**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident, who was not determined by a physician to lack the ability to make informed healthcare decisions, was provided with opportunities to make decisions in their best interest for the Care Plan process. This was evidenced by one (1) of three (3) residents sampled for participation in the Care Plan process (Resident #64). Findings include: Review of the facility's Advance Directives policy with a revision date of December 2016 revealed: Policy Statement - Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation . 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. Review of Resident #64's Durable Power of Attorney (DPOA) for Health Care Decisions document revealed, I appoint the person named below to be my agent to make health care decisions for me when and only when I cannot make decisions or communicate what I want done. Review of Resident #64's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated moderate cognitive impairment. In an interview on 1/10/25 at 4:25 p.m., Social Worker #1 stated that Resident #64 was determined by his/her physician to lack the capacity to make informed healthcare decisions. Social Worker #1 stated that they did not document a decline in the resident's decision-making capacity, nor could they provide the physician's documentation about such a change. In an interview on 1/10/25 at 4:30 p.m., Social Worker #2 stated that Resident #64 had a Durable Power of Attorney (DPOA) representative who was notified of healthcare concerns and asked to acknowledge changes in care and services. The surveyor asked Social Worker #2 why Resident #64 was not asked to participate in planning his/her care and to acknowledge changes in his/her care and services. Social Worker #2 stated that the resident was not able to participate in the planning of his/her care at the time, due to his/her cognitive status. Social Worker #2 stated that the decision-making authority of the DPOA representative was placed into effect upon the date of the resident's signature on the DPOA document and not after the resident's physician determined that he/she was no longer able to make informed healthcare decisions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were acknowledged by the resident. This was evidenced for one (1) of three (3) residents sampled for Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Resident #64). Findings include: Review of Resident #64's Durable Power of Attorney (DPOA) for Health Care Decisions documents revealed, I appoint the person named below to be my agent to make health care decisions for me when and only when I cannot make decisions or communicate what I want done. Review of Resident #64's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated moderate cognitive impairment. In an interview on 1/10/25 at 4:25 p.m., Social Worker #1 stated that Resident #64 was not notified of the determination of non-coverage, because the resident was determined by his/her physician to lack capacity to make informed healthcare decisions. Social Worker #1 stated they did not document that a decline had occurred in the resident's cognitive status, nor could they provide documentation that Resident #64's physician determined the resident was no longer able to make his/her own informed healthcare decisions - to include acknowledging the receipt of the Beneficiary Notice of Non-Coverage. In an interview on 1/10/25 at 4:30 p.m., Social Worker #2 stated that Resident #64 had a Durable Power of Attorney (DPOA) representative who was making healthcare decisions on behalf of the resident. The surveyor asked Social Worker #2 why Resident #64 was not asked to participate in his/her own healthcare decision-making - to include being informed of and acknowledging receipt of the Beneficiary Notice of Non-Coverage. Social Worker #2 stated that Resident #64 was not able to do so at the time due to his/her cognitive condition. Social Worker #2 stated that the decision-making authority of the DPOA representative was placed into effect upon the date of the resident's signature on the DPOA document and not after the resident's physician determined that he/she was no longer able to make informed healthcare decisions.

Based on interviews and record review, the facility failed to develop a Comprehensive Care Plan after a significant change in the status/condition of a resident. This was evidenced by Resident #10 having had an unwitnessed fall with major injury resulting in a right hip replacement and pubic bone fracture on 7/24/24. The Care Plan was not revised within seven (7) days to ensure timeliness of a person-centered comprehensive assessment to address the resident's needs for one (1) of one (1) resident sampled for Comprehensive Care Plan timeliness (Resident #10). Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a revision date of March 2022, noted: Policy Interpretation and Implementation . 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Review of Resident #10's face sheet documented an admission date of 2/1/21. Medical diagnoses included Senile Degeneration of Brain, Major Depressive Disorder, Hypertension, Dementia and Type II Diabetes. Review of Resident #10's significant change status/condition Care Plan dated 8/19/24 documented the resident had sustained a pubic bone fracture on 7/24/24. An interview with the Assistant Director of Nursing (ADON), on 1/10/25 at 10:16 a.m., revealed Resident #10's Care Plan was not updated within the seven (7) day timeframe. The ADON stated the Care Plan, which reflected the fall on 7/24/24, was updated on 8/19/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility's cleaning checklist, the facility failed to maintain the physical environment in a safe, clean, comfortable and homelike manner on 200 Hall for two (2) residents who resided on this hall (Resident #48 and Resident #53), and failed to maintain in a safe, clean manner a lounge area and ice machine shared by residents from both 100 and 200 Halls. The combined census on the 100 and 200 Halls on 1/7/25, the first day of the survey, was 45. Findings include: During the initial tour of 200 Hall on 1/7/25, beginning at 12:55 p.m., observation found the carpeting on the hall was not clean, with small pieces of paper trash, small fragments of gauze, and debris noted throughout the length of the hallway from one (1) end of the residential corridor to the other. The carpeting on this hall was found to be in the same state when observed throughout the rest of the afternoon on 1/7/25 and throughout the day on 1/8/25. An observation was made of Resident #48's semi-private room in the presence of a visiting family member at 1:01 p.m. on 1/7/25. At the time of the observation, Resident #48 was sitting upright in a specialty chair at bedside facing the TV as the visitor sat on the edge of Resident #48's bed. When asked if he/she had any concerns regarding care and/or services, Resident #48 shook his/her head no. When asked if the visitor had any concerns, the visitor pointed to trash on the floor (including cotton balls), expressed concern about the cleanliness of the room, and stated he/she would usually just pick up the trash himself. Further observation found trash under the center of Resident #48's bed and several pillows under the head of Resident #48's bed by the wall. An observation was also made of the other half of Resident #48's semi-private room, which was occupied by Resident #53, who was out of the room at the time of this observation. This observation found trash on the floor in front of the foot of Resident #53's bed, as well as a cushion (labeled with Resident #53's name) on the floor under a wooden armchair positioned next to the sink and across from the foot of Resident #53's bed. At 10:36 a.m. on 1/8/25, a repeat observation was made of the room shared by Resident #48 and Resident #53. This observation found the floor on Resident #53's side of the room was not clean, with trash, equipment (including the seat cushion labeled with Resident #53's name), and debris on floor under the sink and furniture. Trash was also observed on the floor at the foot of Resident #48's bed (including cotton balls) and pillows and paper trash under Resident #48's bed. Beginning at 9:15 a.m. on 1/10/25, a tour was conducted of the shared lounge located across from the nursing station and at the juncture of 100 Hall and 200 Hall. This tour was conducted in the company of the Assistant Director of Nursing (ADON). When asked what this space was called, the ADON stated he/she always referred to as the common area. The common area was divided into a living room area (with a TV, tables, and chairs on vinyl plank flooring) and a sunroom area (with potted plants, floor-to-ceiling window panels, [NAME] tile flooring, and a door to an outside courtyard). During this tour, the following concerns were noted: - A disposable exam glove was under rear wheel of the medication cart parked by the piano; in the living room area; - Accumulations of dirt were seen in the corners of walls and behind the potted plants in the sunroom area; - Heavy accumulations of dust were found along the top surfaces of wooden chair rail molding along the walls of the perimeter of the common area; the dust was easily removed with rubbing by a finger; - The wooden baseboards around the perimeter of the common area, including in the sunroom area, had heavy accumulations of dust; the dust was easily removed with rubbing by a finger; - The [NAME] tile flooring in the sunroom area was generally clean, except within about two (2) inches of the wooden baseboard, where the tile was noticeably discolored; - Multiple cobwebs were noted in the corners of the frames of the floor-to-ceiling windows in the sunroom area, in the corners of the walls and floors, and stringing from a wall-mounted light sconce to the frame and the automatic closing device on the adjacent door leading into a courtyard, which was marked with signage stating: NO PUBLIC USE and THIS IS NOT AN EXIT; - Dust build-up was on the bottom rungs of all the chairs placed around two (2) tables in the common area, which was easily removed with rubbing by a finger; - Pieces of paper trash was found on the open floor, as was a bottle cap under an end table in the living room area; and - The doorknob to a door labeled HOSPICE SUPPLIES ONLY was loose from the door and missing one (1) of two (2) screws intended to secure the doorknob to the door. The above findings were verified by the ADON at the time of the observations, after which the observations were halted to allow the ADON to invite supervisors for the Housekeeping and Facilities (Maintenance) departments to join the tour. A tour of the 200 Hall began at approximately 9:35 a.m. on 1/10/25, in the company of the ADON, the Facilities Director (who was supervisory over Housekeeping and Facilities), the Facilities Supervisor, and Housekeeping Supervisor #5, with the following concerns noted: - The left-hand leaf of the double doors going from the Health Care Center to the Administrative Offices, which had been held open by a magnetic holder, was closed, and the surveyor pointed to heavy accumulations of dark-colored dust, debris and webbing in the corner of the floor behind the door as well as on all three (3) door hinges. - The ice machine located across from the nursing station was noted to be dripping water into the collection tray. On the front of the ice machine and on the collection tray were heavy accumulations of a white substance consistent in appearance with lime build-up, which was easily removed by scrapping with a fingernail. The vent on the left side of the ice machine was coated with an accumulation of dust. The polyvinyl chloride (PVC) piping leading from the left side of the machine to an air-gapped drain in the wall beside the machine was coated with a heavy accumulation of dust. The floor under the machine was not clean. When interviewed at the time of the observation, the Facilities Director confirmed it was the responsibility of Facilities staff to maintain the cleanliness of the ice machines. - As the group traveled down the 200 Hall from the nursing station, accumulations of dust and debris were observed along the top edge of the wooden baseboards, the top edge of the backboard to the wooden handrails, and inside the wells of the handrails lining both sides of the hall. - The surveyor commented to the accompanying staff that the carpets looked clean today, but they were visibly soiled with pieces of trash and debris on Days 1 and 2 of the survey. The Housekeeping Supervisor confirmed the expectation that the carpets in the hallways were to be vacuumed daily. At 9:39 a.m. on 1/10/25, the surveyor released the left-hand leaf of the double doors between rooms [ROOM NUMBERS] to examine the carpeting behind the previously closed door. On the carpeting were multiple pieces of debris which were yellow-orange in color with an appearance consistent with food particles. - Examination of a resident room whose occupant was not present (room [ROOM NUMBER]) found the open floor of the room to be generally clean, but the floor between the wall and the wardrobe near the window was found to have debris and a large particle of food (possibly a cookie) visible just inside the opening to that space. Examination of the vent to the packaged terminal air conditioner (PTAC) unit found an accumulation of debris inside the unit. The bottom rung of a wooden armchair (identical to the chairs seen in the common area) was found to have a heavy accumulation of dust easily removed with rubbing by a finger. - A framed picture in the hallway outside of room [ROOM NUMBER] was tested for cleanliness, by running a finger across the top of the frame. This resulted in finding a heavy accumulation of dust. - Debris, including a piece of medical tape with writing on it, was noted within the well of the handrail outside of room [ROOM NUMBER]. - The left-leaf of the double doors across from a door labeled HOUSEKEEPING CENTRAL STORAGE was released from the magnetic hold-open device. Examination of the carpeted flooring behind where the door had been held open against the wall found the carcass of a large, winged insect on the floor, as well as a heavy accumulation of debris in the corner behind the door. All the above findings were verified by all staff members accompanying the surveyor at the time of the observations. At 9:51 a.m. on 1/10/25, the surveyor asked the Facilities Director and Housekeeping Supervisor #5 about expectations for cleaning residents' rooms. They reported that at a minimum, on a DAILY basis, the residents' rooms were to be dusted, sinks cleaned, and floor swept and mopped (including under beds, sinks, and easily movable furniture, such as an armchair). When asked about routine cleaning of the hallways, they reported that the carpeting in the hallways was to be vacuumed daily and the handrails dusted/wiped down daily, including inside the wells of the handrails. At approximately 9:55 a.m. on 1/10/25, the surveyor knocked on the door to Resident #48's room and obtained permission from his/her to enter and examine his/her room in the company of the same facility staff. Upon entering the room, the surveyor noted the open floor of the room had been swept and mopped, but on the floor under the head of Resident #48's bed were three (3) bed pillows. Under the wooden armchair beside the sink across from the foot of Resident #53's bed was the seat cushion labeled with Resident #53's name. The surveyor reported to the facility staff having observed pillows under Resident #48's bed on Day 1 and Day 2 for the survey, as well as trash on the floor around Resident #48's bed, including paper trash and cotton balls. Upon exiting Resident #48's room, the ADON reported the cotton balls were likely used to obtain the resident's capillary blood glucose levels, and the ADON re-entered the room to remove the pillows from the floor. At approximately 10:00 a.m. on 1/10/25, the surveyor asked the Facilities Director and Housekeeping Supervisor #5 for the facility's policies and procedures for cleaning the resident rooms and common areas, as well as any cleaning schedules, cleaning checklists that had been completed during the current week, and the schedule as worked for the Housekeeping Department for the week of the survey (1/7/25 through 1/10/25). The Facilities Director stated he/she was not sure whether such policies and procedures existed, but they did have a sheet on each housekeeper's cart that provided direction to staff on what was to be cleaned and how often. At 10:24 a.m. on 1/10/25, the Facilities Director presented a two-page document titled Health Center and stated, These tasks are to be done daily. No policies or procedures, completed cleaning checklists, or a copy of the Housekeeping Department's schedule as worked for the current week were provided. Review of the document titled Health Centered contained the following (quoted verbatim): Clean and disinfect all high touch surfaces to include door knobs, key pads hand rails, faucets, crash carts etc. 100 Hall __ Clean Nurses Stations Daily (Sweep, Mop, Trash & Clean Counters) __ Clean Med-Room Daily (Sweep, Mop, Clean Counters & Sink) __ Clean Both Offices Daily (Sweep, Mop, Trash & Clean Counters) __ Clean Soil Utility Room Daily (Sweep & Mop & Clean Sink) __ Clean Linen Room Daily (Sweep & Mop) NOTHING ON TOP SHELVES! __ Clean Supply Room (Sweep & Mop) Daily 200 Hall __ Clean Beauty Shop Daily (Sweep, Mop, Trash, Clean All Counters, Bathroom, & Mirrors) __ Clean Soil Utility Room Daily (Sweep, Mop & Clean Sink) __ Clean Ice Maker 2X [twice] A Daily __ Clean Linen Room Daily (Sweep & Mop) NOTHING ON TOP SHELVES! __ Clean HCC [Health Care Center] Lounge Daily (Sweep, Trash, Wipe Down Tables & Chairs, MOP 3X [three times] A Week) __ Clean Restorative Therapy 2X A Week (Vacuum, Wipe Down Table, Trash) __ Clean Chaplains Office 1X A Week (Vacuum, Wipe Down Tables, Trash, Dust) __ Deliver Morning & Afternoon Personals (11AM & 2PM) Clean and disinfect all high touch surfaces to include door knobs, key pads hand rails, faucets, crash carts etc. Monday - Clean handrails on beds, overhead lights & glove boxes Tuesday - Pull out nightstands and beds, sweep & mop behind them. Wednesday - Dust all furniture and sprinkler heads and vents. Thursday - Clean blinds & window sills Friday - Clean janitor cart & closet. Clean floor sink, sweep & mop. When interviewed again at 3:20 p.m. on 1/10/25, the Facilities Director confirmed there were no policies or procedures for cleaning the resident rooms or common areas and that a copy of the checklist identified above was kept on each housekeeping cart as a reference tool only. The Facilities Director confirmed that the checklist was not actually filled out by housekeeping staff each day, turned in, or retained. When asked how the facility verified that the tasks identified on the checklist were being completed at the frequencies specified, the Facilities Director stated it was the responsibility of the Housekeeping Supervisor to do spot checks daily. According to the Facilities Director, [He/She, referring to Housekeeping Supervisor #5] is supposed to 'spot check' at least one (1) room on every hall every day. The Facilities Director acknowledged that additional monitoring was indicated in view of the findings made during a tour of 200 Hall and the lounge or common area shared by the residents on 100 Hall and 200 Hall.

Based on observation, interview and record review, the facility staff failed to ensure an environment free from accident hazards. Staff failed to secure the contents of an unattended treatment cart stored in a lounge used by residents on the 100 and 200 Halls. The cart contained medicated creams, ointments, and topical sprays, as well as bandage scissors. The unlocked treatment cart presented a potential hazard to all residents residing on 100 and 200 Halls. Findings include: Review of the facility policy titled Security of Medication Cart, revised April 2007, noted: Policy Interpretation and Implementation . 4. Medication carts must be securely locked at all times when out of the nurse's view. On 1/7/25 at 12:41 p.m., the surveyor observed an unlocked treatment cart in which were stored band aids, bandages, gauze, gauze tape, lidocaine pain spray, medicated ointments and creams, and bandage scissors. The cart was stored in an open lounge area, and multiple residents were observed to be within six (6) feet of the treatment cart. In an interview on 1/7/25 at 12:42 p.m., Registered Nurse (RN) Charge Nurse #4 stated he/she accidentally left the cart unlocked after being called away to assist someone. RN Charge Nurse #4 stated he/she should have secured the cart by locking it before leaving it unattended.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to clean the kitchen floors, preparation table, shelves and drawers, stove, the grill, grill area, ovens, sides and front of the deep fat fryer, refrigerators, and the steamer/convection ovens. Findings include: Review of the undated Sanitization policy read in part: Policy Statement - The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and implementation - 1. All kitchens, kitchen areas and dining areas shall be kept clean . 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. During the initial tour of the kitchen on 1/7/25 at 11:24 a.m., the following items were not clean in the kitchen. The kitchen floors had food debris, black colored grime and grease under the stove, grill, ovens, steamers and preparation tables. in the kitchen. The food preparation tables, shelves and drawers had food debris and crumbs on and in them; the stove had dried food debris and accumulated grease on the front, sides and back of it; the grill and grill area had food debris and accumulated grime and yellow colored grease on the front and sides of the table to include the wheels of the grill table; the ovens had black food debris built up inside and the outside of the ovens had food debris on the doors and sides; there was yellow grease build up on the sides and front of the deep fat fryer; the refrigerators had dried food substances inside to include dried beverages that had not been cleaned up, and the handles had food sticky debris stuck to them and in the crevices around the handle, the bottoms of the outside of the refrigerators had stains on them; the tilt skillet, and the steamer/convection ovens had black colored food debris inside, and the glass doors were yellowish/brownish in color with gunky handles. There was a sign posted on the steamer that read: Top steamer lunch cook clean after lunch is over. Evening cook check and reclean before leaving if needed. During a second tour of the kitchen on 1/9/25 at 10:04 a.m., the following items were not clean the kitchen. The kitchen floors had food debris, black colored debris, grease under all areas in the kitchen. The preparation tables, shelves and drawers had food debris and crumbs; the stove had dried food debris and accumulated grease on the front, sides and back; the grill and grill area had food debris and accumulated grime and yellow colored grease on the front and sides of the table to include the wheels of the grill table; the ovens had black food debris built up inside and the outside of the ovens had food debris on the doors and sides; there was yellow grease build up on the sides and front of the deep fat fryer; the refrigerators had food debris inside to include beverages that had not been cleaned up, the handles had food debris stuck to them and in the crevices, the bottoms of the outside of the refrigerators had stains on them; the tilt skillet, and the steamer/convection ovens had black colored food debris inside, the glass doors were yellowish / brownish in color. There was a sign posted on the steamer that read: Top steamer lunch cook clean after lunch is over. Evening cook check and reclean before leaving if needed. Observation of the plate warmer revealed it had dried food substances inside and outside to include crevices. During an observation and interview on 1/9/25 at 11:04 a.m., Chef #3 stated that all staff cleaned the kitchen. He/She pointed out a white board on the wall with the dates 12/28 and 12/29 that had a list of staff and items to be cleaned. Chef #3 stated that he/she had been out, and the whiteboard had not been updated. He/she stated that he/she and the Executive Chef were responsible for ensuring the kitchen was cleaned. He/she stated they were also responsible for monitoring to ensure that the tasks were completed. Chef #3 stated it was important to clean the kitchen to prevent illness to the residents and keep rodents and bugs out. During an observation and interview on 1/9/25 at 12:08 p.m., the Director of Dining Services (DDS) agreed the aforementioned items were not clean. He/she said, Just needs to be cleaned. The DDS stated it was important to clean the kitchen to prevent cross contamination, not get people sick, keep bugs out, and not get dirt in the food. He/she also stated he/she had not been in the kitchen as often as he/she should have been.

Based on interviews and record review, the facility failed to maintain a Quality Assessment and Performance Improvement (QAPI) Committee with the participation of the Medical Director and Infection Control Preventionist (or designee) for three (3) out of six (6) quarterly meetings. Findings include: Review of the facility's Quality Assurance and Performance Improvement policy, dated 3/15/24, noted, Policy Interpretation and Implementation . 5 . The following individuals serve on the committee: Administrator, or designee who is in a leadership role; Director of Nursing Services; Medical Director; Infection Preventionist . Review of QAPI committee meeting attendance sheets revealed all required committee members signed the attendance sheets for meetings held on 9/21/23, 3/21/24, and 6/20/24. On 12/21/23, the signature of the Medical Director was not present on the sign-in sheet for this quarterly meeting. On 9/19/24, the signature of the Infection Control Preventionist was not present on the sign-in sheet for this quarterly meeting. On 12/19/24, the signatures for both the Medical Director and the Infection Control Preventionist were not present for this quarterly meeting. In an interview on 1/10/25 at 10:16 a.m., the Assistant Director of Nursing (ADON) verified the sign-in sheets and identified the roles of the committee members. It was revealed that neither the Medical Director nor a designee participated in the 12/21/23, and 12/19/24 meetings and the Infection Control Preventionist did not participate in the 9/19/24 and 12/19/24 meetings. The ADON stated that he/she was new to the role of coordinating the QAPI Committee Meetings and he/she was not aware of required attendance of members.

Based on interview and record review, the facility failed to notify the resident's responsible party to obtain consent prior to starting a new medication for one sampled resident (Resident #2) out of three sampled residents. The facility census was 88 residents. The Director of Nurses (DON) and the Administrator were notified on 7/9/24 of Past Non-Compliance which occurred on 5/10/24. All nursing staff were in-serviced on notification of responsible parties on 6/21/24. The deficiency was corrected on 6/21/24. Review of the facility's policy titled Charting and Documentation dated July 2017 showed: -Any changes in the resident's condition shall be documented in the resident's medical record. -Documentation should include notification of the family. 1. Review of Resident #2's undated admission record showed the resident had a Durable Power of Attorney (DPOA) and had a diagnosis of dementia (a progressive mental disorder characterized by memory problems, impaired reasoning, and personality changes). Review of the resident's care plan dated 2/10/23 showed: -The resident had dementia. -Special instructions the resident's DPOA wanted to be contacted for any medication changes. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/3/24 showed the following staff assessment of the resident: -Severely cognitively impaired. -Had a diagnosis of dementia. Review of the resident's psychiatry/medication progress note dated 5/7/24 showed: -The visit was for follow-up on the resident's behaviors. -The resident had a diagnosis of dementia. -New orders included: --Add Memantine (cognition-enhancing medication used to treat dementia by decreasing abnormal activity in the brain, which can slow down the decline of one's thinking, memory and reasoning) 5 milligrams (mg) every morning for one week, then increase to 5 mg twice a day, then increase to 10 mg every morning and 5 mg at bedtime and then 10 mg twice a day for behaviors related to dementia. Review of the resident's psychiatry/medication progress note dated 5/15/24 showed: -The visit was for follow-up on the resident's behaviors. -New orders included: --Increase Memantine to 5 mg twice a day the next week and weekly thereafter. --Increase Memantine to 10 mg every morning, 5 mg at bedtime and then 10 mg twice a day for behaviors related to dementia. Review of the resident's Medication Administration Record (MAR) dated May 2024 showed the resident received: -Memantine 5 mg at bedtime for dementia 5/10/24-5/15/24. -Memantine 5 mg at bedtime for dementia 5/30/24-5/31/24. -Memantine 5 mg twice a day for dementia 5/16/24-5/29/24. -Memantine 5 mg in the morning for dementia on 5/30/24. -Memantine 10 mg in the morning for dementia on 5/31/24. Review of the resident's MAR dated June 2024 showed the resident received: -Memantine 10 mg in the morning for dementia 6/1/24-6/17/24. -Memantine 5 mg at bedtime for dementia 6/1/24-6/16/24. Review of the resident's communicate note dated 6/17/24 showed: -The resident's DPOA was notified of a new order for Memantine and one other medication. -The resident's DPOA did not approve of the recommended medications. Review of the resident's communication note dated 6/21/24, documented by the DON showed: -A conference call was held with the resident's DPOA. -They discussed the DPOA's grievance filed regarding not being notified when medication changes were made. Review of the facility's in-service education form dated 6/21/24 showed the facility's nurses were educated on notifying families of changes. During an interview on 7/9/24 at 11:19 A.M., Licensed Practical Nurse A said: -The charge nurse should have notified the resident's DPOA when a new physician's order was given for a new medication. -The resident's DPOA usually declined any recommendations for new medications. During an interview on 7/9/24 at 11:50 P.M., the Administrator said (with the DON present): -The resident's DPOA notified him/her that the resident was prescribed and administered a medication without notifying him/her. -The charge nurses were in-serviced on 6/21/24 of their responsibility for notifying DPOAs of recommended medication changes. During an interview on 7/9/24 at 12:23 P.M., the DON said: -The psychiatrists did not enter their orders into the electronic health record but gave verbal orders to the charge nurses. -The charge nurse at the time of the verbal order was responsible for contacting the resident's DPOA. -The ADON in-serviced all the charge nurses on 6/21/24 that they should contact the DPOA regarding any medication changes. -They also developed a form to obtain consent for an evaluation by the psychiatry group and to receive treatment recommendations. During an interview on 7/9/24 at 2:00 P.M., the resident's DPOA said: -The facility did not notify him/her prior to administering Memantine, which was a new medication for the resident. -He/She found out about the new medication when he/she received the resident's pharmacy bill on 6/17/24. -He/She informed facility staff at that time that he/she had not approved the administration of Memantine and wanted it discontinued. MO00237772

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide safe transfer assistance for one sampled resident (Resident #3). On 1/25/24 the resident was transferred by four staff from his/her wheelchair to a shower chair without the use of a gait belt, while the resident physically resisted. Staff grabbed the resident by his/her arms and lifted him/her up from the wheelchair, resulting in bruising on the back of his/her right upper arm, left lower arm below the elbow, and on the right upper outer arm. The facility census was 87 residents. Review of facility policy Safe Lifting and Movement of Residents, revised 7/2017, showed: -In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility used appropriate techniques and devices to lift and move residents. -Residents safety would be incorporated into goals and decisions regarding the safe lifting and moving of residents. -Nursing staff, in conjunction with the rehabilitation staff, would have assessed the individual residents' needs for transfer assistance. -Staff documented the residents transferring and lifting needs in the care plan. -Staff responsible for direct resident care would be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. A policy on gait/transfer belts was requested from the facility and not provided. 1. Review of Resident #3's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Morbid (severe) obesity; -Unspecified Osteoarthritis (a degenerative disease of the bones and joints); -Low back pain; and. -Need for assistance with personal cares. Review of the resident's care plan, revised 5/12/22, showed: -The resident required assistance by two staff to move between surfaces and necessary. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 11/3/23, showed: -The resident was cognitively intact. -The resident had not exhibited any refusal of cares during the look-back period. -The resident needed partial/moderate assistance, staff person does less than half the effort for transfers. During interview and observation on 2/2/24 at 9:05 A.M., the resident said: -On 1/25/24 about 10:00 A.M., he/she was given a shower by four staff after he/she refused the shower; -He/she tried to fight the staff then gave up; -The staff did not use a gait belt. -The staff grabbed him/her by his/her arms and lifted him/her up from the wheelchair. -The resident had a thumb size dark purple bruise with a green ring around it on the back of his/her right upper arm. A thumb size dark purple bruise on the left lower arm below the elbow and a finger size dark purple bruise on the right upper outer arm. During a phone interview on 2/2/24 at 11:07 A.M., Licensed Practical Nurse (LPN) A said: -He/She was asked to give the resident a shower on 1/25/24, because the resident had not had a shower in over a month. -He/She took the resident to the shower room. -The resident said no; -The resident hit LPN A; -Staff touched the resident's arms and used the resident's arms to lift the resident up. -The resident needed assistance with standing. -He/She helped the resident by grabbing the waist band of the residents' pants, and did not use a gait belt. -The resident was supposed to be assisted by two staff for transfers. -He/she did not say whether the resident needed a gait belt or not. During a phone interview on 2/2/24 at 11:20 A.M., Certified Nurse Aide (CNA) A said: -It was the resident's shower day (1/25/24). -He/She stood in front of the resident. -LPN A and CNA C stood the resident up without a gait belt. -The resident used his/her legs to stand up with the staff steadying him/her with arms around the resident's arms. -No gait belt was used during the transfer to the shower chair or back to wheelchair. -The resident was to be assisted by two staff for transfers. -He/She has never seen a a care plan on a resident. -He/she did not think the resident needed a gait belt. During a phone interview on 2/2/24 at 11:32 A.M., CNA B said: -LPN A asked him/her to help give the resident a shower. -He/She went to the shower room. -LPN A brought the resident to the shower room in his/her wheelchair. -He/She was standing behind the wheelchair holding the wheelchair. -LPN A and CNA C helped the resident stand up, by holding the resident's arms (arms looped around the residents arms and under the residents arms) to prevent the resident from falling. -The resident was fighting the staff. -The resident hit the CNA in the face. -The resident was an assist of one staff for all cares. -The resident did not have a gait belt on. -He/she did not know if the resident required a gait belt for transfers. During an interview on 2/6/24 at 10:41 A.M., CNA F said gait belts were to be used for all residents anytime a resident was transferred without using a mechanical lift. During an interview on 2/6/24 at 10:46 A.M., Registered Nurse (RN) B said gait belts were to be used for all transfers unless the resident was a mechanical lift. During an interview on 2/6/24 at 10:55 A.M., Certified Occupational Therapist Assistant A said a gait belt was to be used for all transfers. It was the safest way to transfer a resident. During an interview on 2/6/24 at 10:58 A.M., Physical Therapy Assistant A said a gait belt was to be used with all manual transfers. During an interview on 2/6/24 at 11:00 A.M., the Director of Rehab said it was his/her expectation gait belts be used for all transfers when the resident was moved, unless the resident required a mechanical lift. During an interview on 2/6/24 at 11:04 A.M., Certified Medication Technician (CMT) B said gait belts were to be used for all transfers. During an interview on 2/6/24 at 11:06 A.M., CMT A said gait belts were to be used anytime a resident was stable and transferred, and if a resident was unstable a mechanical lift was to be used. During an interview on 2/6/24 at 11:08 P.M., LPN E said anytime a resident is transferred a gait belt should be used. During an interview on 2/6/24 at 11:09 A.M., CNA J said a gait belt would be used for all transfers. During an interview on 2/6/24 at 11:10 A.M., CNA I said a gait belt should be used during all transfers. During an interview on 2/6/24 at 11:11 A.M., CMT C said a gait belt should be used for all transfers. During an interview on 2/6/24 at 12:00 P.M., the Administrator and Director of Nursing said: -It was both their expectation a gait belt would be used unless it was care planned that the resident was self-transfer or the resident used a mechanical lift. -All staff were trained on the use of gait belts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #37's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity). -Dysphagia (difficulty swallowing). Review of the resident's admission Note, dated 1/16/23, showed LPN A documented: -The resident had no teeth. -Broken or ill-fitting dentures were not assessed. -Abnormal mouth tissue was not assessed. -Lack of natural teeth was not assessed. Review of the resident's Durable Power of Attorney (DPOA) for Health Care, dated 1/18/23, showed the resident had named an agent to have full authority over healthcare decision making when he/she was incapacitated as certified by one physician. Review of the resident's Significant Change MDS dated [DATE], showed staff assessed the resident and documented the resident: -Had a BIMS of 13, which indicated he/she was cognitively intact. -Required set-up assistance for meals and oral hygiene. -Had no dental issues. -Had unclear speech. -Had difficulty communicating. -Had a poor appetite several days during the look-back period. Observation on 6/26/23 at 12:55 P.M. showed the resident had no teeth. During an interview on 6/26/23 at 12:55 P.M., the resident said: -He/she had lost his/her dentures a few years ago. -No one had ever asked him/her if he/she was interested in getting new dentures. Review of the resident's care plan, last revised 6/28/23, showed: -Staff were to clean the resident's gums multiple times a day. -Staff documented the resident had communication problems related to dentition problems. During an interview on 6/28/23 at 1:00 P.M., the DON said: -He/she could not find any dental notes for the resident. -He/she did not believe the resident had seen the dentist since admitting to the facility. During an interview on 6/28/23 at 2:24 P.M., the DON said: -The resident had not had dentures in 20 years. -The resident was admitted without dentures or teeth. -He/she was unsure if anyone had asked the resident if he/she was interested in dentures. Review of the resident's SS Note, dated 6/28/23 at 2:25 P.M., showed SS A documented: -He/she had met with the resident regarding dentures. -The resident stated interest in obtaining dentures. -The SS explained to the resident that it might be difficult given how long the resident had not had teeth. -The resident stated he/she would like to pursue dentures, regardless of possible difficulties. During an interview on 6/29/23 at 8:15 A.M., CNA A said: -He/she was aware the resident didn't have any teeth but thought it was the resident's choice. -He/she guessed the resident wasn't interested based on the resident's life story, so he/she had never asked about the resident's desire for dentures. During an interview on 6/29/23 at 8:42 A.M., Registered Nurse (RN) A said he/she expected staff to ask any resident without teeth if they were interested in obtaining dentures. During an interview on 6/29/23 at 9:35 A.M., the resident said: -He/she wasn't able to eat a lot of foods because he/she didn't have any teeth. -He/she was bothered that he/she couldn't eat what he/she wanted but no one had ever offered to help. During an interview on 6/29/23 at 11:14 A.M., LPN A said: -The resident had a family member that worked at the facility. -He/she had asked the family member working at the facility about the resident's teeth and the family member said the resident hadn't had teeth for a long time. -He/she normally ask residents about dentures on admission but since the resident's family member worked there, he/she had spoken with him/her instead. -He/she believed the resident would refuse dental appointments that were not furnished within the facility's building and a denture consult would require the resident to see an outside dentist. -He/she was unsure if the resident had been declared incapacitated. During an interview on 6/29/23 at 1:05 P.M., the DON said the resident had not been declared incapacitated by a physician or the courts. During an interview on 6/30/23 at 8:34 A.M., Social Worker A said: -The resident hadn't had teeth in over 20 years so his/her family probably hadn't thought about it. -The staff were aware the resident didn't have teeth but the resident didn't like leaving the building for appointments so he/she assumed the resident would not be interested and did not ask. During an interview on 6/30/23 at 9:03 A.M., the resident said the staff kept telling him/her getting dentures would be a big ordeal but he/she still wanted to try. During an interview on 6/30/23 at 1:17 P.M., the DON said: -The resident had never been offered dentures because his/her family member worked in the facility and said the resident wouldn't want them. -He/she had discussed dentures with the resident's family member and that family member decided the resident wouldn't benefit from dentures. -The resident was able to make choices for himself/herself. -The resident had never mentioned he/she wanted dentures. -During recent discussions with the resident's family, the family said to follow the resident's choices but they did not believe it would be beneficial. -He/she didn't realize the resident was able to make his/her own choices because the resident had signed a DPOA. Based on observation, interview and record review, the facility failed to provide supporting documentation for the use of a wandering type bracelet (are monitoring devices that are attached to patients and electronically notify nurses when the patient attempts to leave the ward or unit to which the patient is assigned) safety device to include changes in resident behavior, or exit seeking behaviors for one sampled resident who was his/her own responsible person and who's Brief Interview for Mental Status (BIMS) score was 15 (A score of 13 to 15 would indicate the resident was cognitively intact); and to document the resident's right to consent either verbal or written consent, for the use of a wandering safety device for one sampled resident (Resident #16); and to allow one sampled resident (Resident #37) who was cognitively intact the ability to make decisions for himself/herself out of 19 sampled residents. The facility resident census was 80 residents. Review of the facility Wander and Elopements Policy revised on 3/19 showed: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the resident. -If a resident identified at risk for wandering, elopement , or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident safety. Review of the facility Resident Right's policy revised on 2/21 showed: -The resident has the right to be treated with respect, kindness and dignity. -To be free from corporal punishment or involuntary seclusion, and physicals restrains not required to treat the resident's symptoms. -The right to choose to participate in, decision-making regarding his or her care. 1. Review of Resident #16's admission Face Sheet showed: -The resident was his/her own responsible party. -Had diagnoses of Major Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) and Parkinson's Disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). Review of the resident's Psychiatric Services Visit Summary dated 3/17/23 showed: -The resident believed he/she was a werewolf and would howl like a wolf at times. -He/she believed the facility staff were injecting people with fertility drugs. -The resident was very sensitive to new medications and often had adverse reactions to Antipsychotic medication. -Note: There was no documentation related to any wandering or exit seeking behaviors. Review of the resident's Social Services (SS) Progress note dated 3/24/23 at 3:30 P.M. showed -SS staff were visiting with the resident on 3/23/23 and he/she began to get angry with SS during their visit. -Staff tried to redirect him/her, the resident got upset and put his/her fist up out of frustration. -Nursing staff came to assist the resident out of the SS office. -There was no documentation related to any wandering behaviors or being at risk for elopement. Review of the resident's SS Progress Note dated 4/27/23 at 11:09 A.M. showed: -SS met with the resident for his/her quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) review. -The resident was sitting in his/her room at the time of the visit. -The resident said he/she was feeling down, tired, and having trouble concentrating at times. -SS suggested that he/she see the facility psychologist, the resident was agreeable to seeing the psychologist. -The resident signed a consent form to see the psychologist the next time the psychologist visited the facility. -Note: There was no documentation related to exit seeking behavior or wandering off the unit. Review of the resident's Quarterly MDS dated [DATE] showed he/she: -Had a BIMS score of 15 (a score between 13 to 15 would indicate the resident cognitively intact). -Was able to make his/her needs known and able to understand others. -Had no documentation related to having wandering behaviors or being at risk for elopement. Review of the resident's Psychiatric Services Consult dated 4/29/23 showed the resident: -Was depressed due to his/her diagnosis of Parkinson's. -Was alert and oriented times four (oriented to person, place, time and to circumstance) -Thought process was logical and goal directed. -Had no evidence of any perceptual disturbance, paranoia or delusional thinking during the assessment. -Note: There was no documentation related to having wandering or exit seeking behaviors. Review of the resident's hand written Care Plan Conference Summary dated 5/4/23 showed: -The resident was having frequent paranoid situations. --There was no detailed behavioral documentation of what the paranoid situation included. -The resident and two family members were present during the Care Plan meeting. -No documentation related to the resident having wandering or exit seeking behaviors. Review of the resident's BIMS interview and assessment for MDS dated [DATE] showed the resident: -Was able to understand and express ideas, and wants both verbally and non-verbally. -Had a BIMS score of 15 which indicated he/she was cognitively intact. Review of the resident's Elopement Evaluation assessment dated [DATE] at 9:13 A.M. showed: -The resident did not have a history of elopement while at home. -He/she did not have wandering behavior and had goal directed activity. -The resident would wander aimlessly or non-goal-directed. -The resident did have wandering behaviors and would likely affect the safety or well-being of himself/herself or others. -His/Her wandering behavior was likely to affect the privacy of others. -He/she was not recently admitted or re-admitted (within past 30 days). -The final elopement score of four indicated the resident was at risk for elopement. -Had no supporting documentation of any safety interventions that were put in place. -Did not have any supporting documentation for the need of or for the use of a wandering safety device. Review of the resident's Health Status Note dated 6/23/23 at 4:51 P.M., showed: -The resident's wandering safety device was placed on his/her left ankle for safety. -Nursing staff had placed a call to the resident's family member to inform him/her of the wandering safety device placement. -The family member said he/she was ok with resident's wandering safety device placement. -Note: There was no documentation of the resident (who was his/her own responsible person) having consented to the use of a wandering safety device or that his/her physician had been notified prior to use of the wandering safety device. Review of the resident's Treatment Administration Record (TAR) dated 6/2023 showed a new physician order dated 6/23/23 at 11:00 P.M., for a wandering safety device to be placed on the resident's left ankle, nursing staff were to check the wandering safety device placement every shift and replace the wandering safety device as needed. Review of the resident's Physician Order Sheet (POS) dated 6/2023 showed: -A new physician order for a wandering safety device to be placed on his/her left ankle, nurse staff were to check the wandering safety device placement every shift and replace the device if needed (ordered on 6/23/23 at 11:00 P.M.). -Nursing staff were to monitor the resident's skin integrity at the site of the wandering safety device every shift (ordered on 6/25/23 at 3:00 P.M.). Review of the resident's Personalized Care Plan updated on 6/26/23 showed; -The resident was an elopement risk related to his/her impaired safety awareness. -The resident wandered aimlessly related to his/her cognitive impairment. -Interventions included placement of a wandering safety device to his/her left ankle, nursing staff were to check placement of the wandering safety device every shift. Observation on 6/26/23 at 9:18 A.M. of the resident in his/her room showed: -He/she was sitting in his/her recliner chair, with a wandering safety device on his/her left ankle. -The resident was able to make his/her needs known. Observation on 6/27/23 at 10:28 A.M., showed the resident: -Was in a low wheelchair able to propel self in room. -Had a wandering safety device on his/her left ankle. Review of the resident's electronic Medical Record on 6/28/23 at 9:48 A.M., showed: -The resident did not have supporting documentation for the use or need of a wandering safety deviceto include any wandering or, exit seeking behaviors or having a change in his/her mental status related to paranoia. -The resident did not have any documentation that written or verbal consent was obtained by the facility staff for the use of the wandering safety device. During an interview on 6/28/23 at 9:32 A.M., Certified Nursing Assistant (CNA) H said: -The resident had a diagnosis of Parkinson's and his/her symptoms of Parkinson's had increasingly got worse. He/she had episodes of confusion at times. -The nursing staff were responsible for the resident's Elopement Assessment and monitoring of safety devices such as a wandering safety device. -He/she was not aware of the resident having wandering or exit seeking behaviors. Observation on 6/28/23 at 11:23 A.M., of the resident in the main dining area showed he/she was sitting at a table in his/her wheelchair with a wandering safety device placed on his/her left ankle. During an interview on 6/29/23 at 8:58 A.M., the resident said: -He/she had a safety monitor on his/her left ankle because he/she had wandered over to his/her old apartment, and did not inform facility staff he/she was leaving the unit. -He/she would not always notify facility staff when leaving the unit. -Since the placement of the wandering safety device, he/she had not attended any off unit activities. He/she said had no place to go this week. -A wandering safety device was placed on his/her left ankle so facility staff would be able to locate him/her. -The resident did not feel offend or discouraged by having to wear the wandering safety device. It did not affect his/her ability to move freely within the facility. -Facility staff did not ask permission of him/her before the placement of the wandering safety device. During an interview on 6/29/23 at 9:11 A.M., CNA A said: -The resident was able to propel himself/herself around the facility and would leave the unit without telling staff. -It was like playing hide and seek with the resident. -The resident liked to visit with peers. During an interview on 6/29/23 at 11:42 A.M., Licensed Practical Nurse (LPN) C said: -The facility recently completed new elopement assessments on 6/23/23 for any residents who were at risk for or had the potential for wandering and if they had a BIMS score below nine (moderately cognitively impaired) they were given a wandering safety device. -The resident had a history of thinking he/she was a werewolf and would howl at times. -He/she had not seen the resident have wandering behaviors, exit seeking behaviors, packing up personal items or stating he/she wanted to go home or leave the facility. -The resident did like to attend activities off the unit on the assisted living side. -He/she would document any wandering behaviors, wanting to leave the facility, or exit seeking in the resident medical records. -Elopement assessments for wandering were to be completed quarterly by the nursing staff and he/she would expect to have supporting documentation of the resident's behaviors of wandering or exit seeking noted in the resident's medical record. During an interview on 6/29/23 at 12:04 P.M., LPN A said: -The resident's wandering safety device was put in place for his/her safety and to let facility staff know by alarm where the resident was at and to ensure he/she was not wandering out facility doors. -The resident had a mental health consult that documented the resident had a delusion of believing he/she was a werewolf. -On 6/23/23 the resident had a BIMS assessment completed, he/she thought it was nine or below, but after review of the documentation he/she noticed the resident's BIMS score was 15. -The residents Elopement Evaluation Assessment would include any noted behavioral changes in the resident. -The resident had a past behavior of thinking he/she was a werewolf and he/she was teaching other residents how to howl like a wolf. -He/she had a diagnosis of Parkinson's with behavioral changes. -The resident was able to make his/her own decisions and choices. -The resident was able to propel himself/herself throughout the facility. -The resident's wandering safety device would alarm if the resident got close to an exit and that was how staff monitored the whereabouts of the resident. -Review of the resident's medical record with LPN A showed the resident's last behaviors were documented in 3/23. The resident did not have any supporting documentation related to why the resident was at risk for wandering or if he/she had any wandering behaviors. -He/she would expect to have documentation of any wandering behaviors or when the resident did not notify the facility staff when leaving the unit. During an interview on 6/30/23 at 10:50 A.M., Infection Control Preventionist (ICP) said: -If residents were at risk for wandering, then an assessment would be completed to see if safety devices such as a wandering safety device was needed. -The facility staff had notified the resident's family member and noted in the medical record. -The resident was able to make needs known and if he/she did not want the wandering safety device he/she could let staff known or could cut the wander guard bracelet off. -The resident had Parkinson's which caused hallucinations at times, the resident thought he/she was a werewolf. During an interview on 6/30/23 at 11:40 A.M., Director of Nursing (DON) said: -The facility did not have any written consents for use of a wandering safety device. -The assessment for use was the elopement assessment that was completed on 6/23/23, and use of a wandering safety device was dependant on the score. -They facility had notified the resident's family member and documented in his/her nursing notes. -He/she would expect nursing staff to document the resident being notified of the use of the wandering safety device and had agreed to the safety measure. -The resident's family member was notified of placement of the wandering safety device. -The resident was his/her own responsible person, he/she was able to make his/her needs known and had a BIMS of 15. -After completing the Elopement Evaluation Assessment, the resident scored at risk for wandering and the facility placed the wandering safety device on the resident due to the finding of the evaluation. During an interview on 6/30/23 at 1:18 P.M., the DON and Assistance Director of Nursing (ADON) said: -On 6/23/23, the facility nursing staff had completed an Elopement Evaluation Assessment on all residents, due to a prior incident of a resident exiting the facility. -Any resident who had the potential for at risk of wandering or exit seeking and had a BIMS, lower than nine had an Elopement Assessment completed by facility nursing staff. -On 6/23/23 any resident with a score that indicated they were at risk was given a wandering safety device. -The resident had shown no behaviors of exit seeking, of wanting to leave the facility or wandering. -He/she had no current behaviors documented related to delusions of being a werewolf. -The facility had past documentation by mental health specialist showing the resident had delusions of being a werewolf. -The resident had a BIMS score of 15. -During the day the resident was not confused, during the night the resident was more confused. -The facility did not have documentation of the night time confusion. -The residents with an elopement assessment score of 3 or more were at risk for elopement or wandering. And the facility had placed wandering safety devices on those residents at risk for wandering or elopement. -He/She would expect facility nursing staff to have documentation of the residents being educated and accepted the use of the wandering safety device. -The resident's family was called and agreed to the use of the wandering safety device. -He/she would expect nursing staff to have supporting documentation for the use of the wandering safety device to include any wandering behaviors, exit seeking behaviors or change in mental status. -The resident's care plan should be comprehensive and personalized to include any current wandering behaviors or incidents and any delusional behaviors noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the privacy of one sampled resident (Resident #4) during a blood glucose test (a test that measures the amount of glucose (sugar) levels in the blood) and when receiving insulin (a hormone produces in the pancreas which regulates the amount of sugar in the blood) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Dignity dated February 2021 showed staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #4's face sheet showed he/she admitted to the facility with the following diagnoses: -Alzheimer's Disease (a progressive mental deterioration that can occur in middle or old age due to degeneration of the brain) with Early Onset (having an age of onset of Alzheimer's younger than [AGE] years old). -Diabetes Mellitus Type Two (DMII- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 4/24/23 showed the resident had severely impaired cognition. Review of the resident's Physician Order Sheet (POS) dated June 2023 showed the resident received Levemir (long-acting insulin) FlexTouch Solution Pen-Injector 100 Units (U)/ milliliters (ml) (Insulin Detemir): Inject 18 U subcutaneously two times a day for DMII. Observation on 6/29/23 at 7:23 A.M. of a blood glucose test and insulin administration performed by Certified Medication Technician (CMT) A showed: -He/she gathered all supplies needed and walked from the medication cart to the resident sitting in a common area adjacent to the dining room. -He/she introduced himself/herself and told the resident that he/she was going to perform a blood glucose test. -He/she did not ask the resident if he/she wanted to go into his/her room or provide a private setting to perform the test. -He/she completed the test and walked back to the medication cart. -He/she then gathered all of the supplies needed to perform insulin administration on the resident. -He/she walked back to the resident and told him/her that he/she needed insulin. -He/she asked the resident if he/she could lift up his/her shirt to inject the insulin into the resident's abdomen. -He/she did not ask the resident if he/she consented to perform the procedure in the common area. -The resident lifted up his/her shirt just below the chest and pulled his/her pants down just below his/her navel exposing the resident's skin and part of his/her brief. -After completing the insulin administration he/she walked back to the medication cart, disposed appropriate supplies, and charted the insulin administration. During an interview on 6/29/23 at 7:36 A.M. CMT A said: -He/she thought the procedure went okay. -He/she would not have done anything differently. -He/she would be able to receive appropriate consent from the resident in order to perform procedures in common areas. -He/she could have given the resident more options for the insulin administration instead of just asking the resident to expose his/her stomach for the administration. During an interview on 6/30/23 at 8:43 A.M. Licensed Practical Nurse (LPN) D said: -Blood sugar tests and insulin administration should not be performed in common areas unless the resident refused to leave the area. -If a resident refused to leave the common area for a test or procedure the resident would need to consent to the procedure being performed in the common area or be pulled aside to a more private area. -Care staff should always ask for consent from a resident before any procedure. -Residents with a diagnosis of dementia would be able to consent to procedures performed in any common area or dining room. -If a resident in a common area needed to receive insulin the care staff should pull the resident aside and see if the insulin could go into the arm instead of the abdomen. During an interview on 6/30/23 at 9:01 A.M. LPN E said: -When performing a blood glucose test or insulin administration it should not be done in the dining room or common area. -He/she always attempted to have any resident go into their room before a procedure was completed, but if the resident refused, he/she would try to provide privacy as best possible. -A resident with dementia can consent to certain procedures as long as the procedure is explained to the resident. -If a resident is adamant about staying in the common area for insulin administration he/she would give the insulin into the resident's arm. -It is not appropriate to give insulin into the abdomen or stomach area in a non-private setting. -The CMT should have given the resident a choice of where to receive the insulin and should have provided more privacy. -When certain cares are not provided in privacy it is a dignity issue for the resident. -If he/she saw a CMT or nurse perform a blood glucose test or insulin administration in a non-private setting he/she would pull the staff person aside after the procedure was completed and educate them on resident privacy and dignity. During an interview on 6/30/23 at 10:26 A.M. Registered Nurse (RN) B said: -He/she was unsure if a blood glucose test or insulin administration could be performed in a common area and would need to see the facility policy. -He/she would think that it would be a privacy issue if performed in a common area. -Residents with a diagnosis of dementia would not be able to give consent for how a procedure was performed. -If a resident refused or was unable to leave the common area for insulin administration he/she would give the resident the insulin in the arm. If he/she saw a CMT or nurse try to perform a blood glucose test or insulin administration in a non-private setting he/she would walk over to the resident and assist in providing privacy and once the procedure was completed he/she would educate them to be more mindful of the resident's privacy. During an interview on 6/30/23 at 1:18 P.M. the Director of Nursing (DON) said: -He/she would expect staff to take a resident to their room when performing a test or procedure. -A resident with dementia would be able to consent for procedures and should be asked how they would like it done. -Any person receiving insulin would want privacy and would expect staff to give options of where and how the procedure was completed. -Regardless if a resident refused or did not want to leave the common area privacy should be given in some shape or form.

Based on observation, interview, and record review, the facility failed to follow professional standards by not aspirating (draw fluid by suction) or flushing an peripheral intravenous catheter (PIVC or IV-a thin plastic tube inserted into a vein using a needle) prior to administering medication for one sampled resident (Resident #278) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy, titled Dispensing and Administration of Saline and Heparin Flushes for IV Catheters dated February 2017, showed staff were required to flush any type of IV catheter: -With 10 milliliters (ml) of Normal Saline (a sterile solution that is a mixture of sodium chloride and water) prior to administering medication through the IV. -With 10 ml of Normal Saline after administration of any medication through the IV. Review of the facility's policy titled Peripheral Intravenous Catheter Flushing dated 2021 showed: -Staff were to obtain, document, and submit to the pharmacy, orders for a PIVC to be flushed. -Staff were required to flush a PIVC to ensure and maintain catheter patency (the state of being unobstructed). -A prescriber's order, to include flushing agent, volume, and frequency, was required to flush a PIVC. -Catheter patency was required to be verified prior to each use. This required aspirating the catheter to obtain positive blood return. -Staff were to flush the catheter after aspirating blood and observe for signs of complications. -If resistance was met when flushing, staff were not to attempt any further flushes, but were to remove the catheter and insert a new peripheral catheter. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Sepsis (a life-threatening complication of an infection). -Cellulitis (a serious bacterial skin infection) of the right lower limb. -Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). Review of the resident's Treatment Administration Record (TAR), dated 6/29/23, showed: -An order for Ceftazidime (an antibiotic) two grams to be given daily via IV entered on 6/23/23 and discontinued 6/26/23. This medication was documented as given on 6/24/23, 6/25/23, and 6/26/23. -An order for Ceftriaxone (an antibiotic) two grams to be given daily via IV entered 6/28/23 to be given until 7/3/23. This medication was documented as given on 6/28/23 and 6/29/23. -An order for a Normal Saline flush to be given via IV once a shift (three times a day) for patency. This medication was documented as given as ordered. Observation on 6/29/23 at 8:49 A.M. showed: -Licensed Practical Nurse (LPN) A entered the resident's room and prepared the IV medication. -LPN A pulled up the resident's sleeve and exposed the insertion port of the IV catheter. -LPN A wiped the insertion port of the IV catheter with alcohol, attached the IV medication tubing, opened the IV tubing clamps, and started the IV medication pump. -LPN A removed his/her gloves and promptly left the resident's room. -NOTE: LPN A did not aspirate or flush the line prior to starting the IV medication, and did not observe the resident's IV site for complications such as infiltration (when the catheter goes through or comes out of a vein) or phlebitis (inflammation of the vein as noted by redness, warmth, and pain in the affected area). During an interview on 6/29/23 at 8:49 A.M., LPN A said: -There was nothing he/she would have done differently. -He/she did not aspirate or flush the IV line prior to administering the IV medication because there was no order to do so. During an interview on 6/29/23 at 9:22 A.M., LPN B said: -He/she was IV certified. -IV lines were to be flushed before IV medication was started. -If there was no order to flush before administering the IV medication, he/she would call the doctor to obtain an order. During an interview on 6/29/23 at 10:52 A.M., LPN C said: -He/she was IV certified. -IV lines must be flushed prior to giving IV medication to ensure the line was patent. -If there was no order to flush prior to giving IV medication, he/she would call the doctor to obtain an order. During an interview on 6/30/23 at 1:17 P.M., the Director of Nursing (DON) said: -IV lines were to be aspirated and flushed with Normal Saline prior to starting IV medication. -If there was no order to flush an IV line before giving IV medications, he/she expected the staff to call and get an order.

Based on observation, interview, and record review, the facility failed to ensure the wheels on all mobile devices were locked prior to transferring and repositioning one sampled resident (Resident #278) out 19 sampled residents. The facility census was 80 residents. A copy of the facility's policy on accidents and transferring of residents was requested and not received at the time of exit. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Abnormalities of gait and mobility. -Muscle Weakness. -Fall from chair. Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 5/25/23, showed: -The resident had a Brief Interview for Mental Status (BIMS) of six, indicating the resident had severe cognitive impairment. -Extensive staff assistance was required for bed mobility. -Extensive staff assistance was required for transferring from one surface to another. Review of the resident's care plan, last revised 6/28/23, showed: -Staff documented that the resident was at risk for falls. -Staff documented on 4/22/21 that the resident had fallen while attempting to transfer and that the wheelchair brakes were not working properly. Observation on 6/26/23 at 9:57 A.M. showed: -Certified Nurse Assistant (CNA) D and CNA E were performing peri-care for the resident in his/her bed, while Licensed Practical Nurse (LPN) A performed a skin assessment. -As CNA D and CNA E rolled the resident to his/her other side to continue peri-care, the bed moved approximately 15 centimeters (cm) which resulted in the top right side of the headboard hitting the wall. -LPN A put his/her leg against the bottom half of the bed and the bed stopped moving. -The wheels on the bed were observed to be in the unlocked position. -All staff continued with their duties. -CNA D and CNA E placed the brief under the resident and again turned him/her to finish placing the brief. -Staff stood directly against the bed to prevent it from moving. -When the cares were complete, CNA D, CNA E, and LPN A covered the resident, lowered the bed, and left the room. -NOTE: No staff member locked the wheels to the bed prior to leaving the room. During an interview on 6/26/23 at 10:09 A.M., CNA D said: -He/she did see the bed move when the resident was rolled to his/her side. -He/she had looked at the lock on the bed and it appeared locked so he/she wasn't sure how the bed had moved. During an interview on 6/26/23 at 10:10 A.M., CNA E said: -He/she saw the bed move when the resident was rolled to his/her side. -He/she was not sure why the bed had moved. -The locking levers on some of the beds didn't work well so they appear locked but actually are not. During an interview on 6/29/23 at 8:15 A.M., CNA A said: -He/she expected the bed and wheelchair to be locked prior to moving a resident. -He/she checked the locks on all mobile devices before transferring a resident. During an interview on 6/29/23 at 9:38 A.M., CNA B said: -All wheels on all mobile devices were to be locked before transferring a resident. -He/she ensured all mobile devices were locked before transferring a resident. -If a bed moved while he/she was providing cares, he/she would lock it immediately before resuming cares. During an interview on 6/29/23 at 10:54 A.M., CNA C said: -He/she had found beds unlocked on occasion. -If a bed moved while he/she was providing cares, he/she would immediately stop and lock the bed before continuing with cares. During an interview on 6/29/23 at 11:14 A.M., LPN A said: -All mobile devices were to have the wheels checked to ensure they are locked before transferring a resident. -If a bed moved while he/she was providing cares, he/she would lock the wheels before continuing with cares. -He/she had not noticed the bed move while providing cares to the resident on 6/26/23. During an interview on 6/30/23 at 1:17 P.M., the Director of Nursing (DON) said: -Any items with wheels were to be verified as locked before attempting a transfer. -If a bed moved during cares and multiple care givers were present, he/she expected one staff member to stop and lock the bed before continuing cares. -No staff had reported difficulty with locking the wheels on any beds.

Based on observation, interview, and record review, the facility failed to ensure a suprapubic (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) catheter (flexible tube) was monitored, cleaned as ordered, and that an assessment of the resident's ability to perform the task had been completed, for one sample resident (Resident #20) out of 19 sampled residents. The facility census was 80 residents. The facility's policy for self-care of catheters was not received at time of exit. Review of the facility's policy, dated October 2010, titled Suprapubic Catheter Care showed staff were to: -Observe urine for any unusual appearance. -Check the resident frequently to ensure tubing was free of kinks. -Empty the collection bag. -Observe the stoma (a surgically made hole) for redness or skin breakdown. -Document the characteristics of the urine and skin after care was performed. Review of the facility's policy, dated February 2021, titled Self-Administration of Medications showed: -The Interdisciplinary Team (IDT) was to assess each resident's cognitive and physical ability to determine whether self-administration was safe and clinically appropriate. -If it was deemed safe for a resident to self-administer medication, it was to be documented in the medical record and care plan. -Self-administration of medication was to be reassessed periodically. Review of Drugs.com article, dated 7/2/23, titled How to Care for Your Suprapubic Catheter showed the insertion site was to be cleaned twice a day. 1. Review of Resident #20's face sheet showed he/she was admitted with the following diagnoses: -Urinary Tract Infection (UTI). -Retention of urine. -Encounter for fitting and adjustment of a urinary device. Review of the resident's Urologist's note from the hospital, dated 2/9/23, showed: -The urologist noted that the resident was able to plug the catheter during the day as the resident was able to void the majority of the urine but did not completely empty his/her bladder. -The physician did not indicate the resident was able to perform any of these cares independently. Review of the resident's Care Plan, last revised 5/4/23, showed: -The resident required one staff to assist with showering. -The resident required one staff to assist with dressing. -The resident had limited physical mobility. -The resident had impaired cognitive function due to short term memory loss. -The resident was at risk for infection related to the suprapubic catheter. -Staff were to check the tubing for kinks each shift. -Staff were to monitor the urine output and characteristics. -The resident was to change from a drainage bag to a leg bag (a drainage bag that straps to the leg for discretion) every morning and wear the leg bag throughout the day. -The resident was to change from the leg beg to a drainage bag at night independently. During an interview on 6/26/23 at 1:10 P.M., the resident said: -Staff applied a urine drainage bag to his/her catheter at bedtime. -He/she disconnected the drainage bag in the morning. -Staff changed the catheter tubing once a month. -He/she used the same urine drainage bag for approximately 10 days. -He/she did not use a new drainage bag every day but staff did give him/her a new one every once in a while. Observation on 6/27/23 at 10:06 A.M. showed: -The resident's catheter drainage bag was tied to the hand rail in the bathroom and had nothing covering the end that attached to the resident's urinary catheter. -The resident had a solid plastic cone inserted into the opening of his/her catheter. -The resident was not wearing a leg bag. During an interview on 6/27/23 at 10:08 A.M., the resident said: -He/she removed the urine drainage bag every morning and placed a cap into the urinary catheter to prevent leaking. -The cap he/she currently had in his/her catheter tubing wasn't actually for the catheter but the staff couldn't find the right thing so he/she had been told to use a plastic cone. -Staff did not give the resident a new cap every day, he/she used the same one until he/she requested a new one. Review of the resident's Order Report Summary, dated 6/28/23, showed: -The physician ordered an abdominal ultrasound due to pain and swelling. -Staff were to check the level of the drainage bag each shift to ensure it was below the bladder. -Staff were to clean the suprapubic site every eight hours as needed. -An additional physician's order requesting the catheter to be changed monthly. -An order for the resident to change to a leg drainage bag every morning and wear it throughout the day. -An order for the resident to change from a leg drainage bag to a regular drainage bag at night. -Staff were to confirm securement of the catheter tubing every shift. Review of the resident's Treatment Administration Record (TAR), dated 6/28/23, showed: -Staff documented each shift that the placement of the drainage bag had been checked. -Staff documented each shift that they ensured the securement of catheter. -No catheter care had been documented by staff for the month of June 2023. During an interview on 6/28/23 at 1:11 P.M., the resident said: -Staff had never told him/her that a leg bag was to be used during the day. -He/she had a leg bag but only used it when he/she was running errands. -When staff attached the urine drainage bag at night, sometimes the entire bag would fill and have to be drained immediately. -He/she would occasionally remove the cap on his/her urinary catheter during the day to see if anything would drain but usually only a small amount of urine came out. -He/she had significant abdominal bloating that staff had said was gas. During an interview on 6/28/23 at 1:56 P.M., the resident said: -Staff had never watched him/her connect or disconnect either drainage bags. -Staff had never watched him/her drain the drainage bag. -He/she cleaned the insertion site of the suprapubic catheter when he/she showered twice a week. -Staff cleaned the insertion site of the suprapubic catheter once a month when the catheter was replaced. During an interview on 6/29/23 at 7:24 A.M., Licensed Practical Nurse (LPN) C said: -The resident was independent with cares. -The resident managed all catheter care including capping the catheter and attaching his/her own drainage bag at night. -Staff ask the resident each morning about the resident's urine output. -Nurses were responsible for changing the catheter tubing each month. -He/she gave the resident the end of a syringe to cap the urinary catheter. -He/she gave the resident a new cap to place on the drainage bag, when not in use, approximately weekly. -The resident cleaned his/her insertion site independently. -He/she did not believe the facility assessed the resident to ensure the resident was competent to perform the catheter care. -He/she did not know the resident was supposed to wear a leg bag during the day. -He/she expected the physician's orders to be followed. Observation on 6/29/23 at 8:08 A.M. showed the resident's urine drainage bag tubing was wrapped around the hand rail in the bathroom, with the end exposed to air. During an interview on 6/29/23 at 8:15 A.M., Certified Nursing Assistant (CNA) A said: -He/she was aware the resident drained his/her drainage bag independently. -He/she did not believe it was appropriate to reuse the drainage bag but, if it was to be reused, it should be capped and not left open to air. -Nurses were responsible for ensuring the resident had all necessary supplies for the catheter. -He/she expected the care plan to be followed. -He/she believed the resident cleaned the insertion site independently but was not sure. During an interview won 6/29/23 at 8:42 A.M., Registered Nurse (RN) A said: -All drainage bags were to be visualized by staff every shift. -Nurses were responsible for cleaning catheter insertion sites. -Any resident who wanted to provide their own catheter care was to be watched by staff to ensure they were capable of managing it correctly and that the activity was completed. -If a resident complained of abdominal distention and had a urinary catheter, he/she would attempt to drain it to see if that was the problem. -He/she expected the physician's orders to be followed. -If a resident refused to wear a leg bag, it was to be documented on the TAR. -Once a drainage bag was detached it could not be used again. During an interview on 6/29/23 at 9:38 A.M., CNA B said: -Nurses were responsible for cleaning the catheter insertion sites. -If a resident completed the insertion site cleaning themselves, staff should watch to ensure it was done correctly. -Once a drainage bag was removed it should not be reused due to possible contamination. -He/she expected the care plan to be followed. During an interview on 6/29/23 at 10:54 A.M., CNA C said: -He/she did not observe or chart on the resident's catheter or urine because the resident did everything himself/herself. -Nurses were responsible for cleaning the insertion site. -He/she expected the physician's orders and care plan to be followed. -He/she wasn't sure if the resident used a leg bag because the resident did his/her own cares. -Drainage bags could not be reused once detached from the catheter. During an interview on 6/29/23 at 11:14 A.M., Licensed Practical Nurse (LPN) A said: -The resident cleaned his own catheter insertion site. -The resident was to notify the staff if he/she had any problems with the catheter. -The resident was to clean the insertion site daily. -He/she knew the resident washed the insertion site daily because when he/she entered the room the resident would be at the sink washing himself/herself. -He/she expected an assessment of the resident's ability to perform cares before being deemed independent. -The resident was to be assessed quarterly to ensure proper technique for any procedure performed independently. -He/she was aware the resident removed the drainage bag in the mornings. -The resident was to place a blue cap over the catheter tubing and was given a new cap weekly. -It was okay to reconnect a drainage bag as long as the tip was cleaned before being reconnected. -He/she had never seen the resident cap the catheter tubing with anything but a blue cap. -The resident's abdominal distention was due to gas. -If the resident needed his/her catheter drained, he/she would do it themselves. -The physician's orders and care plan were to be followed. -He/she was aware the resident did not usually wear the leg drainage bag during the day. -He/she expected an order for the catheter to be capped if that was something the facility allowed. -He/she had never known the resident to refuse cares. Observation on 6/30/23 at 8:24 AM. showed: -The urine drainage bag tubing was wrapped around the hand rail in the bathroom, with the end exposed to air, with approximately 300 mililiters (ml) of clear yellow urine in the bag. During an interview on 6/30/23 at 1:17 P.M., the Director of Nursing (DON) said: -Catheter drainage bags were to be visualized by staff every day. -Nurses were to provide/observe catheter care and sign off that it was completed on the TAR. -The resident's catheter was cleaned by the nurses. -He/she knew the resident provided some of his/her own cares, believed both the resident and nurses cleaned the resident's insertion site. -The insertion site was to be cleaned daily or more often and documented on the TAR. -The resident was an exception because he/she provided some of their own cares. -The resident's insertion site was to be cleaned per the order, which was as needed only, because the resident completed his/her own cares. -Staff should have assessed the resident for competency in completing insertion site cleaning before allowing him/her to perform the task independently. -He/she believed the urologist had assessed the resident's ability to perform catheter care and therefore the facility did not need to complete an assessment for self-care. -He/she was unsure how often the resident should be reassessed for providing self-cares. -If the urologist ordered the catheter to be capped, there should have been an order. -Staff supplied the resident with supplies when he/she asked for them. -The resident knew what he/she needed and knew what to ask for. -A drainage bag that had been detached from the catheter and left open to air should not be reused. -Every time the resident detached the drainage bag from the catheter, a new drainage bag should be given to him/her for that night. -He/she did not know if nursing staff told the resident how often to clean the insertion site.

Based on interview, and record review, the facility failed to ensure one sampled resident (Resident #278) was free from unnecessary medications by ordering and administering an incorrect medication multiple times, out 19 sampled residents. The facility census was 80 residents. Review of the facility's Medication Therapy policy, dated April 2007, showed each resident's medication regimen was to include only medications necessary to treat existing condition. Review of the facility's undated policy titled General Guidelines for Transcribing Orders onto the Medication Administration Record (MAR) showed staff were to transcribe the information as it was written on the order. Review of missouricareereducation.org's undated Certified Medication Technician Student Manual, Lesson Plan 6, Transcribing Physician's Orders-General Principles showed: -All transcriptions were to be error-free. -Staff were to verify medication orders by writing them down and reading them back to the physician. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Sepsis (a life-threatening complication of an infection). -Cellulitis (a serious bacterial skin infection) of the right lower limb. -Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). Review of the resident's hospital discharge paperwork, dated 6/22/23, showed the physician ordered Ceftriaxone (an antibiotic) two grams to be given daily via intravenous (IV existing or taking place within, or administered into, a vein), to be completed 6/29/23. Review of the resident's Consultation Report, dated 6/26/23, showed the pharmacist notified the facility via telephone at 10:10 A.M. on 6/26/23 that the resident's medication was to be Ceftriaxone but the facility's order showed Ceftazidime (an antibiotic). Review of the resident's Progress Note, dated 6/26/23, showed a Registered Nurse (RN) documented the medication had been transcribed incorrectly on admission and that the order was discontinued. Review of the resident's Treatment Administration Record (TAR), dated 6/29/23, showed the resident received two grams of Ceftazidime via IV on three days; 6/24/23, 6/25/23, and 6/26/23. During an interview on 6/29/23 at 10:24 A.M., the resident's family member said he/she had been notified the resident had been given the wrong medication. During an interview on 6/29/23 at 11:57 A.M., Pharmacist A said: -Ceftazidime was hard on the kidneys. -Ceftazidime was to be renally dosed (dosage based on kidney clearance rate so it does not build up in the system and become toxic). -He/she expected blood work to be performed, resulted, and reviewed prior to administering Ceftazidime, to ensure there was no kidney damage. -He/she was not aware of any blood work performed prior to or after the resident received Ceftazidime. During an interview on 6/30/23 at 1:17 P.M., the Director of Nursing (DON) said: -The resident had received Ceftazidime by mistake. -He/she was unaware that Ceftazidime was renally dosed. -He/she was unaware that the resident had acute kidney failure while hospitalized . -He/she was not aware of any blood work performed before or after the administration of Ceftazidime.

Based on interview, and record review, the facility failed to ensure one sampled resident (Resident #278), out of 19 sampled residents, was free from a significant medication error by administering the incorrect antibiotic for three days. The facility census was 80 residents. Review of the facility's Medication Therapy policy, dated April 2007, showed each resident's medication regimen was to include only medications necessary to treat existing condition. Review of the facility's undated policy titled General Guidelines for Transcribing Orders onto the MAR (Medication Administration Record) showed staff were to transcribe the information as it was written on the order. Review of missouricareereducation.org's undated Certified Medication Technician Student Manual, Lesson Plan 6, Transcribing Physician's Orders-General Principles showed: -All transcriptions were to be error-free. -Staff were to verify medication orders by writing them down and reading them back to the physician. 1. Review of Resident #278's face sheet showed he/she was admitted with the following diagnoses: -Sepsis (a life-threatening complication of an infection). -Cellulitis (a serious bacterial skin infection) of the right lower limb. -Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). Review of the resident's hospital discharge paperwork, dated 6/22/23, showed the physician ordered Ceftriaxone (an antibiotic) two grams to be given daily via Intravenous (IV) route, to be completed 6/29/23. Review of the resident's Consultation Report, dated 6/26/23, showed the pharmacist notified the facility via telephone at 10:10 A.M. on 6/26/23 that the resident's medication was to be Ceftriaxone but the facility's order showed Ceftazidime (an antibiotic). Review of the resident's Progress Note, dated 6/26/23, showed a Registered Nurse (RN) documented the medication had been transcribed incorrectly on admission and that the order was discontinued. Review of the resident's Treatment Administration Record (TAR), dated 6/29/23, showed: -Staff entered an order for Ceftazidime two grams to be given daily via IV on 6/23/23. -The resident received two grams of Ceftazidime via IV on three days; 6/24/23, 6/25/23, and 6/26/23. -Staff discontinued the Ceftazidime on 6/26/23 and entered an order for Ceftriaxone to start on 6/28/23. Review of the resident's Five Whys Analysis, dated 6/26/23, showed: -Staff had transcribed the medication incorrectly upon admission. -Staff had clicked on the wrong medication because the medications were listed next to each other. -Staff had not read back the order to the physician. Review of the resident's Emergent Quality Assurance Form 10, dated 6/26/23, showed: -Staff documented the antibiotic had been transcribed incorrectly. -Staff documented the antibiotic should have been Ceftazidime but the nurse ordered Ceftriaxone (NOTE: This is incorrect-Ceftriaxone was to be ordered and the Ceftazidime was ordered in error). During an interview on 6/29/23 at 10:24 A.M., the resident's family member said: -He/she had been notified the resident had been given the wrong medication. During an interview on 6/29/23 at 11:57 A.M., Pharmacist A said: -Ceftazidime was hard on the kidneys. -Ceftazidime was to be renally dosed (dosage based on kidney clearance rate so it does not build up in the system and become toxic). -He/she expected blood work to be performed, resulted, and reviewed prior to administering Ceftazidime, to ensure there was no kidney damage. -He/she was not aware of any blood work performed prior to or after the resident received Ceftazidime. During an interview on 6/30/23 at 1:17 P.M., the Director of Nursing (DON) said: -The resident had received Ceftazidime by mistake. -He/she expected staff to transcribe medications correctly. -He/she was unaware that Ceftazidime was renally dosed. -He/she was unaware that the resident had acute kidney failure while hospitalized . -He/she was not aware of any blood work performed before or after the administration of Ceftazidime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to offer and provide dental services for one sampled resident (Resident #37) out of 19 sampled residents. The facility census was 80 residents. The facility did not provide a copy of their dental policy at time of exit. 1. Review of Resident #37's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity). -Dysphagia (difficulty swallowing). Review of the resident's admission Note, dated 1/16/23, showed Licensed Practical Nurse (LPN) A documented: -The resident had no teeth. -Broken or ill-fitting dentures were not assessed. -Abnormal mouth tissue was not assessed. -Lack of natural teeth was not assessed. Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 6/23/23, showed staff assessed the resident and documented the resident: -Had a Brief Interview for Mental Status (BIMS) score of 13, which indicated he/she was cognitively intact. -Required set-up assistance for meals and oral hygiene. -Had no dental issues. Observation on 6/26/23 at 12:55 P.M. showed the resident had no teeth. During an interview on 6/26/23 at 12:55 P.M., the resident said: -He/she had lost his/her dentures a few years ago. -No one had ever asked him/her if he/she was interested in getting new dentures. Review of the resident's care plan, last revised 6/28/23, showed: -Staff were to clean the resident's gums multiple times a day. -Staff documented the resident had communication problems related to dentition problems. During an interview on 6/28/23 at 1:00 P.M., the Director of Nursing (DON) said: -He/she could not find any dental notes for the resident. -He/she did not believe the resident had seen the dentist since being admitted to the facility. During an interview on 6/28/23 at 2:24 P.M., the DON said: -The resident had not had dentures in 20 years. -The resident was admitted without dentures or teeth. -He/she was unsure if anyone had asked the resident if he/she was interested in dentures. Review of the resident's Social Services Note, dated 6/28/23 at 2:25 P.M., showed Social Worker (SW) A documented: -He/she had met with the resident regarding dentures. -The resident stated interest in obtaining dentures. -The SW explained to the resident that it might be difficult given how long the resident had not had teeth. -The resident stated he/she would like to pursue dentures, regardless of possible difficulties. During an interview on 6/29/23 at 8:15 A.M., Certified Nursing Assistant (CNA) A said: -Staff were to look at every resident's teeth. -Staff should have offered dentures to any resident that has no natural teeth. -All nursing staff were responsible for checking resident's teeth. -He/she was aware the resident didn't have any teeth but thought it was the resident's choice. -He/she guessed the resident wasn't interested based on the resident's life story, so he/she had never asked about the resident's desire for dentures. During an interview on 6/29/23 at 8:42 A.M., Registered Nurse (RN) A said: -Nurses were to evaluate all resident's teeth on admission. -He/she expected staff to ask any resident without teeth if they were interested in obtaining dentures. During an interview on 6/29/23 at 9:35 A.M., the resident said: -He/she wasn't able to eat a lot of foods because he/she didn't have any teeth. -He/she was bothered that he/she couldn't eat what he/she wanted but no one had ever offered to help. During an interview on 6/29/23 at 11:14 A.M., LPN A said: -The resident had a family member that worked at the facility that had told him/her the resident hadn't had teeth for a very long time. -He/she believed the resident would refuse dental appointments that were not furnished within the facility's building and a denture consult would require the resident to see an outside dentist. -He/she would normally ask about dentures on admission but since the resident's family member worked at the facility and had told him/her that the resident didn't want dentures, he/she had never asked the resident. During an interview on 6/30/23 at 8:34 A.M., SW A said: -A resident could request to see the dentist and the facility would schedule an appointment. -He/she was not sure who should have initiated a dental consult for the resident. -The resident hadn't had teeth in over 20 years so his/her family probably hadn't thought about it. During an interview on 6/30/23 at 9:03 A.M., the resident said the staff kept telling him/her getting dentures would be a big ordeal but he/she still wanted to try. During an interview on 6/30/23 at 1:17 P.M., the DON said: -All residents were to be offered dentures if they had no teeth. -He/she was unsure how often dental exams were to be performed. -There was a dentist in the facility and the staff were able to request an appointment for residents. -The resident had never been offered dentures because his/her family member worked in the facility and said the resident wouldn't want them. -He/she had discussed dentures with the resident's family member and that family member decided the resident wouldn't benefit from dentures. -The resident was able to make choices for himself/herself. -The resident had never mentioned that he/she wanted dentures. -During recent discussions with the resident's family, the family said to follow the resident's choices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #278's face sheet showed he/she was readmitted with the following diagnoses: -Sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). -Cellulitis of the right lower limb (a deep infection of the skin caused by bacteria). Observation on 6/29/23 at 8:49 A.M., showed LPN A: -Entered the resident's room and laid the resident's medication and supplies directly on a bedside table without a barrier. -Placed the IV medication bag on the IV pole at an elevated level, turned on the IV pump (machine that regulates the rate of administration), inserted the IV tubing spike into medication, set the machine for the prescribed rate, removed the cap covering the luer connector, allowed the medication to fill the IV tubing, removed all air bubbles, closed the clamp on the tubing to stop the medication from flowing, but left the luer connector uncovered. -Held the exposed luer connector in his/her right hand while threading the IV line into the pump, which resulted in the exposed luer connector making direct contact with the IV pump multiple times. -Attached the luer connector the resident's IV line and began administering the prescribed medication without cleaning or replacing the potentially contaminated IV tubing's luer connector. During an interview on 6/29/23 at 8:49 A.M., LPN A said there was nothing he/she would have done differently. During an interview on 6/30/23 at 1:17 P.M., the DON said IV supplies should not be placed on a bedside table without a barrier. Based on observation, interview and record review, the facility failed to use adequate handwashing to prevent cross contamination during resident care for one sampled resident (Resident #45); to ensure the intravenous (IV-a medical technique that administers fluids, medications and nutrients directly into a person's vein) medication tubing's luer connector (the male end of the IV tubing that is inserted into the female end of an IV line that has been placed in a person's vein to form a secure yet detachable leak-proof connection) remained sterile while administering IV antibiotics; and to ensure supplies were placed on a barrier for one sampled resident (Resident #278) out of 19 sampled residents. The facility census was 80 residents. The facility's policy and procedure for administering IV fluids was requested and not received at time of exit. Review of SimpleNursing.com's article, dated 6/6/22, titled How to Start an IV showed staff were to: -Hang the IV bag from something elevated and fill the tubing with solution via gravity. -Remove any air bubbles from the line by tapping or squeezing the line. -Ensure the IV's luer connector did not touch anything that would compromise its sterility (free from bacteria or other living organisms). 1. Review of Resident #45's Face Sheet showed he/she was admitted on [DATE], with diagnoses including Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), falls, difficulty walking, high blood pressure, muscle weakness and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/31/23, showed the resident: -Was alert with significant cognitive impairment. -Needed extensive assistance with bed mobility, toileting, dressing, grooming and bathing. -Needed total assistance of two staff for transfers. Observation on 6/28/23 at 1:02 P.M., showed the resident was sitting in his/her specialized wheelchair in his/her room. Certified Nursing Assistant (CNA) F and CNA G entered the resident's room with the full body lift, and without washing or sanitizing their hands, put on gloves, closed the resident's door and began attaching the resident's sling to the lift. CNA G lifted the resident into his/her bed while CNA F positioned the resident. They locked the wheels on the resident's bed then both CNA F and CNA G rolled the resident to the side to remove the sling from underneath him/her. The following occurred: -CNA F removed the resident's pants and brief while CNA G obtained a clean brief and placed it on the bed. -CNA F used wet wipes to clean the resident's groin from front to back and placed the soiled wipes in the trash while CNA G held the resident on his/her side. -CNA F then discarded his/her gloves, used hand sanitizer, gloved, then paced a clean brief on the resident with the assistance of CNA G (CNA G did not dispose of his/her gloves, wash/sanitize his/her hands or re-glove before assisting with putting on the resident's clean brief). -Both CNA F and CNA G removed their gloves and discarded them -CNA F lowered the resident's bed, put the floor mat down on the floor, and paced the call light within reach of the resident. CNA F then washed his/her hands at the sink, turning off the water with a paper towel. CNA F then removed the full body lift from the resident's room. -CNA G, without washing or sanitizing his/her hands, put on a clean pair of gloves and began placing linen in a plastic bag. After doing so, he/she left the resident's room without washing or sanitizing his/her hands. During an interview on 6/28/23 at 1:11 P.M., CNA F said: -He/she had sanitized his/her hands before he/she left the prior room he/she was in. -He/she was supposed to wash or sanitize his/her hands upon entry, then put on gloves. -Staff were supposed to remove gloves and wash or sanitize their hands anytime they complete incontinence care (dirty task) and then re-glove and put clean briefs on the resident. -Staff were supposed to wash or sanitize their hands before leaving the resident's room. During an interview on 6/28/23 at 1:13 P.M., CNA G said: -He/she was supposed to wash or sanitize his/her hands before or upon entering the resident's room, before they assist the resident and then wash or sanitize his/her hands before leaving the resident's room. -He/she should wash or sanitize his/her hands between clean and dirty tasks and whenever he/she removed his/her gloves. -He/she did not know why he/she did not wash or sanitize his/her hands upon entering the resident's room, after assisting the resident or before leaving the resident's room. -He/she was rushing. During an interview on 6/30/23 at 12:49 P.M., Registered Nurse (RN) D said: -He/she expected nursing staff to wash or sanitize their hands upon entering the resident's room and glove prior to completing any cares. -Nursing staff should wash or sanitize their hands whenever they complete a dirty task and they should wash or sanitize their hands before leaving the resident's room. -Nursing staff should not enter the resident's room and put on gloves without washing or sanitizing their hands. - Nursing staff should not leave the resident's room without washing or sanitizing their hands. During an interview on 6/30/23 at 12:45 P.M., Licensed Practical Nurse (LPN) F said: -Nursing staff should wash or sanitize their hands upon entering the resident's room before providing any cares, anytime they are handling bodily fluids they should wash their hands, after providing incontinent care before they put on the clean brief, with any dirty task and before leaving the resident's room. -Nursing staff should wash or sanitize their hands after handling soiled or dirty linen or trash before leaving the resident's room. During an interview on 6/30/23 at 1:18 P.M., the Director of Nursing (DON) said: -Nursing staff should wash their hands, put on gloves then assist the resident. -If they were performing incontinence care and their hands were visibly soiled, they should wash their hands. -If their hands were not soiled, he/she still expected nursing staff to wash or sanitize their hands after completing incontinence care, before starting a clean task. -Nursing staff should wash or sanitize their hands after completing any dirty task prior to completing a clean task, to include handing linen and trash. -Nursing staff should wash or sanitize their hands before leaving the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a bed-hold form was completed and sent for three sampled residents who were discharged to the hospital (Resident #3, #7 and #328) out of 19 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Bed-Holds and Returns dated March 2022 showed: -All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). -Residents are provided written information about these policies at least twice: --Well in advance of any transfer (in the admission packet). --At the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. Review of Resident #328's face sheet showed he/she admitted to the facility with the following diagnoses of Diabetes Mellitus Type Two (DMII- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/15/23 showed the resident discharged the facility on 6/15/23 with return-anticipated. Review of the resident's bed-hold form received 6/29/23 showed: -The bed-hold agreement that was signed by the resident was dated 4/4/23. -A copy of the notice of bed-hold policy and rights was dated 6/15/23 but did not include a resident or staff signature. During an interview on 6/30/23 at 8:48 A.M. Licensed Practical Nurse (LPN) D said: -He/she thought Administration was responsible for sending out the bed-hold forms. -He/she had never transferred a resident out of the facility without Administration being present in the building. -He/she would call the supervisor on duty if Administration was not able to send out the bed-hold form at the time of transfer. During an interview on 6/30/23 at 9:13 A.M. LPN E said: -He/she was unsure if a bed-hold form needed to be sent out with the resident during transfer out of the facility. -He/she new the form existed, but was not educated on the process of what needed to be done with the form. -He/she thought that the admissions person would be the person to complete the bed-hold forms. During an interview on 6/30/23 at 10:21 A.M. Registered Nurse (RN) B said: -He/she needed more education on the bed-hold process. -He/she knew there were rules regarding bed-holds that needed to be followed. -He/she would check with the admissions person to see if a bed-hold needed to be sent out with the resident upon transfer out of the facility. During an interview on 6/30/23 at 1:18 P.M. the Director of Nursing (DON) said: -He/she expected the nurses to complete the bed-hold forms and social services was the back-up to ensure completion of the bed-hold forms. -Bed-holds needed to be sent out regardless if social services was in the building. -He/she would expect the nurses to complete a nurses note upon transfer of a resident that included if the bed-hold form was sent with the resident. -He/She was not aware that the bed-hold forms were being completed improperly before survey. 2. Review of Resident #3's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including heart failure, seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain), high blood pressure, falls, pain and low iron level. Review of the resident's Bed Hold Form dated 3/16/22, showed the resident elected to hold his/her bed should he/she be discharged from the facility. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with minimal cognitive impairment. -Needed limited assistance with bathing, dressing, hygiene, and needed extensive assistance with toileting. Review of the resident's MDS Record showed the resident discharged from the facility, on 4/26/23, to the hospital and re-entered the facility on 4/29/23. Review of the resident's Nursing Notes showed: - On 4/26/23 the resident reported to the nurse that he/she believed he/she was having signs and symptoms of atrial fibrillation (irregular heartbeat) after breakfast. The resident requested to go to the hospital and the nurse notified his/her family and physician. The nurse documented that the resident did not take his/her morning medications prior to leaving. The emergency services staff escorted the resident to the hospital at 9:00 A.M. At 9:08 A.M., the nurse called the hospital emergency room and the hospital nurse reported the resident was being admitted for heart exacerbation and respiratory failure. -On 4/29/23 The resident arrived at the facility at 7:10 P.M., via personal vehicle accompanied by his/her daughter and other family. His/her daughter provided the resident's medication list and staff welcomed the resident back. He/she showed no signs of pain, no skin changes no added concerns. The nurse obtained his/her vital signs. Assessments were in progress, the nurse made the resident's physician aware of the resident's re-admission and management. Review of the resident's Medical Record showed there was no documentation showing the facility staff explained the bed hold procedure or provided the resident with a bed hold form upon his/her discharge to the hospital. There was no documentation showing the bed hold form was provided to the resident's responsible party upon the resident's hospitalization. 3. Review of Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including bladder cancer, kidney failure, urinary track infection, high blood pressure, muscle weakness, pain and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Review of the resident's Bed Hold Form dated 1/17/23, showed the resident elected to hold his/her bed should he/she be discharged from the facility. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with minimal cognitive impairment. -Needed limited assistance with toileting and one person assistance with bathing, but was independent with transfers, mobility, dressing, hygiene, and eating. Review of the resident's MDS Record showed the resident discharged from the facility, on 5/12/23, to the hospital and re-entered the facility on 5/17/23. Review of the resident's Nursing Notes showed: -On 5/12/23 the resident's family stated the edema (fluid in the tissues) had been going on for too long and requested that the resident be sent to the hospital. The nurse left notification for the physician and the resident left to go to the hospital. -On 5/13/23 the emergency room nurse called and reported this resident was admitted to the hospital for a blood clot, and the final report was pending. They administered medication to treat it and the resident's family was at his/her bedside. -On 5/18/23 the resident was readmitted to the facility on the day shift. The resident denied pain, and his/her vital signs were within normal limits. The resident has been resting with his/her eyes closed, call light within reach as well as personal items on bedside table. Continue to monitor during the rest of this shift. -There was no documentation showing the nurse notified the resident or family of the bed hold procedure or that the bed hold form was provided and signed by the resident or family prior to discharging to the hospital. Review of the resident's MDS Record showed the resident discharged from the facility, on 5/26/23, to the hospital and re-entered the facility on 5/31/23. Review of the resident's Social Services Progress Note dated 6/1/23, showed: -The resident was in the hospital from [DATE] to 5/31/23. -The resident was readmitted to the facility on [DATE] with a diagnosis of Hematuria (the presence of blood in the urine). -The Social Worker would continue to follow the resident and provide assistance where needed. Social Service to follow and assist as needs arise. Review of the resident's Medical Record showed there was no documentation showing the facility staff provided the resident with the bed hold form or explained the procedure to the resident or family/responsible party prior to or upon discharge to the hospital. 4. During an interview on 6/28/23 at 2:26 P.M., the DON said: -All residents are asked to sign the Bed Hold Agreement upon admission. -Since Resident #3 and #7 were both private pay, he/she did not think that they had to provide the bed hold form upon hospitalization for residents who were private pay. -They only provided the bed hold form upon hospitalization with residents who were insured through Medicaid/Medicare. During an interview on 6/28/23 at 2:58 P.M., the Administrator said: -They have all residents sign the Bed Hold Agreement upon admission. -Residents #3 and #7 were both in certified and licensed beds even though they were private pay. -Residents who were private pay did not receive a bed hold form for signature upon each hospitalization, but they would hold the resident's bed. -For those residents on Medicaid/Medicare, the nurses were supposed to complete the bed hold form and get the resident or responsible party's signature upon sending the resident out to the hospital. The nurse completing the form should make a copy and send the original with the resident to the hospital. -Often the family was notified of the resident's hospitalization by phone, but there should be a copy of the bed hold form in the resident's medical record. During an interview on 6/30/23 at 12:55 P.M., Registered Nurse (RN) C said: -When they send a resident to the hospital, the nurse had the bed hold form that they were supposed to explain to the resident and responsible party and complete. -They were supposed to give the bed hold form to the resident or responsible party to sign and they were to send it with the resident to the hospital. -If the resident was unable to sign, and the responsible party was unavailable at the time, they would notify the responsible party by phone. -They did not usually keep a copy of the signed bed hold form for their records. During an interview on 6/30/23 at 1:18 P.M., the DON said: -They had not been completing bed holds correctly. -They were developing a new process for completing the bed hold forms. -Social Services would ensure the bed hold form was signed by the resident or responsible party. -The nursing staff would issue the bed hold form upon hospitalization if it was an emergent situation. They would make a nursing note and make a copy of the bed hold form so they could have it for their records. -Social Services would complete the follow up (notifying the responsible party) or getting the signatures to acknowledge the form was completed with each hospitalization for all residents who were sent to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain hot foods at or close to 120 ºF (degrees Fahrenheit) for two sampled residents (Residents #35 and #43) who received room trays on 6/29/23. This practice potentially affected at least four residents who received room trays on that date. The facility census was 80 residents. 1. Review of Resident #43's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 5/24/23, showed the resident had moderate cognitive impairment. During an interview on 6/29/23 at 8:58 A.M., Certified Nursing Assistant (CNA) A said he/she worked 3 to 4 days per week and had not seen anyone from the dietary department go out to the hallways to measure the food temperatures. Observation on 6/29/23 at 9:12 A.M., showed: -A room tray was delivered to the nurse's station for the resident. -At 9:17 A.M. CNA A took the resident's tray to his/her room. Observation on 6/29/23 at 9:18 A.M during a temperature check of the hot foods on the resident's tray showed: -The eggs were 110.4 ºF -The sausage was 108.2 ºF During an interview on 6/29/23 at 9:20 A.M., the resident said: -He/she did not like his/her food cold. -No dietary staff had come and measured the temperature of food. -He/she always got his/her food after 9:00 A.M. 2. Review of Resident #35's quarterly MDS dated [DATE] showed the resident was cognitively intact. Observation on 6/29/23 at 9:12 A.M., showed: -A room tray was delivered to the nurse's station for the resident. -At 9:14 A.M., CNA A took the resident's tray to his/her room. During an interview on 6/29/23 at 9:24 A.M., the resident said: -The food had not been very good recently. -Sometimes the food got cold. -He/she said his/her food was cold that day. 3. During an interview on 6/29/23 at 11:07 A.M., the Assistant Director of Dining Services said at that time, there was not a process in place to test the food temperatures of room trays. During an interview on 6/30/23 at 9:35 A.M., the Registered Dietitian (RD) said the food should be palatable when it got to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, the facility failed to do or maintain the following area in a clean, sanitary or comfortable manner: maintain the ceiling vents in the employee breakroom, free of a buildup of dust; ensure the screen over the outdoor vent in the laundry room was completely secured to the wall to prevent the entrance of pests; to maintain the commode seat in resident room [ROOM NUMBER], without any indentations; to ensure there was negative air flow in the shower rooms and the restrooms of the resident rooms on the 600 Hall; to maintain the ceiling vent without a heavy buildup of dust in the 800 Hall shower room; and to maintain the [NAME] Bridge kitchenette at a comfortable temperature during the breakfast meal preparation on 6/29/23. This practice affected no-resident areas (the employee breakroom and the [NAME] Bridge Kitchenette) and at least 4 residents on the 600 Hall. The facility census was 80 residents. 1. Observation on 6/27/23 at 10:59 A.M., with Maintenance Worker B showed a heavy buildup of dust on three ceiling vents in the employee breakroom. During an interview on 6/27/23 at 11:02 A.M., Maintenance Worker B said he/she did not know the last time the ceiling vents were cleaned. 2. Observation on 6/27/23 at 11:55 A.M., with Maintenance Worker B showed a 3 and ¼ inch (in.) gap between the wall and the screen over the outdoor vent, which could potentially let pests into the laundry area. During an interview on 6/27/23 at 11:58 A.M., the Housekeeping Supervisor said he/she had not noticed that gap before. During an interview on 6/27/23 at 11:59 A.M., Maintenance Worker B said he/she could repair that screen to be securely attached to the wall. 3. Observation on 6/27/23 at 1:45 P.M., with Maintenance Worker B showed the commode seat in the restroom of resident room [ROOM NUMBER], with two indentations, which caused the commode seat to not be easily cleanable. During an interview on 6/27/23 at 1:47 P.M., Maintenance Worker B said the commode seat needed to be changed. 4. Observation on 6/28/23 from 8:54 A.M. through 9:21 A.M., with Maintenance Worker B showed the absence of negative air flow from the shower room and resident rooms 601, 606 and 605, as evidenced by the negative air flow vents not being able to provide suction to a tissue paper that was held to those vents. 5. Observation on 6/28/23 a 10:08 A.M., with Maintenance Worker B showed a heavy buildup of dust in and on the ceiling vent in the 800 Hall shower room. During an interview on 6/28/223 at 10:09 A.M., Maintenance Worker B said he/she needed to clean that shower vent. 6. Observation on 6/29/23 at 7:59 A.M., during the breakfast preparation showed: -The ambient air temperature of the kitchenette was 93.3 ºF (degrees Fahrenheit). -Note: The temperature was taken some distance away from the steam table and appliances. Observation on 6/29/23 at 10:15 A.M., after the breakfast preparation showed; -The ambient air temperature of the kitchenette without any appliances operating was 90.9ºF. -Note: The temperature was taken some distance away from the steam table and appliances. During an interview on 6/29/23 at 10:11 A.M. Maintenance Person B said they may have to install another vent in the ACC kitchenette. During an interview on 6/29/23 at 10:13 A.M., the Assistant Dining Services Director, said opening another vent in the past had not been discussed. During an interview on 7/3/23 at 10:16 AM., the Maintenance Director said the motor of the vent which assists in drawing out the hot air out of the kitchenette, was clogged with vegetative matter including seeds and leaves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to place the date on the tray of when the turkey breasts and chicken pieces were taken from the freezer for defrosting; to remove encrusted deposits of burnt-on debris from the stove top; to refrigerate items (dessert toppings, steak sauce, grape jelly); to protect several glasses of juice and plates of apple crisp from a dusty fan in the [NAME] Bridge dining room; to maintain the fans the [NAME] Bridge Kitchenette free from a heavy buildup of dust; failed to measure the temperature of non-pasteurized eggs before they were placed on a plate for service; and to remove debris from the nozzles of the spray wand of the automated dishwasher. This practice potentially affected 80 residents who ate food from the kitchen. The facility census was 80 residents. 1. Observation on 6/26/23 at 8:52 A.M., during the initial kitchen observation showed two turkey breasts and a bin of frozen chicken pieces were taken from the freezer and did not have a date that showed when they were taken from the freezer for defrosting. 2. Observation on 6/29/23 from 6:13 A.M. during breakfast meal preparation showed: -The same two packages of turkey breasts which were taken from the freezer with no date, were taken from the freezer for defrosting. -The presence of encrusted deposits on the stove top. -Open containers of dessert topping, steak sauce and beef base, which were not refrigerated even though label stated refrigerate after opening. -The presence of debris in the nozzles of the spray wand of the automated dishwasher. Observation on 6/29/23 at 6:46 A.M. showed: -Open steak sauce and beef base not refrigerated after opening even though label states -A fan with a heavy buildup of dust that was on and blowing towards the steam table in the [NAME] Bridge kitchenette. -A wall mounted fan with a heavy buildup of dust that was on and blowing towards a table with several glasses of juice and water and containers of apple crisps which were not covered in the [NAME] Bridge dining room. -An open container of grape jelly in the [NAME] Bridge kitchenette which was not refrigerated, even though the label stated refrigerate after opening. Observation on 6/29/23 in the main kitchen showed Dietary [NAME] (DC) B cooked a non-pasteurized egg and failed to check the temperature of the egg before placing it on a plate for service at 8:16 A.M., and again at 8:24 A.M. During interviews on 6/29/23, the following was said: -At 7:43 A.M., Dining Room Server A said he/she did not even notice the fan in the [NAME] Bridge was dusty before he/she was asked about the fan. -At 10:04 A.M., Housekeeper B said he/she started employment at the facility about 1 month ago and in the month he/she had worked at the facility, he/she had not cleaned the fan in the [NAME] Bridge dining room. -At 10:05 A.M., Housekeeper C said it had been about two weeks since he/she cleaned the fan in the [NAME] Bridge dining room. -At 10:06 A.M., the Assistant Director of Dining Services said they have been asking housekeeping to clean the fans because dietary staff get accused of breaking the fans. During interviews about the food service on 6/29/23 from 10:12 A.M. through 10:29 A.M., the Assistant Dining services Director said: -At 10:12 A.M., he/she expected the staff to follow the label recommendations on the containers of condiments. -At 10:20 A.M. he/she understood why the dietary staff needed to place a pull date on the food from the freezer. -At 10:23 A.M., the night shift dietary staff should drain and clean the dishwasher and that cleaning should include removing all the nozzles. -At 10:25 A.M. he/she had been working with the vendors to obtain pasteurized eggs because he/she understood that at times, the temperature of the eggs may not be measured after they were cooked. -At 10:28 A.M., he/she said the stove top grates should be cleaned weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to comply with Federal, State and Local Laws and Professional Standards by allowing one graduate practical nurse (GPN) A to pass medications without an approval letter from the Section for Long Term Care Regulation (SLCR) Registry and Review Unit. The facility had one graduate nurse who did not have the required letter of approval or had a current Certified Medication Technician (CMT) certificate. The facility census was 83 residents. On [DATE] the Administrator was notified of the past noncompliance. On [DATE] the facility administration was notified of the incident and the investigation was started. GPN A was suspended on [DATE]. Education was provided to the administrative and human resources staff on staff qualifications for employment. The deficiency was corrected on [DATE]. Record review of the facility's Licensed Practical Nurse (LPN) job description dated February 2015, showed: -Anyone hires in the role must possess an LPN license. -Provide care to residents in accordance with physician orders, recognized standards of practice and established company policies and procedures. -Monitors residents within state licensure regulations; supervises and directs nursing assistants where allowed by state licensure regulations. -Obtains and administers medication and treatments as prescribed by physician. -Documents and reviews medication and treatment sheets for accuracy and compliance with physician orders, professional standards, federal and state regulations and company policy. 1. Record review of the facility employee file showed: -GPN A had a hire dated of [DATE]. -Last day worked was [DATE]. -Policy violation and unsatisfactory performance. -Did not pass his/her nursing licensing boards and did not notify the facility. During an interview on [DATE] at 9:26 A.M., the Assistant Director of Nursing (ADON) said: -New GPNs had 90 days to take the nursing licensing boards. -He/she heard through the rumor mill that GPN A had not passed his/her nursing licensing boards. -GPN A was pulled from the schedule immediately. -GPN A said he/she did not pass the nursing licensing boards and received a letter on [DATE] stating this fact. -GPN A mainly passed medications when on his/her shift. -The facility had never hired a GPN and will not hire a GPN ever again. -The facility failed to ask GPN A if he/she had passed his/her nursing licensing boards. -GPN A was terminated on [DATE]. During an interview on [DATE] at 10:02 A.M., the Administrator said: -This was the first and last time the facility hired a GPN. -The facility does have several Certified Nursing Assistant's (CNA) in nursing school but they will continue to work as CNA's until they can show proof of having passed their nursing licensing boards. -Then the CNA's will be switched over to the nurse's schedule. -This GPN did not work at the facility before being hired as a GPN. -The facility put together a spread sheet with all of the CNAs in nursing school and are keeping track of when the CNAs finish nursing school and the date the CNAs are taking the nursing licensing boards. During an interview on [DATE] at 9:17 A.M., GPN A said: -He/she started working at the facility in June of 2022. -Took his/her nursing licensure boards on [DATE]. -Received a letter stating he/she did not pass the nursing licensing boards for his/her LPN license on [DATE]. -He/she did not tell the facility that he/she failed and kept working. -The facility was so short staffed he/she thought he/she was helping the facility by continuing to work. -The facility kept putting him/her on the schedule to work. -He/she takes full accountability for his/her wrong doings. -He/she always worked under another nurse because he/she was new and had a lot to learn as a nurse. -He/she did pass medications while working at the facility. -He/she was just an extra body on the floor. -Had worked as a CNA for 10 years before going to nursing school. -His/her CNA certificate had expired while he/she was in nursing school. -He/she did not have a CMT certificate to pass medications. -His/her CNA certificate has been reinstated at this time. -He/she planed on retaking the nursing licensure boards again. MO00209885

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a coordination of care with hospice (end of life care) for one sampled resident (Resident #31) out of 12 sampled residents. The facility census was 84 residents. 1. Record review of Resident #31's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Anaplastic large cell lymphoma (a cancer of the lymph system, part of our immune system). -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behavioral disturbances. Record review of the resident's Order Summary Report (OSR) showed on 11/24/20 to admit to hospice services for a diagnosis of senile degeneration (mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age). Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/27/20 showed the resident: -Was severely cognitively impaired. -Required the extensive assistance of staff for transfers, personal hygiene, and dressing. Was incontinent of bowel and bladder. -Was on hospice services. Record review of the resident's Care Plan dated 11/27/20 showed: -The resident's family had requested hospice services due to the resident's health status and senile degeneration. -The staff needed to assist the resident with transfers, dressing, grooming, turning and repositioning as needed. -The staff needed to monitor for pain or discomfort, provide meal assistance, and provide incontinence care as needed. -The care plan did not contain a coordination of care of hospice services. During an interview on 10/27/21 at 9:35 A.M. Licensed Practical Nurse (LPN) J said: -He/she could not locate the hospice book for the resident. -He/she would try to locate the hospice book. During an interview on 10/27/21 at 9:43 A.M. LPN J said: -He/she contacted hospice services. -He/she was told there might not be a hospice book for this resident. -The hospice director just called back and stated he/she would put a book together and bring it over. -He/she did not know if the resident was seen by the chaplain or social services with hospice. -The nurse came weekly and he/she would ask if an aide was coming that week. -There was no coordinated hospice care plan except for the facility care plan. -There was no coordinated schedule of when hospice was coming or hospice care plan to view a schedule or plan. -Hospice brought supplies in for the resident each week. -He/she did not have written documentation from hospice to show the coordinated plan of care. -He/she was not sure who monitors hospice charting but if he/she had questions he/she would talk to the MDS Coordinator A. During an interview on 10/27/21 10:12 A.M. Registered Nurse (RN) B (Unit Manager) said: -Each resident should have a hospice book on the unit if they were on hospice services. -The hospice book should contain nurses' visits, Certified Nurses Assistant (CNA) visits, spiritual needs and a coordination of the care plan. -The care plan should have the information to coordinate the care for the facility and hospice. -He/she was not sure who monitors hospice services. During an interview on 10/29/21 at 9:28 A.M. MDS Coordinator A and MDS Coordinator B said: -Hospice care plans were completed by hospice staff. -Social Services will add a hospice care plan when they go on hospice. -They update the care plan as needed. -They do not do a coordinated plan of care of which services we provided by whom hospice or the facility. -This information should be in the hospice care plan. -When admitted to hospice should provide a coordinated care plan. -He/she was unsure of who monitors for hospice book and care plan. -The nurses should have access to the coordinate plan of care and a hospice book for quality of care and quality of life needs. During an interview on 10/29/21 at 9:55 A.M. Social Worker A said: -He/she would enter a care plan for hospice upon admission to hospice services. -He/she relied on hospice to complete a hospice plan of care. -The staff follow the plan of care from hospice. -There was not an integrated plan of care. -A hospice book should contain visits from nurses, CNAs, spiritual needs and social services. -The hospice book was to ensure the staff knew how to care for the resident for quality of care and quality of life. -He/she was not aware the resident did not have a hospice book. -He/she was unsure who monitored if a hospice book was available. During an interview on 10/29/21 at 12:11 P.M. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said: -There was a hospice services collaboration of care in front of hospice chart for the staff. -Hospice book contains care collaboration form, care plan, all notes form nursing, CNA, Social Worker, Chaplain, and bath sheets. -The hospice services collaboration of care would show who did baths, visits, and would outline the whole relationship between the facility and hospice for the nurses. -The MDS coordinator would update and create a collaborated care plan. -There should be a hospice book for each resident who was on hospice services -There was not a monitoring system to ensure a hospice book and coordinated care plan were completed. A hospice policy was requested but not received from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure behaviors were documented when a resident has increased behaviors to warrant the use of a Pro Re Nata (PRN-as needed) anti-anxiety medication (a controlled substance medicine that calm and relax people with excessive anxiety, nervousness, or tension), and to document non-pharmacological interventions (any sort of intervention not directly involving a medication) prior to the administration of a PRN anti-anxiety medication for one sampled resident (Resident #12) out of 12 sampled residents. The facility census was 84 residents. Record review of the facility's policy Behavioral Assessment, Intervention and Monitoring revised 3/2018 showed: -The facility would provide residents with behavioral health services as needed to maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. -The nursing staff would identify and document the specific details about the changes of the mental status, behavior and cognitive change. -Interventions would individualized and part of the residents overall care. 1. Record review of Resident #12's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). Record review of the resident's significant change Minimum Data Set (MDS-a federally assessment tool required to be completed by staff for care planning) dated 2/5/21 showed the resident: -Was severely cognitively impaired. -Did not exhibit behaviors. Record review of the resident's Order Summary Report (OSR) showed the following physician's orders: -8/5/21: Monitor for behaviors of delusions every shift. -8/24/21 Monitor for behaviors of restlessness every shift. Record review of the resident's Progress Notes dated 9/1/21 through 10/26/21 showed no documentation of the resident having behaviors. Record review of the resident's Psychiatric Services assessment dated [DATE] showed: -The resident had some increased confusion. -The resident was assessed and the staff were to continue the same medications. Record review of the resident's Medication Administration Record (MAR) dated September 2021 showed the resident did not have any documented behaviors. Record review of the resident's OSR showed the following physician's orders: -Dated 10/1/21: Lorazepam tablet 0.5 milligrams (mg) (an anti-anxiety medication) one tablet by mouth PRN every four hours for anxiety with a stop date of 11/30/21. -There was no documentation in the resident's medical record showing why PRN Lorazepam was ordered. Record review of the resident's MAR dated October 2021 showed: -Dated 10/1/21: Lorazepam tablet 0.5 mg, one tablet by mouth PRN every four hours for anxiety. -The resident was administered Lorazepam 0.5 mg on 10/1/21, 10/4/21, 10/6/21 and 10/21/21. -On 10/1/21, 10/4/21, 10/6/21 and 10/21/21 the staff documented the resident did not have any behaviors. -There was no documentation that showed non-pharmacological interventions were completed prior to the administration of the PRN Lorazepam. Record review of the resident's Care Plan last revised on 10/25/21 showed the resident: -Used anti-anxiety medication related to an anxiety disorder. -Needed the staff to give the medications as ordered by the physician. -Needed the staff to monitor for side effects and effectiveness of the medication. Observation on 10/25/21 at 2:12 P.M. showed the resident seated in a recliner watching a movie in the common area with no behaviors present. Observation on 10/26/21 at 1:33 P.M. showed the resident was in his/her high back wheelchair looking into a resident room but did not wander into the room. -During an interview on 10/28/21 at 8:23 A.M. Licensed Practical Nurse (LPN) J said: -If a resident had increased anxiety he/she would give a PRN anti-anxiety medication if ordered. -He/she would do one on one, redirect them, snacks, back rubs, or check to see if the resident was in pain prior to administration of a PRN anti-anxiety medication. -This was documented on the MAR by the nurse under behavior documentation and codes were put in to show the behavior and the non-pharmacological interventions that were used prior to administering the medication. -The behavioral MAR should match the administration of the PRN anti-anxiety medication. -The resident started having increased behaviors including wandering into rooms and banging on doors. -That was why the Lorazepam PRN order was added for the resident. -There was no documentation on the behavioral flow sheet that indicated the resident was having any behaviors. -The behavioral flow sheet in the MAR should reflect the increased behaviors to justify adding the PRN Lorazepam. During an interview on 10/29/21 at 12:11 P.M. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said: -The nurses were supposed to attempt non-pharmacological interventions prior to administering PRN anti-anxiety medication -The nurse should be documenting what behavior the resident had and the results of the medication in the residents' MAR. -The residents' medical record should all coincide including the behavioral flow sheets and the medication administration. -The behavioral flow sheets should reflect behaviors to justify adding a PRN anti-anxiety medication. -The behavioral flow sheets and PRN anti-anxiety medications were not being monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Out of 30 observed medication opportunities, five errors occurred resulting in an error rate of 16.67%. Facility staff crushed medications not approved for crushing for one resident (Resident #9) and to apply pressure to the corner of the eye following administration of eye drops for one resident (Resident #77). The facility census was 84 residents. Record review of ophthalmioprofessional.com, September 2013 issue Administering Eye Medication showed: - Applying light pressure on the inner canthus (the inner or outer corner of the eye, where the upper and lower lids meet) for one or two minutes while keeping the eyes closed prevents the absorption of medication systemically. -This procedure is especially useful if the resident complains about the taste of the medication, if absorption of the medication may result in harmful systemic (relating to or affecting the body as a whole) effects, or if longer corneal (the outermost layer of the eye) contact time is desired. Record review of the Instillation of Eye Drops policy revised January 2014 showed: -Gently pull the lower eyelid down. -Instruct the resident to look up. -Drop the medication into the mid lower eyelid. -Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops; instruct the resident not to blink or squeeze the eyelids shut, which forces the medication out of the eye. -No instruction to hold gentle pressure to the inner corner of the eye following instillation of eye drops when indicated by physician's order/professional reference. Record review of medlineplus.gov regarding brinzolamide ophthalmic, revised 1/15/16 and for timolol ophthalmic, revised 4/15/17 showed: -Ophthalmic Brinzolamide and timolol ophthalmic are used to treat glaucoma, a condition that increases pressure in the eye and leads to vision loss. -While tilting your head back, pull down the lower lid of your eye with your index finger to form a pocket. -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 lower eyelid. -Close your eye for two to three minutes and tip your head down as though looking at the floor; try not to blink or squeeze your eyelids. -Place a finger on the tear duct and apply gentle pressure. Record review of the facility Crushing Medications policy revised 2018 showed: -Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. -The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed, for example, long acting or enteric medications. -The Medication Administration Record (MAR) or other documentation must indicate why it was necessary to crush the medication. Record review of medlineplus.gov, revised 9/15/19 showed: -Isosorbide extended-release (long-acting) tablets and extended-release capsules are used for the management of chest pain in people who have coronary artery disease (narrowing of the blood vessels that supply blood to the heart). -Isosorbide is in a class of medications called vasodilators. It works by relaxing the blood vessels so the heart does not need to work as hard and therefore does not need as much oxygen. -Swallow the extended-release tablets or capsules whole; do not crush, chew, or divide them. Record review of Klor-Con: Uses, Dosage & Side Effects - Drugs.com updated on [DATE] showed: -Do not crush, chew, or suck on a potassium tablet or capsule. -Call your doctor if you have trouble swallowing a Klor-Con capsule or tablet. You may be able to dissolve the tablet in water, or mix the medicine from a capsule with soft food. Carefully follow your doctor's instructions. Record review of Imdur Advanced Patient Information - Drugs.com, updated Sep 23, 2021 showed: -The extended-release form of Imdur gradually releases medicine to provide its effect for 8 to 10 hours. -Swallow the extended-release tablet whole with a half glass of water. Do not split, crush, or chew it. 1. Record review of Resident #9's updated face showed: -He/she was readmitted to the facility on [DATE]. -He/she had diagnoses of atherosclerotic heart disease native coronary artery (hardening and narrowing of your arteries that supply blood to the heart) without angina pectoris (chest pain) and essential (primary) hypertension (high blood pressure). Record review of the resident's Order Summary Report (OSR) dated 10/28/2021 showed his/her physician ordered: -May crush appropriate medications/open capsules if not contraindicated and co-mingle (mix together) per resident request due to difficulty swallowing, dated 5/10/2021, dated 5/10/21. -Imdur tablet extended release (ER) 24 hour 60 milligrams (mg) (Isosorbide mononitrate ER), give 60 mg by mouth one time a day for hypertension, do not crush or chew, dated 10/8/2021. -Klor-Con M20 tablet extended release 20 milliequivalents (mEq - measure of essential minerals) (potassium chloride ER) give 20 mEq by mouth in the morning for Lasix (diuretic/water pill) use, dated 11/20/2019. -Lasix tablet 40 mg (furosemide (water pill) by mouth in the morning for edema (swelling caused by fluid buildup in the body), dated 11/20/2019. -Tamsulosin HCL (a medication that relaxes the muscles in the bladder so that urine can flow easily) 0.4 mg, give one by mouth one time a day related to urinary frequency, dated 3/1/2015. Observation on 10/27/21 at 9:44 A.M. showed: -Licensed Practical Nurse (LPN) K crushed the resident's medications including his/her Imdur ER 60 mg, Klor-Con M20, and Tamsulosin HCL and mixed the medications with apple sauce. -He/she then administered the medications to the resident. During an interview on 10/27/21 at 11:41 A.M. LPN K checked drug information on his/her smart phone and said: -Imdur ER could not be crushed. -Tamsulosin HCL could not be crushed. -Klor-Con extended release 20 could not be crushed. -He/she was an agency nurse on contract with the facility; not at this facility but at other facilities he/she had been told he/she could crush Klor-Con ER. 2. Record review of Resident #77's Face Sheet showed: -He/she was admitted to the facility on [DATE]. -He/she had a diagnosis of unspecified glaucoma. Record review of the resident's OSR dated 10/28/2021 showed his/her physician ordered: -Brinzolamide Suspension 1%, instill one drop in both eyes two times a day for dry eyes (Note: this medication is used to treat glaucoma). -Timolol Hemihydrate Solution 0.5%, one drop in both eyes two times a day for dry eyes (Note: this medication is used to treat glaucoma). Observation on 10/28/21 at 8:28 A.M. showed: -LPN L instilled (put in) one drop of Brinzolamide Suspension 1 % in the resident's right eye and one drop in the resident's left eye. -LPN L did not apply pressure to the inner corner of the resident's left or right eye following instillation of his/her Brinzolamide Suspension 1 %. -After waiting five minutes between different eye drops, LPN L instilled one drop of Timolol Hemihydrate Solution 0.5% in the resident's right eye and one drop in the resident's left eye. - LPN L did not apply pressure to the inner corner of the resident's left or right eye following instillation of his/her Timolol Hemihydrate Solution 0.5%. During an interview on 10/28/21 at 11:00 A.M. LPN L said: -He/she did not apply pressure to the inner corner of the resident's eyes following instillation of the resident's eye drops. -He/she had never heard to apply pressure to the inner corner of the eyes for one to two minutes following instillation of certain eye drops, including eye drops for glaucoma. 3. During an interview on 10/29/21 12:18 P.M., the Director of Nursing (DON) said: -He/she expected staff to not crush medications that the manufacturer said not to crush or were on the Do Not Crush List (a professional reference list) or that were extended release medications. -He/she expected that for residents with physician's orders to crush medications, the physician's orders would identify which medications could not be crushed by a notation of do not crush. -He/she expected staff to apply gentle pressure to the inner corner of the resident's eye for one to two minutes following instillation of eye drops given for glaucoma.

Based on interview and record review, the facility failed to ensure narcotic counts were completed and signed by two staff each shift for five medication carts and three medication rooms. The facility census was 84 residents. Record review of the facility's Controlled Substance policy dated 4/2019 showed: -Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. -Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. -The Director of Nursing (DON) investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the administrator. 1. Record review of the 100 and 200 hall medication room Eight Hour Verification of Controlled Substances Count showed: -One sheet was used for both the 100 and 200 hall medication room narcotic storage from 8/1/21 - 9/11/21. -The narcotic count record dated 8/1/21 - 8/21/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 28 out of 118 opportunities. -The narcotic count record dated 8/21/21 (night shift) - 9/11/21 (morning shift) showed two staff did not sign the on-coming or off going narcotic count or the same staff signed as both the on-coming and off-going nurse 28 out of 116 opportunities. -The narcotic count record for for the 100 hall medication room dated 9/11/21-9/30/21 showed staff did not sign the on-coming or off-going narcotic count 15 out of 60 opportunities. -The narcotic count record for for the 100 hall medication room dated October 2021 showed staff did not sign the on-coming or off-going narcotic count 39 out of 163 opportunities. -The narcotic count record dated for the 200 hall medication room dated 9/11/21 - 9/30/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 16 out of 110 opportunities. -The narcotic count record dated for the 200 hall medication room dated 10/1/21 - 10/28/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 16 out of 110 opportunities. Record review of the 100 hall medication cart Eight Hour Verification of Controlled Substances Count showed: -The narcotic count record dated 8/1/21 - 8/21/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 44 out of 120 opportunities. -The narcotic count record dated 8/22/21 - 9/9/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 38 out of 116 opportunities. -The narcotic count record for September 2021 showed staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 51 out of 118 opportunities. -The narcotic count record for October 2021 showed staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 17 out of 169 opportunities Record review of the 200 hall medication cart Eight Hour Verification of Controlled Substances Count showed: -The narcotic count record dated 8/1/21 - 8/20/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse nine out of 110 opportunities. -The narcotic count record dated 8/21/21 - 9/9/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 33 out of 110 opportunities. --NOTE: 8/30/21 was not documented on this count sheet, but was on the count sheet for the following month. -The narcotic count record dated 8/30/21 - 9/28/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 28 out of 120 opportunities. -The narcotic count record dated 9/29/21 - 10/18/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 41 out of 122 opportunities. -The narcotic count record dated 10/19/21 - 10/29/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse five out of 61 opportunities. Record review of the 800 hall medication cart Eight Hour Verification of Controlled Substances Count showed: -The narcotic count record dated 8/2/21 - 8/21/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse seven out of 120 opportunities. -The narcotic count record dated 8/22/21 - 9/11/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse three out of 126 opportunities. --NOTE: The narcotic count sheet showed day and evening shift count on 9/10/21, then the next entry was night shift on 9/11/21. -The narcotic count record dated 9/10/21 - 9/29/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 18 out of 120 opportunities. --NOTE: The narcotic count sheet showed the day, evening shift count on 9/10/21 and the night shift narcotic count on 9/11/21. The signatures were not the same for those shifts as those on the previous count sheet. These shifts were counted and signed off on two narcotic count records. -The narcotic count record dated 9/30/21 - 10/19/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 19 out of 120 opportunities. -The narcotic count record dated 10/20/21 - 10/28/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse zero out of 50 opportunities. Record review of the 800 hall medication room Eight Hour Verification of Controlled Substances Count showed: -The narcotic count record dated 8/1/21 - 8/20/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse three out of 120 opportunities. -The narcotic count record dated 8/21/21 - 9/9/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse six out of 120 opportunities. -The narcotic count record dated 9/10/21 - 9/30/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 13 out of 120 opportunities. --A narcotic count record for 10/1/21 - 10/28/21 was requested but not received at the time of exit. Record review of the 800 hall Rehab Medication Room/Liquids Eight Hour Verification of Controlled Substances Count showed: -The narcotic count record dated 8/1/21 - 8/20/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 17 out of 120 opportunities. -The narcotic count record dated 8/21/21 - 9/9/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 13 out of 120 opportunities. -The narcotic count record dated 9/10/21 - 9/29/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 25 out of 120 opportunities. -The narcotic count record dated 9/30/21 - 10/20/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 35 out of 126 opportunities. -The narcotic count record dated 10/20/21 - 10/28/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 14 out of 50 opportunities. Record review of the 700 medication cart Eight Hour Verification of Controlled Substance Count showed: -The narcotic count record dated 10/18/21- 10/29/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse four out of 68 opportunities and was pre-signed for the off-going shift on the evening of 10/29/21. -Narcotic count records for 8/1/21 - 10/17/21 were requested but not received at the time of exit. Record review of the Eight Hour Verification of Controlled Substance Count marked as Rehab medication room for the 800 hall showed: -The narcotic count record dated 8/26/21 - 9/1/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse three out of 42 opportunities. -The narcotic count record dated 9/2/21 - 9/8/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse zero out of 42 opportunities. -The narcotic count record dated 9/9/21 - 9/15/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse one out of 42 opportunities. -Narcotic count records for 8/1/21 - 8/26/21 and from 9/16/21 - 10/28/21 were requested but not received at the time of exit. Record review of the Eight Hour Verification of Controlled Substance Count marked as Rehab showed: -The narcotic count record dated 8/11/21 - 8/21/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse five out of 33 opportunities. A staff member signed three additional times with no date or time the count was completed at the bottom of the form. -The narcotic count record dated 8/22/21 - 9/9/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 13 out of 114 opportunities. 8/25/21 was signed written in two times and signed by different staff on all three shifts and the dates and times between 8/28/21 - 8/30/21 were either not written or were duplicated making it difficult to determine if a count had occurred each shift on those dates. -Narcotic count records for 8/1/21 - 8/11/21 and 9/10/21 - 10/28/21 were requested but not received at the time of exit. Record review of the Eight Hour Verification of Controlled Substance Count marked as Rehab showed: -The narcotic count record dated 8/1/21- 8/11/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse eight out of 66 opportunities. -The narcotic count record dated 8/12/21 - 9/7/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 53 out of 162 opportunities. -Narcotic count records for 9/8/21 - 10/28/21 were requested but not received at the time of exit. Record review of the Eight Hour Verification of Controlled Substance Count marked as Rehab showed: -The narcotic count record dated 8/1/21- 8/19/21 showed two staff did not sign the on-coming or off-going narcotic count or the same nurse signed as both the on-coming and off-going nurse 17 out of 114 opportunities. -Narcotic count records for 8/20/21 - 10/28/21 were requested but not received at the time of exit. 2. During an interview on 10/27/21 at 9:00 A.M., Licensed Practical Nurse (LPN) G said: -The 100 and 200 halls recently changed the narcotic count sheet to one that has three columns, one for each shift when they come on shift and go off shift. -For the new narcotic count sheet, which started in mid-September, the night shift signs in one column when they count as the on-coming and when they count as the off-going nurse, then the day shift will sign in one column when they count as the on-coming and when they count as the off-going nurse, then the evening shift has a column where they will sign when they count as the on-coming and when they count as the off-going nurse. -Staff are supposed to count the narcotics in the medication room and on each medication cart at the beginning and at the end of the shift and sign the Controlled Substance Count log for each area. During an interview on 10/27/21 at 10:35 A.M., LPN B said staff were supposed to count the narcotics each shift and sign the narcotic count sheet when it was completed. During an interview on 10/29/21 at 11:00 A.M., LPN J said staff were supposed to count the narcotics each shift and sign the narcotic count sheet when it was completed. During an interview on 10/29/21 at 12:15 P.M., the DON and Assistant Director of Nursing (ADON) said: -They were having a difficult time finding all of the narcotic sheets from all of the medication carts and medication rooms due to how they were filed. -They provided all of the sheets that they could find, however, with the way the sheets were marked it was difficult to tell which unit they came from or if they were for the medication cart or medication rooms. They think they have identified where they belong based on signatures of staff, but it is unclear if all the records have been accounted for. -They expected staff to count at the beginning and end of each shift and to sign the narcotic count log to show the count was correct. -Some of the days where staff may have signed as both the on-coming and as the off-going may have been if the staff worked a double shift. -No one was auditing the narcotic count sheets to make sure they were signed each day.

Based on observation, interview, and record review, the facility failed to ensure multi-dose medications were dated when opened, including insulin pens and liquid narcotics. The facility census was 84 residents. Record review of the facility's Medication Storage Guidance dated April 2019 located in a medication room showed: -Multidose vials for injection (not specifically mentioned elsewhere): Date when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations. -Tuberculin: Date when opened and discard unused portion after 30 days. -Ativan oral solution: If kept in the refrigerator, date when opened and discard 90 days after opening. -Novolog: good for 28 days after opening. -Lantus: good for 28 days after opening. Record review of the Storage of Medications policy dated November 2020 showed: -The nursing staff is responsible for maintaining medication storage areas in a clean, safe, and sanitary manner. -Discontinued, outdated, or deteriorated drugs are returned to the dispensing pharmacy or destroyed. 1. Observation on 10/27/21 at 8:41 A.M. of the 800 hall medication cart showed: -Two opened, undated Lantus (a long acting insulin) pens. -One opened, undated Novolog (a fast acting insulin) pen. Observation on 10/27/21 at 8:51 A.M. of the 800 hall medication room showed one opened, undated bottle of Ativan Intensol (an anti-anxiety medication). Observation on 10/27/21 at 10:18 A.M. of the 100-200 hall medication room showed: -One opened undated tuberculin (a medication used in the diagnosis of tuberculosis) vial. -Two opened, undated bottles of Ativan. -Three opened, undated bottle of Morphine (a narcotic pain medication). Observation on 10/28/21 at 6:45 A.M. of the 100 hall medication cart showed one opened, undated Lantus insulin pen. 2. During an interview on 10/27/21 at 8:45 A.M., Agency Licensed Practical Nurse (LPN) K said: -He/she thought medications, including insulin pens, should have the date the medication was opened on the bottle, vial, or pen. -It looked as though this facility may date the bag or box the medication was stored in instead of on the medication bottle, vial, or pen. -The three insulin pens in his/her medication cart was not dated when they were opened. -He/she would check the medication cart to ensure medications were dated after he/she completed the morning medication pass. During an interview on 10/27/21 at 8:52 A.M., Registered Nurse (RN) B said: -The Ativan did not have a date it was opened on the bottle or the box. -He/she looked at the controlled medication log for the Ativan and determined it must have been opened on 9/9/21 since that was the first date it was signed out as being used on the controlled medication log. -He/she then wrote the date of 9/9/21 on the Ativan bottle to show that was the date it was first opened and accessed. -Medications should have the date they were opened written on the bottle or vial. During an interview on 10/27/21 at 10:25 A.M., LPN G said: -The tuberculin should have been dated when it was opened. -Medications that have been opened are good until the expiration date on the vial or box. -He/she was not aware of medications having an expiration date after they have been opened. During an interview on 10/27/21 at 10:35 A.M., LPN B said: -The Ativan and Morphine did not have dates on them when they were opened. -He/she would look at the controlled substance log to find the dates the medications were opened. -He/she did not date bottles or vials of medications when they were opened. -He/she was not aware of medications having an expiration date after they have been opened. During an interview on 10/29/21 at 12:12 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said: -He/she expected staff to date the bottle or vial and the bag or box the medication was stored in with the date the medication was opened. -He/she would expect staff to discard and not use any medication that did not have the date the medication was opened written on the bottle or vial. -It was not appropriate to use the date on the controlled substance log as the date the medication was opened. -Whoever opened the medication should date it. -The pharmacy consultant and unit managers audit the medication rooms and medication carts monthly.