident in the wheelchair. The resident's feet touched the floor and the resident fell forward out of the wheelchair striking his/her forehead on the floor. Foot petals were not in place. Record review of CNA B's witness statement, dated 10/23/23, showed he/she was pushing the resident out of his/her room via his/her wheelchair. The resident put his/her feet on the floor and fell out of the wheelchair and bumped his/her head. Review of the resident's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Substantial to maximal assistance required from staff for sitting to standing and transfers; -Uses manual wheelchair and walker for mobility. 3. Review of Resident #14's Continuity of Care Document (CCD) dated 12/13/23, showed the resident's diagnoses included dementia, muscle weakness, unsteadiness on feet, lack of coordination, reduced mobility, and need for assistance with personal care. Review of the resident's quarterly MDS, dated 11/1023, showed the following: -Cognition is severely impaired; -The resident uses a wheelchair for mobility. Review of the resident's care plan, updated 12/6/23, showed the following: -The resident is a fall risk due to weakness and dementia which causes him/her to forget where he/she is and were he/she is going; -The resident requires assistance of one staff member for transfers; -The resident uses a wheelchair for longer distances. Observation on 12/12/23 at 6:30 A.M. showed the following: -CNA L pushing the resident down the hallway toward the shower room with no foot pedals on his/her wheelchair; -The resident was wearing non-skid socks and his/her feet got stuck on the floor; -The resident's head and upper torso suddenly jolted forward in the wheelchair; -CNA L said Oh, pick your feet up, buddy!. During interview on 12/12/13 at 6:35 A.M., CNA L said the following: -The resident normally will hold his/her feet up; -He/She was reminding the resident to lift his/her feet. During an interview on 12/13/23 at 6:00 P.M., the Director of Nursing (DON) said she would expect staff to provide food pedals/foot rests for all residents who require transfer by wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate care and services to an urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine) consistent with acceptable standards of practice, for two residents with a urinary catheter (Residents #4 and #18), in a review of 14 sampled residents. The facility census was 37. Review of the Nurse Assistant in a Long Term Care Facility, 2001 revision, showed the following: -The bladder is considered sterile, the catheter, drainage tubing and bag are a sterile system; -Drainage tubing/bags must not touch the floor. Review of the facility policy, Catheter Care and Emptying Drainage Bag, dated 4/5/23, showed the following: -The purpose of this procedure is to prevent catheter associated urinary tract infections; -Keep drainage bag below the bladder level and be sure bag/tubing is free from the floor contact. Place drainage bag into protective cover. 1. Review of Resident #18's Continuity of Care Document (CCD) showed the resident's diagnoses included neuromuscular dysfunction of bladder, disorder of kidney and ureter, chronic kidney disease, urinary tract infection, and sepsis. Review of the resident's nurse's note, dated 9/28/23 at 4:37 P.M., showed an order for Keflex (an antibiotic) 500 milligrams (mg) by mouth twice daily for five days for urinary tract infection (UTI). Review of the resident's nurse's note, dated 9/28/23 at 10:15 P.M. showed the following: -The resident was exhibiting a low grade fever of 98.9; -The resident was cooperative, but also appeared to exhibit difficulties breathing; -The resident's temporal temperature continued to rise to 100.1; -The resident had a grimace on his/her face, but not able to verbalize discomfort; -The resident was sent to emergency room (ER) at 10:15 P.M. -Hospital called to inform the facility that the resident was in serious situation, and that he/she may have had an allergic reaction to one of the antibiotics administered today; -The attending Physician was yet to determine a Diagnosis of UTI or a reaction to the antibiotic. Review of the resident's nurse's note, dated 09/30/23 at 12:02 A.M. showed the following: -The charge nurse contacted the hospital to inquire about the health status of the resident and plans for his/her return; -The charge nurse was informed that the resident was diagnosed with sepsis due to UTI. Review of the resident's nurse's note, dated 10/1/23 at 7:00 P.M., showed the following: -The resident returned to the facility; -New order received for Levaquin (an antibiotic) 75 mg on 10/3/23 for one dose. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 10/25/23, showed the following: -Severely impaired cognition; -Dependent on staff for toileting, showering, lower body dressing, and putting on footwear; -Substantial to maximal assistance required from staff for upper body dressing, rolling left to right, sitting to lying, sitting to standing, and transfers; -Resident has indwelling catheter; -Occasionally incontinent of urine; -Frequently incontinent of bowel. Review of the resident's care plan, updated 10/31/23, showed the following: -The resident had a urinary catheter but had occasional episodes of bladder and bowel incontinence; -The resident required assistance for all activities of daily living (ADL's); -The resident requires assistance from two staff for transfers, toileting, and dressing; -Monitor the resident for incontinence and provide the resident with good peri-care with all incontinent episodes; -Provide resident with good catheter care every shift. During an interview on 12/10/23 at 1:40 P.M., the resident's family member said the resident gets frequent UTIs. Observation on 12/11/23 at 9:35 A.M. showed the resident lay asleep in bed. His/Her bed was in the low position and the catheter bag lay on the floor. Observation on 12/12/23 at 5:40 A.M. showed the resident lay asleep in bed. His/Her bed was in the low position, and the catheter bag lay on the floor. Observation on 12/13/23 at 3:35 P.M. showed the resident lay asleep in bed. His/Her bed was in the low position, and the catheter bag lay on the floor. 2. Review of Resident #4's care plan, dated 7/17/23, showed the resident had a urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine). Review of the resident's August 2023 physician order sheet (POS) showed the following: -Diagnoses included neurogenic bladder (the lack of bladder control due to a brain, spinal cord or nerve condition); -Urinary catheter (original order dated 07/20/23). -An order dated 8/23/23 for Cipro (an antibiotic) 500 mg one by mouth two times daily for five days for UTI. Review of the resident's September 2023 POS showed: -Indwelling urinary catheter (original order dated 07/20/23); -An order dated 9/6/23 for Cipro 500 mg one by mouth two times daily for five days for UTI. -An order dated 9/21/23 for Cipro 500 mg one by mouth two times daily for five days for UTI. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a urinary catheter. Observations on 12/12/23 showed the following: -At 5:15 A.M., the resident lay in his/her bed. The urinary drainage bag, contained within a dignity bag, lay on the floor; -At 5:25 A.M., CNA C emptied the resident's urinary drainage bag, put the drainage bag in the dignity bag and laid it on the floor. During an interview on 12/12/23 at 5;25 A.M., CNA C said he/she always put the catheter drainage bag on the floor. During an interview on 12/13/23 at 6:00 P.M., the Director of Nursing (DON) said the following: -The urinary catheter bags should be in a privacy bag and should not be touching the floor. -She would not expect the catheter drainage bags to be touching/lying on the floor.

Based on observation, interview, and record review, the facility failed to administer the correct dosage of levothyroxine (a medication to treat hypothyroidism, a condition in which the thyroid doesn't produce enough thyroid hormone) from the order date of 10/4/23 through 12/12/23 for one resident (Resident #33), in a review of 14 sampled residents. The facility census was 37. Review of the facility's undated policy, Medication Error, showed the following: -A medication error is the failure to administer medications as prescribed and/or the administration of medication not prescribed by a licensed physician/nurse practitioner/physician's assistant, e.g. incorrect dosage, time of administration and/or route, and omission of dosages; -Medication errors include the medication was given in the wrong dosage. Review of Drugs.com for levothyroxine (a medication to treat hypothyroidism, a condition in which the thyroid doesn't produce enough thyroid hormone) showed the following: -Take levothyroxine exactly as prescribed by your physician; -Taking more than the recommended dose will not make this medicine more effective, and may cause serious side effects; -Symptoms of overdosage of levothyroxine include change in consciousness, confusion, disorientation, loss of consciousness, and sudden loss of coordination; -Other side effects include diarrhea, muscle weakness, unusual tiredness or weakness. 1. Review of Resident #33's Continuity of Care Document (CCD), dated 12/12/23, showed the resident's diagnoses included hypothyroidism. Review of the resident's nurse's note, dated 10/03/23 at 1:53 P.M., showed the following: -New order received and noted via fax; -Diagnoses: Hypothyroidism; -Begin levothyroxine 12.5 micrograms (mcg) by mouth daily. Review of the resident's Medication Administration Record (MAR) for October 2023 showed the following: -Levothyroxine 25 mcg tablet, take 1/2 tablet daily (12.5 mcg); -Staff documented the resident received the levothyroxine daily (starting 10/4/23). Review of the resident's MAR for November 2023 showed the following: -Levothyroxine 25 mcg tablet, take 1/2 tablet daily (12.5 mcg); -Staff documented the resident received the levothyroxine daily. Review of the resident's Physician Orders, dated December 2023, showed an order for levothyroxine 25 mcg tablet, take 1/2 tablet daily (12.5 mcg). Give once a morning. Give 12.5 mcg by mouth daily for hypothyroidism (original order dated 10/4/23). Observation on 12/12/23 at 6:05 A.M. showed Certified Medication Technician (CMT) P administered a full 25 mcg tablet of levothyroxine to the resident. Review on 12/12/23 at 6:10 A.M. of the resident's medication card showed the showed the following: -Levothyroxine 25 mcg tablet. Take one tablet daily; -12 of the 14 day dose had been administered/punched out of the card. During an interview on 12/12/23 at 6:10 A.M., Certified Medication Technician (CMT) P said the following: -He/She gave the resident the full tablet the entire time (since the resident started on this medication 10/4/23); -He/She was not allowed to cut a tablet in half. Review of the resident's Medication Administration Record for December 2023 showed the following: -Levothyroxine 25 mcg tablet, take 1/2 tablet daily (12.5 mcg); -The resident received levothyroxine daily (through 12/12/23). During an interview on 12/12/23 at 10:00 A.M., the pharmacist said the following: -The pharmacy had been filling the one tablet of 25 mcg daily since they received the order on 10/3/23; -The pharmacy technician translates the order and must have missed the directions of 1/2 tab. Review of the Medication Error Report, dated 12/12/23, showed the following: -Full dose of 25 mcg had been given daily for two to three full cards; -Incorrect order printed on card from pharmacy; -The resident received more medication than ordered. During an interview on 12/13/23 at 9:00 A.M., Licensed Practical Nurse (LPN) T said the following: -He/She does not recall ever cutting any medication in half since he/she has worked at the facility; -If a CMT would require a medication to be cut, they would notify him/her and he/she would have to cut it in half. During an interview on 12/12/23 at 1:50 P.M., LPN J said staff should have been checking the medication card for levothyroxine against the physician order. During an interview on 12/13/23 at 6:00 P.M., the Director of Nursing (DON) said the following: -She would expect staff to follow physician's orders for administering medications; -She would expect staff to match the medication dosage on the medication card to the physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for three residents (Resident #10, #12 and #25), in a review of 14 sampled residents. The facility census was 37. Review of the facility's policy, Care Plans-Comprehensive, revised 2010, showed the following: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -The facility's care planning/Interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS; -Each resident's comprehensive care plan is designed to: -a. Incorporate identified problem areas; -b. Incorporate risk factors associated with identified problems; -c. Build on the resident's strengths; -d. Reflect the resident's expressed wishes regarding care and treatment goals; -e. Reflect treatment goals, timetables and objectives in measurable outcomes; -f. Identify the professional services that are responsible for each element of care; -g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; -h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and -i. Reflect currently recognized standards of practice for problem areas and conditions; -Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or care area triggers in isolation may have little, if any, benefit for the resident; -Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process; -Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change; -The care planning/interdisciplinary team is responsible for the review and updating of care plans: -a. When there has been a significant change in the resident's condition; -b. When the desired outcome is not met; -c. When the resident has been readmitted to the facility from a hospital stay, and; -d. At least quarterly. 1. Review of Resident #25's Continuity of Care Document (CCD), undated, showed the following: -The resident was admitted to the facility on [DATE]; -The resident had a legal guardian; -Medical diagnoses included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbance, psychotic (a disconnection from reality) disturbance, mood disturbance or anxiety; Type 2 diabetes mellitus (too much sugar in the bloodstream) without complications; depression (a common mental disorder characterized by persistent sadness and a lack of interest or pleasure in previously enjoyable activities), and atherosclerotic heart disease (damage or disease in the heart's major blood vessels) of native coronary artery (the main blood vessel that supplies blood to the left side of the heart muscle) without angina pectoris (chest pain). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/29/23, showed the following: -Cognitively impaired; -No behavioral symptoms; -Required substantial to maximal assistance for mobility; -Received an antipsychotic medication; -No indication the resident received insulin, an antiplatelet or an antidepressant medication. Review of the resident's December 2023 physician orders sheet showed the following: -Aricept (a medication used to slow the progression of dementia) 10 milligrams (mg), one tablet by mouth daily (original order dated 09/01/22); -Clopidogrel (an antiplatelet medication used to help prevent the body from forming blood clots, often used to prevent heart attacks or strokes) 75 mg tablet, one tablet by mouth daily, (original order dated 03/25/22); -Duloxetine (a medication used to treat depression) delayed release, 30 mg capsule by mouth twice a day (original order dated 4/13/23); -Levemir FlexTouch U-100 insulin (a medication to treat diabetes), 27 units subcutaneous (beneath the skin) twice a day (original order dated 04/21/23); -Memantine (a medication used to treat dementia) extended release (ER) capsule 24 hour, sprinkle, one table by mouth daily; -Novolog Flexpen U-100 insulin, two units with meals three times a day, subcutaneous, give in addition to sliding scale. Hold if blood sugar (BS) less than 110 milligrams per deciliter (mg/dl); -Novolog Flexpen U-100 insulin per sliding scale, subcutaneous, four times a day, with meals and at bedtime. Hold if BS is less than 110 mg/dl; if BS is 150-200 mg/dl, give two units; if BS is 201-250 mg/dl, give four units; if BS is 251-300, give six units; if BS is 301-350, give eight units; if BS is 351-400, give 10 units; if BS is 401-450, give 12 units; if BS is greater than 451, call nurse practitioner (NP) or physician; -Seroquel (an antipsychotic medication) 25 mg, one tablet by mouth two times a day (original order dated 04/13/23). Review of the resident's current care plan, last revised 07/05/23, showed no evidence staff updated the care plan to include the following: -Diagnosis of dementia, goals or individualized interventions to include the use of medications Aricept and memantine; -Diagnosis of diabetes mellitus (DM), goals or individualized interventions to include the use of insulin therapy; -Diagnosis of depression, goals or individualized interventions to include the use of the medication duloxetine; -Diagnosis of atherosclerotic heart disease, goals or individualized interventions to include the use of the antiplatelet medication clopidogrel; -Use of an antipsychotic medication Seroquel, goals or individualized interventions. 2. Review of Resident #10's physician's orders, dated 7/5/23, showed an order for regular diet and house supplement (nutritional supplement) three times a day (TID) with meals. Review of the resident's weight record dated 7/12/23 showed the resident weighed 109 pounds. Review of the resident's care plan, dated 7/18/23, showed the following: -The resident is on a regular diet and can feed himself/herself; -Make sure he/she is getting food/drinks that he/she likes to eat/drink; -Monitor his/her weight monthly. Report any abnormal weights to the charge nurse so he/she can notify the physician. Review of the resident's care plan showed no documentation regarding house supplements with meals. Review of the resident's weight record showed the following: -On 8/4/23, the resident weighed 100.5 pounds; -On 9/13/23, the resident weighed 101 pounds; -On 10/5/23, the resident weighed 97 pounds; -On 11/29/23, the resident weighed 91.5 pounds. Review of the resident's physician's orders, dated 12/4/23, showed an order for weekly weights. Review of the resident's weight record, dated 12/5/23, showed the resident weighed 89.5 pounds. (Review showed the resident had a 17.9% weight loss from 7/12/23 through 12/5/23.) Review of the resident's care plan showed no documentation regarding continued weight loss and new order for weekly weights. 3. Review of Resident #12's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis of diabetes and renal failure. Review of the resident's care plan, dated 11/14/23, showed the following: -He/She has a fistula/graft (a connection that's made between an artery and a vein for dialysis access) in his/her right upper arm for hemodialysis (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately) related to renal failure; -Avoid unnecessary diagnostic procedures in right arm. No finger sticks, blood pressures or labs are to be done in right arm; -He/She had to have his/her right upper arm shunt (the connection from a hemodialysis access point to a major artery) declotted in March and April 2023. He/She has hospitalized both times. He/She had to have a permcath (a flexible tube used for dialysis treatment placed into the blood vessel in the neck or upper chest) placed in April and have dialysis through it; -Monitor and report signs of localized infection in right arm (localized swelling, redness, pain or tenderness, heat at the infected area, purulent drainage, loss of function). Review of the resident's nurse's notes, dated 11/20/23 at 7:59 P.M., showed the following: -The resident returned to the facility from the hospital; -Permcath placed on left upper chest for dialysis; -Resident plans to schedule with physician to place permanent fistula. Observation on 12/12/23 at 5:28 A.M. showed the following: -The resident lay awake in bed; -The resident had scarring on the inner side of both arms; -The resident had a permcath present on his/her left upper chest. Review of the resident's care plan showed no documentation regarding the removal of the fistula from the resident's right arm and placement of a permcath in his/her left upper chest in November 2023. During an interview on 12/10/23 at 1:30 P.M. the resident said the following: -He/She has had fistulas in both of his/her arms. Both of his/her fistulas went bad; -He/She currently has a perm-cath in his/her left chest which is managed by the dialysis clinic; -The only thing the facility staff does is reinforce the perm-cath dressing if it comes undone. 4. During an interviews on 12/12/23 at 12:15 P.M. and 12/13/23 at 3:15 P.M., the MDS/care plan coordinator said the following: -She is responsible for completing the initial and comprehensive care plans for residents; -She is responsible for updating care plans with a significant change, with any change or new concerns, or every three months following a care plan meeting with the resident and/or resident representative; -She tried to update care plans when changes in a resident's status occurred, but didn't always get those completed; -Care plans should reflect a resident's specific care areas, goals and interventions. During an interview on 12/13/23 at 6:00 P.M., the director of nurses (DON) said care plans should be updated to reflect a resident's needs and/or changes in status when they occur.

Based on interview and record review, the facility failed to ensure three nurse aides (NA C, NA D and NA E) completed a nurse aide training program within four months of their employment in the facility. The facility census was 37. 1. Review of the undated list of NA's employed by the facility showed the following: -NA C's date of hire was 2/27/23; -NA D's date of hire was 5/15/23; -NA E's date of hire was 2/27/23. 2. Review of NA C's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. 3. Review of NA D's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. 4. Review of NA E's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. During an interview on 12/13/23 at 3:00 P.M. NA D said he/she was working evening shift. He/she was working full time and was not enrolled in Certified Nurse Aide (CNA) class. During an interview on 12/13/23 at 10:15 A.M. and 12:55 P.M. the Director of Nursing said the following: -She has only been the Director of Nursing for approximately one month; -She was aware NAs are to be certified within a period of time; -The facility does not have a policy for completion of CNA classes within four month of hire, but CNA classes should be completed per the regulation. -NA C is currently not in CNA class. He/She was going to move and he/she put in his/her two weeks notice but his/her plans changed; -NA D was PRN (as needed) and just recently came back to work full time. NA D was currently not in CNA class; -NA E was in CNA class, but she was not sure how far along the CNA was in the class.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to adequately document appropriate diagnoses of residents or resident behaviors to justify the implementation or continued used of antipsychotic medications (a type of psychiatric medication used to treat certain types of mental health problems, such as schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), for three residents (Residents #10, #21 and #25) in a review of 14 sampled residents. The facility also failed to complete a 14 day review for the as-needed (PRN) use of a benzodiazepine (a drug that produces sedation and hypnosis) for one resident (Resident #21) and one additional resident (Resident #34). The facility census was 37. A review of the facility policy, Antipsychotic Medication Use, dated 3/16/23, showed the following: -Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction (GDR)and re review; -Policy Interpretation and Implementation: -1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms and risks to the resident and others; -3. The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; -4. The attending physician and the facility staff will identify acute psychiatric episodes, will differentiate them from enduring psychiatric conditions; -7. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (DSMM, the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders), current or subsequent editions: -a. Schizophrenia; -b. Schizo-affective disorder; -d. Delusional disorder; -e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); -f. Psychosis in the absence of dementia; -10. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: -b. Persistent or likely to reoccur without continued treatment; -11. Antipsychotic medications will not be used if the only symptoms are one or more of the following: -c. Restlessness; -e. Mild anxiety; -f. Insomnia; -k. Uncooperativeness; -13. Residents will not receive prn doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; -14. The need to continue prn orders for psychotropic medications beyond 14 days require that the practitioner document the rationale for the extended order, the duration of the prn order will be indicated in the order; -15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication; -16. The staff will observe, document and report to the attending physician, information regarding the effectiveness of any interventions, including antipsychotic medications in 30 days; -18. The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Review of www.drugs.com for Seroquel (generic name quetiapine) showed the following: -Seroquel is used to treat schizophrenia and to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder), a disease that causes episodes of depression, episodes of mania, and other abnormal moods); -Seroquel is used in combination with antidepressant medications to treat major depressive disorder in adults; -Seroquel may increase the risk of death in older adults with mental health problems related to dementia; -Potential adverse effects of Seroquel include somnolence (sleepiness), postural hypotension (a drop in the blood pressure when a person stands), motor, and sensory instability, which may lead to falls, and consequently, fractures (broken bones) or other injuries. 1, Review of Resident #10's July 2023 physician's orders showed an order for quetiapine (anti-psychotic medication) 25 milligrams (mg), give ½ tablet (12.5 mg) at bedtime PRN agitation (open ended order with no stop date); order date of 7/5/23. Review of the resident's care plan, dated 7/18/23, showed the following: -The resident is on scheduled clonazepam (anti-anxiety medication) twice daily for diagnosis of anxiety disorder; he/she also takes ramelteon (hypnotic medication) at bedtime and quetiapine PRN agitation; -After administering these medications, monitor for side effects including confusion, muscle weakness, anxiety, dizziness, difficulty breathing or moving, poor coordination or change intastee. If any of these side effects are present, notify the charge nurse; -Monitor the resident for signs/symptoms of anxiety, such as restlessness, feeling light-headed or dizzy, hot flashes or sweating, headache, or other aches and pains, fast breathing or feeling like pins and needles. If any of these are present, notify the charge nurse. Review of the resident's Medication Administration Record (MAR), dated 7/1/23-7/31/23, showed staff documented on 7/27/23 at 12:17 P.M., the resident received quetiapine 25 mg ½ tablet by mouth for restlessness and agitation. Staff documented the medication was effective. Review of the resident's physician's orders, dated 8/1/23-8/31/23, showed an order for quetiapine 25 mg give ½ tablet by mouth PRN agitation (open ended order with no stop date), order date of 7/5/23. Review of the resident's MAR, dated 8/1/23-8/31/23, showed no documentation the resident received quetiapine 25 mg give ½ tablet by mouth PRN agitation. Review of the resident's physician's orders, dated 9/1/23-9/30/23, showed an order for quetiapine 25 mg give ½ tablet by mouth PRN agitation (open ended order with no stop date); order date of 7/5/23. Review of the resident's MAR, dated 9/1/23-9/30/23, showed the following: -On 9/21/23 at 3:57 P.M., staff documented the resident received quetiapine 25 mg ½ tablet by mouth for behavior issue. Staff documented the medication was effective; -On 9/26/23 at 4:11 P.M., staff documented the resident received quetiapine 25 mg ½ tablet by mouth for behavior issue. Staff documented the medication was effective; -On 9/27/23 at 4:17 P.M. staff documented the resident received quetiapine 25 mg ½ tablet by mouth for behavior issue. Staff documented the medication was effective. Review of the resident's physician's orders, dated 10/1/23-10/31/23, showed an order for quetiapine 25 mg give ½ tablet by mouth PRN agitation (open ended order with no stop date); order date of 7/5/23. Review of the resident's MAR, dated 10/1/23-10/31/23, showed no documentation the resident received quetiapine 25 mg give ½ tablet by mouth PRN agitation. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 10/18/23, showed the following: -Moderate cognitive impairment; -Diagnoses of malnutrition and anxiety; -Medications included anti-anxiety medication; -As needed (PRN) antipsychotic, no GDR; -No behaviors. Review of the resident's MAR, dated 10/1/23-10/31/23, showed no documentation the resident received quetiapine 25 mg give ½ tablet by mouth PRN agitation. Review of the resident's physician's orders, dated 11/1/23-11/30/23, showed an order for quetiapine 25 mg give ½ tablet by mouth PRN agitation (open ended order with no stop date) (start date 7/5/23). Review of the resident's MAR, dated 11/1/23-11/30/23, showed staff documented on 11/28/23 at 10:01 A.M., the resident received quetiapine 25 mg ½ tablet by mouth for agitation. Review of the resident's physician's orders, dated 12/1/23-12/31/23, showed an order for quetiapine 25 mg give ½ tablet by mouth PRN agitation (open ended order with no stop date) (start date 7/5/23). Review of the resident's MAR, dated 12/1/23-12/31/23, showed staff documented on 12/1/23 at 6:46 A.M., the resident received quetiapine 25 mg ½ tablet by mouth for behavior issue. Staff documented the medication was effective. Review of the resident's pharmacist's recommendations showed no recommendations regarding use of PRN quetiapine. 2, Review of Resident #21's physician's orders, dated 10/19/23, showed an order for quetiapine 25 mg by mouth daily at bedtime for insomnia. Review of the resident's MAR, dated 10/19/23-10/31/23, showed staff documented the resident received quetiapine 25 mg by mouth daily at bedtime for insomnia. Review of the resident's admission MDS, dated [DATE], showed the following: -Short and long term memory problems; -Hallucinations; -No behaviors; -Diagnoses of osteoporosis, fracture, dementia and anxiety; -Two or more no injury falls since last assessment; -One major injury fall since last assessment; -Taking antipsychotic and hypnotic medication; -No GDR. Review of the resident's physician's orders, dated 11/1/23-11/30/23, showed an order for quetiapine 25 mg by mouth daily at bedtime for insomnia. Review of the resident's care plan, dated 11/2/23, showed the following: -He/She is sometimes able to make his/her needs known; -He/She has confusion and memory loss due to dementia/encephalopathy (a brain disease that alters the brain function); -He/She has had fewer episodes of confusion; -No documentation regarding the use of quetiapine 25 mg by mouth daily at bedtime for insomnia. Review of the resident's MAR, dated 11/1/23-11/30/23, showed staff documented the resident received quetiapine 25 mg by mouth daily at bedtime for insomnia. Review of the resident's physician's orders, dated 12/1/23-12/11/23, showed an order for quetiapine 25 mg by mouth daily at bedtime for insomnia. Review of the resident's MAR, dated 12/1/23-12/11/23, showed staff documented the resident received quetiapine 25 mg by mouth daily at bedtime for insomnia. Review of the resident's pharmacist's recommendations dated 8/8/23-12/11/23 showed no recommendations regarding quetiapine for insomnia. 3. Review of Resident #25's undated Continuity of Care Document (CCD), showed the following: -The resident was admitted to the facility on [DATE]; -The resident had a legal guardian; -Medication: Seroquel (antipsychotic used to treat schizophrenia, bipolar disorder and depression) 25 mg, one tablet by mouth two times a day for diagnosis of depression; -Medical diagnoses depression, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety. Review of the resident's physician progress notes, dated 03/31/23, showed the resident's nurse practitioner (NP) documented the following: -Chronic medical condition of dementia without behavioral disturbance and depressive disorder; -The resident was sitting in his/her recliner with no concerns; -Psychiatric findings normal; -Continue current medications and treatments. Review of the resident's physician progress notes, dated 04/21/23, showed the resident's physician documented the following: -Chronic medical condition of dementia without behavioral disturbance and depressive disorder; -Psychiatric findings normal; -The resident's chronic medical conditions are stable at this time, continue all current medications and treatments. Review of the resident's care plan, last revised 07/05/23, showed no focus, goals or interventions specific to the use of the antipsychotic medication, Seroquel. Review of the resident's physician progress notes, dated 07/26/23, showed the resident's NP documented the following: -Chronic medical condition of dementia without behavioral disturbance and depressive disorder; -The resident was sitting in his/her recliner with no complaints; -Psychiatric findings normal; -Continue current medications and treatments. Review of the resident's nursing progress notes, from 08/01/23 through 12/01/23, showed no documentation of behaviors related to his/her diagnosis of dementia without behavioral disturbance. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively impaired; -No behavioral symptoms; -Required substantial to maximal assistance for mobility; -Medical diagnosis of dementia and depression; -One fall during the look back period; -Received an antipsychotic medication; -No GDR, declined by provider. Review of the document, Pharmacist Drug Regimen Review, dated 10/10/23, showed the following: -The consulting pharmacist documented the resident took quetiapine 25 mg two times daily; -She requested that the provider consider a dose reduction for the resident; -Facility staff wrote: Resident's behaviors stable at this time. Please advise on the document and faxed it to the provider; -The resident's provider wrote Continue the current dose on 10/17/23. Review of the resident's physician's order sheet for December 2023, showed an order for Seroquel 25 mg by mouth two times daily, with no specific medical diagnosis listed, no end date (original order date of 04/13/23). Observation on 12/10/23 at 3:00 P.M., showed the resident lay in his/her bed and appeared to be sleeping. Observation on 12/11/23 at 2:15 P.M., showed the resident sat in his/her recliner and was calm and cooperative during an interview with the surveyor. Observation on 12/12/23 at 5:30 A.M., showed the resident lay in his/her bed and appeared to be sleeping. Observation on 12/12/23 at 6:15 A.M., showed staff transferred the resident by wheelchair to the shower room and he/she appeared calm. During an interview on 12/12/23 6:30 A.M., Certified Nurse Assistant (CNA) L said the following: -The resident was cooperative with bathing; -He/She was not aware of any behaviors by the resident, he/she was usually pretty good (calm) with cares. Observation on 12/12/23 at 10:40 A.M., showed the resident appeared to be sleeping in his/her recliner. Observation on 12/13/23 at 9:00 A.M., showed the resident sat in his/her recliner and appeared to be sleeping. During an interview on 12/13/23 at 12:00 P.M., the resident's legal guardian said the following: -When the resident first arrived at the facility, he/she was a little grouchy and would refuse his/her care at times; -The resident had been doing well now for at least six months and he/she had not been notified of any issues or behaviors. During an interview on 12/13/23 at 2:55 P.M., Licensed Practical Nurse (LPN) R said the following: -He/She was not aware of any behaviors by the resident; -If a resident had behaviors, staff would document those in the nurse's note section of the chart, there are no specific behavior documentation flow sheets. 4. Review of Resident #34's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -No behaviors; -Diagnoses of dementia, anxiety and depression; -Not taking antianxiety medication. Review of the resident's care plan, dated 9/6/23, showed the following: -Diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, depression and anxiety; -The resident is sometimes tearful and upset, not knowing where he/she is or what he/she should be doing. This happens mostly in the evenings; -He/She was started on Zoloft (anti-depressant medication) on 8/28/23 for depression; -Monitor the resident after administering Zoloft for side effects such as nausea, decreased appetite, tremor, shaking, agitation, sweating and feeling tired; -The resident has short term memory loss due to his/her diagnosis of dementia; -The resident is usually oriented to self and place. He/She frequently needs re-oriented to time. Review of the resident's November 2023 physician's orders showed an order for lorazepam (anti-anxiety medication) 0.5 mg by mouth at bedtime PRN (open ended order with no stop date); order date of 11/21/23. Review of the resident's MAR, dated 11/21/23-11/30/23, showed the following: -On 11/27/23 at 5:17 A.M., staff documented the resident received lorazepam 0.5 mg by mouth for sitting up in bed crying. Staff documented the medication was effective; -On 11/30/23 at 7:26 A.M., staff documented the resident received lorazepam 0.5 mg by mouth for anxiety. Staff documented the medication was effective. Review of the resident's physician's orders, dated December 2023, showed an order for lorazepam 0.5 mg by mouth at bedtime PRN (open ended order with no stop date); order date of 11/21/23. Review of the resident's MAR, dated 12/1/23-12/13/23, showed staff documented the resident received lorazepam 0.5 mg by mouth on 12/2/23 at 1:53 A.M. for behavior issue: anxious, tearful and wandering. Staff documented the medication was effective. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -No behaviors; -Taking anti-anxiety and anti-depressant medication. During an interview on 12/12/23 at 12:15 P.M. and 12/13/23 at 9:50 A.M., the MDS and care plan coordinator said the following: -The consulting pharmacist made recommendations for a dose reduction of Seroquel for Resident #25 in April and October 2023; -The director of nurses (DON) or the charge nurse would usually follow-up with the resident's provider about the recommendations, to see if a dose change was needed; -The provider would usually ask the nursing staff if the resident had had any behaviors; the facility is small, so all staff know about how Resident #25 had been doing; -Resident #25 had been pretty stable, he/she got along with his/her roommate but he/she could have moments of being grouchy; -The facility did not have a specific charting method or form for behaviors; nursing would just put that information into the progress notes if it occurred; -Facility staff were encouraged to document any behaviors; -If a provider declined a GDR or discontinuance of an antipsychotic for a resident with no documented behaviors, facility staff did not necessarily ask for supporting documentation or reasoning from the provider, sometimes they would if a resident had gone a long time with no behaviors. During an interview on 12/13/23 at 6:00 P.M., the DON, said the following: -She would expect staff to document any behaviors by a resident in the resident's progress notes; -The resident's care plan should reflect the use of an antipsychotic medication and/or an antianxiety medication. During an interview on 12/12/23 at 11:00 A.M., the consulting pharmacist said the following: -She reviewed the residents nursing and provider progress notes, looked for falls, side effects (of the antipsychotic), or any new issues every month; -She requested a dose reduction every six months if there were no behaviors documented; -It was up to the provider to make a decision regarding dose changes or discontinuance of an antipsychotic; -She had recommended a dose reduction of Seroquel for Resident #25 in April and October 2023 but the provider had declined those; -Dementia with unspecified psychosis was an off-label (unapproved indication or in an unapproved age group) diagnosis for antipsychotic use due to the black box warning (a warning for certain prescription drugs that the United States Food and Drug Administration (FDA) specifies has potential serious side effects with their use; -Facility staff should have documented any behaviors-or no behaviors-by the resident, if there was no documentation of behaviors, then there was no need for an antipsychotic; -Insomnia and/or agitation were not approved diagnoses for the use of an antipsychotic. During an interview on 12/14/23 at 8:00 A.M., the Nurse Practitioner (NP) said the following: -She tries to review the consulting pharmacist's notes when she sees those; -She made decisions on dose changes (reductions or discontinuance) of an antipsychotic based on what the facility told her about the resident and how he/she was doing; -If facility staff said the resident was doing ok (no behaviors), she would not necessarily make any medication changes; -When Resident #25 first came to the facility, he/she was crying a lot and asking to go home but she was not aware of any behaviors by the resident at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to keep the medication cart containing drugs and biologicals locked when not in use. The cart remained unlocked for the entire morning medication pass. The facility census was 37. Review of the facility's undated storage of medication policy showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Observation on 12/12/23 at 5:30 A.M. showed Certified Medication Technician (CMT) P entered room [ROOM NUMBER]-1 to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 5:40 A.M. showed CMT P entered room [ROOM NUMBER] again to administer medications to the other resident in the room. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 5:45 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 5:47 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 5:49 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 5:53 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 5:56 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 6:02 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 6:05 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 6:15 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. Observation on 12/12/23 at 7:15 A.M. showed CMT P entered room [ROOM NUMBER] to administer medications to the resident. CMT P left the medication cart unlocked and unattended in the hallway. During an interview on 12/12/23 at 1:10 P.M., CMT P said he/she normally did not lock the medication cart, unless he/she was going all the way down the hall from the cart. If the cart was outside of the resident room door, he/she did not lock the cart. During an interview on 12/12/23 at 1:50 P.M., Licensed Practical Nurse (LPN) J said he/she would expect staff to lock the medication cart if they walked away from the cart and it was not in their sight. During an intrview on 12/13/23 at 6:00 P.M., the Director of Nursing (DON) said she expected the medication nurse to lock the medication carts at all times when the cart was not in the medication nurses' direct sight.

Based on observation, interview, and record review, the facility failed to follow menus for three sampled residents (Residents #12, #18 and#25) and five additional residents (Residents #4, #6, #13, #22 and #23) on therapeutic diets to ensure staff served the proper food items and portion sizes as directed. The facility census was 37. Review of the facility policy, Menus, revised December 2008, showed menus shall meet the nutritional needs of residents, be prepared in advance, and be followed. 1. Review of the Diet Orders, provided by the facility, showed four residents (Residents #4, #6, #12 and #25) had physician's orders for a diabetic (consistent carbohydrate) diet. Review of the spreadsheet menu for the lunch meal on 12/11/23 showed staff was to serve residents on a consistent carbohydrate (CCHO) diet a 3-ounce portion of macaroni and tomatoes. Observation on 12/11/23 during the lunch meal service between 11:55 A.M. and 12:42 P.M., showed [NAME] Q served all four residents on a diabetic/CCHO diet a 4-ounce portion macaroni and tomatoes. Review of the spreadsheet menu for the lunch meal on 12/12/23 showed staff were to serve residents on a CCHO diet half of a baked potato. Observation on 12/12/23 during the lunch service between 12:32 P.M. and 1:00 P.M., the Dietary Manager served all four residents on a diabetic/CCHO diet a full baked potato. 2. Review of the Diet Orders, provided by the facility, showed four residents (Residents #13, #18, #22 and #23) with physician's orders for a mechanical soft diet. Review of the spreadsheet menu for the lunch meal on 12/11/23 showed staff was to serve residents on a mechanical soft diet a #8 dip (1/2 cup) of ground herb chicken with gravy. Observations on 12/11/23 showed the following: -At 11:27 A.M. of the steam table prior to the meal service showed a #12 dip (1/3 cup) in the ground chicken; -During meal service between 11:55 A.M. and 12:42 P.M., [NAME] Q served all four residents on a mechanical soft diet a #12 dip of ground chicken. 3. Review of the Diet Orders, provided by the facility, showed one resident (Resident #12) with a physician's order for low sodium, low potassium, low phosphorous diet (renal diet). Review of the spreadsheet menu of the lunch meal on 12/11/23 showed staff was to serve residents on a renal diet a 4-ounce portion of low salt buttered noodles. Observation on 12/11/23 at 11:55 A.M., showed [NAME] Q served Resident #12 a 4-ounce portion of macaroni and tomatoes (instead of buttered noodles). Review of the spreadsheet menu for the lunch meal on 12/12/23 showed staff was to serve residents on a renal diet a 4-ounce portion of buttered rice and a 4-ounce portion of applesauce. Observation on 12/12/23 at 1:00 P.M., the Dietary Manager served Resident #12 a whole baked potato (instead of buttered rice) and a piece of iced applesauce cake (instead of applesauce). 4. During interview on 12/15/23 at 1:20 P.M., the Dietary Manager said the following: -He would expect staff to follow the spreadsheet menus for portion sizes; -The menus with portion sizes are located in a binder on a shelf in the kitchen, but are not currently accessible at the steam table; -He glances through the menu binder but is not good at looking at it during the meal service; -On 12/12/23, he had looked at the binder prior to meal service for portion sizes but didn't think about it again when he was serving the residents.

Based on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. Staff did not perform proper handwashing technique during meal preparation, did not store food items and maintain and clean equipment under sanitary conditions, and did not maintain a clean and sanitary environment in the kitchen. The facility census was 37. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised December 2008, showed the following: -Employees must wash their hands: -After handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -After engaging in other activities that contaminate hands; -Gloves are considered single-use items and must be discarded after completing the task for which they are used; -The use of disposable gloves does not substitute for proper handwashing. Review of the facility policy, Food Receiving and Storage, revised December 2008, showed all food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of an undated Cleaning List, provided by the facility, showed staff were clean the can opener daily. Review of the facility policy, Sanitization, revised December 2008, showed the following: -All kitchen areas shall be kept clean; -All utensils, counters, shelves and equipment shall be kept clean; -All equipment, food contact surfaces and utensils shall be washed and sanitized using hot water and /or chemical sanitizing solutions; -Manual washing and sanitizing will employee a three-step process for washing, rinsing, and sanitizing. Sanitize with hot water or chemical sanitizing solution. -The Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen. 1. Observation on 12/11/23 at 10:20 A.M., showed [NAME] Q performed the following: -He/She wore gloves and opened the door to the walk-in refrigerator by the handle; -He/She obtained two bags of raw chicken from the walk-in refrigerator, closed the door to the walk-in unit, and took the bags of chicken to the preparation counter; -He/She opened the bags of raw chicken, and then placed his/her gloved hands directly into the flour and stuffing mixture in a bowl on the preparation counter and mixed it together with his/her gloved hands; -He/She reached into the bag of chicken and removed pieces of raw chicken with his/her gloved hands, placed the chicken in the stuffing/flour mixture and then put the chicken on a pan. He/She repeated this process for 20 pieces of chicken; -He/She removed his/her gloves, and without washing his/her hands, put on oven mitts, then removed the oven mitts, picked up a container of paprika from the counter, opened it and sprinkled it onto the chicken, put on the oven mitts and placed the pans of chicken in the oven; -He/She removed the oven mitts, placed a new pan on the preparation counter and put on gloves without washing his/her hands; -He/She opened another bag of raw chicken, reached into the bag and removed pieces of raw chicken with his/her gloved hands, placed the chicken into the stuffing/flour mixture and put the chicken on a pan; -He/She removed his/her gloves, and without washing his/her hands, picked up the container of paprika from the counter, opened it and sprinkled it onto the chicken; -He/She dumped the liquid contents from the bags that held the raw chicken into the sink and put the bags into the trash can. He/She placed his/her arms, up to his/her elbows, into the trash can. The bags and his/her arms came into direct contact with the swing top lid of the trash can; -Without washing his/her hands, he/she picked up a bowl of raw chicken wings from the preparation counter, opened the door to the walk-in refrigerator by the handle, placed the bowl in the refrigerator and closed the door. Observation on 12/11/23 at 11:30 A.M., showed [NAME] Q performed the following: -He/She put on gloves, picked up raw chicken wings from a bowl with his/her gloved hands, placed the wings in a bowl containing stuffing/flour mixture, and placed the wings onto a pan; -He/She removed his/her gloves, and without washing his/her hands, opened a container of paprika, sprinkled it over the chicken, placed the pan of chicken in the oven, and closed the door to the oven. He/She covered an opened can of evaporated milk with plastic wrap, marked the date with a pen on the plastic wrap, dropped the lid to the pen on the floor, picked the lid up off the floor, opened the door to the drink refrigerator, and placed the evaporated milk inside. He/She dumped the stuffing/flour mixture from the bowl into the trash can, sorted through the meal cards, put on oven mitts, removed a pan of corn from the oven, and removed the oven mitts. -Without washing his/her hands, he/she put on gloves, opened the oven door, put the oven mitts on over his/her gloves, removed a pan of chicken from the oven, removed the oven mitts and then placed chicken from the pan into a steam table pan on the steam table with tongs. Observation on 12/12/23 at 12:32 P.M., showed the dietary manager wore gloves as he served the residents from the steam table. At 1:02 P.M., he opened the door to the upright refrigerator with his gloved hands, reached into the opened box of frozen hamburger patties and obtained frozen patties from the box with his/her gloved hands, placed them on a plate, opened the door to the microwave and placed the plate of frozen patties inside. 2. Observations on 12/11/23 between 9:05 A.M. and 12:30 P.M., and on 12/12/23 between 11:53 A.M. and 1:00 P.M. showed the following: -A plastic scoop was stored in the bulk sugar container. The scoop handle rested directly on the sugar; -A plastic scoop was stored in the bulk flour container. The scoop handle rested directly on the flour; -The lids on the bulk flour and sugar containers were soiled with a buildup of debris; -A buildup of dark debris was visible on the counter-mounted can opener; -An airhandler was suspended from the ceiling over the drink refrigerator and the preparation counter. There was a buildup of dusty debris on the sides of the unit, on the metal hangers and on the vents; -The stand mixer was located directly next to the trash can used for meal preparation. The bowl and beater blade, located in the bowl, were not covered; -A heavy buildup of black, dusty debris on the vent cover and the inside of the duct work located over the dishmachine; -An area of black, mold-like debris, approximately 3 feet long by 10 inches wide, was located on the wall above the metal backsplash by the dishwashing sink; -A buildup of dust and debris on the ceiling vent in the walkway between the dietary manager's office and the dishmachine area; -A buildup of dusty debris on the baffle filters and on the extinguishing system piping and nozzles within the rangehood. 3. Observations on 12/11/23 showed the following: -A box of frozen pork patties was stored in the upright freezer. The box and the plastic bag containing the frozen patties were open to air and were not sealed; -A box of frozen beef steak burgers was stored in the upright freezer. The box and the plastic bag containing the frozen burgers were open to air and were not sealed; -A ½-gallon container of almond milk, located in the drink refrigerator, expired on 11/2/23; -In the hallway near the dry food storage room, four packages of hot dog buns sat on a rack containing bread products. Two packages had a best use by date of 11/18/23, one package had a best use by date of 11/21/23, and one package had a best use by date of 11/23/23. Observation on 12/12/23 at 12:35 P.M., showed a partial opened package of hamburger buns lay on a tray by the food preparation counter and the steam table. The best use by date on the package was 11/28/23. 4. Observation on 12/11/23 at 10:10 A.M., showed [NAME] Q washed dishes in the three-compartment sink. After washing and rinsing the dishes in the first two compartments, he/she dipped and rolled a colander, a large mixing bowl, a small pan, and a stock pot in the sanitizer for approximately two to three seconds. He/She quickly dipped two spatulas, two whisks and a knife in the sanitizer. He/She washed and rinsed a second stock pot, but did not place it into the sanitizer prior to placing it on a strainer at the end of the sink. Review of the sanitizer label showed to sanitize by immersing articles in sanitizer for at least 60 seconds at a temperature of 75 degrees Fahrenheit. 5. Observation on 12/11/23 at 9:45 A.M., showed the drain hose for the ice machine, located in the kitchen, was placed directly into the floor drain. There was no air gap between the end of the drain hose and the floor drain. 6. During interview on 12/15/23 at 1:20 P.M., the Dietary Manager said the following: -The maintenance staff was responsible for cleaning the rangehood and filters. The facility had not had a maintenance staff for a couple of months and the responsibility had not been reassigned. He believed the rangehood and filters were last cleaned in October 2023. He had not noticed the filters and rangehood needed cleaned prior to the survey; -Staff should not store scoops in the bulk containers; -He would like for bags around frozen food to be sealed and the boxes to be closed; -The facility did not have a process for checking for expired foods. He tried to check for the expired foods monthly, but didn't always have the time. -Maintenance staff had always been responsible for cleaning the air handler and ceiling vents. No one had told him anything different; -The ice machine located in the kitchen was there prior to his employment as the dietary manager. He had not checked for an air gap between the drain hose and the floor drain; -He would like for staff to run the can opener through the dishmachine daily; -He expected for the mixer bowl to be covered; -He believed staff were to immerse items in the sanitizer in the three-compartment sink for three minutes; -He expected staff to wash their hands after removing their gloves; -Staff should not touch the refrigerator doors with their gloved hands; -He was in a hurry when he touched the refrigerator door and frozen hamburger patties with his gloved hands on 12/12/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for two residents (Resident #9 and Resident #12), in a review of 14 sampled residents. The facility failed to ensure proper infection control was utilized for respiratory care supplies for five residents (Resident #4, #7, #18, #30 and #289). The facility failed to ensure procedures were implemented to address prevention of Tuberculosis (TB) for four newly hired employees (Activity Director, Dietary Aide I, Licensed Practical Nurse (LPN) J and Registered Nurse (RN) K) of ten new employees reviewed, when the facility failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for TB testing for long-term care employees. The facility failed to develop a policy to address Legionella Control that included specific control parameters based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards, failed to complete an assessment to identify potential sources of Legionella growth, failed to develop a water management team that conducted meetings and failed to complete a water flow map. The facility census was 37. Review of the facility's hand hygiene policy, dated 8/21/2023 showed the following: -Employees must wash their hands for at least twenty {20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: -Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); -Before and after assisting a resident with personal care (e.g., oral care, bathing, etc.); -Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); -Before and after assisting a resident with toileting (hand washing with soap and water); -After contact with a resident's mucous membranes and body fluids or excretions; -After removing gloves; -After completing duty; -When to Use Alcohol-Based Hand Rub: In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are NOT visibly soiled, use an alcohol based hand rub containing 60-95% ethanol or isopropanol for all the following situations: -Before and after direct contact with residents; -Before donning sterile gloves; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After removing gloves; -Removing PPE: Hand hygiene is always the final step after removing and disposing of personal protective equipment; -Use of Gloves: The use of gloves does not replace handwashing/hand hygiene. Review of Infection Control Guidelines for Long-Term Care Facilities, emphasis on Body Substance Precautions, dated July 1999, showed the following: -Handwashing remains the single most effective means of preventing disease transmission. Wash hands often and well; -Wash hands whenever they are soiled with body substances, before performing invasive procedures and when each resident's care is completed. Review of the facility policy, Cleaning and Disinfection of Resident Care Items and Equipment (continuous positive airway pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while one sleeps), dated 4/5/23, showed the following: -Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to manufacturer guidelines and facility policy; -Daily: Masks and cushion is to be washed with an antibacterial soap and laid to dry on a clean towel. Once dry place in zip lock bag for cleanliness. Review of the facility's infection control policy, dated 8/11/23, showed no guidance on the cleaning and storage of respiratory supplies. Review of the facility policy, Facility Infection Control Program, revised 5/2012, showed the following: -This facility's TB Infection Control Program includes the early identification, isolation, and transfer of persons with active tuberculosis. The program incorporates the following components: a. Assignment of responsibility for the oversight of TB infection control to the Infection Control Committee. The Director of Nurses (DON) is designated to oversee the TB program; d. Screening and surveillance of residents and employees for latent tuberculosis infection (LTBI) and active TB as appropriate for the current TB risk classification; e. A protocol for the prompt recognition and transfer of persons with suspected or identified active TB; -No guidance regarding when to administer and read the tuberculin skin test for new employees. Review of the Department of Health and Senior Services Tuberculosis Screening for LTCF Employees Flowchart, updated 03/11/14, showed the following: -Administer TST 1st step prior to employment. (Can coincide reading the results with the employee start date by administering TST 2-3 days prior to the employee start date); -Read results of 1st step TST within 48-72 hours of administration; -If 1st TST is negative, administer 2nd step within 1-3 weeks; -Read results within 48-72 hours of administration; -The employee cannot start work for compensation until the 1st step TST is administered and read. Review of the facility's Enteral Nutrition policy, revised December 2011, showed it did not address the storage of feeding tube syringes when not in use or how often they were to be changed. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. Review of the facility's Legionella Water Management Program policy, revised July 2017, showed the following: -The facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella; -As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team; -The water management team will consist of at least the following personnel: the infection preventionist, the administrator, the medical director or designee, the director of maintenance and the director of environmental services; -The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease; -The water management program includes the following elements: an interdisciplinary water management team, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situation that can lead to Legionella growth, specific measures used to control the introduction and/or spread of Legionella, the control limits or parameters that are acceptable and that are monitored, a diagram of where control measures are applied, a system to monitor control limits and the effectiveness of control measures, a plan for when control limits are not met and/or control measure are not effective; and documentation of the program; -The water management program will be reviewed at least once a year, or sooner if any of the following occur: the control limits are consistently not met, there is a major maintenance or water service change, there are any disease cases associated with the water system, or there are changes in laws, regulations, standards or guidelines; -The policy did not include how often or when the water management team would meet, acceptable temperature ranges for hot and cold water, how the facility was going to monitor or test resident's for Legionella if resident's developed signs and symptoms, and how results would be documented. The policy did not include reporting any cases of Legionellosis to the health department and to the state agency. During an interview on 12/28/23 at 4:16 P.M., the director of nurses (DON) said the facility did not have a policy for oxygen use/tubing change. The facility did not provide a policy regarding nebulizer tubing/equipment storage or changing. 1. Review of Resident #9's undated, continuity of care document (CCD), showed his/her diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety. Review of the resident's care plan, dated 05/30/23, showed the resident required assist of one staff for transfers, dressing, toileting and personal hygiene. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 11/24/23, showed the following: -Cognitively impaired; -Required a wheelchair; -Required substantial to maximal assistance with toileting hygiene and mobility; -Frequently incontinent of bowel, occasionally incontinent bladder. Observation on 12/11/23 at 9:00 A.M., showed the following: -Certified Nurse Assistant (CNA) M entered the resident's room and donned gloves; CNA M did not wash his/her hands and did not use a hand sanitizer; -CNA M removed the resident's pants while the resident lay on his/her bed; -CNA M opened the front of the resident's urine saturated adult brief, pulled it off and threw it away in the trash can at bedside; -With soiled gloves, CNA M picked up a package of wet wipes on the bed and wiped the resident's perineum, assisted the resident to turn over to his/her right side by touching his/her left shoulder and hip with the same soiled gloves, and used the same wet wipes on the resident's bottom, then threw the wet wipes into the trash can at bedside; -CNA M did not change gloves and obtained and placed a clean adult brief under the resident, assisted the resident to roll onto his/her back and fastened the new brief; -CNA M pulled the resident's pajama pants back on and up, still wearing the same soiled gloves; -CNA M covered the resident up with blankets, touching the blankets with the soiled gloves; -CNA M removed his/her gloves and threw them into the trash can at bedside, tied the trash up and carried it into the south hallway and placed it into a larger trash receptacle; -CNA M did not wash his/her hands or use a hand sanitizer after he/she removed the soiled gloves; -CNA M went into another resident's room, and without washing his/her hands or using a hand sanitizer, and with no gloves on, moved a walker closer to a resident and assisted the resident to a standing position; -CNA M assisted the resident into the bathroom, pulled his/her brief and pants down and assisted the resident to sit on the toilet; -CNA M straightened the resident's blankets on his/her chair, with no gloves on, and did not wash his/her hands or use a hand sanitizer; -CNA M donned gloves without washing his/her hands or using a hand sanitizer and wiped the resident's bottom with wet wipes, using his/her right hand; the resident said he/she had a small bowel movement; -With soiled gloves, and using his/her right hand, CNA M assisted the resident to a standing position, pulled the resident's brief and pants up and guided the resident back to his/her bed by touching the resident's low back; -CNA M removed his/her right hand glove during the process and threw it into the trash can at bedside, and kept his/her left hand gloved; -CNA M assisted the resident to sit in the chair, removed his/her left glove and threw it into the trash can at bedside. During an interview on 12/11/23 at 9:45 A.M., CNA M said the following: -He/She usually washed his/her hands before and after providing care to residents; -He/She did not wash his/her hands today but thought he/she had used hand sanitizer between resident cares; -He/She always put on clean gloves for resident care and changed those when they were soiled. 2. Review of Resident #12's quarterly MDS dated [DATE] showed the following: -Requires substantial/maximal assistance for toileting hygiene; -Always incontinent of bladder; -Frequently incontinent of bowel; -Diagnosis of renal failure. Review of the resident's care plan, dated 11/14/23, showed the following: -He/She has areas on his/her bottom that have poor skin integrity from sitting at dialysis and in his/her wheelchair; -He/She wished to have Calmoseptine (barrier cream) applied to areas on his/her buttocks twice daily and as needed; -He/She is occasionally incontinent of bowel and bladder; -Assist him/her with good peri-care after incontinent episodes; he/she has left hemiplegia (paralysis of one side of the body) and requires assist of one for toileting and transfers; -He/She requires assist of two for transfers and toileting due to his/her left hemiplegia. Observation in theresident'ss room, on 12/12/23 at 5:28 A.M., showed the following: -Licensed Practical Nurse (LPN) G and CNA H entered the resident's room; -LPN G and CNA H assisted the resident to a sitting position on the side of the bed; -CNA H assisted the resident to stand beside the bed; -LPN G removed the resident's incontinence brief as the resident stood at the side of the bed; -The resident was incontinent of a small amount of feces; -With gloved hands, LPN G provided pericare; -Feces was visible on the disposable wipes; -Without changing his/her gloves or washing his/her hands, LPN G opened a container of A&D ointment (skin protectant) and with the same gloved hands, dipped his/her soiled gloved hand into the A&D container and applied the A&D ointment to the resident's buttocks; -LPN G removed his/her gloves and washed his/her hands; -LPN G applied a clean incontinence brief and pulled up the resident's pajama pants; -CNA H pivoted the resident to the wheelchair. During an interview on 12/12/23 at 6:35 A.M., LPN G said the following: -He/She usually changes gloves and washes hands between dirty and clean; -He/She should have washed his/her hands after providing peri-care and before applying A&D ointment. 3. Review of Resident #289's face sheet showed the resident had diagnoses that included obstructive sleep apnea (sleep related breathing disorder). Review of the resident's December 2023 physician order sheets (POS) showed the following: -CPAP on at bedtime, off while awake; -No orders regarding the cleaning or storage of the CPAP supplies. Review of the resident's medication administration record (MAR) and treatment administration record (TAR) showed no documentation to show the resident's CPAP mask was cleaned or changed/replaced. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/08/23, showed the following: -Dependent for toileting hygiene; -Occasionally incontinent of bowel and bladder. Review of the resident's care plan, dated 12/09/23, showed the following: -Required assistance of two staff with personal hygiene, toileting hygiene, and bed mobility; -Occasional urinary incontinence; -No documentation regarding the use of a CPAP. Observation in the resident's room, on 12/10/23 at 1:35 P.M., showed the resident's CPAP mask on the resident's bed; the mask was not in a storage bag. Observation on 12/12/23 at 6:15 A.M. showed the following: -CNA A and CNA B entered the resident's room; neither staff washed his/her hands and donned gloves; -The resident lay in bed and was incontinent of bladder; -CNA A rolled the resident to his/her side; -CNA B wiped the resident's inner, upper thighs and perineum (the area between the genitals and the rectal opening) with the wet wipes; -CNA B did not change gloves and assisted CNA A to turn the resident to his/her right side, touching the resident on his/her left shoulder and left hip with soiled gloves, pulled the soiled incontinence brief out from under the resident and tucked a new incontinence brief under the resident; -CNA B then removed gloves, put on new gloves, did not wash hands with soap and water or use hand sanitizer between glove changes, put a clean chux (a disposable ultra-absorbent incontinence pad) under the resident, grabbed a tube of skin barrier cream from the resident's night stand with his/her soiled gloves, applied the skin barrier cream to the resident's buttocks and then removed one glove that was used to apply skin barrier cream; - Without washing his/her hands with soap and water or using hand sanitizer, CNA B put on one new glove, assisted CNA A to turn the resident onto his/her back by touching the resident's left shoulder and left hip and fastened the resident's new incontinence brief. Observation in the resident's room on, 12/13/23 at 8:50 A.M., showed the resident's CPAP mask on his/her table; the mask was not in a storage bag. During an interview, on 12/12/23 at 9:40 A.M., the resident said his/her CPAP mask has not been cleaned since he/she was admitted . 4. Review of Resident #18's CCD, dated December 12, 2023, showed the resident had diagnoses that included chronic obstructive pulmonary disease (COPD) (lung disorder). Review of the resident's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Feeding tube (flexible plastic tube placed into the stomach or bowel that provides nutrition) on admission; -Feeding tube while a resident. Review of the resident's care plan, updated 10/31/23, showed the resident is on gastrostomy tube (G-tube) (a tube that is inserted through the belly that brings nutrition directly into the stomach) feedings. Review of the resident's physician orders, dated December 2023, showed the following: -Ipratropium-albuterol solution (inhaled lung medication) for nebulization (by way of a machine that turns liquid medication into a mist to be inhaled); 0.5 milligrams (mg) - 3 mg (2.5 mg base)/3milliliterss mlL); amount: one vial; four times daily as needed for COPD, (start date 11/21/23); -Ipratropium-albuterol solution for nebulization; 0.5 mg - 3 mg (2.5 mg base)/3mlL; amount: one vial; inhalation, special instructions: One vial, twice daily for 7 days (Start Date 10/6/23 - End Date 10/10/23) (for Chronic obstructive pulmonarydiseasee); -Ipratropium-albuterol solution for nebulization; 0.5 mg - 3 mg (2.5 mg base)/3mlL; amount: one vial; twice daily until 10/24/23 (Start date 10/10/23) for COPD; -Monitor percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube placed directly into the stomach) patency every shift and as needed. Check residual (refers to the fluid/contents that remain in the stomach) feeding per PEG tube as needed; -Jevity 1.5 CAL (tube feeding nutrition) -50 cubic centimeters (cc)/hour (HR), continuously, with 75 cc free water flush every two hours; may disconnect feeding for showers or therapy (start date 5/10/23, end date 11/28/23); -Flush peg tube with 75 ml of water every two hours (start date 5/15/23, end date 11/28/23). Observation in the resident's room on 12/10/23 at 1:40 P.M., showed the following: -A nebulizer mask sat on a recliner beside the resident's bed; the tubing and mask were not stored in a bag when not in use; -A feeding tube syringe on the nightstand on a paper towel; the syringe was not stored in a bag/bottle when not in use. Observation in the resident's room, on 12/12/23 at 5:40 A.M., showed the resident's nebulizer mask face down on the recliner; the tubing and mask were not stored in a bag when not in use. Observation in the resident's room, on 12/13/23 at 3:35 P.M., showed the resident's feeding tube syringe on top of a paper towel on the night stand; the syringe was not stored in a bottle or bag; 5. Review of Resident #30's CCD showed the resident had diagnoses that included COPD, acute respiratory failure with hypoxia (low oxygen level), and bronchitis (respiratory infection) last diagnosed on [DATE]. Review of the resident's care plan, dated 11/27/23, showed no documentation regarding oxygen or nebulizer treatments. Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. Review of the resident's December 2023 POS showed the following: -Pulmicort suspension (inhaled lung medication) 0.5 milligrams (mg)/2 milliliter (ml) 1 vial per nebulizer (a machine that turns liquid medication into a mist to be inhaled) twice daily (BID); -Oxygen at two liters per minute per nasal canula (LPM/NC) as needed (prn) at bedtime; -No orders addressing cleaning, changing or storage of respiratory supplies. Review of the resident's MAR and TAR showed no documentation to show the resident's oxygen tubing or nebulizer tubing/supplies were being cleaned or changed/replaced. Observation of the resident in his/her room, on 12/10/23 at 1:42 P.M., showed the resident in bed with oxygen tubing in his/her nostrils; the oxygen tubing was not labeled with a date to indicate when the tubing had last been changed. Observation in the resident's room, on 12/11/23 at 8:30 A.M., showed the following: -Oxygen tubing in a bag, taped to the oxygen concentrator, dated 11/16/23; -Nebulizer kit in a bag on the resident's nightstand; no date on the bag or supplies to show when it had last been changed. Observation of the resident in his/her room, on 12/13/23 at 8:55 A.M., showed the following: -The resident in bed, oxygen placed in his/her nares; the tubing was not labeled with a date; -Nebulizer tubing on his/her nightstand, not on apaper [NAME], not stored in a bag and undated. 6. Review of Resident #4's face sheet showed the resident had diagnoses that included COPD. Review of the resident's care plan, dated 7/17/23, showed the resident was to always use oxygen. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Received oxygen therapy; -Moderate cognitive impairment. Review of the resident's December 2023 POS showed the following: -Oxygen at two LPM per NC, titrate (adjust) to keep oxygen saturation (spo2) (measurement of how much oxygen ones blood is carrying as a percentage of the maximum it could carry) over 90 percent (%) (a normal level of oxygen is usually 95 % or higher); -No orders found for changing and storage of respiratory supplies. Review of the resident's MAR and TAR showed no documentation to show the resident's oxygen tubing had been changed/replaced. Observation of the resident in his/her room, on 12/10/23 at 1:40 P.M., showed the resident in bed with oxygen tubing in his/her nares; the oxygen tubing was not labeled with a date. Observation of the resident in his/her room, on 12/11/23 at 8:05 A.M., showed the resident in his/her wheelchair with oxygen tubing in his/her nares; the oxygen tubing was not labeled. Observation of the resident in his/her room, on 12/12/23 at 5:15 A.M., showed the resident sleeping in his/her bed with oxygen tubing in his/her nares; the oxygen tubing was not labeled. Observation of the resident in his/her room, on 12/13/23 at 8:54 A.M., showed the resident in bed with oxygen tubing in his/her nares; the oxygen tubing was not labeled. 7. Review of Resident #7's undated CCD showed diagnosis of Alzheimer's dementia (a progressive and debilitating disease that causes severe cognitive decline and affects the ability to function in daily life) and cough. Review of the resident's care plan, dated 10/04/23, showed no focus, goals or interventions for the diagnosis of cough and the as-needed use of oxygen. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively impaired; -No documentation to show oxygen use. Review of the resident's December 2023 POS, showed an order for oxygen at two to three LPM/NC to keep oxygen saturations at 91% . Observation on 12/10/23 at 1:55 P.M. showed the resident's oxygen tubing draped over the oxygen concentrator at bedside and open to air (the oxygen tubing was not stored in a bag while not in use). Observation on 12/13/23 at 9:00 A.M. showed the resident's oxygen tubing draped over the oxygen concentrator at bedside (the oxygen tubing was not stored in a bag while not in use). 8. Review of the Activity Director's employee file showed the following: -Date of hire 8/22/23; -First TST administered on 8/22/23 and read on 8/25/23 (three days after the first date of resident contact); -Second TST administered on 9/5/23 and read on 9/7/23. 9. Review of Dietary Aide I's employee file showed the following: -Date of hire 8/9/22; -First TST administered on 8/8/22 and read on 8/10/22 (one day after the first date of resident contact); -Second TST administered on 9/11/22 and read on 9/13/22. 10. Review of LPN J's employee file showed the following: -Date of hire 7/30/22; -First TST administered on 7/30/22 and read on 8/1/22 (two days after the first date of resident contact); -Second TST administered on 8/26/22 and read 8/27/22 (read in 24 hours). 11. Review of Registered Nurse (RN) K's employee file showed the following: -Date of hire 3/17/23; -First TST administered on 3/17/23 and read on 3/19/23 (two days after the first date of resident contact); -Second TST administered on 3/31/23 and read on 4/3/23. During an interview on 12/12/23 at 2:00 P.M. the Assistant Administrator said the date of hire is the first date of resident contact. 12. The facility provided no evidence or documentation that a water management team had been developed, that they had a water management program, that anyone had identified areas in the water system where Legionella bacteria could grow and spread, did not have a plan to reduce the risk of Legionnaire's disease, did not have a detailed description and diagram of the water system in the facility and had not identified areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. The facility had not tested the temperature ranges of water to ensure they were within the ASHRAE recommendations to prevent Legionella growth. No minutes from a water management team meeting were provided. During an interview on 12/12/23 at 1:20 P.M. and 12/13/23 at 11:00 A.M., the Infection Preventionist (IP)/LPN A -She became the IP a few weeks ago, starting this position on 11/27/23, and has completed the 20 hour training course; -She is in charge of TB testing; the facility does a 2 step TB test upon hire and then yearly; -The DON asks the charge nurse to administer the first TST prior to date of hire; -The TST should be read 48 hours after the test is administered; -The charge nurse tells the staff when the first TST is to be read and when the second TST is to be administered; -Staff don't always show up on the date the TST are to be read; -The first TST should be read by the first date of resident contact. During an interview on 12/13/23 at 12:30 P.M., 12/13/23 at 600 P.M.M. and 6:30 P.M. and 12/20/23 at 11:56 A.M., the DON said the following: -She became the DON one month ago; -She would expect staff to wash their hands prior to and after direct resident care; -She would expect staff to change their gloves during personal care of a resident; She would expect staff to remove soiled gloves, wash their hands or use a hand sanitizer and change gloves after providing personal care and prior to touching clean items; -Staff should wash hands with soap and water after changing gloves and after providing perineal care and before putting on new gloves; -Staff should wash hands, or at least use hand sanitizer, between changing gloves; -Oxygen, nebulizer tubing and humidification bottles should be dated/labeled when changed; -Oxygen and nebulizer tubing should be kept in a Ziploc bag when not in use; -She is not sure what the policy states, or if there is a policy regarding the changing of oxygen tubing, nebulizer tubing/masks or how often this is done; -There was not an order for cleaning of nebulizer supplies for Resident #30; -There was not an order for the changing of oxygen tubing for Resident #30 or #4; -There was not an order for cleaning/storage of the CPAP mask for Resident #289; -The four new employees (Activity Director, Dietary Aide I, LPN J and RN K) were hired under the previous DON; -The IP just assumed responsibility of employee TB testing; -She would expect feeding tube syringes to be stored in a bag if not in use; -She would expect staff to follow any facility policy. During an interview on 12/12/23 at 2:30 P.M., 12/13/23 at 6:00 P.M. and 6:30 P.M., the Administrator said the following: -The charge nurse changes respiratory supplies out, but he wasn't sure how often; -He would expect employee TB testing to be completed per the regulation. -There was currently no Legionella water management program; the only thing he could find in the binder was something that looked like there needed to be a [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to have an adequate audible system for the residents to signal the nursing staff when they were in need of staff assistance. The facility also failed to ensure one resident (Resident #21)'s call light functioned properly when the light did not illuminate above the resident's door. The facility census was 37. The facility did not provide a policy regarding the resident call light system. Review of the DHSS exception log showed the facility did not have an approved exception for a wireless call light system. 1. Review of Resident #21's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/26/23 showed the following: -Short and long term memory problems; -Dependent on staff for toileting hygiene, personal hygiene, sitting to lying, sit to stand, and chair/bed to chair transfer; -Frequently incontinent of bladder and bowel; -Diagnoses of osteoporosis, fracture, dementia and anxiety; -Two or more no injury falls since last assessment; -One major injury fall since last assessment. Review of the resident's care plan dated 11/2/23 showed the following: -He/She is sometimes able to make his/her needs known; -He/She has had fewer episodes of confusion; -Re-direct him/her and encourage him/her to use his/her call light and ask for help if he/she does seem confused; -He/She requires assistance with transfers and most ADLs; -He/She requires assist of two for all transfers and toileting; -Make sure his/her call light is in reach; -He/She has a fall mat beside his/her bed; -He/She can place him/herself on this mat; -Sometimes it is more comfortable for him/her to lie on the mat next to his/her bed. Observation on 12/12/23 at 7:02 A.M. in the resident's room showed the following: -The resident lay on his/her back with his/her upper body on the mattress and his/her lower body on the fall mat; -The resident yelled Help, help!; -The resident scooted further off the end of the bed; -The resident had activated his/her call light; -The light on the box above his/her bed was illuminated; -The light above his/her door was not illuminated; -SA staff also activated the resident's call light by pushing the call light button. The light only illuminated in the room. The light above the door did not illuminate. No sound was emitted; -SA staff had to call for staff assistance; -Registered Nurse (RN) K entered the resident's room; -RN K confirmed the resident's call light was activated but only illuminated in the room. Observation on 12/13/23 at 8:21 A.M. in the resident's room showed the following: -The resident sat in his/her wheelchair; -The resident pushed his/her call light; -A light illuminated on the box on the wall in the resident's room; -There was no sound in or outside the resident's room when the call light was on; -The light above the resident's door did not illuminate; -The administrator changed out the light bulb above the resident's door; -The light above the resident's door still did not illuminate. During and interview on 12/13/23 at 8:30 A.M. the resident said the following: -His/Her call light had not worked for several days; -He/She has had several falls; -He/She has to yell for staff or go out in the hall and find staff if his/her call light isn't working. During an interview on 12/12/23 at 7:10 A.M. Certified Nurse Aide (CNA) B said the following: -The resident's call light has not been working on and off for the last two to three months; -The resident's call light does not light above the door; -If the call light does not light above the door and does not sound in the hallway, staff do not know the resident needs assistance. During an interview on 12/12/23 at 7:08 A.M. Registered Nurse (RN) K said the following: -The resident's call light only lights up in the resident's room; -The light above the resident's door did not work; -If the call light is activated the light should illuminate above the resident's door. 2. Observation on 12/10/23 at 1:55 P.M. showed the light above occupied resident room [ROOM NUMBER] illuminated red, indicating the bathroom call light was activated. No sound was emitted in the south hallway and no facility staff were present. During an interview on 12/11/23 at 9:00 A.M., CNA M said the following: -When a resident pushed his/her call button, a light would come on above the entry door into the resident's room; -A white light meant the resident just needed something, a red light meant the resident was in the bathroom and needed assistance; -There were no sounds emitted when the light came on; -A box at the nurses' station would display the room number as it emitted a sound; -The sound from the call light box was very soft and staff could not hear it; -Staff did not know when a call light was on unless they could see it while they were on the hallway where the light was on, or unless another staff called on the walkie-talkie for resident assistance; -The walkie-talkies used were not connected to the call light system; -Staff usually just know when the lights were on because they were always up and down the hallways and it was a small facility. During an interview on 12/12/23 at 5:50 A.M., RN K said the following: -The facility had a call light box at the nurses' station that would emit a soft sound and indicate the resident room when a call button was pushed; -The call light system was encased in a larger, clear plastic box that was locked so staff could not adjust the sound that was emitted; -Staff would not be able to hear the call light system sound if they were away from the nurses' station, but they could see the light on above the resident's room; -If staff were in a resident's room, they would not be able to hear the call light box sound and would just have to see the light on above the resident's door when they came back out into the hallway. 3. Observation on 12/12/23 at 5:52 A.M. showed the following: -Three call lights were illuminated on the east hall; -The call lights were not audible on the east hall. During anintervieww on 12/12/23 at 6:00 A.M., CMT P said the following: -He/She cannot hear the call lights; -The only way he/she knows a call light is on is by seeing the light on outside the resident's room; -If he/she is in a resident room, he/she would not know if another call light on. 4. Observation on 12/12/23 in the east hallway showed the following: -At 6:40 A.M. the light above occupied resident room [ROOM NUMBER] was illuminated. The call light did not sound in the east hallway. CNA L walked by the resident's room and into another resident's room; -At 6:46 A.M. the light above occupied resident room [ROOM NUMBER] remained illuminated. No sound was emitted on the hallway. CNA L walked by the resident's room; -At 6:52 A.M. RN K entered the resident's room and said whose got the light on? RN K assisted the resident to the bathroom and RN K exited the room; -At 6:55 A.M. the light above occupied resident room [ROOM NUMBER] illuminated red indicating the bathroom call light was activated. No sound was emitted in the hallway. 5. Observation on 12/13/23 at 8:31 A.M. showed the following: -Two call lights were illuminated on the south hall; -The call lights were audible at the nurses' station; -The call lights were not audible on the south hall. 6. Observation on 12/13/23 at 8:40 A.M. in the facility's clean and dirty utility rooms showed the following: -Both rooms had a light fixture on the walls of the room; -A call light was turned on; -The lights in the clean and dirty utility rooms did not illuminate; -There was no sound audible in the clean and dirty utility rooms; -No call light duty station was present in the clean or dirty utility rooms. During an interview on 12/13/23 at 8:40 A.M. CNA B said the following: -Staff can't hear the call lights unless you are standing at the nurses' station; -Lights do not illuminate in the clean or dirty utility rooms; -The call lights are not audible in the clean or dirty utility rooms; -The old call light system was very audible; -The new call light system can't be heard down the halls at all. During an interview on 12/13/23 at 8:21 A.M. the Administrator said the following: -The facility does not currently have a maintenance director; -In October 2023, the facility had to replace the old call light system; -Several call lights went down then the entire call light system went down; -The new call light system is only audible at the nurses' station; -The light above the resident's door should illuminate when the resident activates the call light; -He has not had any problem with the call lights not sounding at the nurses' station; -He has had to replace a few bulbs outside the resident rooms; -He has replaced a bulb outside Resident #21's room; -He was not aware Resident #21's call light was not working; -When a call light is activated, the light on the wall above the resident's bed and the light above the resident's door should illuminate; -The call lights do not sound in the residents' rooms or on the hall; -He did not realize the call lights need to be audible down the hall; -If staff were in a resident room with the door shut they would not be able to hear a call light; -The facility does not have an exception for a wireless call light system; -Facility staff do not wear pagers connected to the call light system; -Facility staff do use walkie talkies but the call light notification is not sent to the walkie talkies. MO 227930

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer with required information (reason for transfer/discharge, date of transfer/discharge, location to which the resident is transferred or discharged , appeal rights and contact information, ombudsman contact information) to the resident and/or resident representative for three residents (Resident #17, 18, and #39) in a review of 12 sampled residents, and one closed record (Resident #140) when the facility initiated transfer to the hospital. The facility census was 40. During an interview on 12/29/20, at 1:33 P.M., the administrator said the facility does not have a policy on discharge notices for facility initiated discharges. 1. Review of Resident #17's medical record showed the following: -Original admission date of 7/27/18; -Resident was discharged to the emergency room (ER) for evaluation and treatment on 9/25/20; -There was no documentation the facility provided notice to the resident or resident's representative. 2. Review of Resident #18's face sheet showed an admission date of 11/6/19. Review of the resident's medical record showed the following: -Resident discharged to the hospital on 8/1/20; -There was no documentation the facility provided written notice to the resident or the resident's representative. 3. Review of Resident #39's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical record showed the following: -He/She was transferred to the emergency room for evaluation after a fall on 11/26/20; -No documentation the facility provided written notice to the resident and/or the resident's representative notifying them of the resident's transfer to the hospital. 4. Review of Resident #140's medical record showed the following: -Original admission date of 8/22/18; -Resident discharged to the hospital on [DATE]; -No documentation the facility provided written notice to the resident or the resident's representative notifying them of the resident's transfer to the hospital. 5. During an interview on 12/30/20 at 11:00 A.M., the director of nursing (DON) said the following: -The facility does not have written discharge notice for residents discharged to the hospital; -He/She did not know about the requirement. During an interview on 12/29/20, at 1:33 P.M., the administrator said the following: -The facility does not issue a discharge notice to residents being discharged to the hospital or other facility initiated discharges that are medical or routine; -The facility was not issuing any written notice at discharge with information on how to appeal; -He/She did not know about the requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS; a federally mandated assessment instrument required to be completed by facility staff) for three residents (Residents #17, #18, and #29) in a review of 12 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The census was 40. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, directs staff as follows: -Comprehensive Assessments are required comprehensive assessments include the completion of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. They consist of: admission Assessment, Annual Assessment, Significant Change in Status (SCSA)Assessment, Significant Correction to Prior Comprehensive Assessment -The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change. A significant change is a major decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; -Impacts more than one area of the resident's health status; and -Requires interdisciplinary review and/or revision of the care plan. -Assessment Completion refers to the date that all information needed has been collected and recorded for a particular assessment type and staff have signed and dated that the assessment is complete. A 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 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. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. Review of the facility policy Comprehensive Assessments and the Care Delivery Process, dated 2001 and last revised 12/16 showed comprehensive assessments will be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. Assessment and information collection includes (what, where and when). The objective of the information collection (assessment) phase is to obtain, organize and subsequently analyze information about a patient. 1. Assess the individual. Gather relevant information from multiple sources, including observation, physical assessment, symptom or condition-related assessments (Braden, AIMS, falls, etc .), resident and family interview, hospital discharge summaries, consultant reports, lab and diagnostic test results and evaluations from other disciplines (dietary, respiratory, social services, etc.). 2. Complete the Minimum Data Set within 14 days after admission, within 14 days after it is determined that the resident has had a significant change in physical or mental condition and annually. Information analysis steps include how and why. a. Define issues, including problems, risk factors and other concerns to which all disciplines can relate. Determine CAAs that have been triggered during completion of the MDS and Expanding on the triggered CAAs and the data gathered in step one, begin to define problems and symptoms within the context of the overall clinical picture. For example, try to determine what precipitates, aggravates or causes problems instead of simply listing the problems. b. Define conditions and problems that are causing or could cause other problems. Identify potential causes or contributing factors of problems or symptoms including medical, psychosocial, environmental and functional. Arrange conditions, problems and outcomes in their proper order based on the information gathered in steps one and two. Try to determine the interrelationship between the existing problems. For example, does one symptom or cluster of symptoms seem to appear or worsen when another symptom or cluster of symptoms appears or worsens? Determine the most plausible relationships between the conditions and their causes. Define current treatments and services; link problems and diagnoses. Identify the current interventions and treatments and link these to problems and diagnoses they are supposed to be treating. Identify overall care goals and specific objectives of individual treatments. Evaluate whether or not these treatments are accomplishing the anticipated results. Make decisions about care and treatment. Apply clinical reasoning to assessments information and determine the most appropriate interventions. Decision making leading to a person-centered plan of care includes selecting and implementing interventions, based on the results of the above. Monitoring results and adjusting interventions based on the results of the above. Monitoring results and adjusting interventions includes periodically reviewing progress and adjusting treatment. Continue to define or refine the objectives of specific treatments as well as overall care and services. Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals. Completed assessments (baseline, comprehensive, MDS, etc.) are maintained in the resident's active record for a minimum of 15 months. These assessments are used to develop, review and revise the resident's comprehensive care plan. 1. Review of Resident #17's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -No delirium; -Always continent of bowel; -No weight loss; -Not on a physician prescribed diet regimen. Review of the resident's quarterly MDS dated [DATE] showed the following: -Moderately impaired cognition; -Delirium present, fluctuates (comes and goes, changes in severity). difficulty focusing attention, easily distractable or having difficulty keeping track of what is being said; -Occasionally incontinent of bowel; -No weight loss; -Not on a physician prescribed diet regimen. Review of the resident's monthly weight record showed he/she weighed 197 on 6/10/20 and 175.4 on 12/12/20, a 10.96% weight loss in six months. The resident was not on a physician prescribed weight loss regimen. The facility did not complete a SCSA when the resident experienced changes in his/her cognition, continence of bowel and had weight loss. 2. Review of Resident #18's admission MDS, 11/18/19, showed the following: -Cognitively intact; -Independent with bed mobility, transfers, ambulation, dressing, and toilet use; -Balance unsteady but can correct self; -No indwelling catheter; -Continent of bowel; -No falls; -Weight 164, no significant weight loss. Review of the resident's admission MDS, dated [DATE], showed the following: -Requires limited physical assist of one staff member for bed mobility, transfers, ambulation and toilet use; -Requires extensive physical assist of one staff member for dressing; -Balance unsteady cannot correct without help; -Indwelling catheter use; -Frequently incontinent of bowel; -One fall without injury and one fall with injury; -Significant weight loss not on a physician prescribed weight loss plan; -Therapeutic and mechanically altered diet. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Weight 150 lbs; -Significant weight loss not on a physician prescribed weight loss plan. The facility did not complete a SCSA when the resident had changes to his/her ADL (activities of daily living), balance, falls, indwelling catheter use, bowel continence, and weight loss. 3. Review of Resident #29's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis include chronic kidney disease stage 4 (severe) and congestive heart failure; -Weight 208 lbs.; -Diuretic medication daily; -No opioid medication. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment -Weight 250 lbs; -Significant weight gain, not on a physician prescribed plan; -No diuretic medications; -Opioid medication daily. The facility did not complete a SCSA when the resident had changes to his/her cognition, a significant weight gain, discontinuation of diuretic medication, and an increase in administration of opioid medications. During an interview on 12/29/20, at 11:10 A.M., the MDS Coordinator said the following: -He/She evaluates if a resident needs a SCSA MDS; -If the resident has 2-3 changes since the last assessment a SCSA is completed; -He/She does not know if he/she should compare to the last comprehensive assessment; -Changes can include new skin issues, weight loss, or changes in ADL care; -He/She does not calculate for a six month weight loss until their quarterly MDS is due. During an interview on 1/5/21, at 11:00 A.M., the director of nursing (DON) said the following: -Significant changes in the residents' condition are monitored through daily meetings; -The MDS Coordinator does the significant change MDS; -SCSAs are done if there are two or more changes in the resident's condition; -SCSAs are done according to the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review the baseline care plan with the resident/responsible party within 48 hours of admission, or provide a copy of the baseline care plan to the resident/responsible party for four residents (Resident #25, #29, #32 and #241) in a review of 12 sampled residents. The facility census was 40. 1. During an interview on 12/30/20, at 3:30 P.M., the assistant administrator said the facility did not have a policy for baseline care plans. 2. Review of Resident #25's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's admission Assessment, dated 8/25/20, showed the resident admitted at 11:55 A.M., and transferred with one person assist with a cane or walker. Review of the resident's Bed Rail Consent, dated 8/25/20, showed the resident was to use soft care assist rail on bilateral upper bed. Review of the resident's baseline care plan, undated, showed the following: -Safety Care section did not include walker and cane use, transfer instructions, or bed rail use; -No date or time completed; -No review with resident or family; -No documentation staff provided a copy to the resident or family. 3. Review of Resident #29's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Bed Rail Consent, dated 6/5/20, showed the resident was to use bed rails. Review of the resident's baseline care plan, undated, showed the following: -Safety Care section did not include bed rail use; -ADL (activities of daily living) and dietary section not completed; -No date or time completed; -No review with resident or family; -No documentation staff provided a copy to the resident or family. 4. Review of Resident #32's physician order sheet, dated 12/08/20 - 12/31/20, showed the following: -admitted to the facility 12/08/20; -Diagnosed diabetes mellitus (too much sugar in the blood), hyperlipidemia (high concentration of fats or lipids in the blood), congestive heart failure (a condition in which the heart doesn't pump adequate blood to meet the body's need), chronic obstructive pulmonary disease (lung disease that blood airflow making it hard to breathe), fracture of head and neck of right femur (broken right hip), chronic atrial fibrillation (abnormal heart rhythm that beats irregular and quickly). Review of the resident's progress notes dated 12/8/20, showed the following: -Arrived by facility van and staff; -admitted following COVID-19 policy and procedure; -Skin assessment completed; -Faint crackles left upper lobe with shortness of breath on exertion. Review of the resident's baseline care plan showed completion date of 12/9/20, no resident signature or evidence a copy was given to the resident. 5. Review of Resident #241's physician order sheet, dated 12/1/20 - 12/31/20, showed the following: -admitted to the facility 12/23/20; -Diagnoses included diabetes mellitus, hyperlipidemia, hypokalemia (low potassium level in blood), hypertension (high blood pressure), heart failure, cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), and gastro-esophageal reflux disease without esophagitis (nonerosive acid reflux). Review of resident's progress notes dated 12/23/20 showed the following: - Arrived by facility van and staff; -Open area on right foot; -Ace wrap on left arm with swollen fingers; -Both lower extremities with pitting swelling with pedal pulses present; -Placed in 14 day isolation per policy. Review of the resident's undated baseline care plan showed the following: -Activities of daily living problems related to grooming, toileting, bathing and dressing; -Diabetic diet; -Safety issues related to falls and uses a walker for mobility with two assist for transfers; -admitted for wound care and diabetes; -No indication of completion date, resident signature or a copy given to the resident. During an interview on 12/29/20, at 11:10 A.M., the Minimum Data Set (MDS), a facility mandated assessment instrument completed by facility staff, Coordinator said the following: -He/She or the admitting nurse complete the baseline care plan; -He/She would expect the baseline care plan to include the resident's baseline care needs and equipment needed to care for the resident; -He/She was responsible to make sure the baseline care plan was completed; -The baseline care plan was not reviewed with the resident or responsible party; -A copy of the baseline care plan was not given to the resident or responsible party; -There was no documentation of who completed the baseline plan of care, or the date and time it was completed, He/She did not audit the care plants to ensure they were completed within 48 hours. During an interview on 1/5/21, at 11:00 A.M., the director of nursing (DON) said the following: -She would expect nurses to complete the baseline care plan within 48 hours of admission; -She did not know if the baseline care plan was reviewed with the resident and/or responsible party; -She did not know if the resident and/or responsible party was given a copy of the baseline care plan; -She did not know the baseline care plan did not include the date and time it was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for six residents (Resident #7, #9, #17, 19, #22, and #39) in a sample of 12 residents. The facility census was 40. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, dated October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the Interdisciplinary team (IDT) a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Review and revise the current care plan, as needed; and 11. Communicate with the resident or his/her family or representative regarding the resident, care plans, and their wishes. 1. During an interview on 12/30/20, at 3:30 P.M., the assistant administrator said the facility did not have a policy for care plans. 2. Review of Resident # 9's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnosis of Alzheimer's disease, macular degeneration, dysphagia, GERD, edema, Vitamin D deficiency, and weakness. Review of the resident's care plan, last updated 9/21/20, showed the following: -At risk for Nutritional Status related to a mechanically altered diet; -Goal: no significant weight variance; -Dependent on staff with eating, at times can feed himself/herself but needs encouragement from staff; -Pureed diet, no seeds, and Greek yogurt daily; -The care plan did not include aspiration risk, and swallowing difficulties. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 10/22/20, showed the following: -Severe cognitive impairment; -Diagnosis include Alzheimer's (dementia); dysphagia, (oropharyngeal phase (problem with swallowing involving the mouth and the throat behind the mouth); -Mechanically altered diet; -No swallowing issues (diagnosis shows presence of swallowing problem): -Requires limited physical assistance of one staff member for eating; Review of the resident's Physician's Orders, dated 12/1/20-12/22/20, showed the following: -Pureed Diet; -12/23/20 Nectar thick liquids and thin liquids with medications; -Do not give seeds; -Greek yogurt BID with meals; -Encourage increased fluid intake. Review of the resident's Nurses Notes dated 12/16/20, showed the staff documented new order received and noted after trial of nectar thick liquids related to increased coughing with thin liquids. Review of the resident's Physician Orders, dated 12/23/20, showed a new order for Speech Therapy to evaluate and treat for dysphagia. Review of the resident's care plan showed the care plan did not include any updated in aspiration risk, swallowing difficulties, speech therapy evaluation or new order for nectar thickened liquids. Observation on 12/28/20, at 12:37 P.M., showed the following: -Staff served the resident a puree diet, thin liquids, tea with ice, juice and water; -The resident made no attempts to feed himself/herself; -Certified nurse assistant (CNA) A fed the resident; -The resident coughed between bites, and audibly tried to clear his/her throat; -The coughing increased and the resident said he/she was done eating; -CNA A removed the resident from the table; -The resident consumed less than 10% of his/her meal. Observation on 12/29/20, at 12:25 P.M., showed the following: -CNA A served the resident a pureed diet, with water, juice, and tea with ice; -The drinks were thin liquids, did not contain thickener; -An unidentified staff member gave the resident a drink of juice and the resident coughed. During an interview on 12/30/20, 1:33 P.M., CNA I said the following: -The resident does not consistently eat well; -He/She started coughing a lot; -He/she recently started nectar thick liquids; -The care plan tells staff how to take care of the residents. 3. Review of Resident #39's physician order sheet dated 3/6/20 showed an order for left heel to apply sure prep (a skin protectant wipe) daily. Review of the resident's care plan dated 4/10/20 showed the following: -Problem category pressure ulcer with goal of no pressure ulcers by next review and approaches for left ankle resolved (no date indicated as to when resolved) and a line through the approach for a treatment of sure prep to left heel; -Problem of nutritional status with a goal of no significant weight variances with an approach of monthly weight to monitor for significant weight variances and drinks with a sippy cup. Review of the resident's monthly weight record showed the following: -Weight on 7/14/20 was 148; -Weight on 8/8/20 was 143; -Weight on 9/14/20 was 136; -Weight on 10/21/20 was 129.8, 12.29%, 18.2 lbs, significant weight loss in 90 days; -Weight on 11/21/20 was 134. Review of the resident's physician order sheet for 12/1/20 - 12/31/20 showed the following: -Order dated 11/9/20 for left outer ankle to cleanse area with normal saline and apply boarded foam change every 72 hours; -Order dated 12/16/20 for right buttock open area to be cleansed with normal saline and apply bacitracin (antibiotic ointment) ,and cover with dry dressing twice a day and as needed; Calmoseptine (ointment or cream to act as a moisture barrier to protect and heal skin irritations) to gluteal cleft and bilateral buttocks twice a day and as needed; position side to side in bed. Review of the resident's care plan last reviewed 12/17/20 did not include any new interventions to address the resident's significant weight loss or skin issues. Review of the resident's monthly weight record showed the resident's weight on 12/21/20 was 130.6 which was a significant weight loss of 17.4 lbs/11.7% in six months. Review of the resident's dietary progress notes dated 12/29/20 showed to continue with weekly weights and will continue to monitor weights and consumption. Review of the resident's care plan did not include any updates or revisions following the continued weight loss, and a new pressure ulcer. 4. Review of Resident #7's care plan, dated 4/30/20, showed the following: -Nutritional status problem with goal of no significant weight variances and approach of weight weekly to monitor for significant changes; -Activities of Daily Living (ADL) problem of dependent for all ADL's; -Urinary incontinence that can put at risk for pressure/skin breakdown with intervention of unable to reposition self and depend on staff to reposition. Review of the resident's physician order sheet showed weights Tuesday and Friday and fax to physician every two weeks ordered 2/5/20. Review of resident's monthly weight record showed the following: -Weight in August 2020 was 194.9; -Weight in October 2020 was 197; -Weight in November 2020 was 204.8; -Weight in December 2020 was 207.6. Observation on 12/28/20 at 10:51 A.M. showed an air mattress and mattress topper on the resident's bed frame. Review of the resident's care plan showed no documentation to address the resident's weight gain or use of an air mattress on the resident's bed. 5. Review of Resident #19's monthly weight record showed the following: -Weight on 8/4/20 was 122.2 pounds; -Weight on 9/9/20 was 113.2 pounds which was a significant loss of 7.36 % in one month. Review of the resident's nutritional note dated 9/20 showed the dietary manager suggested verbal cues for eating. Review of the resident's care plan dated 11/18/20 showed the following: -Nutrition and approaches (including weekly weights) were not added until 12/29/20; -Supplements were not added to the care plan; -Verbal cues recommended 9/20 were not added to the care plan. Review of the resident's POS dated 12/20 showed the following: -Diagnoses included dementia, major depression, vitamin deficiency, hypothyroidism, and nutritional deficiency; -Regular diet (4/17/19); -Ensure(nutritional supplement -four ounces) with each meal (12/29/20). Review of the resident's care plan did not include interventions to address nutrition or recommendations after a weight loss. 6. Review of Resident #17's care plan dated 5/14/20 showed: -Problem: nutritional status, regular diet; -Goal: I would like to have no significant weight variances; -Approaches: broken natural teeth and loose partial plates, assist needed for meals at times,monitor my weight monthly to assess for significant loss; Review of the resident's monthly weight record showed the following: -Weight on 6/10/20 was 197; -Weight on 12/12/20 was 175.4 -The resident had a 10.96% loss in six months. The resident's care plan did not include interventions to address the resident's significant weight loss. 7. Review of Resident #22's monthly weight record for 2020 showed the following: -Weight on 11/20 was 178 pounds; -Weight on 12/20 was 161 pounds; -The resident had a significant weight loss of 9.6% in one month. Review of the resident's care plan dated 11/27/20 showed the following: -Problem: Nutritional, regular diet; -Goal: I wish to have no significant weight variances by next review date; -Approaches: Ate independently in room, provide foods I enjoy, monitor weight monthly and report changes. Review of the resident's POS dated 12/20 showed a new order for Boost (supplement) daily (12/2/20). The resident's care plan was not revised to address the weight loss or additional interventions. 8. During an interview on 12/29/20, at 11:10 A.M., the MDS Coordinator said the following: -He/She completes the residents' comprehensive care plan; -When residents have changes to their care or new interventions he/she adds them to the care plan; -Nurses can also update the care plans; -If changes are missed on the care plan we catch them when we do their quarterly care plan and add them at that time. During an interview on 1/05/21, at 11:05 A.M., the director of nursing said the following: -The care plan should be updated if a resident has any changes in care or new interventions; -The care plan tells staff how to care for each resident; -Nurses can update the care plans; -The MDS coordinator updates the care plans and monitors the care plans; -Care plans should be updated according to the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of Resident #25's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with eating; -Not taking diuretics; -Weighs 280 lbs. Review of the resident's Weight Record showed the resident's weight on 11/11/20 was 280 lbs. Review of the resident's Physician's Orders dated 11/23/20, showed the physician ordered bumetanide (a strong diuretic 'water pill'), 2 milligrams (mg) once a day. Review of the resident's laboratory results, dated 11/24/20, showed the following: -Brain neuropeptic peptides (BNP) (measure of protein produced in the heart when it is enlarged with fluid, normal range is less than 1800 for this resident) was 6948 critically high; -Blood urea nitrogen (BUN) (measure of how well kidneys are working, normal is 8-23) was 39 high. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Took diuretics six out of seven days. Review of the resident's laboratory results, dated 12/1/20, showed the resident's BUN was 51(high). Review of the resident's Weight Record on 12/5/20 showed a weight of 224 lbs, a 20 % loss. Review of the resident's laboratory results, dated 12/28/20, showed the resident's BUN was 126 critically high. Review of the resident's medical record showed no documentation facility staff notified the physician or dietitian of the resident's weight loss. Observation on 12/28/20, at 10:59 A.M., showed the following: -The resident lay in his/her bed; -A large water pitcher with lid and straw sat on his/her bedside table. During an interview on 12/28/20, at 10:59 A.M., the resident said the following: -He/She requested a different water pitcher several times, they never bring a small one, even a cup with a lid would work; -He/She was so thirsty and could not drink out of the large water pitcher; -The water pitcher was too heavy for him/her, and with the size if he/she angles it to get a drink he/she would just end up wearing it. Observation on 12/28/20, at 8:59 A.M., showed the following: -The resident lay in his/her bed; -A large water pitcher with a lid and straw sat on his/her bedside table. Observation on 12/28/20, at 12:24 P.M., showed the following: -The resident lay in his/her bed; -A large water pitcher with lid and straw sat on his/her bedside table. During an interview on 12/30/20, 1:33 P.M., CNA I said the following: -The resident had a lot of edema, now he/she looks a lot thinner, he/she was not sure if it was all fluid or actual fat, he/she doesn't eat well. During an interview on 1/4/21, at 1:30 P.M., the dietary manager (DM) said he/she does not know how the resident eats, the resident had fluid issues. During an interview on 12/20/20, at 3:58 P.M., the DON said the following: -The resident has had fluid issues; -He/She doesn't know if the December weight was accurate or if a re-weight was done; -He/She does not know if the facility notified the physician and/or dietitian of the resident's December weight. 8. Review of Resident #39's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's nutritional assessment, completed 3/10/20, showed the following: -Diagnosis included intellectual disabilities, vitamin D deficiency (too little vitamin D in the body), lactose intolerant (inability to fully digest lactose in dairy products), hypothyroidism (the thyroid gland does not produce enough thyroid hormone), and gastro-esophpageal reflux disease (reflux of stomach acid into the esophagus); -Diet order of mechanical soft with binders on meat, no added salt and lactose intolerance; -No order for supplements; -Average intake 40-60% at most meals, eats more at breakfast; -Weight of 156 lbs; -Weight history/changes is blank; -Set-up assistance needed; -No swallowing or chewing problems. Review of the resident's annual MDS, dated [DATE], showed the following: -No swallowing disorders; -Weight of 151 lbs; -Mechanically altered diet. Review of the resident's care plan, reviewed 4/10/20, showed the following: -Diagnosis include major depressive disorder and hypokalemia (low potassium in the body); -Problem of nutritional status on a mechanical diet with binders on meat and no added salt diet; -Goal of no significant weight variances; -Approaches of no dairy due to lactose intolerant, likes hot dogs and sweet potatoes for lunch and supper, likes Pepsi to drink in sippy cup, weigh monthly and monitor for significant weight variances and report changes to charge nurse; -The care plan did not include weight loss or any interventions related to weight loss. Review of the resident's quarterly dietary assessment, dated 6/20/20, showed the following: -No nourishment indicated; -Weight of 134 lbs; -Goal weight, weight last quarter and weight 6 months ago were left blank; -Intake is fair; -No changes since last review influencing nutrition/hydration; -Assistive devices sippy cups. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Moderately impaired decision making ability; -No swallowing disorders; -Weight of 134 lbs; -Weight loss of 5% or more in the last month or gain of 10% or more in last 6 months: not on physician-prescribed weight-loss regimen; -No nutritional approaches. Review of the resident's monthly weight sheet for July 14, 2020 showed a weight of 148 lbs. Review of the resident's monthly weight sheet for August 3, 2020 showed a weight of 143 lbs. Review of the resident's monthly weight sheet for September 14, 2020 showed a weight of 136 lbs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired decision making ability; -Cognition is blank; -No swallowing disorders; -Weight of 136 lbs; -Weight loss of 5% or more in the last month or gain of 10% or more in last 6 months: yes, not on physician-prescribed weight-loss regimen; -No nutritional approaches. Review of the resident's quarterly nutritional assessment, dated 10/7/20, showed the following: -Mechanical soft diet with binders on meat, no added salt, lactose intolerant; -No nourishment; -Weight 129.8 lbs; -Goal weight, weight last quarter, weight six months ago were all blank; -Changes since last review influencing nutrition/hydration was blank; -Feeding ability was marked as set up; -Assistive devices was blank. Review of the resident's monthly weight dated October 21, 2020 showed a weight of 129.8 lbs. Review of the resident's monthly weight dated November 21, 2020 showed a weight of 134 lbs. Review of the resident's physician order sheet, dated 12/1/20 - 12/31/20, showed the following: -No dairy products - lactose intolerance; -Diet: low fat, mechanical soft with binders on meat, no added salt; -Slightly smaller portions of food; -No additional weights, such as weekly weights, ordered. Review of the resident's monthly weight dated December 21, 2020 showed a weight of 130.6 lbs, a loss of 17.4 lbs, or 11.7%, in six months. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Decision making ability is blank; -No swallowing disorders; -Weight loss of 5% or more in the last month or gain of 10% or more in last six months: yes, not on physician-prescribed weight-loss regimen; -No nutritional approaches. Observation in the dining room, on 12/28/20 at 12:15 P.M., showed the following: -The resident had three sippy cups with clear liquid in one, white liquid in one and juice in the third one; -An adaptive ring was on the edge of plate with the opening toward the resident; -The resident's hands were shaking during the meal resulting in portions of food falling to the floor or on his/her clothing protector; -No staff offered to provide feeding assistance; --The resident consumed approximately 25% of the meal. During interview on 12/30/20, at 1:30 P.M., CNA A and CNA K said they had not noticed any weight loss with the resident. During an interview on 12/29/20 at 8:25 A.M., LPN C said the following: -The resident will not allow staff to assist him/her in feeding; -The resident has lost weight since admission, but he/she is not sure as to how much weight; -The adapter plate is faced with the closed section toward the resident because he/she scoops the food against the rim to help get it on his/her spoon; -Weight loss concerns would be reported to the DON. During interview on 12/30/20, at 10:50 A.M., the dietary manager said the following: -He/She participates in routine weight reviews during resident care plan meetings; -There was no specific routine meeting to address resident weight changes; -She reports weight loss to the DON or dietitian; -The resident only lost three pounds in the last month and had some health issues the past few months; -If a resident has a weight loss she would discuss with the DON and then fax the physician to get new orders; -The dietitian would also normally be contacted, the dietitian saw the resident in March; -The resident does not like supplements; -She was not sure if the physician had been contacted about the resident's weight loss; -She did not identify the resident had lost greater than 10% since July, 2020. 9. Review of Resident # 29's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Weight Record, dated 6/5/20, showed the resident weighed 207.6. Review of the resident's laboratory results, dated 6/18/20 showed the following: -BUN (normal value 8-23) 56- high; -Creatinine (normal value 0.55-1.02) 3.3-high; -Glomerular filtration rate (GFR, value below 60 indicates kidney disease, 15 or less may indicate kidney failure) 14 L; -Sodium (normal value 134-145) 140. Review of Resident #29's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis include Chronic Kidney Disease stage 4 (severe); Congestive Heart Failure, and Diabetes Mellitus; -Weight 208 lbs.; -Diuretic medication daily. Review of the resident's Weight Record, dated 7/1/20, showed the resident weighed 220.2 pounds, a gain of 12.6 lbs., 5.7% in one month. Review of the medical record did not show notification of the physician or dietitian of the weight gain. Review of the resident's laboratory results, dated 7/9/20 showed the following: -BUN 63- high; -Creatinine 3.0-high; -Sodium 138; -.GFR 16 low. Review of the resident's Weight Record, dated 8/12/20, showed the resident weighed 220 pounds. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Weight 220 lbs.; -No significant weight gain; -Diuretic medication daily. Review of the resident's Nurses Notes, dated 9/11/20, showed the following: -Lasix (water pill) is discontinued; -Sodium restriction is discontinued; -New order for calcium. Review of the resident's medical record did not include a weight for September. Review of the resident's Laboratory results, dated 10/15/20 showed the following: -BUN 71- high; -Creatinine 2.9-high; -Sodium 142; -GFR 16 low. Review of the resident's Weight Record, dated 10/19/20, showed the resident weighed 251 lbs., gain of 43.4 lbs., 17.2 % in four months. Review of the medical record did not show notification of the physician or dietitian of the weight gain. Review of the resident's nurses notes, dated 10/22/20, showed the following: -Diet changed to diabetic, low sodium, low potassium, and low phosphorous; -Aranesp (treat anemia caused by kidney failure) injection. Review of the resident's nurses notes, dated 11/3/20, showed the physician ordered no Gatorade because of the resident's sodium level. Review of the resident's laboratory results, dated 11/5/20 showed the following: -BUN 66- high; -Creatinine 3.4-high; -Sodium 143; -GFR 14 low. Review of the resident's Weight Record, dated 11/19/20, showed the resident weighed 256 lbs., a gain of 48.4 lbs., a 23.31 % gain in five months. Review of the resident's medical record did not show notification of the physician or dietitian of the weight gain. Review of the resident's nurses notes, dated 11/10/20, showed critical high potassium level reported to the physician, with new orders for Kayexalate (medication to decrease potassium level). Review of the resident's Nurses Notes, dated 11/28/20, showed the resident had edema, redness, and warmth of his/her nose. Review of the resident's Laboratory results, dated 12/3/20 showed the following: -BUN 82- high; -Creatinine 3.5-critically high; -Sodium 142; -GFR 13 low. Review of the resident's Nurses Notes, dated 12/3/20, showed high phosphorous level and abnormal labs faxed to the physician. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Weight 250 lbs; -Significant weight gain, not on a physician prescribed plan; -No diuretic medications. During an interview on 1/4/21, at 1:30 P.M., the DM said the facility has not addressed the resident's weight gain. During an interview on 12/20/20, at 3:58 P.M., the DON said he/she did not know if the facility notified the physician and/or dietitian of the resident's weight gain. During an interview on 12/29/20, at 12:34 P.M. and 1/4/21 at 1:17 P.M., the dietary manager (DM) said the following: -Dietary staff do not thicken liquids for the residents that require them; -Nursing is responsible to thicken liquids for the residents; -He/She did not know if the nursing staff had been in-serviced on the amount of thickening powder to add to make fluids nectar thick; -Residents on thickened liquids and pureed diets should not have ice in their drinks because they might aspirate; -He/She records the weights in the residents' charts; -He/She does not calculate the weight loss, he/she may ask staff to reweigh if see on that is way off; -The care plan team looks at the residents' weights on their annual or quarterly review; -No one reviews weights monthly or weekly; -When the care plan team identifies a significant weight loss with their annual or quarterly review, an intervention is added, and they try to get an order from the physician; -Normally he/she would go through the dietitian for recommendations, he/she has not gone through the dietitian since at least April; -He/She was not sure about the percentages but usually considers anything over 7% in 6 months a weight loss or gain, 3 months 5%, or if is it 8% in 6 months, but could be wrong; -The MDS coordinator calculates the percentage of weight loss or gain. -The dietitian has not done any assessments since March; -The dietitian was not allowed in and the facility is paper charting only, no electronic medical record; -Resident #29 has some fluid issues, but the team has not evaluated for weight gain. The facility has not addressed the resident's weight gain; -Resident #25 has had some fluid issues. During an interview on 12/28/20 at 3:16 P.M.,12/30/20 at 3:58 P.M. and 1/5/21 at 11:05 A.M., the DON said the following: -CNAs thicken liquids for the residents; -Thickened fluids should not have ice; -He/She does not know if the nursing staff has had training on how much thickener to use for the right consistency; -Staff should accommodate residents if they need smaller cups instead of the large water pitchers in their rooms; -The RD has not come into the facility since March; -The DM reviews the weekly and monthly weights, then reports them to the dietitian and the physician; -There is no way to do a clinical review offsite, the facility does not have electronic records; -The DM can call the RD; -The facility does not evaluate the resident's weights until the quarterly MDS review; -If a resident has a weight loss, they should be rewieghed to ensure an accurate weight, then notify the physician and the dietitian; -If a resident has weight loss, it should be addressed on the care plan with new interventions to attempt to stabilize the residents weight; -He/She did not know the DM was not certified; -Daily weights are faxed to the physician on Fridays, monthly weights are monitored by the DM on a monthly basis and he/she notifies the physician and dietitian; -The RD reviews weights, makes intervention recommendations; -Care plans are updated with significant weight changes or new interventions, and nursing sends communication to the dietary staff to update the meal cards; -Re-weights should be done if there is a gain or loss --fluid retention 3 lb wt gain, reweigh, 5 lbs on monthly weights-document on the weight paper. During an interview on 1/4/21, at 1:37 P.M., the registered dietitian said the following: -He/She will answer questions from the facility by phone; -The facility is not sending weights to her to be evaluated; -He/She has not reviewed a resident record since before COVID19 in March; -He/She does not have any documentation about when the facility has called him/her, only a few questions about specific residents; -Significant weight loss or weight gain is considered 5% in one month or 10% in six months; -If a resident has significant weight loss or weight gain the facility should try to find the cause of the loss/gain and put interventions in place to stabilize the resident's weight; -The resident should be followed and re-evaluated to ensure the current interventions are working, and adjust them if needed; -Nursing staff calculate the percentages of weight loss; -The facility has had a change of management staff so he/she is not sure if they are using the same process, he/she has not been in the facility for the last ten months; -Before COVID19 the DM and he/she would go over every resident's weight each month and write recommended interventions; -This last few months he/she did not know what has been going on, During an interview on 1/13/21, at 3:05 P.M., Physician G said the following: -The facility has only allowed him/her to come in the building to see the residents one time in October; -He/She struggles to get current weights for his/her residents; -The weights for the residents are always missing and sometimes he/she has to wait for weeks for them to send a new weight; -The weight record for the residents are not complete so he/she can only compare this month's weight to last month; -The facility did not notify him/her the registered dietitian was not evaluating the residents since March; -He/She expects a registered dietitian to follow his/her residents; -He/She expects the facility to weigh every resident monthly, and weekly or daily based on the resident's orders; -He/She expects the facility to evaluate the weights within a day or two and report any significant weight gains or losses to the dietitian and the physician; -If a resident has a weight loss he/she would start a supplement or find out what might have caused it and start weekly weights to monitor the loss; -He/She was not notified of Resident #18's weight loss; -Resident #18 should have all liquids nectar thick, he/she has already suffered aspiration pneumonia in August; -Resident #2 has significant congestive heart failure and his/her weight fluctuates, he/she was not notified of the weight loss in April 2020, which needs to be monitored closely; -Resident #22 is a new resident to him/her, the facility has not notified him/her the resident had a weight loss in December. During an interview on 1/15/20, at 8:41 A.M., the medical director said the following: -The facility has a consultant dietitian that is responsible for reviewing issues with weight loss, swallowing and problems of that nature; -He was not aware the dietitian had not been in the building for reviews since March; -The dietitian should review any significant weight loss/gain and make recommendations; -He would expect diet orders, such as thickened liquids, to be followed as ordered; -He was unsure if specific weight loss/gains had been reported but follows the residents on rounds. Based on observation, interview, and record review, the facility failed to consistently monitor residents' weights, ensure interventions were implemented to address weight loss/gain, refer to a registered dietitian or physician for significant weight loss/gain, ensure fluid balance was maintained, and re-evaluate interventions for effectiveness for eight residents (Resident #18, #17, #19,#22, #2, #25, #39 and #29) of 12 sampled residents with significant weight loss and/or weight gain, and failed to ensure thickened liquids were provided for two residents (Resident #18, and #9). The facility census was 40. Review of the facility policy Nutrition (Impaired)/Unplanned Weight Loss, last revised September 2017, showed the following: -Nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individuals with anorexia (lack or loss of appetite for food), weight loss or gain, and significant risk for impaired nutrition; -The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake; -The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions; -For individuals with recent or rapid weight gain or loss (more than a pound in a day) the staff will review for possible fluid and electrolyte imbalance and a cause; -The physician will review carefully and rule out medical causes of oral or swallowing problems before authorizing other consults or interventions to modify diet consistency; -The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes; -The staff and physician will review and consider existing dietary restrictions and modified consistency of diets; -Physician and staff will monitor nutritional status an individual's response to interventions and possible complications of such interventions. Review of the facility's policy Weight Assessment and Intervention, revised September 2008, showed the following: -Multidisciplinary team will prevent, monitor and intervene for undesirable weight loss for residents; -Nursing staff will measure residents' weights on admission, the next day, and weekly for two weeks thereafter, if no concerns are noted then measured monthly thereafter; -Weights will be recorded in the weight record chart and in the individual's medical record; -A 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 dietitian in writing and must be confirmed in writing; -The dietitian will respond within 24 hours of receipt of written notification; -The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: a. 1 month-5% weight loss is significant, greater than 5% is severe; b. 3 month-7.5% weight loss is significant; greater than 7.5% is severe; c. 6 month-10% weight loss is significant; greater than 10% is severe; -Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss; -Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident's legal surrogate; -Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment; -Interventions for undesired weight gain should consider resident preferences and risk, a weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement. Review of the facility policy Hydration-Clinical Protocol dated 2001 and last revised 9/17 showed the following: Assessment and Recognition -The physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). The physician will distinguish various types of fluid and electrolyte imbalance (for example, hyponatremia, hypernatremia, pre-renal azotemia, etc.) from true hydration (clinically significant loss of total body water); -The staff, with the physician's input, will identify and report to the physician individuals with signs and symptoms (lethargy, delirium, increased thirst, etc) or lab test results that might reflect existing fluid and electrolyte imbalance. The physician and staff will identify significant risk for subsequent fluid and electrolyte imbalance; for example, individuals with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well; Cause Identification: -The physician will help identify the cause of any existing fluid and electrolyte imbalance or help staff document why the individual should not be tested or evaluated. A limited review for causes (for example, based on the clinical situation and a basic metabolic profile (BMP) may be appropriate even if an extensive work up is not. Treatment/Management The physician will manage significant fluid and electrolyte imbalance, and associated risks appropriately and in a timely manner. Timeliness depends on the severity, nature and causes of the fluid and electrolyte imbalance. For minor, uncomplicated fluid and electrolyte imbalance, oral rehydration may suffice. For more severe or complicated fluid and electrolyte imbalance, subcutaneous or intravenous hydration may be needed. Any medications that are contributing to fluid and electrolyte imbalance should be tapered or stopped (at least temporarily), or the physician should provide clinically valid documentation as to why they cannot or should not be changed, even temporarily. The staff will provide supportive measures such as supplemental fluids an adjusting environmental temperature, where indicate. Monitoring and Follow-Up The physician and staff will monitor for the subsequent development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals. For example, replacement may be adequate if the resident is clinically stable, not having delirium, voiding at least every three to four hours, and urine specific gravity (where attainable) is less than 1.015. The physician will adjust treatments based on specific information (lab results, level of consciousness, etc.) relevant to that individual. Oral replacement may be adequate if the patient is clinically stable, not having delirium, voiding at least every three to four hours and the urine specific gravity is less than 1.015. Repeating the basic metabolic profile and/or serum osmolality can help track progress in correcting abnormalities. 1. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 5/4/20, showed the following: -Moderate cognitive impairment; -No swallowing issues; -Weight 176 lbs.; -On a therapeutic diet. Review of the resident's Weight Record, dated 6/12/20, showed the resident weighed 175 pounds (lbs.). Review of the resident's Weight Record, dated 7/2/20, showed the resident weighed 172 lbs. Review of the resident's admission MDS, dated [DATE], showed the following: -Weight 159 lbs.; -No swallowing issues; -Significant weight loss not on a physician prescribed weight loss plan; -Therapeutic and mechanically altered diet. Review of the resident's nutritional quarterly assessment, dated 8/18/20, showed the dietary manager documented the following: -Tolerating nectar thickened liquids at this time; -Control consistent carbohydrate diet 4 gram (gm) no added salt (NAS); -Mechanical soft diet with nectar thickened liquids; -Daily boost Glycemic Control; -The assessment did not include the resident's weights. Review of the resident's care plan, dated 8/19/20, showed the following: -At risk for nutritional status; -On 4 gm NAS, Control consistent carb diet with nectar thickened liquids; -Thickened liquids at meal times; -Can drink Pepsi in his/her room; -Speech therapy (ST) at this time; -No complications with my diet through next review date; -Eats independently; Review of the resident's Weight Record, dated 9/1/20, showed the resident weighed 159 lbs. Review of the resident's Weight Record, dated 10/3/20, showed the resident weighed 152 lbs. Review of the resident's Weight Record, dated 11/2/20, showed the resident weighed 150 lbs., a 14.29 % weight loss in six months. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Weight 150 lbs; -No swallowing issues; -Significant weight loss not on a physician prescribed weight loss plan; -Therapeutic and mechanically altered diet. Review of the resident's Weight Record, dated 12/4/20, showed the resident weighed 150.4 lbs. Review of the resident's care plan showed no updates or new interventions related to his/her weight loss. Observation on 12/28/20 at 12:22 P.M., showed the following: -The resident sat in his/her wheelchair at his/her bedside table; -Staff served the resident his/her tray which included a regular mechanical soft consistency meal with iced tea and iced water; -The drinks were regular liquids and not thickened; -The resident's bedside table was not positioned/set up by staff so his/her meal could be easily accessed (reached); -The resident dropped food from his/her utensils when he/she attempted to bring his/her food to his/her mouth; -The resident coughed and cleared his/her throat several times while eating and drinking. During an interview on 12/28/20, at 3:16 P.M., the Director of Nurses (DON) said the following: -If a weight was questionable there should be a re-weight done and documented; -There was no other weight documented for August or September for the resident. Observation on 12/29/20, at 12:22 P.M., showed the following: -The resident sat in his/her wheelchair at his/her bedside table; -Staff served the resident his/her tray, which included a regular mechanical soft consistency diet with iced tea and iced water; -Both the tea and water were regular thin consistency; -The resident's bedside table was at an angle approximately one foot from the resident's knees; -When the resident spoke, he/she had audible gurgle from his/her throat causing the resident to cough. During an interview on 12/29/20, at 12:22 P.M. and 12/30/20 at 1:33 P.M. Certified Nurse Aide (CNA) I said the following: -The resident was not supposed to have ice in his/her drinks because it could cause aspiration, the drink should be refrigerated to serve cold (no ice); -The resident was sitting very far from his/her bedside table today; -Staff are expected to place the resident's tray where he/she could reach it; -The resident already has tremors (involuntary, rhythmic muscle contraction leading to shaking movements in one or more parts of the body) in his/her hands, reaching that far would cause him/her to drop food while he/she was eating; -The resident coughs a lot; -The resident[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to assess residents for risk of entrapment, document attempted alternatives prior to installing a bed rail, or provide informed consent on the safety risk associated with bed rail use for five residents (Resident #18, #7, #25, #29, and #32) in a review of 12 sampled residents and one additional sample resident (Resident #23) who had bed rails in place on their beds. The facility census was 40. Review of the facility's Bed Safety Policy, revised December 2007, showed the following: -Our facility shall strive to provide a safe sleeping environment for the resident; -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA; c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; d. Ensure the bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment. -The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. Review of the Food and Drug Administration's Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm; -Assessment by the health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when patients or parts of their body are caught between rails and mattress, more serious injury from falls when patients climb over rails, skin bruising, cuts and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an ongoing assessment of the patient's physical and mental status and closely monitor high-risk patients; -Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail; -Reduce the gaps between the mattress and side rails; -A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent, regular basis. 1. Review of Resident #18's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's quarterly minimum data set (MDS) a federally mandated assessment tool, dated 11/18/19, showed the following -Moderate cognitive impairment; -Independent with transfers and bed mobility. Review of the resident's Consent for Use of Side Rails, dated 11/6/19, showed the following: -The resident or family representative have read the benefits and potential negative outcomes on the back of this form of side rail use; -The back of the form was blank; -Recommend one 1/4 bed rail on the right upper side of the bed; -I do consent to the use of of the side rails recommended above; -I understand that I have the right to refuse the use of side rails or can revoke this consent at anytime. Review of the resident's medical record did not include an entrapment assessment for the use of bed rails, alternatives tried before placement of bed rails, or informed consent materials that showed risks associated with side rail use. Review of the resident's nurses notes, dated 8/7/20, showed staff found the resident on the floor. Review of the resident's care plan, dated 8/19/20, showed it did not include bed rail use. Review of the resident's nurses notes, dated 10/8/20, showed the following: -At 4:00 A.M., the resident fell while trying to get to the commode, lost balance, fell backwards, hit head tender with hematoma (bruising); -At 5:10 P.M. found the resident on the floor; -At 11:40 P.M., found the resident on the floor next to his/her bed. Review of the resident's nurses notes, dated 10/9/20, showed the staff found the resident on the floor and resident sent to the emergency room for shoulder pain. Review of the resident's nurses notes, dated 12/1/20, showed the staff found the resident on the floor next to his/her bed. Observation on 12/28/20, at 3:25 P.M., showed the resident in bed with 1/4 bed rails raised on both sides of the upper part of the bed. Observation on 12/29/20, at 6:28 A.M., showed the resident lay at an angle in his/her bed with his/her head against the left upper bed rail and his/her feet hung off the right lower side of the bed. Both upper bed rails were in a raised position. Observation on 12/30/20, at 1:30 P.M., showed the resident lay in bed with 1/4 bed rails raised on both sides of the upper part of the bed. 2. Review of Resident #7's care plan, last reviewed 8/5/2020, showed the following: -Diagnosis of Alzheimer's disease (dementia - a progressive disease that destroys memory and other important mental functions), dementia, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness); -Unable to make needs known; -Totally dependent on staff for all activities of daily living (ADLs); -Unable to reposition self. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Nonverbal status; -Total dependence on staff for all aspects of ADL's and transfers. Review of the resident's undated consent for use of side rails showed the resident did not use side rails and had a low bed with a mat. Observation on 12/29/20 at 5:20 A.M. showed the resident lay in bed with his/her eyes closed. The left 1/4 side rail was in the raised position, the right side of the bed was pushed against the wall, and the bed in a waist high position. Observation on 12/29/20 at 7:40 A.M. showed the resident lay awake in bed with the left 1/4 side rail in the raised position, the right side of the bed was pushed against the wall, and the bed in a waist high position. During an interview on 12/29/20, at 7:45 A.M., Certified Nurse Aide (CNA) I said the resident did not use the side rail and once in bed the resident did not change positions independently. Review of the resident's medical record showed no documentation the facility completed an assessment to indicate use of a 1/4 length side rail on the resident's bed or an evaluation for entrapment risk. 3. Review of Resident #32's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's consent for use of side rails, dated 12/8/20 showed the following: -Use of left and right upper 1/4 rail; -Purpose of use for mobility; -He/She consented to the use of side rail and signed the consent 12/8/20. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Extensive assist of two staff members for bed mobility, transfers, ambulation, locomotion, dressing, toileting and hygiene. Review of the resident's care plan, dated 12/18/20, showed the following: -History of falls with recent fracture; -Assist of two staff for transfers, toileting and ADL's. Observation on 12/28/20, at 11:05 A.M., showed the resident lay in bed with his/her eyes closed. Both upper rails were in the raised position and the bed up against the wall. Observation on 12/29/20, at 5:23 A.M., showed the resident lay in bed with his/her eyes closed. Both upper rails were in the raised position and the bed up against the wall. During an interview on 12/29/20, at 9:34 A.M., the resident said he/she used both side rails for bed mobility and transfers. Review of the resident's medical record did not include an assessment for the use of bed rails or education provided to show the risk associated with the use of side rails. 4. Review of Resident #23's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Consent for Side Rails, dated 11/13/20, showed the following: -One 1/4 rail on the right upper side of the bed; -I do consent to the use of the side rail recommended above; -I have the right to refuse the use of side rails or can revoke this consent at anytime. Review of the resident's medical record showed no entrapment assessment for the use of bed rails, alternatives tried before placement of bed rails, or informed consent materials that showed risk associated with side rail use. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with bed mobility; -Limited physical assistance of one staff member with transfers; -Balance unsteady only stabilize with staff assistance; -History of falls. Review of the resident's care plan, last updated 11/30/20, showed it did not include the use of side rails. Observation on 12/28/20, at 10:45 A.M., showed the following: -The resident sat on the side of his/her bed; -The right upper part of his/her bed had a raised, 1/4, round side rail; -A large gap, approximately six inches wide was noted between the mattress and the bed rail. Observation on 12/29/20, at 5:46 A.M., showed the following: -The resident sat on the side of his/her bed; -The right upper part of his/her bed had a raised, 1/4, round side rail; -A large gap, approximately six inches wide was noted between the mattress and the bed rail. During an interview on 12/29/20, at 10:48 A.M., the maintenance director said there was more than a 4 1/2 inch gap between the resident's bed and his/her mattress. 5. Review of the Resident #25's Face sheet, showed the resident was admitted to the facility on [DATE]. Review of the resident's Consent for Use of Side Rails, dated 8/25/20, showed the following: -The resident or family representative have read the benefits and potential negative outcomes on the back of this form of side rail use; -The back of the form was blank; -Recommend right and left upper soft care assist rail, -I do consent to the use of of the side rails recommended above. I understand that I have the right to refuse the use of side rails or can revoke this consent at anytime. Review of the resident's medical record did not include an entrapment assessment for the use of bed rails, alternatives tried before placement of bed rails, or informed consent materials that showed risk associated with side rail use. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with bed mobility; -Limited physical assistance of one staff member for transfers. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Extensive physical assistance of two or more staff members with transfers; -One fall since admission. Review of the resident's care plan, last dated 11/30/20, did not include the use of bed rails. Observation on 12/28/20, at 12:05 P.M., showed the resident lay in bed with 1/4 bed rails raised on both sides of the upper part of the bed. Observation on 12/29/20, at 5:46 A.M., showed the resident lay in bed with 1/4 bed rails raised on both sides of the upper part of the bed. Observation on 12/30/20, at 12:45 P.M., showed the resident lay in bed with 1/4 bed rails raised on both sides of the upper part of the bed. 6. Review of Resident #29's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Consent for Side Rails, dated 6/5/20, showed the following: -The resident or family representative have read the benefits and potential negative outcomes on the back of this form of side rail use; -The back of the form was blank; -Types of side rails was not completed; -I do consent to the use of the side rail recommended above (types of side rails); -I have the right to refuse the use of side rails or can revoke this consent at anytime. Review of the resident's medical record did not include an entrapment assessment for the use of bed rails, alternatives tried before placement of bed rails, or informed consent materials that showed risk associated with side rail use. Review of the resident's care plan, dated 6/18/20, showed it did not include bed rail use. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Requires limited physical assistance of one staff member with bed mobility and transfers. Review of the resident's quarterly MDS, dated [DATE], showed the resident requires extensive physical assistance of one or more staff members for bed mobility and transfers. Observation on 12/28/20, at 11:05 A.M., showed the following: -The resident lay in his/her bed; -1/4 rails were raised on both sides of the bed. Observation on 12/29/20, at 6:45 A.M., showed the following: -Resident in his/her bed; -1/4 rails were raised on both sides of the bed. Observation on 12/30/20, at 1:05 P.M., showed the following: -Resident in his/her bed; -1/4 rails were raised on both sides of the bed. 7. During an interview on 12/30/20, at 6:29 A.M., registered nurse (RN) L said the following: -On admission the charge nurse asks the resident if they want bed rails; -Nursing does not complete a side rail assessment or a risk assessment with the use of side rails; -The resident or family sign a consent; -Nursing notifies maintenance to install the bed rail; -He/She did not know what entrapment risk with bed rail use was; -There was no education on specific risk of side rail use, just the one sided consent form that staff provide to the resident; -To his/her knowledge there was no back side to the form or additional education given; -He/She did not know if any resident was inappropriate for side rail use or at risk for injury related to the use of bed rails. During an interview on 12/30/20, at 10:11 A.M., RN L said nursing does not complete side rail assessments. During an interview on 12/30/20, at 10:29 A.M., CNA K said the following: -He/She was not sure who decides if a resident gets bed rails; -If residents has bed rails staff make sure the rails are raised up. During an interview on 1/5/21, at 11:05 A.M., the director of nursing said the following: -All equipment used by a resident should be on the resident's care plan; -The facility does not have an assessment to evaluate entrapment risk with bed rail use; -The facility does not have a system to document interventions tried before bed rails are installed; -He/She does not know if the facility has a policy; -If a resident does not use a side rail it should be documented in the nurses notes and the side rail removed; -She was not aware of any routine side rail assessments being completed, just the consent for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the recommendations made by the licensed pharmacist during the monthly medication regimen reviews were communicated to the physician, and a response recorded from the physician for four residents (Resident #9, #18, #29, and #39), in a review of 12 sampled residents. The facility census was 40. Review of the facility policy on Medication Regimen Reviews (MMR), revised May 2019, showed the following: -The Consultant Pharmacist reviews the medication regimen of each resident at least monthly; -The goal of the MMR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication; -The MMR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities; -Within 24 hours of the MMR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity; -If the identified irregularity represents a risk to a person's life, health, or safety, the Consultant Pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally, and documents the notification; -If the physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if Medical Director is the physician of record) the Administrator; -The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it; -Copies of the MMR reports, including physician responses, are maintained as part of the permanent medical record; -The facility includes a review of key issues related to medications and medication irregularities as part of the (QAPI )program (Quality Assurance and Performance Improvement program - a plan that involves each discipline to focus on resident outcomes to improve safety and quality of care delivered). 1. Review of Resident #9's face sheet showed the resident was admitted to the facility on [DATE]. Review of the facility's Pharmacist Nursing Home Summary, dated 8/11/20, showed it did not include the resident as reviewed. Review of the resident's medical record did not include a pharmacist recommendation for August 2020. Review of the facility's Pharmacist Nursing Home Summary, dated 9/22/20, showed the following: -The pharmacist sent a recommendation to the physician for the resident; -The resident has PRN (as needed) orders for Imodium (medication for loose stools), Zofran (medication for nausea), and Tramadol (medication for pain) that have not been used in 90 days; -Will request the physician discontinue all three medications, (second request). Review of the resident's medical record did not show evidence of the recommendation to the physician for the 9/22/20 visit. Review of the facility's Pharmacist Nursing Home Summary, dated 10/13/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Resident has PRN orders for Imodium, Zofran, and Tramadol that has not been used in 90 days; -Will request the physician discontinue all three medications, (third request). Review of the resident's medical record showed no evidence of the recommendation to the physician for the 10/13/20 visit. Review of the facility's Pharmacist Nursing Home Summary, dated 11/17/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Resident has PRN orders for Imodium, Zofran, and Tramadol that has not been used in 90 days; -Will request the physician discontinue all three medications, (fourth request). 2. Review of Resident #18's face sheet showed the resident was admitted to the facility on [DATE]. Review of the facility's Pharmacist Nursing Home Summary, dated 8/11/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Communication: The resident has an order for calcium (supplement) two times daily at 7:00 A.M., and 3:00 P.M., due to calcium binding with several medications, he/she recommends changing the times of the medication. Review of the resident's medical record showed no evidence of the recommendation to the physician for a change of time with calcium for the 8/11/20 visit. Review of the facility's Pharmacist Nursing Home Summary, dated 9/22/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Communication: The resident has an order for calcium two times daily at 7:00 A.M., and 3:00 P.M., due to calcium binding with several medications, he/she recommends changing the times of the medication (second request). Review of the resident's medical record did not include a pharmacist recommendation. 3. Review of Resident # 29's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the facility's Pharmacist Nursing Home Summary, dated 7/14/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Diagnosis missing for omeprazole (medication that reduces stomach acid). Review of the resident's medical record showed no evidence of the recommendation to the physician for the 7/14/20 visit. Review of the facility's Pharmacist Nursing Home Summary, dated 9/22/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Diagnosis missing for omeprazole (second request); -Order for Allopurinol (medication to reduce uric acid) without a lab order to support it, will request uric acid level yearly. Review of the resident's medical showed the pharmacist recommendation for 9/22/20 in the chart, omeprazole and Allopurinol not addressed. Review of the facility's Pharmacist Nursing Home Summary, dated 10/13/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Diagnosis missing for omeprazole (third request); -Order for Allopurinol without a lab order to support it, will request uric acid level yearly (second request). Review of the resident's medical record showed the pharmacist's recommendation of 10/13/20 in the resident's chart did not include a response by the physician. Review of the facility's Pharmacist Nursing Home Summary, dated 11/17/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Diagnosis missing for omeprazole (fourth request); -Order for Allopurinol ) without a lab order to support it, will request uric acid level yearly (third request). Review of the resident's medical record did not include a pharmacist recommendation for 11/17/20. Review of the facility's Pharmacist Nursing Home Summary, dated 12/8/20, showed the following: -Pharmacist sent a recommendation to the physician for the resident; -Diagnosis missing for omeprazole (fifth request). Review of the resident's medical record showed the 12/8/20 pharmacist recommendation in the resident's chart did not include a response by the physician. 4. Review of Resident #39's MMR showed the following: -Consultant Pharmacist recommendation on 2/11/20, the resident has a PRN order for Albuterol Nebs (breathing treatment) from 4-16-19. It has not been administered in the past three months. I will ask Medical Director to discontinue this medication; -Consultant Pharmacist recommendation on 3/10/20 with the same recommendation as 2/11/20 with 2nd request notation. Review of the resident's medical record showed the 2/11/20 and 3/10/20 pharmacist recommendations in the resident's chart did not include a response by the physician. During an interview on 1/5/21, at 11:45 A.M., Licensed Practical Nurse (LPN) M said the following: -The pharmacist makes recommendations and then the recommendations are faxed to the physicians; -The physician's office then sends the recommendations back to the facility with a response; -At times the physicians do not respond, the facility has more trouble with one physician than the other; -The facility does not have a policy of when to follow up on unanswered recommendations. During an interview on 1/5/21, at 11:00 A.M., the director of nursing (DON) said the following: -Pharmacy recommendations are faxed to the physician by LPN M; -LPN M handles tracking and getting the information to the right place. During an interview on 1/14/21, at 1:16 P.M., the pharmacist said the following: -The facility sends him/her the Physician's Order Sheet and the Medication Administration Record every month to review; -He/She has been having trouble getting a response from the physicians and has had to make the same recommendations for two or three months; -He/She seemed to have more issues getting a response from one physician group but has had issues with both physicians; -He/She would expect staff to follow up with the physician if his/her recommendations were unanswered. During an interview on 1/15/20, at 8:41 A.M., the Medical Director said the following: -The facility passes on communication from the pharmacy in a variety of ways depending on the situation, it could be faxed, a phone call or during rounds; -The facility should track and follow the pharmacist recommendation if approved by the physician; -He would not expect the pharmacist to have to request the same recommendations multiple months in a row without a response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR), or document a clinical reason to justify the need to continue psychotropic medication (a medication capable of affecting the mind, emotions, and behavior) for two residents (Resident #18 and #39) in a review of 12 sampled residents. The facility census was 40. Review of the facility policy Medication Regimen Reviews, revised May 2019, did not address gradual dose reduction of psychotropic medication. 1. Review of Resident #18's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Physician's Orders, dated 11/6/2019, directed the staff to administer Duloxetine (a medication for depression) 30 milligrams (mg) daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive issues; -No signs or symptoms of depression -Administered antidepressant medication daily. Review of the resident's Pharmacist Recommendations dated 1/14/20, 2/11/20, 3/10/20 and 4/14/20 did not include a request for a gradual dose reduction of Duloxetine. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No signs or symptoms of depression; -Administered antidepressant medication daily. Review of the resident's Pharmacist Recommendations, dated 5/27/20, 7/14/20 and 8/11/20 did not include a request for a gradual dose reduction of Duloxetine. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No signs or symptoms of depression; -Administered antidepressant medication daily. Review of the resident's care plan, dated 8/19/20, showed the following: -Did not include depression; -Did not include antidepressant medication monitoring. Review of the resident's Pharmacist Recommendations, dated 9/22/20 and 10/13/20 did not include a request for a gradual dose reduction of Duloxetine. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No signs or symptoms of depression; -Administered antidepressant medication daily. Review of the resident's Pharmacist Recommendations, dated 11/17/20 and 12/18/20 did not include a request for a gradual dose reduction of Duloxetine. Review of the resident's Physician's orders, dated December 2020, directed the staff to administer Duloxetine 30 mg daily. Review of the resident's medical record did not include evidence of monitoring for side effects of psychotropic medication. 2. Review of Resident #39 face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's physician order sheet dated 3/5/20 showed the following: -Sertraline 50 mg daily with special instructions dated 12/13/19, physician declined GDR, has intermittent periods of crying. Decrease in dose not recommended at this time. (On 5/9/19 GDR declined due to decreasing Zyprexa); -Zyprexa 10 mg at 7:00 A.M. and 7:00 P.M. with special instructions 5/9/19-GDR done. Decreased dosage from 20 mg to 10 mg; 1/9/20-order changed from 10 mg at bedtime to 10 mg in A.M. and at bedtime. Review of the resident's annual MDS, dated [DATE], showed the following: -Unable to interview for BIMS score to determine cognitive status; -Moderately impaired decision making ability; -No signs of depression; -Behavior, such as pacing/picking/yelling, not directed at others exhibited 1-3 days during observation period; -Administration of antidepressant and antipsychotic medication daily. Review of the resident's care plan, revised 4/10/20, showed the following: -Diagnosis of obsessive-compulsive disorder (excessive thoughts/obsessions that lead to repetitive behaviors) and major depressive disorder (a mood disorder that interferes with daily life); -Scheduled Zyprexa with a goal of no signs/symptoms of depression by next review; -Monitor for the following side effects: dizziness, drowsiness, numbness or dry mouth; -Monitor for signs/symptoms of depression. Review of the resident's Pharmacist Recommendations, dated 4/14/2020, 5/27/20 and 6/9/20 did not include a request for a gradual dose reduction of Sertraline or Zyprexa. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Unable to interview for BIMS score to determine cognitive status; -Moderately impaired decision making ability; -No signs of depression; -Administration of antidepressant medication daily. Review of the resident's Pharmacist Recommendations, dated 7/14/2020, 8/11/20 and 9/22/20 did not include a request for a gradual dose reduction of Sertraline or Zyprexa. Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS score to determine cognitive status was not answered; -Moderately impaired decision making ability; -No signs of depression; -Administration of antidepressant and antianxiety medication daily. Review of the resident's Pharmacist Recommendations, dated 10/13/20, 11/17/20 and 12/18/20 did not include a request for a gradual dose reduction of Sertraline or Zyprexa. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Minimal signs of depression; -Administration of antidepressant and antipsychotic medication daily. Review of the residents's medical record did not contain evidence of monitoring for side effects of psychotropic medication. During an interview on 1/5/21, at 11:45 A.M., licensed practical nurse (LPN) M said the following: -The pharmacist makes recommendations for the GDRs on psychotropic medications; -He/She does not know how often GDRs are supposed to be attempted; -The facility does not track when GDRs are due, the pharmacist does. During an interview on 1/5/21, at 11:00 A.M., the director of nursing (DON) said the following: -The pharmacist reviews the medications and GDRs, and makes recommendations; -LPN M coordinates all of the information to and from the pharmacist; -Psychotropic GDRs should be done every six months or more often if needed; -If no behaviors then staff would request a GDR from the physician; -She has not seen any type of an assessment to monitor for side effects of psychotropic mediation; -LPN M tracks the GDRs; -GDRs should be recommended to the physician by a nurse or the pharmacist; - The response to the pharmacist from the physician should be in the residents chart. During an interview on 1/14/21, at 1:16 P.M., the pharmacist said the following: -Gradual dose reductions should be attempted twice the first year, and annually after that unless there is a clinical reason not to; -He/She makes the recommendations to the physician and the physician can agree or disagree; -He/She missed the gradual dose reduction due for Resident #18, he/she is not sure how he/she missed it; -He/She missed the gradual dose reduction due for Resident #39, During an interview on 1/15/21, at 8:41 A.M., the Medical Director said the following: -The DON and physician should track GDRs; -GDRs should be attempted on an individual resident to resident basis; -He would expect staff to monitor for side effects of psychotropic medications.

Based on observation and interview, the facility failed to ensure insulin vials were properly labeled for one resident (Resident #241) in a review of 12 sampled residents and one additional resident (Resident #10). In addition the facility failed to properly secure a stock controlled substance, removed expired medication and label an open injectable in the medication room. The facility census was 40. Review of the facility's policy for Insulin Administration from MED-PASS 2001, revised September, 2014 showed if opening a new insulin vial, record expiration date and time on the vial. 1. Observation on 12/29/20 at 6:38 A.M. in the medication cart showed the following: -An open, undated vial of Lantus (long acting) insulin for Resident #10; -An open, undated vial of Lantus insulin for Resident #241. 2. Observation of the facility's only medication storage room on 12/30/20, at 1:05 P.M., showed the following: -One opened bottle of Debrox ear wax removal aid, expiration date of 8/17/20; -Three bottles of normal saline, unopened, with expiration date of 10/30/20; -One open, undated vial of Tuberculin derivative (injectable purified protein used to detect previous exposure to tuberculosis) with expiration date of 2/22; -Four unopened vials of lorazepam (a controlled substance used to treat anxiety) and one unopened bottle of liquid lorazepam in an unsecured box in the unsecured refrigerator. During an interview on 12/30/20, at 1:15 P.M., Certified Medication Technician (CMT) J said checking for expired medications in the medication room was all of the CMTs' and nurses' responsibility. During an interview on 12/29/20 at 6:40 A.M., and 12/30/20 at 1:20 P.M., Registered Nurse (RN) L said the following: -Licensed nurses count the lorazepam every shift, it should probably be locked in a box; -All insulin vials are dated when they are opened so staff know when to discard them; -He/She did not know why the two Lantus vials were not dated. During an interview on 1/5/21, at 11:00 A.M., the Director of Nursing (DON) said the following: -She would expect each CMT or licensed nurse to check the medication room for expired medications; -Controlled substances should be in a locked box; -She would not expect lorazepam to be in the refrigerator and not secured; -She expected any vial to be dated when opened; -She was not aware of any system check for expired medication in the medication room.

Based on observation, interview and record review the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during care for two residents (Resident #17, and 241) in a review of 12 sampled residents, and failed to follow infection control practices while performing catheter care and dressing changes for two residents (Resident #17 and #39). The facility census was 40. Review of the facility policy Standard Precautions dated 2001 and last revised 10/18 showed standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Personnel are trained in the various aspects of Standard Precautions to ensure appropriate decision-making in various clinical situations. Hand Hygiene refers to handwashing with soap (anti-microbial or non-microbial) or the used of alcohol-based hand rub (ABHR), which does not require access to water. Hand hygiene is performed with ABHR or soap and water before and after contact with the resident, before performing an aseptic task, after contact with items in the resident's room and after removing PPE. Hands are washed with soap and water whenever visibly soiled with dirt, blood or body fluids; after removing gloves and before eating and after using the restroom. Sinks, soap, water, disposable towels and ABHR are available to personnel and visitors in readily accessible and visible locations throughout the facility. Except as noted above, ABHR is preferred for hand hygiene. Artificial fingernails are discouraged among staff with direct resident contact. Personnel assist the residents with hand hygiene before meals, after toileting and when indicated. Proper hand washing technique is described in the hand washing/ hand hygiene policy and procedure. Gloves (clean and non-sterile) are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin and other potentially infected material. 1. Review of Resident #39's care plan, revised 4/10/20 showed the following: -Incontinent of bladder/bowel at times that could lead to skin issues; -He/She has a goal of no pressure ulcers by next review. Review of the resident's Physician order sheet, dated 12/1/20 - 12/31/20, showed an order received on 12/16/20 to apply bacitracin (an antibiotic ointment) and cover with a dry dressing twice a day and as needed. Position side to side in bed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/21/20, showed the following: -Frequently incontinent of bladder and bowel; -At risk for pressure ulcers with no current pressure ulcers. Observation 12/29/20, at 9:55 A.M., showed the following: -The resident lay clothed in bed on an incontinent pad; -Registered Nurse (RN) L entered the resident's room. He/she wore gloves; -With gloved hands RN L removed the resident's pants and the resident's brief that were both soiled with urine; -RN L provided peri-care using disposable wipes; -Without changing gloves or washing hands, RN L turned the resident to his/her left side and removed the dressing on the resident's right buttock. With the same soiled gloves, RN L cleaned the open areas with normal saline soaked 4x4's, applied bacitracin ointment to the new dressing, and applied the dressing to the buttock. Without changing gloves or washing his/her hands, RN L went to the resident's closet to get a new brief. He/She touched the closet door handle, opened the door and obtained a brief. With soiled gloves, RN L applied the clean brief on the resident after rolling the resident from side to side; -With the same soiled gloves, RN L removed a clean pair of pants from the resident's closet, dressed the resident again and removed his/her soiled gloves; -Without washing his/her hands, RN L went to the treatment cart to get additional supplies. RN L did not perform hand hygiene prior to donning a clean pair of gloves. 2. Review of Resident #17's care plan, dated 5/14/20 showed the following: -Suprapubic catheter with potential for urinary tract infections (UTI); -Cleanse suprapubic site daily with soap and water, pat dry, apply split sponge; -Resident would like to be free from UTI's; -Assist of one with personal hygiene; -9/25/20 treated for UTI, Levaquin (antibiotic) 500 milligrams (mg) daily times five days. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by facility staff, dated 11/5/20, showed the following: -Total dependence of one staff for bed mobility; -Extensive assist of one staff for personal hygiene; -Always continent of bladder and bowel. Review of the resident's Physician Order Sheet (POS), dated 12/20 showed the following: -Diagnoses included neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve damage) and UTI; -Urinary catheter (thin, sterile tube inserted into the bladder to drain urine) (suprapubic) to gravity drainage; -Cleanse around catheter opening with soap and water. Pat dry. Apply split sponge around tubing daily. Observation on 12/29/20 at 7:29 AM showed the following: -The resident lay in bed; -Certified Nurse Aide (CNA) A and CNA B entered the resident's room to perform morning cares; -Licensed Practical Nurse (LP) C entered the resident's room, washed hands and applied gloves; -LPN C exposed the resident's catheter site, removed the old dressing, threw it in the trash, de-gloved, and without washing his/her hands, donned clean gloves. He/She washed the catheter site with soapy water, de-gloved and without washing his/her hands, re-gloved and then rinsed the site. He/She de-gloved, re-gloved without washing his/her hands first and placed the new split sponge dressing; -CNA B sprayed wipes with perineal cleaner, and performed care to the resident's front perineal area, de-gloved and without washing hands re-gloved and laid the catheter bag on the bed. CNA B cleansed the resident's rectal area with eight to ten wipes with soft, grayish stool noted with each wipe. CNA B de-gloved and without washing his/her hands, re-gloved and placed a clean brief under the resident. CNA A hung the catheter bag back on the bed frame. CNA B (with same soiled gloves) performed catheter care. During interview on 1/7/21 at 11:15 M CNA A and CNA B said hands should be washed before and after cares and with gloves changes and if soiled gloves touched clean items, they would be contaminated. Hands should be washed after performing perineal care and before performing catheter care. During interview on 1/7/21 at 11:22 AM LPN C said hands should be washed with gloves changes and gloves should be changed when soiled and when moving from a dirty task to a clean task. 3. Review of Resident #241's physician order sheet, dated 12/1/20 - 12/31/20, showed the following: -admitted to the facility 12/23/20; -Diagnoses included diabetes mellitus, hyperlipidemia (high fats in the blood), hypokalemia (low potassium level in blood), hypertension (high blood pressure), heart failure, cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), and gastro-esophageal reflux disease without esophagitis (nonerosive acid reflux). Observation on 12/29/20, at 6:45 A.M., showed the following: -RN L gathered supplies to obtain a blood glucose (monitor, lancet, test strip, alcohol pads, and a cotton ball in the hall at the medication cart; -RN L donned gloves and picked up the supplies; -He/She entered the resident's room; -The resident's urinal was on his/her bedside table with urine in the urinal; -RN L placed the resident's blood glucose test supplies next to the resident's urinal on the table without a barrier; -He/She picked up the resident's urinal with his/her gloved right hand and placed the urinal by the sink; -RN L took an alcohol swab and wiped off the inner part of his/her right glove with an alcohol wipe, he/she did not clean the entire surface; -RN L did not change his/her gloves or wash his/her hands; -RN L performed the blood glucose test, placed the monitor in a plastic bag, removed his/her gloves, washed his/her hands, and returned the supplies to the medication cart. During an interview on 12/29/20, at 11:20 A.M., RN L said the following: -Handwashing should occur before and after doing a treatment, or you can use alcohol gel; -Handwashing should occur during a treatment if going from one treatment to another treatment and change gloves; -The same pair of gloves should not be used to remove an old dressing and then apply a new dressing; -He/She did not remove his/her gloves during the treatment of the resident, they should have been removed after removing the soiled attend and should have had a new pair donned after hand hygiene; -Clean items should not be touched with soiled gloves; -He/She does not know why he/she did not change gloves when they became soiled. During an interview on 12/30/20, at 3:42 P.M., the DON said the following: -She would expect staff to wash their hands when entering a room, apply gloves, if gloves become soiled remove them, wash hands, apply a new pair of gloves for care, remove when done and wash hands; -She would not expect resident care to be completed or a treatment to be done with soiled gloves; -She would not expect any resident items or any items to be touched with soiled gloves; -It is not acceptable to wipe soiled gloves with alcohol and then do a blood glucose finger stick; -If a surface is touched with soiled gloves she considers the surface touched to be contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for five residents (Resident #7, #18, #25, #29 and #32 ) of 12 sampled residents and one additional resident (Resident #23). The facility census was 40. Review of the facility's Bed Safety Policy, revised December 2007, showed the following: -Our facility shall strive to provide a safe sleeping environment for the resident; -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -To try to prevent deaths/injuries from the beds and related equipment (including the frame, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA; c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; d. Ensure the bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment. -The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Between 1985 and January 1, 2009, 803 incidents of patients caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA; -Of those reported 480 died and 138 had non-fatal injuries; -Most patients were frail, elderly or confused; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when patients or parts of their body are caught between rails and mattress, more serious injury from falls when patients climb over rails, skin bruising, cuts and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 1. Review of Resident #23's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Consent for Side Rails, dated 6/5/20, showed the following: -One 1/4 rail on the right upper side of the bed; -I do consent to the use of the side rail recommended above; -I have the right to refuse the use of side rails or can revoke this consent at anytime. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, dated 11/20/20, showed the following: -Moderate cognitive impairment; -Independent with bed mobility; -Limited physical assistance of one staff member with transfers; -Balance unsteady only stabilize with staff assistance; -History of falls. Review of the resident's care plan did not include the use of side rails. Observation on 12/28/20, at 10:45 A.M., showed the following: -Resident sat on the side of his/her bed; -Right upper part of his/her bed with a raised, 1/4, round side rail; -A large gap, approximately 6 inches wide between the mattress and the bed rail. Observation on 12/29/20, at 5:46 A.M., showed the following: -The resident sat on the side of his/her bed; -A 1/4 round side rail on the right upper part of his/her bed; -A large gap, approximately 6 inches wide between the mattress and the bed rail. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. During an interview on 12/29/20, at 10:48 A.M., the maintenance director said there was more than a 4 1/2 inch gap between the resident's bed and his/her mattress. He/She would need to fix it right away. 2. Review of Resident #18's Face Sheet showed the resident admitted to the facility on [DATE]. Review of Resident #18's quarterly MDS dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with transfers and bed mobility. Review of the resident's Consent for Use of Side Rails, dated 11/6/19, showed the following: -Recommend one 1/4 bed rail on the right upper side of the bed; -I do consent to the use of of the side rails recommended above; -I understand that I have the right to refuse the use of side rails or can revoke this consent at anytime. -The form notes the resident or family representative have read the benefits and potential negative outcomes on the back of this form of side rail use; -The back of the form was blank, and did not include benefits and potential negative outcomes of bed rail use. Review of the resident's Care Plan, dated 8/19/20, showed it did not include bed rail use. Observation on 12/28/20, at 3:25 P.M., showed the resident in bed with 1/4 bed rails raised on both sides of the upper part of the bed (only one rail was identified on consent). Observation on 12/29/20, at 6:28 A.M., showed the resident in bed at an angle with his/her head against the left upper bed rail and his/her feet hung off the right lower side of the bed. Both upper bed rails in a raised position. Observation on 12/30/20, at 1:30 P.M., showed the resident in bed with 1/4 bed rails raised on both sides of the upper part of the bed. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. 3. Review of Resident #7's care plan, last reviewed 8/5/20, showed the following: -Diagnosis of Alzheimer's disease (dementia - a progressive disease that destroys memory and other important mental functions) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness); -Unable to make needs known; -Totally dependent on staff for all activities of daily living (ADL's); -Unable to reposition self. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Nonverbal status; -Total dependence on staff for all aspects of ADL's and transfers. Observation on 12/28/20 at 10:51 A.M. showed the resident's bed to be unoccupied with a 1/4 side rail raised and the bed in the high position. Observation on 12/29/20 at 5:20 A.M. showed the resident lay in bed sleeping with the left 1/4 side rail in the raised position, the right side of the bed pushed against the wall, and the bed in a waist high position. Observation on 12/29/20 at 7:40 A.M. showed the resident awake in bed with the left 1/4 side rail in the raised position, the right side of the bed pushed against the wall, and the bed in a waist high position. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. 4. Review of the Resident #25's Face sheet, showed the resident admitted to the facility on [DATE]. Review of the resident's Consent for Use of Side Rails, dated 8/25/20, showed the following: -Recommend right and left upper soft care assist rail, -I do consent to the use of of the side rails recommended above. I understand that I have the right to refuse the use of side rails or can revoke this consent at anytime. -The form notes the resident or family representative have read the benefits and potential negative outcomes on the back of this form of side rail use; -The back of the form is blank, and did not include benefits and potential negative outcomes of bed rail use. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with bed mobility; -Limited physical assistance of one staff member for transfers. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Extensive physical assistance of two or more staff members with transfers; -One fall since admission. Review of the resident's Care Plan, last dated 11/30/20, did not include bed rails. Observation on 12/28/20, at 12:05 P.M., showed the resident in bed with 1/4 bed rails raised on both sides of the upper part of the bed. Observation on 12/29/20, at 5:46 A.M., showed the resident in bed with 1/4 bed rails raised on both sides of the upper part of the bed. Observation on 12/30/20, at 12:45 P.M., showed the resident in bed with 1/4 bed rails raised on both sides of the upper part of the bed. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. 5. Review of Resident #29's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Consent for Side Rails, dated 6/5/20, showed the following: -Types of side rails not completed; -I do consent to the use of the side rail recommended above (types of side rails); -I have the right to refuse the use of side rails or can revoke this consent at anytime. -The form says the resident or family representative have read the benefits and potential negative outcomes on the back of this form of side rail use; -The back of the form is blank, and did not include benefits and potential negative outcomes of bed rail use. Review of the resident's Care Plan, dated 6/18/20, showed it did not include bed rail use. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis include Chronic Kidney Disease stage 4 (severe) and Congestive Heart Failure; -Requires limited physical assistance of one staff member with bed mobility and transfers. Review of the resident's quarterly MDS, dated [DATE], showed the resident requires extensive physical assistance of one or more staff members for bed mobility and transfers. Observation on 12/28/20, at 11:05 A.M., showed the following: -Resident in his/her bed; -1/4 rails bed both raised sides of the bed. Observation on 12/29/20, at 6:45 A.M., showed the following: -Resident in his/her bed; -1/4 rails bed both raised sides of the bed. Observation on 12/30/20, at 1:05 P.M., showed the following: -Resident in his/her bed; -1/4 rails bed both raised sides of the bed. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. 6. Review of Resident #32's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's consent for use of side rail, dated 12/8/20 showed the following: -Use of left and right upper 1/4 rail; -Purpose of use is for mobility; -He/She consented to the use of side rail and signed the consent 12/8/20. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Extensive assist with two staff members for bed mobility, transfers, ambulation, locomotion, dressing, toileting and hygiene. Review of the resident's care plan, dated 12/18/20, showed the following: -History of falls with recent fracture; -Assist of two staff for transfers, toileting and ADL's. Observation on 12/28/20, at 11:05 A.M., showed the resident asleep in bed with both upper rails in the raised position and the bed up against the wall. Observation on 12/29/20, at 5:23 A.M., showed the resident asleep in bed with both upper rails in the raised position and the bed up against the wall. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. 7. During an interview on 12/30/20, at 6:29 A.M., Registered Nurse(RN) L said the following: -Nursing notifies maintenance to install the bed rail; -He/She does not know what entrapment zones are; -He/She thinks maintenance does some kind of bed safety check; -If something did not work on a resident's bed he/she would report to maintenance. During an interview on 12/29/20, 10:48 A.M., the maintenance director said the following: -He/She started at the facility a couple of months ago; -He/She had not found any previous documentation of resident bed safety checks; -He/She just received a form to document bed entrapment zones checks but had not completed them yet; -He/She has not had time to go through manufacturer recommendations and compatible devices since his/her start date. During an interview on 12/30/20, at 1:05 P.M., the director of nursing said the following: -The facility has not done safety checks for entrapment zones on the resident beds that he/she knew of; -He/She just gave the maintenance director a new form to use to check entrapment zones, but it had yet to be implemented.

Based on interview and record review, the facility failed to employ a qualified director of food and nutrition services. The facility did not have a dietary manager (DM) with a background and/or training in food preparation, food service and/or food storage. The facility also did not utilize the services of their qualified, consultant Registered Dietitian (RD) to assist the DM. This practice effected all residents in a facility with a census of 40. Record review of the facility's Dietitian policy, from MED-PASS 2001, revised October 2017 showed under policy interpretation and implementation #1. A qualified dietitian or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents; #2 A food and nutrition services manager will oversee the productions, storage, and delivery of food. The dietitian will work closely with the Food and Nutrition services manager and clinical staff. #7 if a dietitian is not employed full timed (35 or more hours per week) a director of food service management will be designated. this individual will: a. be a certified dietary manager; or b. be a certified food service manager; or c. be nationally certified in food service management and safety; or d. have an associate's (or higher) degree in food service management or hospitality (must be from an accredited institution and include courses in food service or restaurant management); e. meet any state requirements for food service or dietary managers; and f. receive frequently scheduled consultations from a qualified dietitian or qualified nutrition professional. Review of the facility's policy Nutritional Assessment, revised October 2017, showed the following: -As part of the comprehensive assessment, a nutritional assessment including current nutritional status and risk factor for impaired nutrition shall be conducted for each resident; -The Dietitian, in conjunction the interdisciplinary team, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition; -The Dietitian will identify: a. An estimate of calorie, protein, nutrient and fluid needs; b. Whether the resident's current intake is adequate to meet his/her nutritional needs; and c. Special food formulations. 1. Record review on 12/28/20 at 10:49 A.M. of the resident dietary review folder showed no dietitian review since March 2020. During interview on 12/28/20 at 10:49 A.M. and 1/4/21 at 1:17 P.M. the DM said the dietitian had not been at the facility since COVID 19 (corona virus disease 2019, a highly contagious virus), started due to family health concerns. Normally she would go through the dietitian for recommendations, but the facility had not consulted with the dietitian since April 2020. The dietitian had not completed any nutritional assessments since March 2020. She started at the facility in January 2019. She was not certified as a food service worker or a certified dietary manager During an interview on 1/04/21, at 1:37 P.M., the RD said the following: -He/She had not been to the facility; -The facility was not sending monthly weights to evaluate or any resident records. -He/She has not reviewed a resident record since before COVID19 in March; -Before COVID19 the DM and he/she would go over every resident's weight each month and write recommended interventions; -This last few months he/she did not know what had been going on. During an interview on 12/30/20, at 3:58 P.M., the director of nursing said he/she did not know the DM was not certified. During an interview on 12/30/20, at 12:09 P.M. and 3:00 P.M. the administrator said the following: -The DM is a Licensed Practical Nurse (LPN); -The DM is not certified, he/she started as the DM a year ago; -The DM wanted to wait to start classes until the RD was back to help him/her; -The DM was not enrolled in any program to become certified; -The RD has not been in the building since COVID started in March. .

Based on interview and record review, the facility failed to notify the physician of a change in condition for one resident (Resident #40), in a review of 15 sampled residents. The facility census was 43. 1. Review of the facility policy Change in a Resident's Condition or Status, last revised 5/17, showed: The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/ emotional/ mental condition; need to alter the resident's medical treatment significantly and with the need to transfer the resident to a hospital. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and/or impacts more than one area of the resident's health. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. 2. Review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 1/20/19, showed the following: -Speech clear; -Usually made self understood and understood others; -Independent with bed mobility, transfers, ambulation in room and corridor and toilet use; -Walker for ambulation. -Occasionally incontinent of bladder and bowel. Review of the resident's nurse's notes, dated 2/23/19 at 10:26 P.M., showed the resident was very agitated this shift. He/she was trying to get out the front door before supper; several times almost falling out of his/her wheelchair. The resident was getting physical and trying to hit staff and started swearing. PRN Ativan (anti-anxiety medication) 0.5 milligram (mg) given intramuscularly (IM) to decrease agitation. Review of a Change of Condition Report from facility staff to the physician, dated 2/23/19 at 10:13 P.M., showed needing order for a urinalysis (UA). The resident's urine is very cloudy and the resident has had mental status changes. Would like to get as soon as possible (ASAP). Review of a document titled Event Report (provided by the physician) dated 2/23/19 to 2/26/19, showed the following: -Office received faxes (four total) for Resident #40 requesting a UA ASAP because patient was having mental status changes. Fax sent 2/23/19 at 10:13 P.M. 2/23/19 was a Saturday. The office was closed over the weekend. -On 2/26/19 at 11:42 A.M., called the Director of Nursing (DON) and reported the issue and the physician should have been called. Director of Nursing (DON) stated he/she was addressing the issue. Review of nurse's notes showed the following: -On 2/26/19 at 10:59 A.M., a new order was received to obtain UA and CT Scan (X-ray image) for diagnosis of mental status changes; -On 2/26/19 at 9:00 P.M., the resident is confused and has a problem getting right words to express himself/herself. There has been a change in the resident's physical/mental status. The resident required two staff to assist with his/her transfer tonight and did not walk. The resident used a wheelchair as his/her main mode of travel. Total care patient. UA due in the morning and CAT scan on Friday. Review of the resident's nurses' notes, dated 2/27/19 at 2:00 A.M., showed UA obtained via straight catheter (a thin, sterile tube inserted into the bladder to drain urine from the body). Resident experienced pain and had 500 cc residual, cloudy, purulent, yellow urine with a strong odor. Review of a UA report, dated 2/27/19, showed the following: -Leukocytes (white blood cells) - moderate (normal is negative); -Protein - trace (normal is negative); -Glucose - greater than/equal to 000 (normal 0-0.8 millimoles(mmol)/Liter/L); -Blood - moderate (normal is negative); -White blood cells (WBCs) - too numerous to count (normal is none); -Red blood cells (RBC) - 15-20 (normal is none); -Bacteria - 4+ (normal is none). Review of the resident's nurse's notes, dated 2/28/19 at 9:00 A.M., showed the physician was in the facility. New order for Keflex (antibiotic) 500 mg three times daily for five days. Review of the urine culture report, dated 3/1/19, showed the following: -Yeast greater than 100,000 colony forming unit (CFU)/milliliter(ml) after two day incubation. -2/28/19, give 1 gram (gm) Rocephin (antibiotic) IM one time at bedtime. During interview on 4/11/19 at 2:20 P.M., the resident's physician said the following: -He/she was only in his/her office on Tuesdays and Thursdays; -His/her office (which is closed on Saturday) received a fax, dated 2/23/19, requesting a UA for the resident ASAP; -His/her first opportunity to address the fax would have been 2/26/19, which he/she did and gave the order for the UA; -He/she would have expected staff (who felt the resident needed a UA ASAP) to call him/her as he/she was always available to them; -He/she would not expect staff to fax an ASAP UA request (for a resident with mental status changes) to a closed office. During interview on 4/23/19 at 2:55 P.M., Licensed Practical Nurse (LPN) G said the following: -Staff should not send a fax requesting lab work for a resident ASAP (due to change in condition) to a physician office which is closed; -He/she should have phoned the physician and the order would have been given at that time. During interview on 4/12/19 at 5:05 P.M. and 4/23/19 at 2:00 P.M., the director of nursing said the following: -He/she would not expect nursing staff to send a fax requesting an ASAP UA to a closed physician clinic. He/she expected staff to call and get the order; -He/she would have expected staff to ask the physician for the needed UA on 2/25/19 when staff spoke with the physician regarding the resident's Haldol. (Record review showed staff received a telephone order regarding the resident's Haldol on 2/25/19.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents (Resident #36 and #37) with a mental disorder had a DA-124 Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) level II screen is required) as required, in a review of 15 sampled residents. The facility census was 43. 1. Record review of the Missouri Department of Health and Senior Services (DHSS) guide titled, PASARR Desk Reference, dated 3/3/08, showed: -The PASARR is a federally mandated screening process for any person for whom placement in a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening (completion of the DA124C form). -A Level II assessment is completed on those persons identified at Level I who are known or suspected to have a serious mental illness (such as schizophrenia, dementia, major depression, etc., MR or related MR condition to determine the need for specialized service (completion of the DA124A/B form). The facility responsible for completing the DA124A/B and/or DA124C forms is also responsible for submitting completed form(s) to DHSS, Division of Regulation and Licensure, Section for Long Term Care Regulation, Central Office Medical Review Unit (COMRU); -PASARR screening is required: To assure appropriate placement of persons known or suspected of having a mental impairment; -To assure that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment; -To be compliant with the OBRA/PASARR federal requirements, see 42 CFR 483.Subpart C; and -To assure Title XIX funds are expended appropriately and in accordance with Legislative intent. 2. Review of Resident #37's Annual Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 9/24/18 showed the following: -Diagnosis of bipolar disease (mental illness); -Received antipsychotic medications for the past seven days; -Received antidepressant medications for the past seven days; -Received antipsychotic medications on a routine basis; -No documentation that a PASARR was completed for the resident. Review of the resident's quarterly MDS dated [DATE] showed the following: -Diagnosis of bipolar disorder and depressive disorder; -Received antipsychotic medications for the past seven days; -Received antidepressant medications for the past seven days; -Received antipsychotic medications on a routine basis; -No documentation that a PASARR was completed for the resident. Review of the resident's care plan updated 3/27/19 showed the following: -admission date of 6/18/13; -Diagnosis of bipolar disorder and major depressive disorder; -The resident received psychotropic medications that could have side effects. Staff should monitor for drowsiness and dizziness. Review of the resident's April 2019 Physician's Order Sheet (POS) showed the following: -Celexa (anti depressant medication) 40 milligrams (mg) daily at 7:00 A.M. for major depressive disorder; -Seroquel (antipsychotic medication) 25 mg two times daily at 7:00 A.M. and 8:00 P.M. for bipolar disorder. Review of the resident's medical record showed no PASARR screening (Level I or II). 3. Review of Resident #36's admission MDS, dated [DATE] showed the following: -Diagnoses included depression and anxiety; -Received antipyschotic medications the past seven days; -Received antidepressant medications the past seven days; -Received antipsychotic medications on a routine basis; -No documentation that a PASARR was completed for the resident. Review of the resident's Significant change MDS, dated [DATE] showed the following: -Diagnoses included manic depression (bipolar disorder); -Received antipyschotic medications the the past seven days; -Received antianxiety medications for the past five days; -Received antidepressant medications for the past seven days; -Received antipsychotic medications on a routine basis; -No documentation that a PASARR was completed for the resident. Review of the resident's care plan dated 3/21/19 showed the following: -Resident admitted on [DATE]; -Diagnoses included major depressive disorder and bipolar disorder; -Problem: I take medications which can cause side effects such as drowsiness or dizziness. Monitor me closely after giving me these medications. Review of the Resident's POS, dated April 2019 showed the following: -Amitriptylline 50 mg po daily at 7:00 P.M. for major depressive disorder; -Latuda 60 mg po daily at 8:00 P.M. for bipolar disorder; -Zoloft 25 mg po daily at 7:00 A.M. for major depressive disorder; -Ativan 0.5 mg po PRN (as needed) two times daily for anxiety disorder. Review of the resident's medical record showed no PASARR screening. 4.During interview on 4/12/19 at 10:50 A.M. the MDS coordinator said residents admitted with a serious mental illness should have a PASARR completed prior to admission. He/She was responsible for entering the PASARR information into the resident's MDS. Resident #37 and #36 did not have a PASARR completed as required. During interview on 4/11/19 at 4:25 P.M. the administrator said residents' PASARR reports should be in the medical record as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS; a federally mandated assessment instrument required to be completed by facility staff) for five residents (Residents #6, #19, #33, #37, and #39) in a review of 15 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 43. 1. During interview on 4/11/19 at 12:10 P.M. the MDS Coordinator said he/she followed the Resident Assessment Instrument (RAI) 3.0 manual while completing residents' MDS. 2. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision the care plan. The Manual also showed a Significant Change in Resident Status (SCSA) is appropriate if there is a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement). Guidelines for determining significant change in resident status included the following: -Any decline in an ADL physical functioning area where a resident is newly coded as 3, 4, or 8; -Resident's incontinence pattern changes from 0 or 1 to 2, 3, or 4; -Emergence of a pressure ulcer at Stage II or higher, when no pressure ulcers were previously present at Stage II or higher; -Emergence of an unplanned weight loss problem (5% change in 30 days or 10% change in 180 days). 3. Review of Resident#39's quarterly MDS dated [DATE] showed the following: -The resident's cognition was moderately impaired; -He/she required extensive assistance of one staff with bed mobility, transfers, walking in and out of his/her room, and locomotion on and off of the unit; -He/she required limited assistance of one staff with personal hygiene. Review of the resident's quarterly MDS dated [DATE] showed the following: -His/her cognition improved from moderately impaired to intact; -He/she required limited assistance of one staff with bed mobility, transfers, and locomotion on and off of the unit; -He/she required extensive assistance of one staff with personal hygiene; -He/she only ambulated in his/her room once or twice with assist of one staff and did not ambulate out of his/her room. Review of the resident's quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]: -The resident's cognition improved from moderately impaired to intact; -The resident improved in bed mobility, transfers and locomotion on and off the unit from extensive assist to limited assist; -The resident declined in personal hygiene from limited assist to extensive assist; -The resident declined in ambulation from extensive assist to only ambulated in his/her room once or twice with assist of one staff and did not ambulation out of his/her room; -The resident's assessment met the criteria for significant change in status. Review of the resident's quarterly MDS dated [DATE] showed the following: -His/her cognition declined and now was mildly impaired; -He/she showed a decline in ADLs and now required extensive assistance of two staff with bed mobility and transfers; -Ambulation in his/her room did not occur; -He/she now required extensive assistance of one staff on and off of the unit. Review of the resident's quarterly MDS dated [DATE] showed the following when compared to the previous quarterly dated 12/16/18 showed the following: -The resident's cognition declined from intact to moderately impaired; -The resident declined in bed mobility and transfers from limited assist to extensive assist; -The resident declined in ambulation in his/her room from only occurred once or twice with staff assist to did not occur; -The resident's assessment met the criteria for a significant change in status. Observation of the resident on 4/09/19 at 12:26 P.M showed he/she sat in his/her room with his/her left arm in an immobilizer during lunch. He/she was not eating and said his/her arm hurt too bad to eat. He/she wore oxygen and rubbed his/her left arm. 4. Review of Resident #33's quarterly MDS dated [DATE] showed the following: -He/She required extensive physical assistance of two staff with transfers; -He/She required limited assistance of one staff with eating; -He/She was frequently incontinent of bladder; -He/She was always continent of bowel. Review of the resident's quarterly MDS dated [DATE] showed the following declines in his/her condition: -He/She was now physically dependent on two staff for all transfers; -He/She was now dependent on one staff to assist with eating; -He/She was now always incontinent of bladder; -He/She was now always incontinent of bowel. The resident's quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]: -The resident declined in transfers from extensive assist to totally dependent; -The resident declined in eating from limited assist to totally dependent; -The resident declined in continence from frequently incontinent of bladder to always incontinent of bladder and always continent of bowel to always incontinent of bowel; -The resident's assessment met the criteria for significant change in status. During an interview on 4/12/19 at 12:05 P.M., Certified Nurse Aide (CNA) A said the following: -The resident had declined in transfer status; -The resident used to be a two person stand up transfer and now required the Hoyer lift for transfers since he/she returned from the hospital a few months ago; -Three or four months ago, the resident was able to use the toilet, but now is always incontinent of bowel and bladder; -The resident did not move around and required staff to turn and reposition him/her. 5. Review of Resident #6's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Walking in room did not occur; -Required limited assistance of one staff member with locomotion on the unit; -Required limited assistance of one staff member with dressing; -Required set up help with eating; -Not steady, only able to stabilize with staff assistance with moving from seated to standing position and moving on and off the toilet; -Weight 94 pounds. Review of the resident's quarterly MDS dated [DATE] showed the following: -Moderately impaired cognition; -Walking in room occurred once or twice; -Independent with locomotion on the unit, dressing and eating; -Weight 109 pounds. The resident's quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]: -The resident improved in cognition from severe to moderately impaired cognition; -The resident improved in walking in room from did not occur to occurred once or twice; -The resident improved in locomotion on the unit and with dressing from required limited assistance of one staff member to independent; - The resident improved in eating from required set up help to independent; -14 percent weight gain in three months; -The resident's assessment met the criteria for significant change in status. Observation of the resident from 4/9/19 through 4/12/19 showed the resident transferred him/herself to the wheelchair, propelled him/herself down the hallway to the dining room, ate independently, brushed his/her own teeth and hair without staff assistance and transferred with staff assistance to the toilet. During interview on 4/11/19 at 12:10 P.M. the MDS Coordinator said the resident had improved in status and needed a significant change MDS for improvement. 6. Review of Resident #19's quarterly MDS dated [DATE] showed the following: -He/She required extensive assistance of two staff with toileting; -He/She was frequently incontinent of bowel and bladder; -He/She weighed 188 pounds. Review of the resident's quarterly MDS dated [DATE] showed the following: -He/She was totally dependent on two or more staff with toileting; -He/She was always incontinent of bowel and bladder; -His/Her weight was 170 pounds (18 pound weight loss since previous assessment). The resident's quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]; -The resident declined from extensive assist to totally dependent with toileting; -The resident's continence declined from frequently incontinent to always incontinent of both bladder and bowel; -10.4% weight loss in three months; -The resident's assessment met the criteria for significant change. 7. Review of Resident #37's quarterly MDS dated [DATE] showed the following: -Required extensive assistance of one staff member with bed mobility, dressing, eating, and personal hygiene; -No functional limitation in range of motion of upper and lower extremities. Review of the resident's quarterly MDS dated [DATE] showed the following: -Required total assistance of two staff members with bed mobility and dressing; -Required total assistance of one staff member with eating and personal hygiene; -Functional limitation in range of motion with impairment of one upper extremity and both lower extremities. The resident's quarterly MDS dated [DATE] showed the following when compared to the previous quarterly MDS dated [DATE]; -The resident declined from extensive assistance of one staff member to total assistance of two staff members with bed mobility and dressing; -The resident declined from extensive assistance to total assistance of one staff member with eating and personal hygiene; -The resident declined from no functional limitation in range of motion of upper and lower extremities to functional limitation in range of motion with impairment of one upper extremity and both lower extremities; -The resident's assessment met the criteria for significant change in status. Observation of the resident from 4/9/19 through 4/12/19 showed the resident required two staff members and total assistance with bed mobility, dressing and toileting. The resident was incontinent and wore incontinence briefs. Staff transferred the resident to a wheelchair with a gait belt. The resident was unsteady and had limited weight bearing during the transfer. He/she required one staff member total assistance to propel the wheelchair to the dining room and required total assistance with eating. During interview on 4/11/19 at 12:10 P.M. the MDS Coordinator said the resident had declined in status and needed a significant change MDS for decline. 8. During an interview on 4/12/49 at 5:00 P.M., the Director of Nursing said the following: -He/she expected the MDS Coordinator to follow the RAI process and follow the guidelines of when to complete a MDS when a resident has had a significant change in their status; -He/she would expect a MDS for a significant change be completed if changes in a resident's status triggered for one.

Based on observation, interview and record review facility staff failed to follow professional standards when administering eye drops for two residents (Residents #31 and #35) in a review of 15 sampled residents. The facility census was 43. 1. Review of the facility policy, Instillation of Eye Drops, last revised 1/14 showed the following: The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. -Staff was to wash and dry hands thoroughly (if treating both eyes, wash and dry before each eye) -Put on gloves; -If the resident is sitting up, tilt his/her head backward slightly; -Gently pull the lower lid down. Instruct the resident to look up. -Drop the medication into the lower eyelid; -Instruct the resident to slowly close his/her eyelid to allow for even distribution of the eye drops; -Instruct the resident not to blink or squeeze the eyelid shut which forces medicine out of the eye; -Remove gloves and discard. Wash and dry hands thoroughly. 2. Review of the brimonidine opthalmic (eye medication used to treat (glaucoma) (a group of eye conditions which can cause blindness)) manufacturer's guidelines, dated 7/18 showed while looking up, gently squeeze the dropper so that a single drop falls into the pocket made by the lower eyelid. Remove your index finger from the eyelid, close your eye for two to three minutes and tip head down as though looking at the floor. Try not to blink or squeeze your eyelids. 3. Review of the timolol opthalmic (beta-blocker eye medication used to treat glaucoma) manufacturer's guidelines, dated 11/07 showed gently close the eye after administration of the drop, do not blink. Keep the eyes closed and apply pressure to the inner corner of the eye with your finger for one to two minutes to allow the medicine to be absorbed by the eye. 4. Review of Resident #31's physicians order sheets (POS) dated 4/19 showed the following: -Diagnosis of glaucoma; -Brimonidine 0.2% opthalmic- one drop both eyes two times daily for glaucoma (5/25/18); -Timolol maleate ophthalmic drops 0.5% one drop to both eyes two times daily (5/25/18). Observation on 4/9/19 at 3:45 P.M. in the resident's room showed the following: -The resident sat in his/her wheelchair; -Certified Medication Technician (CMT) I entered the resident's room, handed the resident a Kleenex and administered brimonidine one drop into each eye; -CMT I did not instruct the resident to close his/her eyes for two to three minutes or hold pressure to the lacrimal duct. Observation on 4/9/19 at 4:00 P.M. in the resident's room showed the following: -CMT I entered the resident's room, handed the resident a Kleenex and administered timolol one drop into each eye; -CMT did not instruct the resident to close his/her eyes or hold pressure to the lacrimal duct. 5. Review of Resident #35's Physician Order Sheet (POS), dated 4/19 showed the following: -Diagnosis included glaucoma; -Brimonidine 0.2% eye drops- one drop both eyes three times daily for glaucoma (9/14/17); -Timolol ophthalmic 0.5% apply to both eyes two times daily for open angle glaucoma with borderline findings (9/14/17). Observation on 4/9/19 at 3:52 P.M. in the resident's room showed the following: -The resident lay in bed; -CMT I entered the resident's room, administered brimonidine one drop into each eye and patted the resident's eyes momentarily; -CMT I did not instruct the resident to close his/her eyes for two to three minutes or hold pressure to the lacrimal duct. Observation on 4/9/19 at 4:05 P.M. in the resident' room showed the following: -CMT I entered the resident's room, administered timolol one drop into each eye; -CMT I did not instruct the resident to close his/her eyes or hold pressure to the lacrimal duct. During interview on 4/12/19 at 4:25 P.M. CMT I said the following: -He/she had been taught to pull the lower lid of the eye down and administer the drop in the corner and hold pressure for 30 seconds or if the resident was able, instruct them to do so; -He/she forgot to hold pressure after administering the eye drops. During interview on 4/12/19 at 5:05 P.M the Director of Nursing (DON) said he/she would expect staff to hold pressure to the lacrimal duct for at least one minute after a medicated eye drop was given.

Based on observation, interview and record review the facility failed to accurately label insulin to facilitate consideration of precautions and safe administration for four (Resident #16, #37, #40, and #143) of 15 sampled residents and one additional resident (Resident #23). Facility census was 43. 1. Review of the facility's policy for labeling of medications from the 2001 MED-PASS Guide last revised in April of 2007 showed the following: -All medications in the facility would be properly labeled in accordance with current state and federal regulations; -The policy provided was not specific for labeling of insulins (medication used to lower blood sugar) once they were opened. -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 2. Review of the 2017 Nursing Drug Handbook showed the following: -Victoza, a medication used to treat diabetes mellitus (condition which causes elevated blood sugar levels) should be discarded 30 days after initial use; -Humalog Insulin (medication used to treat diabetes mellitus) should be used within 28 days after initial use; -Lantus Insulin (medication used to treat diabetes mellitus) should be stored at room temperature for up to 56 days after initial use. 3. Review of Resident #16's Physician's Order Sheet (POS) dated 4/1/19 to 4/30/19 showed the following: -The resident had a diagnosis of diabetes mellitus; -The resident had an order dated 8/16/18 for Victoza 0.6 milligram (mg) per one milliliter (ml); administer 1.8 mg subcutaneous (SQ, under the skin) after breakfast every morning at 8:30 A.M. Observation of the facility's medication storage room on 4/12/19 at 4:21 P.M. showed a used Victoza insulin pen labeled for the resident that was was opened, undated, and had an order date of 3/24/19. Review of the resident's medication administration record (MAR) dated 4/1/19 to 4/30/19 showed staff documented the resident received 1.8 mg of Victoza 0.6 mg/1 ml SQ after breakfast every morning at 8:30 A.M. as ordered from 4/1/19 to 4/12/19. 4 Review of Resident #23's POS dated 4/1/19 to 4/30/19 showed the following: -The resident had a diagnosis of diabetes mellitus; -The resident had an order dated 2/28/19 for Lantus U-100 100 unit/ ml., administer 10 units SQ every morning at 7:00 A.M. Review of the resident's medication administration record (MAR) dated 4/1/19 to 4/30/19 showed staff documented the resident received Lantus 10 units SQ every morning at 7:00 A.M. from 4/1/19 to 4/12/19. Observation of the facility's medication storage room on 4/12/19 at 4:21 P.M. showed an opened and undated vial of Lantus insulin that was labeled for the resident with an order date of 1/23/19 and medication missing from the vial. 5. Review of Resident #40's POS dated 4/1/19 to 4/30/19 showed the following: -The resident had a diagnosis of diabetes mellitus; -The resident had an order dated 3/20/19 for Lantus 30 units SQ every morning at 7:00 A.M. Review of the resident's MAR dated 4/1/19 to 4/30/19 showed staff documented the resident received Lantus 30 units SQ every morning at 7:00 A.M. from 4/1/19 to 4/12/19. Observation of the facility's medication storage room on 4/12/19 at 4:21 P.M. showed an opened and undated vial of Lantus insulin that was labeled for the resident with an order date of 3/14/19 and medication missing from the vial. 6. Review of Resident #37's POS dated 4/1/19 to 4/30/19 showed the following: -Diagnosis of diabetes mellitus; -Novolog (Humalog) insulin 100 unit/ml ordered on 1/11/19 administer per sliding scale four times daily before meals and at bedtime. If blood sugar was 150-199, give one unit. If blood sugar was 200-249, give two units. If blood sugar was 250-299, give three units. If blood sugar was 300-349, give four units. If blood sugar was 350 or above give five units and notify the physician; -On 4/2/19 the sliding scale Humalog insulin 100 unit/ml order was changed. If blood sugar was 150-199, give two units. If blood sugar was 200-249, give four units. If blood sugar was 250-299, give six units. If blood sugar was 300-349, give eight units. If blood sugar was 350 or above notify the physician. Review of the resident's MAR dated April 2019 showed staff documented administration of Humalog insulin per sliding scale directions four times daily before meals and at bedtime from 4/1/19 through 4/11/19. Observation of the facility's medication storage room on 4/12/19 at 4:21 P.M. showed an opened and undated vial of Humalog Insulin that was labeled for the resident with an order date of 3/19/19 and medication missing from the vial. 7. Review of Resident #143's POS dated 4/1/19 to 4/30/19 showed the following: -The resident had a diagnosis of diabetes mellitus; -The resident had an order dated 4/5/19 for Lantus 100 unit/ml, administer 25 units SQ every day at bedtime; -Lantus order was changed on 4/6/19 to 28 units SQ every day at bedtime. Review of the resident's MAR dated 4/1/19 to 4/30/19 showed the following: -The resident received Lantus 100 unit/ml; administer 25 units SQ every day at bedtime daily on 4/5/19 and 4/6/19; -Staff documented that the resident received Lantus 28 units SQ every day at bedtime from 4/6/19 to 4/11/19. Observation of the facility's medication storage room on 4/12/19 at 4:21 P.M. showed an opened and undated vial of Lantus insulin that was labeled for the resident with an order date of 4/6/19 and medication missing from the vial. During an interview on 4/12/19 at 4:25 P.M., Licensed Practical Nurse (LPN) A said the following: -Nurses were supposed to label insulin when opened because insulin was only good for 28 days after it had been opened; -He/She did not know why the insulins were not labeled; -He/She would assume the insulin was opened on the order date, but they should be replaced if not dated because he/she did not know for sure when they were opened. -He/She would hope that insulin with a start date of 1/23/19 was not still in use because that would be past the 28 days. During an interview on 4/12/19 at 5:00 P.M., the Director of Nursing (DON) said that insulin should be dated and timed when the vials and/or syringes were opened. Staff should not use insulins if they were not labeled. Insulins were good for 28 days after they were opened. He/she expected staff to discard the insulin and reorder it if it was not dated.

Based on observation, interview and record review the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for two of 15 sampled residents (Resident #40, and #41), failed to follow infection control practices while performing blood glucose monitoring for one resident (Resident #37) and one additional resident (Resident #17) and while administering eye drops for one sampled resident (Resident #31) and one additional resident (Resident #35). The facility also failed to provide resources and instructions for performing hand hygiene in or near lobby areas or entrances for visitors to the facility. The facility census was 43. 1. Review of the facility policy Certified Medication Technician and Licensed Nurses dated November 2012 showed each resident would be provided with individual glucometers (machine used for obtaining blood glucose levels). In the event one was unavailable, the facility glucometer would be used and cleaned per manufacture recommendations after each use. 2. Review of the facility policy Hand Washing/Hand Hygiene dated August 2015 showed the following: -The facility considered hand hygiene the primary means to prevent the spread of infections; -All staff should be trained and regularly in-serviced on the importance of hand hygiene in preventing an the transmission of healthcare-associated infections; -All staff should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident and visitors; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc) should be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Residents, family members and /or visitors would be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and /or posted throughout the facility; -Wash hands with soap and water when hands were visible soiled; -Use an alcohol-based hand rub or soap and water before and after direct contact with resident and before and after handling an invasive device (medical equipment). -Use an alcohol-based hand rub or soap and water before preparing or handling medications, before donning gloves, before handling clean or soiled dressings and before moving from a contaminated body site to a clean body site during resident care; -Use an alcohol-based hand rub or soap and water after contact with a resident's skin, after contact with blood or bodily fluids, after handling used dressings and contaminated equipment, after contact with objects (medical equipment) in the vicinity of the resident, and after removing gloves; -The use of gloves did not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections; -Single-use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids. 3. Review of the facility policy Personal Protective Equipment, Using Gloves dated September 2010 showed the following: -Use gloves when touching excretions secretions, blood, body fluids, mucous membranes or non-intact skin; -Use gloves when cleaning up spills or splashes of blood or body fluids; -Wash hands after removing gloves (gloves do not replace hand washing) 4. Review of the facility policy, Instillation of Eye Drops, last revised 1/14 showed the following: The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. -Staff was to wash and dry hands thoroughly (if treating both eyes, wash and dry before each eye) -Put on gloves; -If the resident is sitting up, tilt his/her head backward slightly; -Gently pull the lower lid down. Instruct the resident to look up. -Drop the medication into the lower eyelid; -Instruct the resident to slowly close his/her eyelid to allow for even distribution of the eye drops; -Instruct the resident not to blink or squeeze the eyelid shut which forces medicine out of the eye; -Remove gloves and discard. Wash and dry hands thoroughly. 5. Review of Resident #40's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility and dated 3/21/19 showed the following: -Total dependence of two staff for bed mobility; -Presence of stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister); -Presence of urinary catheter (a thin, sterile tube inserted into the bladder to drain urine from the body). Review of the resident's Physician Order Sheet (POS) dated 4/19 showed the following: -Coccyx (tailbone) wound: cleanse with wound cleanser. Apply hydrogel (provides a moist wound-healing environment and helps remove dead tissue from the wound bed) to necrotic (dead tissue), area only with dry dressing every two days or when soiled (3/25/19); -Zeasorb moisture powder (powder to reduce moisture) to reddened areas two times daily and PRN; -Urinary catheter, change monthly and PRN (as needed) 3/14/19. Observation on 4/11/19 at 10:00 A.M. showed the following: -The resident lay in his/her bed; -Licensed Practical Nurse (LPN) E and Certified Nurse Aide (CNA) B stood at the bedside, gloved and preparing to provide cares; -CNA B performed perineal care and without changing gloves or washing hands, opened an alcohol prep pad and wiped the urinary catheter from the insertion site outward using the same area of the pad times two swipes. He/she then dropped the pad between the resident's legs, picked it up and again, wiped from the insertion site downward; -CNA B, without changing gloves and washing hands, rolled the resident to his/her right side and as LPN E held the resident over, wiped the resident's backside; -CNA B, wearing the same, soiled gloves, and LPN E rolled the resident to his/her back and pulled him/her up in bed; -LPN E assisted the resident to roll to his/her left side. There was no dressing to the resident's coccyx. He/She cleansed the wound with wound cleanser and gauze and placed the soiled gauze directly on the bed linens. While wearing the same soiled gloves, he/she applied hydrogel to the wound, pulled his/her pen out of his/her pocket, dated the dressing and applied it over the resident's wound. He/She then applied Zeasorb powder to the resident's reddened groin, peri-area; -LPN E and CNA B, wearing the same soiled gloves, repositioned the resident, picked up and applied the resident's moon boots and placed a wedge behind the resident's back; -LPN E picked up the soiled gauze from the bed and while holding the gauze in in his/her soiled gloved hands pulled the sheet over the resident. During interview on 4/12/19 at 4:20 P.M CNA B said the following: -He/She had been trained to use an alcohol wipe for catheter care; -He/She had been taught to only make one swipe and then fold cloth or get new wipe; -He/She should have used a new alcohol pad for each swipe when performing catheter care; -Gloves should be removed and hands washed after perineal care and new gloves applied before performing catheter care; -Clean items should not be touched with soiled hands. During interview on 4/23/19 at 8:35 P.M , LPN E said the following: -After removing a soiled dressing, gloves should be removed and hands washed before regloving and applying the new one; -Hands should be washed or sanitized with hand gel between glove changes; -Clean items/surfaces should not be touched with soiled hands; -Soiled wound dressing supplies should be placed in the trash can and not on the resident's bed linens. 6. Review of Resident #41's POS, dated 4/19 showed the resident had a malignant neoplasm (malignant growth or tumor) of rectum. Review of the Resident's care plan dated 3/14/19 showed the following: -Problem: I have an ileostomy (connection of the small intestine to the abdominal wall) and need assistance with emptying it and keeping it clean; -Approach: Assist me with cares and keep the skin around the ileostomy clean and monitor for any skin breakdown. Observation on 04/10/19 at 5:05 A.M. showed the following: -LPN H entered the room where the resident lay on his/her back in the bed; -Without washing his/her hands, LPN H applied gloves, laid a pre-cut stoma (artificial opening in the abdominal wall to allow feces to pass through) wafer and colostomy bag on the arm of the resident's recliner. He/she removed the soiled wafer from the resident's abdomen, threw it in the trash, degloved and without washing hands picked up a box of gloves, carried them to the chair along with a disposable towel, placed the towel on the arm of the chair and the stoma supplies on top of the towel. Without washing his/her hands LPN H regloved, picked up a disposable cloth and cleaned around the stoma site multiple times without changing the surface of the cloth. He/she threw the cloth away, removed his/her gloves and without washing his/her hands attached the ileostomy bag to the stoma wafer and laid it back on the towel. He/She picked up the skin prep/adhesive and applied it around the stoma site. He/She fanned the area with his/her hands. Soft stool was noted coming from stoma so LPN H regloved and wiped the stool with a disposable towel, threw it in the trash, and then without washing hands and changing gloves, picked up the wafer with the bag and applied it over the stoma. 7. Review of Resident #31's POS, dated 4/19 showed the following: -Diagnoses of glaucoma (disease of eye that leads to loss of vision); -Brimonidine 0.2% opthalmic- one drop both eyes two times daily for glaucoma (5/25/18); -Timolol maleate ophthalmic drops 0.5% one drop to both eyes two times daily (5/25/18). Observation on 4/9/19 showed Certified Medication Technician (CMT) I completed the following: -At 3:45 P.M., he/she retrieved the resident's brimonidine eye drops from the medication cart, entered the resident's room, handed the resident a Kleenex and without gloving, administered one drop of medication into each of the resident's eyes. CMT I did not wash or sanitize hands after the procedure or before exiting the room; -At 4:00 P.M. he/she re-entered the resident's room with Timolol drops, washed hands and without donning gloves, handed the resident a Kleenex and administered one drop of medication to each of the resident's eyes. CMT I did not wash or sanitize hands after the procedure or before exiting the room. 8. Review of Resident #35's POS, dated 4/19 showed the following: -Diagnosis included glaucoma; -Brimonidine 0.2% eye drops- one drop both eyes three times daily for glaucoma (9/14/17); -Timolol ophthalmic 0.5% apply to both eyes two times daily for open angle with borderline findings (9/14/17). Observation on 4/9/19 showed CMT I completed the following: -At 3:52 P.M. CMT I retrieved Resident #35's brimonidine eye drops from the medication cart, entered the resident's room), and without donning gloves, administered one drop of medication into each of the resident's eyes; -He/She did not wash or sanitize hands after the procedure or before exiting the room; -At 4:05 P.M. he/she re-entered Resident #35's room with the Timolol drops, washed hands and without donning gloves, administered one drop to each eye. He/she did not wash or sanitize hands after the procedure or before exiting the room. During interview on 4/12/19 at 4:25 P.M. CMT I said the following: -He/she should have worn gloves to administer eye drops; -Hands should be washed before and after eye drops are administered, with glove changes and before exiting a resident's room. During interview on 4/12/19 at 5:05 P.M the Director of Nurses (DON) said she would expect staff to wear gloves when administering eye drops and to deglove and wash hands prior to exiting the room and before entering another resident's room. 9. Review of Resident #37's POS dated 4/1/19 showed the following: -Diagnosis of diabetes; -Blood sugar test at 6:30 A.M., 11:30 A.M., 4:00 P.M. and 8:00 P.M. daily. Observation on 4/10/19 at 6:55 A.M. showed the following: -Registered Nurses (RN) C entered the resident's room and laid a plastic box of cotton balls, lancets and alcohol swabs, a notebook, and a plastic bag of supplies directly on the bottom bed sheet on the resident's unmade bed; -RN C opened the plastic box and removed cotton balls and a lancet. He/she left the plastic box opened and lying directly on the bottom bed sheet on the resident's unmade bed; -RN C cleaned the resident's finger with alcohol, stuck his/her finger with the lancet, checked the resident's blood sugar level and placed a cotton ball on the resident's finger; -RN C picked the notebook up off the resident's bottom bed sheet and wrote in the notebook, placed the bag of supplies in the resident's bedside table, closed the plastic box of lancets, cottons balls and alcohol swabs and entered Resident #31's room; -RN C laid the plastic box directly on Resident #31's recliner chair, opened the plastic box, removed supplies and checked the resident's blood sugar level. During interview on 4/10/19 at 7:00 A.M. and 4/11/19 at 11:00 A.M. RN C said the following: -Each resident had their own glucometer machine and it was kept in a plastic bag in the resident's bedside table. The plastic box contained alcohol swabs, cotton balls, and lancets and was kept on the treatment cart. He/She took the box into each resident's room and used the supplies while checking the resident's blood sugar; -He/She should only take into each resident's room the supplies needed and not the entire plastic box of supplies. He/she should place the blood sugar monitoring supplies on a barrier on the resident's bedside table and not directly on the resident's bed linens. Moving the plastic box from one resident room to another room was an infection control issue. 10. Observation of the facility showed the following: - On 4/9/19 at 9:30 A.M. no alcohol based hand cleanser or hand hygiene instructions at the entrance for visitors to the facility; -On 4/10/19 at 4:00 P.M. no alcohol based hand cleanser or hand hygiene instructions at the entrance for visitors to the facility; -On 4/11/19 at 1:00 P.M. no alcohol based hand cleanser or hand hygiene instructions at the entrance for visitors to the facility; -On 4/12/19 at 9:00 A.M. a bottle of alcohol based hand cleanser sat near the copy machine located just inside the facility front door. No hand hygiene instructions were posted at the entrance or near the bottle of alcohol based hand cleanser for facility visitors.