**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident was free from physical abuse when on 5/29/25 Resident #2 touched Resident #1 on his/her shoulder and struck Resident #1 on the buttocks twice, causing Resident #1 to feel violated and pain to his/her buttocks out of 12 sampled residents. The facility census was 79 residents. On 5/7/25 the Administrator was notified of the failure and immediately began an investigation, the residents were separated to ensure safety and law enforcement was contacted. Upon completion of the investigation it was determined the interaction was considered abuse. Training was completed immediately for 100% of all staff on abuse and neglect prior to being allowed to work and completed by 5/30/25. Supervision was increased and Resident #2 was set for alcohol rehabilitation. Review of the facility Abuse and Neglect Policy dated 6/12/24 showed: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. -Physical Abuse is purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. -Physical abuse includes, but it not limited to, hitting, slapping, punching, biting, and kicking. 1. Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses including borderline intellectual functioning (a specific IQ margin between the formal diagnosis of intellectual disability (ID) and average intellectual function) and paranoid schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations). Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 5/10/25 showed the resident was cognitively intact. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including alcohol abuse and adjustment disorder (a mental and behavioral disorder defined by a maladaptive response to a psychosocial stressor). Review of the resident's Quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the facility investigation dated 5/29/25 showed: -Alleged sexual conduct. -On 5/29/25 during the 9:00 P.M. smoke break, Resident #2 first touched Resident #1 on the shoulder and then slapped Resident #1 on the buttocks. -Resident #1 reminded Resident #2 there was a no touch policy in place. -As the residents returned inside the building Resident #2 again struck Resident #1 on the buttocks, but with greater force. -At that time Resident #1 reported the incident to the charge nurse. -Following the incident, the residents were separated and interview individually. -Resident #1 gave a verbal and written statement that were consistent. -Resident #2 was relocated to the opposite side of the building. -Physician, administration, and law enforcement were notified. -There was a determination of abuse and a report was filed with the state. Review of Police Report dated 5/29/25 showed: -Law enforcement was contacted at approximately 9:55 P.M. to investigate assault which a resident touched another resident inappropriately. -Resident #2 was using alcohol. -Resident #1 was interviewed and confirmed the allegations of being touched. -Resident #2 was interviewed and denied having contact with Resident #1. -Resident #2 said he/she was at the gas station drinking beer at the time of the alleged incident. -Video footage of the incident was obtained and confirmed Resident #2 was in the facility during the incident. During an interview on 6/5/25 at 2:43 P.M. Resident #2 said: -He/She did not recall being in contact with Resident #1. -He/She was sure he/she was intoxicated. -If he/she was out of character, it was because he/she was intoxicated. -He/She did not recall speaking with law enforcement about the incident. During an interview on 6/5/25 at 3:03 P.M. Resident #1 said: -On 5/29/25 at about 9:00 P.M. Resident #2 touched him/her on his/her shoulder, then hit him/her on the left butt cheek with an open hand as they were walking through the doorway to go smoke. -He/She reminded Resident #2 there was a no touch policy. -On the way back inside, Resident #2 was behind him/her again and hit him/her on the right butt cheek. -The second time Resident #2 hit him/her it was harder than the first time and hurt. -He/She became angry and upset when Resident #2 hit him/her the second time. -He/She went to the charge nurse immediately to report what happened. -He/She recalled smelling alcohol on Resident #2's breath and could tell by the look on Resident #2's face that he/she was drunk. -When Resident #2 hit him/her on the buttocks it triggered a memory for him/her when he/she was sexually assaulted in a previous facility. -He/She felt is was sexual due to it being inappropriate contact. -The second smack was the most upsetting and he/she felt violated. During an interview on 6/5/25 at 4:01 P.M. the Administrator said: -There had not been any disruptions with Resident #2 when he/she was intoxicated prior to the incident with Resident #1. -Resident #2 had a history of alcohol abuse and due to the incident, the resident had been scheduled for rehabilitation for alcohol. -The incident was considered abuse because of the way Resident #1 felt. MO00254995

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, homelike environment by not sweeping and mopping the floors in the dining room, cleaning the carpet in the common area, cleaning resident rooms and bathrooms and ensuring urine odors were not present throughout the facility. The facility census was 79 residents. Review of the facility Housekeeping - Deep Cleaning Policy dated 6/29/23 showed: -Purpose was to ensure all rooms are clean. -Deep cleaning was to be completed as scheduled. -This includes complete pull-outs of furniture in rooms, wall cleaning, floor cleaning (scrubbing and waxing included), restrooms to be cleaned and disinfected, cob webs removed, beds and rails to be cleaned and free of bugs, sprinkler heads to be cleaned, light covers to be clean and free of bugs, over-bed light covers to be cleaned and free of bugs, sink clean, windows to be cleaned and ensure no spider webs, drapes and curtains to be cleaned (including privacy curtains), call lights to be clean and free from dust/dirt build-up, floors at closets and doorways are to be free from wax/dirt build up, etc. -All areas should be monitored on a daily basis and all resident living areas and non-living areas should be clean and odor free. -Daily cleaning: --Pick up all trash and put into trash can and empty. --Dust mop or sweep floor. --Submerse rag or sponge in with solution and clean surfaces beginning with touch areas on door and work clock or counter clock wise around the room. --Surfaces are to be cleaned including wall smudges, light and call light and side tables, head/foot board/side rails of bed and windows. --Clean the sink around the light fixtures and dispensers. --Clean inside and outside of the trash can. Let it air dry. Replace trash can liner. --Clean bathroom using the same cleanser/disinfectant wall smudges, lights, and call switches, and support rails. Use Honey Bowl to clean inside, outside toilet tank, seat and bowl. -Resident Room Deep Clean: --All resident rooms will be deep cleaned once monthly or more often if needed, as in the case of heavy care rooms. --All above-floor bathroom surfaces will be cleaned with a cleaner/disinfectant. --Bathroom floors will be swept and mopped and any dirt, grime or stains will be hand scrubbed with stiff brush or other equipment suitable for removing surface dirt from entire floor. --If the stain is not removable then the housekeeper will notify the maintenance department with a maintenance request form. --All furniture will be removed, cleaned behind, and upholstered furniture will be thoroughly cleaned. --Carpets will be inspected for cleaning determined by the supervisor. --Resident bed will be stripped with both frame and mattress cleaned with disinfectant cleaner. --Glass surface will be cleaned. --Necessary wall washing to remove smudges and spots will be done with disinfectant cleaner. Review of the facility job description for Environmental Services Director dated 2023 showed: -Position Purpose plans, organizes, supervises and directs all environmental service operations to ensure a clean, safe and orderly resident living environment. -The environmental services director was responsible for efficiently managing the facility's housekeeping operations and the environmental services staff. -The primary function of this position was to ensure nursing home resident enjoy a clean and orderly living environment. -Develops systems and programs for maximizing the effectiveness of the housekeeping functions. -Perform regular daily, weekly, and monthly environmental service inspections in order to ensure the facility is maintained in a safe and sanitary manner according to facility policy. -Maintains required records and reports as outlined in the policies and procedures of the environmental services department. -Consistently follows a written, current master cleaning plan for the entire facility. -Prepares and properly maintains required records, reports and evaluations. Review of the facility job description for Environmental Services Housekeeper dated 2023 showed: -Position purpose ensures the provision of a clean environment for residents and staff, providing high quality services and high standards of cleanliness, ensuring compliance with infection control procedures. -Carries out all cleaning duties as directed by the environmental services director according to required department policies and procedures. -Ensures that daily and deep cleaning schedules are adhered to. -Ensures all necessary documentation is completed daily. -Essential functions: --Dusts furniture, woodwork, equipment and dust-mops floors. --Polishes and cleans fixtures in rooms and bathrooms. --Wet-mops rooms, halls and other areas; shampoos rugs and furniture. --Cleans vents, fan fixates, top of windows, door frames and other high surfaces. --Gathers and disposes of trash and waste materials using specified bags and containers. --Performs terminal cleaning procedures of resident rooms and prepares rooms for new admissions. --Cleans and disinfects all fixtures, floors, mirrors, windows, doors, and walls of bathrooms. Review of undated Housekeeper Job Description showed: -The primary purpose of the position was to perform the day-to-day activities of the housekeeping department in accordance with current, federal, state and local standards, guidelines, and regulations governing the facility, and may be directed by the environmental services director and/or the administrator, to assure the facility was maintained in a clean, safe and comfortable manner. -Duties and Responsibilities: --Perform day-to-day housekeeping functions as assigned. --Clean and polish furnishings, fixtures, ledges, room heating or cooling units, etc. in resident rooms, recreational areas, etc. daily as instructed. --Clean, wash, sanitize, and/or polish bathroom fixtures, ensure water marks are removed. --Clean windows and mirrors in resident rooms, recreational areas, bathrooms, and entrance or exit ways. --Clean floors, to include sweeping, dusting, damp or wet mopping, stripping, waxing, buffing, disinfecting, etc. --Clean carpets, to include vacuuming, shampooing, deodorizing and disinfecting. --Clean walls and ceilings by washing, wiping, dusting, spot cleaning, disinfecting, deodorizing, etc. --Remove dirt, dust, grease, film, etc. from surfaces using proper cleaning or disinfecting solutions. --Clean hallways, stairways and elevators. --Ensure that work and cleaning schedules are followed as closely as practical. Review of Environmental Services Cleaning Procedures for Common Items dated 2022 showed: -Horizontal surfaces such as over bed tables, work counters, beds, mattresses, bedrails and call bells. --Cleaning on a regular basis. --When items are soiled. --Between residents and after discharge. --Clean spills up promptly. -Walls, blinds and curtains. --When visibly dusty or soiled. -Floors. --Clean on a regular basis. --When soiled. --Between residents and after discharge. --Damp mopping. -Carpets and upholstery. --Vacuum and shampoo according to cleaning schedule and as necessary. --Vacuum cleaners should be equipped with a HEPA filter. --Cloth chairs should be vacuumed on a regular basis. --Carpeting should be vacuumed on a regular basis. -Toilets. --Clean on a regular basis. --Clean when soiled. --Clean between resident and after discharge. 1. Review of the facility Housekeeping Daily Cleaning Assignment for 400/600 Hall dated 02/2013 showed: -7:00 A.M. Smoke residents. -7:15 A.M. to 9:00 A.M. Begin morning duties as follows: --Collect dirty laundry barrels from skilled nursing facility (SNF) and take to laundry. --Clean Activity room [ROOM NUMBER] (to also be cleaned at the end of shift). --Complete morning walk through of resident rooms on 400 hall. --Clean 600 shower room. --Clean 600 hall restroom. --Clean 601 employee break room, clean microwave daily and at the end of shift. --Complete morning walk through of resident rooms on 600 hall. --Clean front lobby area to include reception area, reception desk, time clock area and nurses station. --Clean lobby foyer to include the Assistant Director of Nursing (ADON) Office, clean game table after each meal. -9:00 A.M. to 9:15 A.M. Morning break. -9:15 A.M. to 11:30 A.M. Begin the daily total clean of the residents rooms. --When doing daily cleaning all residents' room is to be totally cleaned that would include dusting and sanitizing all areas on your assigned unit being sure that all this would include all toilets, sinks, mirrors being cleaned. --All over bed tables being cleaned and sanitized, all floors being thoroughly swept and mopped that would include under beds and items that are removable. -11:30 A.M. to 12:00 P.M. Lunch break. -12:30 P.M. to 1:30 P.M. Continue assigned duties. --Do scheduled deep clean. --Continue daily total cleaning of residents' rooms. -1:30 P.M. to 1:45 P.M. Afternoon break. -1:45 P.M. to 2:00 P.M. Smoke residents. -2:00 P.M. to 2:50 P.M. Continue daily assignments. --Finish assigned total cleans. --Complete rooms that are assigned as repeat cleans. --Tidy activity lounge, employee break room, public restroom and shower room. -2:50 P.M. to 3:00 P.M. End of shift. --Collect all wet floor signs. --Restock cart with paper and cleaning supplies. -Weekly assignments: --Thursday: Clean central supply and medical records located on 400 hall at the end of shift. --Friday: Clean employees break room refrigerator. --Saturday and Sunday: Collect all dirty laundry barrels to include rehab, sort and start laundry. --Do morning and afternoon trash run. --Clean dining rooms to include lobby game table after each meal. --Sweep and spot mop all common area floors to include all hallways and lobby areas. During an interview on 6/10/25 at 11:23 A.M. Family Member A said: -His/Her spouse was a resident in the facility. -He/She was satisfied with the overall care of his/her spouse. -His/Her only complaint was the cleanliness of the facility. -His/her spouse had several open areas to his/her arms and he/she smeared blood on the wall next to his/her bed. -The blood had not been cleaned from the wall and the resident's room was overall dirty with an odor of urine. -There were cigarette butts all over the ground of the courtyard from the smokers. -Corners of the resident's bathroom and walls do not get cleaned with visible build up. -The toilet in the resident's bathroom was filthy. Observation on 6/11/25 from 11:00 A.M. through 1:00 P.M. showed: -room [ROOM NUMBER] dust and debris on floors, bed frame and windowsill. -room [ROOM NUMBER] bathroom had no shower curtain, dirty towels on the floor and hanging from handrails. -room [ROOM NUMBER] toilet had grime around the base. -The Dining room floor was littered with food, debris, trash and spills from breakfast. -room [ROOM NUMBER] had a strong odor of urine, sticky floor, and dried blood on the wall. -Resident #5's bed was not made up with blood on the pillowcase. (Resident #5 was admitted to the hospital on [DATE] and not yet returned) -room [ROOM NUMBER] bathroom floor was brown with gray/black build up in the corners and strong urine odor. -room [ROOM NUMBER] floor was covered with dirt, trash and debris. -room [ROOM NUMBER] had urinals hanging from the trash can with cords hanging in and around the trash can. -room [ROOM NUMBER] windowsill was covered with dust. -room [ROOM NUMBER] bathroom was covered with black smudges and dark brown spots, grime at the base of the toilet, toilet bowl spotted with an unknown substance and a dark brown line, toilet seat soiled and urine in the toilet. -room [ROOM NUMBER] dirty floor and sink with trash and drinks spilled on both surfaces, and floor sticky. -room [ROOM NUMBER] toilet soiled with urine and feces. -400 hallway had dirt and debris build up in the corners and along base boards. -room [ROOM NUMBER] had cigarette butt on the floor. -500 hallway with dirt and debris in corners. -room [ROOM NUMBER] covered with black tire marks. -600 hallway with dirt, debris in corners and black build up in doorways. -room [ROOM NUMBER] trash all over the floor, old food on the floor, gnats flying around the resident and floor sticky. -room [ROOM NUMBER] floor was dirty and sticky, sink dirty. -room [ROOM NUMBER] bathroom was dirty with urine and feces around the toilet, empty toilet paper rolls on the floor, trash and soiled linens on the floor. -Front foyer carpet sticky and stained. -Entry from front foyer into dining room missing trim from carpet to flooring leaving groove filled with food and debris. -Milk on dining room floor. -The resident courtyard and smoking area was littered with cigarette butts in the grass and on the concrete walk ways. During an interview on 6/11/25 at 11:11 A.M. Licensed Practical Nurse (LPN) A said the housekeeper cleans per their normal routines. During an interview on 6/11/25 at 11:23 A.M. Certified Nursing Assistant (CNA) A said he/she felt housekeeping was doing what they can to clean in the facility. During an interview on 6/11/25 at 11:35 A.M. Certified Medication Technician (CMT) A said housekeeping tried to keep up. During an interview on 6/11/25 at 11:41 A.M. the Housekeeping Supervisor said: -He/She denied having a cleaning schedule in writing for the staff to utilize for daily and/or deep cleaning. -Staff are trained on procedures to clean rooms, lobbies and other areas. -About two months ago there was a reduction in the number of housekeepers. -The build up in the corners, along the baseboards and the doorways was a result of wax build up that was not cleaned up when the floors were waxed about three months ago. -There was no longer a floor technician position at the facility. -The dining room should be cleaned after every meal. -Ideally resident rooms were cleaned daily, unless they were short-staffed or ran out of time, then the trash should be emptied, and supplies replaced. -There were 48 resident rooms to be cleaned. -The housekeeping staff also help with residents smoke breaks. -The floor technician used to clean up the cigarette butts and empty ashtrays and disposals outside. -Staff was assigned halls to clean daily. -He/She monitored by observation if cleaning was getting done. -There was no delegation to clean the dining room, whoever gets to it first or was available, staff were encouraged to switch back and forth. -The dining room was cleaned in the evening by the dietary staff. -Activities was in the dining room on 6/11/25 and the dining room was not cleaned until just before lunch. -He/She presumed the housekeeper was on the 600 hall cleaning when he dining room was emptying. -He/She monitored/inspected throughout the facility maybe twice per week. -He/She was not sure when room [ROOM NUMBER] was cleaned and was unaware there was no shower curtain in the bathroom shower. -He/She reviewed the job description when onboarding housekeeping staff, but did not provide a copy for the staff member. During an interview on 6/11/25 at 12:25 P.M. the Housekeeper said: -He/She pulled the trash in the dining room, lobby, main entrance to the smoking area and the public bathroom. -Once he/she finished trash, then he/she would take the residents out to smoke. -When he/she cleaned resident bathrooms, he/she made sure there was toilet paper, paper towels, toilet cleaned and the floor was mopped. -He/She was not very consistent with his/her cleaning routine. -When cleaning the resident rooms, he/she cleans the mirror, sink, took out the trash, refilled the toilet paper, cleaned the toilet and mopped the floors. -He/She cleaned 55 resident rooms per day. -He/She cleaned 22 rooms prior to the interview on 6/11/25. -He/She was not able to clean all resident rooms daily. -He/She worked four to five days per week. -He/She cleaned the dining room after each meal and again before going home at the end of his/her shift. -He/She looks at the floor to know where to start cleaning rooms daily. -Deep cleaning of resident rooms is only done when a resident moves out. -Some rooms never get deep cleaned because the resident's clean the room themselves. -He/She said very rarely was someone assigned a hall to clean. -They are not able to keep up with the daily cleaning. -He/She felt the smoking breaks take up too much time at 45 minutes per smoke break. -He/She felt there needed to be someone to clean the dining room, like the floor technicians used to do. -He/She was not cleaning windowsills, baseboards or elevated surfaces as he/she was only supposed to do bathrooms. Review of Resident #10's admission Record showed the resident was admitted on [DATE] with diagnoses including muscle weakness and retention of urine. Review of Resident #10's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/22/25 showed the resident was cognitively intact. During an interview on 6/11/25 at 12:40 P.M. Resident #10 said: -He/She felt the facility cleanliness could be better on the main side, the skilled care side of the facility. -He/She did notice the main side and the dining room was sometimes filthy. Review of Resident #11's admission Record showed the resident was admitted on [DATE] with diagnoses including chronic pain syndrome and muscle weakness. Review of Resident #11's MDS dated [DATE] showed the resident was cognitively intact. During an interview on 6/11/25 at 12:43 P.M. Resident #11 said: -Housekeeping does not clean their rooms. -He/She can't even remember the housekeeper had cleaned his/her room. -His/her room has been dirty for as long as he/she could remember. Review of Resident #12's admission Record showed the resident was admitted [DATE] with diagnoses including tobacco use and type 2 diabetes mellitus with hyperglycemia. Review of Resident #12's MDS dated [DATE] showed the resident was cognitively intact. During an interview on 6/11/25 at 1:00 P.M. Resident #12 said: -Housekeeping does not come in his/her room regularly and clean. -He/She cannot remember the last time his/her room had been cleaned. During an interview on 6/11/25 at 1:26 P.M. the Administrator said: -There were no job descriptions available in the employee files for the housekeeping staff. -He/She agreed there was food, trash, debris, and spills on the dining room floor that should have been cleaned up. -He/She agreed the build up throughout the facility corners, baseboards and doorways should have been cleaned. -He/She acknowledged the cigarette butts in the courtyard should be cleaned. -He/She acknowledged the unsanitary conditions in resident rooms noted during the facility walk-through. -He/She said there was no longer a floor technician and housekeeping staff had been reduced. -He/She acknowledged the carpet needed cleaning. MO00255536

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to educate staff on how to de-escalate one sampled resident (Resident #1) with known intellectual and mental health needs per facility policy and the resident's care plan. This effected one out of three sampled residents. The facility census was 78 residents. Review of the facility's policy titled Behavioral Emergency Policy, dated 6/26/24, showed: -The purpose of the policy was to provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to correctly care for the resident in a behavioral crisis, and to ensure that the resident was not being coerced, punished, or disciplined for staff convenience. -Non-physical interventions were the first choice as an intervention unless safety issues demanded immediate physical intervention. -Care would be guided by resident's plan of care and based on the strategies taught by the Crisis Prevention Institute non-violent crisis intervention, or the current company guidance, and would help to respond to difficult behaviors in the safest and most effective way possible. Review of the facility's policy titled Behavioral Health Services Policy, dated 10/31/24, showed: -All staff, including contracted staff and volunteers, should receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. -Education should be based on the role of the staff member and resident needs identified through the facility assessment. -Facility staff would implement person-centered care approaches designed to meet the individual goals and needs of each resident, which included non-pharmacological interventions. -Examples of individualized, non-pharmacological interventions to help meet behavioral needs of all ages may include, but were not limited to: --Ensuring adequate hydration and nutrition. --Exercise. --Individualizing sleep and dining routines. --Supporting the resident through meaningful activities. --Providing support with skills related to verbal de-escalation, coping skills, and stress management. 1. Review of staff training records showed CNA A and CNA C completed training related to tips for challenging behaviors. Records showed LPN A, LPN B, and LPN D did not have documentation of training related to challenging behaviors. Record review during the abbreviated survey showed no staff in-services regarding the resident's behavioral history and direct staff training on behavioral intervention (resident triggers, redirection and intervention) occurred after the incident. Review of Resident #1's admission Record showed the resident admitted to the facility with the following diagnoses: -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Unspecified. -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats), Unspecified. -Mild Intellectual Disabilities. -Cognitive Communication Deficit. -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Recurrent, Mild. -Unspecified Intellectual Disability. Review of the Resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 3/10/25, showed: -The resident was cognitively intact. -The resident did not exhibit any behavioral symptoms during the seven day look back period. Review of the resident's care plan, dated 12/11/24, showed: -The resident was at risk for the following signs and symptoms related to his/her diagnoses of intellectual disability including difficulty communicating, difficulty in socializing with others, difficulty with problem solving or logical thinking, having problems remembering things, and the inability to connect actions with consequences with the following interventions: --Ensure his/her environment is safe. --Limit changes to his/her routine. --Provide him/her with diversional activities. --Provide positive reinforcement. --Use calm and gentle approaches with him/her. -The resident was at risk for the following signs and symptoms related to his/her diagnosis of bipolar disorder including displaying high or low emotions and an increase in the signs and symptoms of depression with the following interventions: --Be consistent. --Calmly direct him/her when he/she had inappropriate behaviors. --Staff were to not get into a power struggle with him/her. --Offer warm baths or soothing music to decrease restlessness. --Take care of any problems that were within the ability of the staff to address immediately. --Use a firm and calm approach with him/her. --Use short and clear explanations or directions with him/her. -The resident was at risk for the following signs and symptoms related to his/her diagnosis of Anxiety Disorder including cursing, hollering, and restlessness with the following interventions: --The staff were to be aware of their body stance and facial expressions when approaching the resident. --Do not argue with him/her or tell him/her that he/she was wrong when he/she was upset. --Do not get close with the resident and remember personal space. -On 5/12/24 the resident became upset with staff about being escorted back upstairs and hit a staff person, which caused a peer to intervene and pushed the resident. -The resident had a history of behavioral challenges that required protective oversight in a secure setting which included a Code [NAME] (a behavioral emergency and/or incident needing physical support and presence when an individual poses a threat to himself/herself or others) being called on the resident on 2/11/24 at 10:30 P.M. because the resident was demanding more snacks and was belligerent, yelled at staff, and made steps toward the nurse. Review of the resident's behavior note, dated 3/12/25 at 10:39 P.M., written by LPN A showed: -The resident had become very aggressive with staff due to the fact that there were no snacks during snack time. -The resident verbally assaulted LPN A and tried to attack LPN A. -The resident then turned to attack an employee who tried to diffuse the altercation. -The resident walked behind the nursing station and said, you think I won't slap you bitch. -LPN A called 911 and EMS was sent out for change in orientation. Review of an Incident Report titled Physical Aggression not Involving Head, dated 3/13/25 at 12:00 A.M., completed by LPN A showed: -He/She had copied the resident's behavior note from 3/12/25 at 10:39 P.M. into the nursing description. -The resident was unable to give a description of the incident. -The immediate action that was taken was to call 911/EMS. -The resident was not sent to the hospital. -The resident was oriented to person, place, time, and situation. -The resident did not have any injuries. -The resident had predisposing physiological factors which included agitation and anxiety. Observation of the video footage recorded of the incident, dated 3/13/25 at 12:17 A.M., showed: -The recording was one minute and 59 seconds long. -The footage took place at the nurse's station near the resident's hall. -LPN A and CNA B were sitting down in a chair in front of computers, CNA A was walking around near the nurse's station, Resident #1 is standing in front of the nurse's station speaking with LPN A, and Resident #2 is standing near the nurse's station. -Resident #1 can then be seen pointing his/her finger at LPN A and stated, anyway I want. -LPN A responded to Resident #1 by pointing his/her finger towards the resident's hall and said, get your ass down there. -Resident #1 responded to LPN A by slamming his/her hands down on the medication cart that was in front of him/her and said, get your ass gone somewhere. -Resident #1 then started to walk around the nurse's station and towards LPN A, LPN A called the resident's name, and another staff person also called out the resident's name. -CNA A then started to move towards Resident #1 by walking in front of the nurse's station. -A staff person can then be heard saying the resident's name and no, no, no, no, no, LPN A's name, no. -LPN A then got up from sitting in his/her seat. -CNA A continued to walk around the nurse's station and CNA B got up from his/her seat. -Resident #1 could then be seen getting close to LPN A and some muffled words were exchanged. -CNA C could be seen entering the frame in upper middle part of the frame. -CNA D could then be seen entering the frame at the bottom right corner. -CNA B was within arm's reach of Resident #1 and stood behind Resident #1. -CNA B then placed his/her hand between LPN A and Resident #1. -LPN A then pushed Resident #1 into CNA A in front of CNA B, CNA D, and Resident #2. -CNA C could still be seen walking towards the nurse's station. -CNA A then grabbed Resident #1 in a bear hug position from behind and started to take Resident #1 away from the nurse's station. -Resident #1 could be heard saying, get the fuck off me nigger, get the fuck off. -CNA A continued to walk with the resident in the same hold position all while LPN A, CNA B, CNA C, and CNA D watched from behind the nurse's station. -Resident #2 remained in the same spot, but could be seen watching the resident with CNA A. -Unintelligible words could be heard from the resident and other staff members. -CNA A then let go of Resident #1, but it could not be directly seen due to a column being in the way. -CNA A then started to walk backwards away from Resident #1 and a staff person could be heard saying, no. -Resident #1 then puts both of his/her fists in the air and stated, come on motherfucker, come on motherfucker, come on motherfucker, lets finish this and was stepping towards CNA A. -CNA A continued to walk backwards and away from the resident. -Once Resident #1 was within arm's reach of CNA A, CNA A reached his/her right hand up and swatted the resident's fists away from him/her. -Resident #1 then started swinging at CNA A with open hands. -CNA A responded by swinging his/her fists towards the resident, making contact with Resident #1's face. -CNA E could be seen entering the top left corner of the frame and was in direct sight of CNA A and Resident #1 when Resident #1 and CNA A were swinging at each other. -CNA A and Resident #1 naturally split apart from each other without staff intervention. -LPN A then walked towards Resident #1 and CNA A and could be heard saying something unintelligible, CNA B, CNA C, and CNA D all remained behind the nurse's station. -LPN A then walked back behind the nurse's station. -Resident #1 and Resident #2 then walk away from the nurse's station together and down the hall. Review of Resident #1's Daily Behavior Symptoms and Cognitive Performance assessment, dated 3/13/25 at 5:58 A.M., showed: -Resident #1 had exhibited physical behavioral symptoms during the shift which included hitting. -Resident #1 had exhibited verbal behavioral symptoms during the shift which included threatening others, screaming at others, and cursing at others. -Resident #1 had exhibited verbal/vocal symptoms like screaming or disruptive sounds during the shift. -Resident #1's behaviors had significantly disrupted care or the living environment. -The intervention that was used for Resident #1's behaviors was redirection/removed from situation/ensured resident safety. NOTE: All other Daily Behavior Symptoms and Cognitive Performance assessments showed no behavioral symptoms were exhibited prior to the incident in the month of March 2025. During an interview on 3/20/25 at 8:45 A.M., the Administrator said: -He/She had received a call on 3/12/25 in which it was reported to him/her that Resident #1 had hit someone, and that Resident #1 was being sent out to the hospital. -The following morning, he/she had called CNA A to check-in with him/her and CNA A reported to him/her that he/she was never hit by Resident #1, that it was only a rumor that he/she had been hit. - When he/she spoke with Resident #1 about the incident, Resident #1 had said that he/she reached his/her limit and had cursed at staff. -Resident #1 denied hitting any staff person. -He/She then reviewed the camera footage from the previous night based off of the information he/she had received from Resident #1. -Resident #1 had intellectual disabilities and mental health disorders but had never been in a physical altercation to his/her knowledge. -Resident #1 had a history of behaviors, mainly getting agitated, but would bang a wall or something similar, it never escalated much more than that. During an interview on 3/20/25 at 10:10 A.M., CNA B said: -Resident #1 would get agitated about smoke breaks at times, but Resident #1 was not normally agitated when he/she worked with Resident #1. -He/She had only worked at the facility for a month, so he/she was not sure about Resident #1's behavioral history or what to do when there was a behavior for this resident. During an interview on 3/20/25 at 10:22 A.M., CNA A said: -He/She had used his/her own knowledge on how to de-escalate the situation, because he/she had never been trained. -Resident #1 was never agitated and was usually respectful towards staff and other residents. During an interview on 3/20/25 at 11:21 A.M., Nurse Practitioner (NP) A said: -LPN A and CNA A had showed a lack of self-control and should not have pushed or hit Resident #1. -The least amount of hands-on would have been the best way to approach the situation. -The staff should have tried to talk through things more calmly with Resident #1 and tried to change the topic or re-direct Resident #1 in a different way. -Resident #1 was known to get loud with other staff and/or residents but was not known to get physical with anyone. -When a resident looked like they were going to hit a staff person, the best way for staff to handle the situation would be to maintain distance between themselves and the resident. -The staff's response should never be to hit the resident back. During an interview on 3/20/25 at 11:35 A.M., Resident #1 said: -He/She got punched in the face. -He/She did not want to talk about the incident because it upset him/her too much. -He/She pointed to the areas where he/she was punched which were his/her left side of the chin and his/her right side of face in between the temple and eye. During an interview on 3/20/25 at 11:47 A.M., CNA D said: -He/She thought Resident #1 was the aggressor in this incident. -Resident #1 would constantly come up to the nurse's station and asks for snacks. -Resident #1 was already aware that there were no snacks available at the time of the altercation. -The resident was not normally physically aggressive. -Resident #1 usually needed a lot of re-direction related to snacks during the night shift. -He/She was unable to say what re-direction worked best for the resident because he/she was not the one that normally did it. During an interview on 3/20/25 at 12:52 P.M., LPN A said: -Resident #1 was constantly coming up to the nurse's station and asking for snacks. -Resident #1 was not normally aggressive. -Resident #1 had never been in that type of altercation before with staff or other residents to his/her knowledge. During an interview on 3/20/25 at 1:28 P.M., CNA C said: - Resident #1 had a known behavior of getting frustrated and agitated when snacks were not available to him/her. -LPN A had told management before about snacks being an issue on night shift. -The facility would not have snacks to give the residents on a consistent basis. -He/She felt everyone had responded appropriately during the altercation. He/She received CALM training but did not know how to re-direct resident. During an interview on 3/20/25 at 2:01 P.M. Resident #2 said: -Resident #1 was reactive to how any person approached him/her, meaning that if someone approached Resident #1 with aggression, then Resident #1 would respond with aggression. -He/She thought Resident #1 would have reacted calmly if the others around him/her had remained calm. -The staff instigated and initiated that type of response from Resident #1. NOTE: Review of Resident #2's quarterly MDS, dated [DATE], showed Resident #2 was cognitively intact. During an interview on 3/20/25 at 2:23 P.M., CMT A said: -A CNA had reported to him/her that Resident #1 was getting sent out for being agitated because there were no snacks. -He/She was questioning this because the staff could have grabbed Resident #1 a sandwich from the kitchen. -He/She just felt like there was not something right with the whole situation. -Resident #1 was not normally physically aggressive. -Resident #1 could get angry, but it all came down to how someone approached Resident #1. -If staff had approached Resident #1 in a calm manner, then Resident #1 would have responded in calm manner. -The staff had not responded to the altercation appropriately and should have walked away from the resident if they felt like Resident #1 was going to be physically aggressive. He/She said that if you got a snack for the resident then he/she would be satisfied, she did receive training related to resident behaviors and de-escalation. During an interview on 3/20/25 at 2:38 P.M., CNA E said: -Resident #1 was not normally aggressive. -If a person was sweet with Resident #1, then Resident #1 would be sweet in response. -He/She had never experienced any physical aggression from Resident #1. During an interview on 3/20/25 at 3:41 P.M., the DON said: -The staff had not responded appropriately to the situation. -The staff had turned the situation into a pissing contest. -The hold that CNA A had on Resident #1 while walking Resident #1 away from the nurse's station was okay, but the force behind it was not okay. -LPN A and CNA A should have walked away from Resident #1 instead of pushing and hitting back at Resident #1. -The staff should have also tried to re-direct Resident #1 instead of egging Resident #1 on. -The staff had not handed out the snacks appropriately that night. -The snacks needed to be passed out to the resident's instead of the resident's coming up to the nurse's station and grabbing the snacks out of the basket. -If the snacks had been passed out correctly then the situation could have been avoided and just that the staff were making the situation worse instead of better by egging on his/her behavior when the resident tried to walk away. -Resident #1 had a known behavior of yelling at times. -If a resident had a known behavior, then it did not need to be documented at each occurrence. -Resident #1 was very motivated by food. -Resident #1 could get fixated on things and repeat the same question(s) over and over, but he/she did not think that those counted as behaviors. -Resident #1 would not be at the facility if Resident #1 had the capability of making appropriate decisions and felt that the staff instigated that response from Resident #1. During an interview on 3/21/25 at 8:39 P.M., CNA D said: -Resident #1 was always going up to the nurse's station to request a snack. -The staff would have to re-direct Resident #1 away from the nurse's station if there was not a snack that could be provided to Resident #1. -He/She would not consider consistently coming to the nurse's station to ask for a snack a behavior. -Resident #1 is at the facility for a reason, but he/she was aware of his surroundings and knows what he/she is doing. -He/She had told the DON that snacks were getting passed out too early in the evening and that there would not be snacks available for night shift. -When a resident was exhibiting a behavior, the staff should approach the resident calmly and talk with them. -Staff should never taunt a resident who was exhibiting a behavior or egg them on in any way. -LPN A was the one who usually re-directed Resident #1 away from the nurse's station. -Most resident behaviors occurred in front of the nurse's stations because there were cameras at the nurse's station. -If a resident was exhibiting a behavior or something questionable was going on, the staff could always call the DON, and the DON would come up to the facility to check-in. During an interview on 3/21/25 at 9:03 A.M., LPN A said: -He/She was unsure about Resident #1's behavioral history. -The CNAs interacted with Resident #1 more often and they would be the ones to provide the redirection. -Resident #1 could be grumpy at times, but nothing usually more than that. -He/She would consider Resident #1 coming to the nurse's station constantly asking about snacks a behavior. -He/She did not have to chart that type of behavior. -Resident #1's Behavior Symptoms and Cognitive Performance assessments were correct. -CNAs needed to report behaviors to him/her or he/she would not know that the resident was exhibiting a behavior and would not chart it. -When Resident #1 would come up to the nurse's station to ask for a snack, the only re-direction he/she would provide to Resident #1 was just telling him/her that there were no snacks available. -He/She had not received any behavioral training from the facility. During an interview on 3/21/25 at 9:40 A.M., CNA A said: -Resident #1 did not normally have any issues on night shift unless there were no snacks. -He/She was unsure of Resident #1's behavioral history. -He/She had received behavioral training from the facility. -He/She was unsure if Resident #1 constantly coming to the nurse's station for snacks counted as a behavior. -He/She was unsure of what the staff normally did to re-direct Resident #1 away from the nurse's station when Resident #1 would come up and ask for snacks. -He/She was unsure of how to re-direct the resident in general, just knew that in order to de-escalate the situation that the resident needed to get away from the nurse's station all together. During an interview on 3/24/25 at 10:37 A.M., CNA B said he/she would not consider Resident #1 going to the nurse's station constantly and asking for snacks a behavior. MO00251027

Based on observation, interview, and record review the facility failed to report abuse for one sampled resident (Resident #1). Facility staff Licensed Practical Nurse (LPN) A, Certified Nursing Assistant (CNA) A, CNA B, CNA C, CNA D, and CNA E all watched abuse and did not report. The facility census was 78 residents. On 3/20/25, the Administrator was notified of the past non-compliance which occurred on 3/12/25. Facility staff were educated on reporting abuse requirements. The deficiency was corrected on 3/14/25. Review of the facility's policy titled Abuse and Neglect Policy, dated 6/12/24, showed: -It was the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within the prescribed time frames. -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm. -New employees would be educated by the department manager, or designee, on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. -The facility would provide resident, families, and staff information on how and to whom they may report concerns, incidents, and grievances without fear of retribution. -Any owner, operator, employee, manager, agent, or contractor of the facility could report an allegation of abuse to the abuse agency hotline without fear of retaliation. -When suspicion of abuse or reports of abuse/neglect/exploitation occur, the following procedure would be initiated: --The licensed nurse would respond to the resident and protect him/her from further incident. --The licensed nurse would remove the accused employee from resident care areas. --The licensed nurse would notify the Administrator or designee. --The licensed nurse would notify the attending physician, resident's family/legal representative, and Medical Director. -Employees were trained through orientation and ongoing training on issues related to abuse prohibition practices, such as: --Reporting allegations without fear of reprisal. --The definition that constituted as abuse. -During orientation of new employees, the facility would cover at least the following topics: --Reporting of abuse and their obligations under law when receiving an allegation of abuse. 1. Review of Resident #1's admission Record showed the resident admitted to the facility with the following diagnoses: -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Unspecified. -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats), Unspecified. -Mild Intellectual Disabilities. -Cognitive Communication Deficit. -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Recurrent, Mild. -Unspecified Intellectual Disability. Review of the Resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 3/10/25, showed the resident was cognitively intact. Observation of the undated video footage recorded of the incident showed: -The recording was one minute and 59 seconds long. -The footage took place at the nurse's station near the resident's hall. -LPN A and CNA B were sitting down in a chair in front of computers, CNA A was walking around near the nurse's station, Resident #1 is standing in front of the nurse's station speaking with LPN A, and Resident #2 is standing near the nurse's station. -Resident #1 can then be seen pointing his/her finger at LPN A and stated, anyway I want. -LPN A responded to Resident #1 by pointing his/her finger towards the resident's hall and said, get your ass down there. -Resident #1 responded to LPN A by slamming his/her hands down on the medication cart that was in front of him/her and said, get your ass gone somewhere. -Resident #1 then started to walk around the nurse's station and towards LPN A, LPN A called the resident's name, and another staff person also called out the resident's name. -CNA A then started to move towards Resident #1 by walking in front of the nurse's station. -A staff person can then be heard saying the resident's name and no, no, no, no, no, LPN A's name, no. -LPN A then got up from sitting in his/her seat. -CNA A continued to walk around the nurse's station and CNA B got up from his/her seat. -Resident #1 could then be seen getting close to LPN A and some muffled words were exchanged. -CNA C could be seen entering the frame in upper middle part of the frame. -CNA D could then be seen entering the frame at the bottom right corner. -CNA B was within arm's reach of Resident #1 and stood behind Resident #1. -CNA B then placed his/her hand between LPN A and Resident #1. -LPN A then pushed Resident #1 into CNA A in front of CNA B, CNA D, and Resident #2. -CNA C could still be seen walking towards the nurse's station. -CNA A then grabbed Resident #1 in a bear hug position from behind and started to take Resident #1 away from the nurse's station. -Resident #1 could be heard saying, get the fuck off me [derogatory name], get the fuck off. -CNA A continued to walk with the resident in the same hold position all while LPN A, CNA B, CNA C, and CNA D watched from behind the nurse's station. -Resident #2 remained in the same spot, but could be seen watching the resident with CNA A. -Unintelligible words could be heard from the resident and other staff members. -CNA A then let go of Resident #1. -CNA A then started to walk backwards away from Resident #1 and a staff person could be heard saying, no. -Resident #1 then puts both of his/her fists in the air and stated, come on mother fucker, come on mother fucker, come on mother fucker, lets finish this and was stepping towards CNA A. -CNA A continued to walk backwards and away from the resident. -Once Resident #1 was within arm's reach of CNA A, CNA A reached his/her right hand up and swatted the resident's fists away from him/her. -Resident #1 then started swinging at CNA A with open hands. -CNA A responded by swinging his/her fists towards the resident, making contact with Resident #1's face. -CNA A and Resident #1 naturally split apart from each other without staff intervention. -CNA E could be seen entering the top left corner of the frame and was in direct sight of CNA A and Resident #1 when Resident #1 and CNA A were swinging at each other. -LPN A then walked towards Resident #1 and CNA A and could be heard saying something unintelligible, CNA B, CNA C, and CNA D all remained behind the nurse's station. -LPN A then walked back behind the nurse's station. -Resident #1 and Resident #2 then walk away from the nurse's station together and down the hall. Review of the text message that CNA D sent to the DON showed: -The text message had been sent on 3/12/25 at 10:03 P.M. -Resident #1 was hitting and threatening LPN A and CNA A. During an interview on 3/20/25 at 8:45 A.M., the Administrator said: -He/She had received a call on 3/12/25 in which it was reported to him/her that Resident #1 had hit someone, and that Resident #1 was being sent out to the hospital. -The following morning, he/she had called CNA A to check-in with him/her and CNA A reported to him/her that he/she was never hit by Resident #1, that it was only a rumor that he/she had been hit. -When he/she spoke with Resident #1 about the incident, Resident #1 had said that he/she reached his/her limit and had cursed at staff. -Resident #1 denied hitting any staff person. -He/She then reviewed the camera footage on 3/13/25 from the previous night based off of the information he/she had received from Resident #1. -None of the staff who were involved in the incident reported to him/her or the DON that Resident #1 had been hit by staff members. During an interview on 3/20/25 at 10:10 A.M., CNA B said: -He/She knew that he/she needed to report any abuse to the charge nurse. -He/She had not reported the altercation, because he/she did not think that abuse occurred. During an interview on 3/20/25 at 10:22 A.M., CNA A said: -He/She was only trying to deflect Resident #1's swinging motions and had not realized that he/she had made contact with Resident #1. -He/She had remembered during the interview that LPN A had pushed Resident #1 during the altercation. -He/She was unsure if the push counted as abuse. -He/She had worked the remainder of his/her shift that night. -He/She thought the nurse reported everything to management, so he/she did not have to report anything. During an interview on 3/20/25 at 11:21 A.M., Nurse Practitioner (NP) A said: -He/She had reviewed the camera footage. -In the video you could see that a staff to resident altercation had occurred. -He/She would categorize the altercation as abuse. -He/She expected all staff to follow the abuse and neglect reporting policy. During an interview on 3/20/25 at 11:47 A.M., CNA D said: -He/She did not think that any type of abuse had occurred during that situation. -He/She had texted the DON about Resident #1 hitting CNA A after the incident occurred. -He/She thought he/she had reported everything appropriately to the DON. -The staff could report anything suspicious or questionable to the DON and the DON usually would come up to the facility to look over things. During an interview on 3/20/25 at 12:19 P.M., the DON said: -He/She had received a text message from LPN A related to the incident during the shift. -He/She had to look through his/her phone to find the text message. -The incident was not reported correctly, no one told the DON or Administrator that CNA A had hit the resident, and no one reported LPN A shoved the resident. -The staff only reported the resident hit CNA A -He/She then said that LPN A had called him/her at 12:25 A.M. and he/she then went to the local hospital to see Resident #1. -He/She had not responded to CNA D's text message because he/she had already spoken to LPN A. During an interview on 3/20/25 at 12:52 P.M., LPN A said: -He/She had called the DON to report what happened. -No abuse occurred during the entirety of the altercation. -He/She thought he/she had reported everything appropriately. During an interview on 3/20/25 at 1:28 P.M., CNA C said: -He/She did not think that any abuse occurred during the altercation and did not report to anyone what had happened. -He/She felt that everyone responded and reported appropriately during the altercation. During an interview on 3/20/25 at 2:38 P.M. CNA E said: -He/She had been walking to the supply room at the time of the altercation. -He/She had only seen Resident #1 hit CNA A. -CNA A was only blocking the Resident #1's swings. -CNA A had not made contact with Resident #1 during the altercation. -He/She thought abuse had not occurred, so he/she did not report it. During an interview on 3/20/25 at 3:41 P.M. the DON said: -The altercation that occurred counted as abuse. -The staff had nor reported the altercation appropriately. -He/She expected staff to report any abuse to him/her or the Administrator immediately. -While the staff reported the altercation, the staff needed to provide him/her with more clarification. -What the staff reported to him/her was too vague and caused unnecessary confusion. -Once the camera footage was reviewed, the facility reported everything appropriately. -The altercation would have been handled differently if the staff had reported the abuse correctly. MO00251027

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow Federal, State and Local Laws to ensure the facility van was licensed legally and proper maintenance was performed to ensure a safe and legal transport for all residents. This failure has the potential to affect all residents in need of transport to and from the facility. The facility census was 77 residents. 1. Review of the facility van service invoice dated [DATE] showed the facility van had brakes serviced and six new tires. Review of facility monthly credit card approval sheet dated [DATE] through [DATE] showed gas for the van on: -[DATE] for $30.75. -[DATE] for $89.27. -[DATE] for $75.03. -[DATE] for $78.62. -[DATE] for $74.74. -[DATE] for $83.20. -[DATE] for $63.26. Review of email dated [DATE] at 4:28 P.M. showed: -Email initiated by the Administrator to four corporate care management members, including the Director of Finance (DOF) and the Regional Nurse Consultant (RNC). -Our van has expired tags by four years. My understanding from my staff is it was never transferred when the facility was purchased. Please let me know what I could do at my end. Review of email dated [DATE] at 11:25 A.M. through 11:27 A.M. showed: - DOF asked , Any update? -Regional Maintenance Director responded, I searched for it yesterday with no luck. Review of email dated [DATE] at 11:09 A.M. showed -DOF responded to previous email, We will have to apply for lost title. Can you please send us all the information you have on the vehicle. -Several team members names were attached to the email. Review of emails dated [DATE] at 1:06 P.M. showed: -Administrator replied to prior email he/she began filling out the title application and was waiting for the vehicle identification number (VIN). -DOF asked the Administrator to send the filled out form for a quick review. Review of email dated [DATE] at 1:13 P.M. showed the Administrator responded to DOF with attachment for the title, I filled out everything I knew. Review of invoice dated [DATE] showed the van had two new tires put on the front. Review of invoice dated [DATE] showed the van had the air conditioner recharged. Review of email dated [DATE] showed the administrator sent, Do we know anything on our van title so it can be licensed? to DOF. Review of Resident #2's Face Sheet showed the resident was admitted on [DATE], with diagnoses including dependence on renal dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood), hemiplegia and hemiparesis (paralysis/weakness affecting one side of the body) following a stroke. Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed the resident was mildly cognitively impaired. During an interview on [DATE] at 5:01 A.M. the resident said he/she was transported in the facility van to dialysis three days per week, on Monday, Wednesday and Friday. During an interview on [DATE] at 8:21 P.M. Van Driver A said: -The facility van has not been licensed for four years. -The facility van has not been inspected. -There was no title for the facility van. -He/She was not sure if the van had insurance. -He/She was told by corporate legal department that if he/she was stopped while driving the van they would take care of it. -The lift on the facility van has not been inspected and is supposed to be inspected every six months. -He/She has told the Administrator the lift needed to be inspected several times. -His/Her main concern was he/she felt the lift was dangerous. During an interview on [DATE] at 2:00 P.M. the Administrator said: -He/She did not have any documentation for the facility van. -There was insurance on the facility van, but was unable to provide proof of insurance at that time. -The facility was using the facility van to transport residents, and there was a transport occurring at the time of the interview. -The facility van had not been legal for operation since he/she started about a year ago. -He/She has sent things to corporate to obtain a title for the facility van, but has never heard anything about the process. During an interview on [DATE] at 2:28 P.M. the RNC said: -They had been working to get a title for the facility van. -The facility van was inherited from the previous company in 2020 with the building. -As far as he/she knew the corporate legal department was working to get the van legal. During an interview on [DATE] at 2:32 P.M. the Corporate Legal Representative said: -The facility van was not licensed because of issues from the previous owner. -There has never been a title turned over from the previous owner, therefore they will need to file for a lost title. -He/She was aware it was an ongoing issue and the license was expired on the facility van. -He/She was not sure how long the facility van license had been expired. -His/Her solution was to purchase a new van for the facility. -He/She said any relevant documents related to the van would be sent for review. During an interview on [DATE] at 3:10 P.M. the Maintenance Director said: -He/She did not know when the last time the van was legal or had any kind of maintenance. -He/She was not responsible for the van and thought the driver was the person who took care of van maintenance. -The van is in use almost daily transporting residents to and from the facility. During an observation on [DATE] at 3:56 P.M. showed: -The facility van parked in the facility parking lot. -Missouri license plate labeled disabled with placard, September and orange 2021 sticker/tab mounted to the front of the van. -Missouri safety inspection dated [DATE]. -Missouri license plate labeled disabled with placard, September and year tab here space with no sticker/tab mounted to the back of the van. During an interview on [DATE] at 4:07 P.M. Van Driver B said: -He/She had no idea when the last time the facility van had been serviced. -The lift in the van tilts towards the back of the van when there was a heavy person on the lift. -He/She had no idea when the last time the lift was serviced or inspected. -Maintenance documentation located in the van was from 2023 for services related to the air conditioner for [DATE], [DATE], and [DATE]. -No legal documents located in the van for title, licensing, inspection or insurance. -He/She has been telling the administration the van needs to be legal and it put him/her at risk with his/her commercial driver's license (CDL- allows a tested and approved driver to operate certain types of motor vehicles including 18-[NAME] trucks, tour buses, school buses, tanker vehicles and vehicles transporting hazardous materials). -He/She was concerned about the engine and service lights that are illuminated on the dash. During an interview on [DATE] at 5:27 P.M. the Administrator said: -He/She did not know when the last time the lift was serviced or inspected, but had not been since he/she started about a year ago. -He/She did not know how often the lift should be serviced or inspected, but most are yearly. -He/She was not aware of any concerns related to the lift. -He/She did not know when the last time the facility van was inspected or serviced for safety and functionality. MO00249465

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers for Medicare and Medicaid Services (CMS) form CMS-10123) and a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form (CMS)-10055) was provided to the resident or their representative for two sampled residents (Residents #14 and #49) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 74 residents. Review of the undated Form Instructions for the NOMNC CMS-10123 form showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Review of the CMS memo (S&C-09-20), dated 1/9/09, showed: -The NOMNC, form CMS-10123 is issued when all covered Medicare services end for coverage reasons. -If the SNF believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled using the SNF ABN (form CMS-10055). -The SNF ABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have. -If the SNF provides the beneficiary with either the SNF ABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. Review of the facility policy titled Medicare Documentation dated 8/25/22 showed the policy did not include instructions to provide a SNF ABN or a NOMNC at least two days prior to Medicare coverage ending. 1. Review of Resident #49's SNF Beneficiary Protection Notification Review form completed by the facility during the survey showed: -The resident's last covered day for Medicare Part A services was 8/23/24. -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. -A SNF ABN and a NOMNC was not provided to the resident or representative. 2. Review of Resident #14's SNF Beneficiary Protection Notification Review form completed by the facility during the survey showed: -The resident's last covered day for Medicare Part A services was 8/30/24. -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. -A SNF ABN and a NOMNC was not provided to the resident or representative. 3. During an interview on 9/25/24 at 11:54 A.M., the Social Services Director said: -He/She has been the Social Services Director for a couple of weeks. -The residents were discharged from Medicare Part A services before he/she started working at the facility. -There are no copies of a SNF ABN or a NOMNC for Residents #49 and #14. -The current process is: --Therapy sends him/her a note when therapy is ending for a resident. --He/She gets the NOMNC/SNFAB signed. --He/She keeps a copy and gives a copy to med to upload. During an interview on 9/27/24 at 11:57 A.M., the Director of Nursing said: -The Social Services Director was responsible for providing notice of termination of Medicare Part A benefits to the resident or their representative. -The did not have a Social Services Director in August 2024. -No one else was designated to provide the notices when they did not have a Social Services Director. -The NOMNC and SNF ABNs should have been provided two days prior to services ending.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff for care planning) was accurate for one sampled resident (Resident #17) out of 19 sampled residents. The facility census was 74 residents. Review of the facility policy titled MDS 3.0 Care Assessment Summary and Individualized Care Plans, revised 11/6/23, showed: -Section L is used to document any dental problems. -Section L was to be completed by nursing staff. -The MDS defined the dental health of the resident and included an assessment of mouth and facial pain. -The focus of section L was the relationship between poor oral health, the quality of life, and the nutritional status of the resident. -MDS's must be kept current and up to date. 1. Review of Resident #17's clinical admission assessment, dated 4/3/24 showed: -The resident had his/her own teeth. -Observation of dental status was not assessed. -Mouth issues were not assessed. Review of the resident's admission MDS, dated [DATE] showed the resident: -Was cognitively intact. -Did not have any dental problems upon admission to the facility. -Did not have any missing teeth upon admission to the facility. -Did not have any abnormal teeth issues upon admission to the facility. Review of the resident's Care Plan, revised 4/23/24 showed no mention of teeth problems or concerns. During an interview on 9/23/24 at 11:56 A.M., the resident said: -He/She had many missing teeth. -He/She was missing teeth on his/her admission date into the facility. -He/She had a hard time chewing food on occasion. -He/She would like to get some dentures. -He/She had not seen a dentist since being admitted into the facility. During an interview on 9/26/24 at 12:00 P.M., the MDS Coordinator said: -A dental assessment should have been completed on the resident as part of the clinical admission assessment. -The nurses and the Director of Nursing (DON) were responsible for completing the clinical admission assessments. -He/She would expect to have been notified if a resident was missing their natural teeth. -He/She would expect the missing of a resident's natural teeth to be placed on the MDS and the care plan. -He/She would expect a resident who had missing teeth to be able to see a dentist after admission to a facility and be offered dentures. During an interview on 9/27/24 at 11:58 A.M., with the DON and the Regional Director of Operations (RDO), said: -The MDS coordinator is responsible for keeping accurate and up to date MDS's. -The MDS was updated on initial assessment, quarterly, and if there was a change in condition. -Teeth issues, including missing teeth should have been reflected on a resident's MDS. -Initial teeth assessments should have been performed by nursing staff. -He/She was unaware of the resident's dental concerns and missing teeth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to comprehensively assess a resident who experienced a significant change in status for one sampled resident (Resident #33) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Significant Change dated 11/6/23 showed: -The facility staff would identify within 14 days a significant change in two or more areas of decline or improvement in the resident's physical or mental condition. -If the resident showed a decline or improvement in two or more areas a significant change assessment would be completed within 14 days. -The significant change was a major decline or improvement in the resident's status that would not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan or both. 1. Review of Resident 33's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/28/24 showed the following staff assessment of the resident: -Moderately cognitively impaired. -Independent with all activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) except he/she required moderate/partial assistance with bathing/showering. -Walked independently. -Did not use a wheelchair. -Displayed mood symptoms that indicated moderately severe depression. -Had occasional pain. -Had no falls. -Weighed 222 pounds. Review of the resident's health status note dated 5/17/24 showed the resident had a blood infection and was on intravenous antibiotics. Review of the resident's inter-disciplinary team meeting note dated 5/29/24 showed: -The team met regarding the resident's change of condition. -It was determined the resident would benefit from being moved from the independent side of the building to the medical side of the building. Review of the resident's admission summary dated [DATE] showed the resident had a fall with altered mental status. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Moderately cognitively impaired. -Independent with eating, oral hygiene, personal hygiene, and chair/bed-to-chair transfer. -Required partial/moderate assistance with toileting hygiene, dressing, putting on and taking off footwear, toilet transfer, and shower transfer. -Required substantial/maximum assistance with bathing/showering. -Had no pain. -Had one non-injury fall. -Weighed 206 pounds (a 7.21% loss over three months) Review of the resident's care plan updated on 7/28/24 showed the resident: -Had impaired thought processes related to a diagnosis of schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Had bipolar disorder (a disorder characterized by extreme mood swings from depression to mania). -Had no plan of care for falls. Review of the resident's Discharge summary dated [DATE] showed the resident was sent to the hospital for a nephrostomy (a tube inserted into the kidney and drains urine into a bag). Observation on 9/23/24 at 1:42 P.M. and on 9/24/24 at 8:58 A.M., showed the resident was in his/her wheelchair in the hallway. During an interview on 9/25/24 at 9:50 A.M., the MDS Coordinator said: -The resident had declined, had unsteady gait, and had fallen. -The resident had metabolic encephalopathy (a brain disorder that occurs when a chemical imbalance in the blood affects the brain) after a hospitalization. -The resident was no longer walking and required a wheelchair. -The resident needed more assistance than before. -He/She thought he/she did a significant change MDS. During an interview on 9/27/24 at 11:57 A.M., the Director of Nursing (DON) said: -They should identify changes in residents' condition with rounding and assessments. -They should have initiated a significant change MDS for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly administer medications by not having a physician's order stating the resident was able to self administer medications , failed to administer medications within the allotted time frame, and failed to ensure prescribed medications were available for one sampled resident (Resident #41) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy, General Medication Administration Process dated 6/26/24 showed: -Keep medication cart stocked with adequate supplies. -Ensure medications were administration were followed; right time. -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. -Observe resident consumption of medication. 1. Review of Resident #41's face sheet showed he/she was re-admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD a group of lung diseases that block airflow and make it difficult to breathe). -Tracheostomy status (a surgically created opening through the neck into the trachea to allow air to fill the lungs) -Malignant Neoplasm of Bronchus and lung (cancer of the lungs) -Cannabis abuse (addiction to marijuana). -Cocaine abuse (an addition to Cocaine which was a stimulant that produces euphoria). -Hypertension (high blood pressure). -Chronic pain syndrome. -Malignant Neoplasm of Liver and bile duct (cancer of the Liver). -Chronic kidney disease (a long standing disease of the kidneys leading to renal failure). -Gastro-Esophageal Reflux disease (GERD - a digestive disease in which stomach acid or bile irritates the food pipe lining). -Other Psychoactive substance dependence (a strong desire or sense of compulsion to take the substance). -Other abnormalities of breathings. -Chest pain. -Depression. -The resident was his/her own responsible person. Review of the resident's Care Plan, dated 6/10/24 showed: -The resident had a potential to have been physically aggressive related to poor impulse control. -Staff were to anticipate the resident's needs, comfort level and pain. -Staff were to monitor, document, and report as needed any signs or symptoms of the resident posing a danger to self or others. -The Care Plan did not address self administering of medications. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 9/2/24 showed: -He/She was cognitively intact. -He/She had a cardiorespiratory condition (heart and lungs). -He/She had cancer. -He/She had high blood pressure. -He/She had renal (kidney) failure. -He/She had depression. -He/She had COPD. -He/She was on scheduled and as needed pain medications. -He/She was on high risk medications; opioid and antidepressants. Review of the resident's Physician's Order Sheet dated September 2024 showed the following orders: -Atorvastatin Calcium (medication used to treat high cholesterol and may reduce the risk of heart attack and other heart problems) one 20 milligram (mg) tablet by mouth once a day for lowering cholesterol and prevent heart disease, dated 9/22/24. -Duloxetine hydrochloride (HCL) oral capsule delayed release particle 20 mg one capsule by mouth two times a day related to depressive disorder, dated 9/22/24. -Hydrocodone (medication used to treat severe chronic pain)- Acetaminophen 5/325 mg one tablet by mouth four times a day for pain. -Amlodipine Besylate ( hypertension- high blood pressure) 5 mg, one tablet by mouth for hypertension, 9/22/24. -Sucralfate 1 Gram (GM) one tablet by mouth two times a day related to GERD, dated 9/22/24. -Tramadol (a controlled substance when combined with other substances, especially heroin or cocaine soul cause respiratory distress and death) HCL 50 MG one tablet by mouth at bedtime, dated 9/22/24. -Albuterol sulfate inhaler (medication that treats and prevents breathing difficulties such as wheezing from lung diseases) two puffs every four hours for shortness of air or wheezing, dated 9/22/24. -Albuterol Sulfate nebulizing (a machine that turns medication into a mist) solution 1.25 mg/3 milliliter (ml) one vial inhale orally via nebulizer every six hours as needed for wheezing, dated 9/22/24. -Budesonide Formoterol Fumarate inhalation aerosol 160/4.5 micrograms (mcg)/ACT two puffs inhale orally two times a day related to COPD (rinse mouth after use), dated 9/22/24. -Fluticasone Propionate inhalation aerosol 44 MCG/ACT one puff inhale orally two times a day related to COPD, dated 9/22/24. -May go out on leave with medications, dated 9/19/24. -Check mouth after giving medications to observe for cheeking medication every shift, dated 9/19/24. -There was no Physician's order which stated the resident was able to self administer the medications. Review of the resident's current medical record showed there was no evaluation for the resident to self administer medications. Observation on 9/23/24 at 12:09 P.M. showed: -The resident had a nebulizer and mask at bedside. -There were three inhalers at bedside; Albuterol (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases), Fluticasone (used to relieve symptoms of rhinitis such as sneezing and a runny, stuffy, or itchy nose and itchy, watery eyes caused by hay fever), and Budesonide (a medication used to manage and treat inflammatory diseases, mainly affecting the airways). -There was one full plastic tube of Albuterol nebulizer treatment at bedside. During an interview on 9/23/24 at 12:09 P.M. the resident said: -He/she administered his/her own inhalers and nebulizer treatments. -The physician gave him/her permission to administer his/her own medications. -The facility ran out of his/her medications. -One of the medications the facility did not have for him/her was a pain medication Hydrocodone and he/she called 911 to go to the hospital for pain control. -One of the Certified Medication Technicians (CMT) always gave him/her medications late. -He/She would have preferred to have the medications at breakfast not almost noon. Observation on 9/24/24 at 1:00 P.M. showed: -The resident had a nebulizer and mask at bedside. -There were three inhalers at bedside; Albuterol, Fluticasone, and Budesonide. -There was one full plastic tube of Albuterol nebulizer treatment at bedside. During an observation and interview on 9/25/24 at 7:26 A.M. with CMT C during medication pass showed: -He/She handed the resident a full tube of Albuterol nebulizer treatment. -He/She asked if the resident needed another inhaler. -The resident answered he/she was still good (had enough). -The resident said the other CMT was always late giving him/her morning medications. -The resident pulled two of the three inhalers out of his/her pocket to show the CMT. -The third inhaler was sitting on the resident's bedside table. -He/She said the resident was able to administer his/her own inhalers and nebulizer treatments. -He/She said the resident had a physician's order to administer his/her own inhalers and nebulizer treatments. -He/She looked on the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the physician's order to allow the resident to self administer the medications. -He/She said there was no order and there should have been an order to allow the resident to self administer the inhalers and nebulizer treatments per self. -The resident had said often the other CMT gave him/her medications late. -Medications should have been given one hour before or after the scheduled time frame. -They have an open time frame for medications 6:00 A.M. to 10:00 A.M. for morning medications. -The resident liked to have his/her medications after breakfast. -The resident was out of some of his/her medications a couple of weeks ago for a couple of days. -One of the medications was the resident's Hydrocodone which he/she took for cancer. -He/She had told the Nurse and the Nurse had called the physician. -The Charge Nurse would have been responsible for ensuring the resident had an order to leave the medications at bedside. During an interview on 9/25/24 at 7:40 A.M. Licensed Practical Nurse (LPN) B said: -If a resident was able to self administer any medications including inhalers or a nebulizer treatment they would have needed an evaluation and a physician's order. -The resident had an order to leave medications such as the inhalers and nebulizer treatment at the bedside as that was what they had always done. -He/She was not able to find a physician's order nor an evaluation in the resident's chart for self administration of the inhaler or nebulizer treatments. -The resident had told him/her several times that he/she would like to have medications closer to breakfast rather than at 11:00 A.M. -One of the CMT's sometimes gave the resident medications late. -Staff had a period of one hour before or after the 6:00 A.M. to 10:00 A.M. timeframe to administer medications. -He/She looked at the administration times and there were a couple of times the resident had received medications at 11:20 A.M. which was late. -If a resident preferred medications to be given closer to breakfast staff should try to do so. -The resident had been out of a couple of medications a week or so ago. -He/She had called the Pharmacy, the physician and told the Charge Nurse. -Medications were usually ordered two or three days before a resident would have ran out. -The Pharmacy makes two deliveries a day so there was no reason to run out. -The Pharmacy needed the Physician to sign the prescription. -The facility also had an Emergency Kit (E kit) to get medications for a resident if needed. -He/She had tried to get the medication from the E Kit but was not able to do so. -He/She had not told anyone about not being able to obtain the medication from the E kit. -The resident got mad and called 911 for Emergency Medical Services (EMS) to take him/her to the hospital. -The resident came back and was threatening to call EMS a second time when they still did not have his/her pain medications. Observation on 9/26/24 at 1:24 P.M. showed there were three inhalers at the resident's bedside; Albuterol, Fluticasone, and Budesonide. Review of the resident's Nurses' Notes dated September 2024 showed: -On 9/17/24 Trazadone (an antidepressant used to treat depression) and Amlodipine (relaxes your blood vessels so that blood can move through them more easily and your heart does not have to work as hard) were on order. -On 9/18/24 Trazadone Amlodipine, and Sucralfate (used to treat and prevent the return of duodenal ulcers (ulcers located in first part of the small intestine) were on order. -On 9/19/24 Tramodol, Amlodipine, and Sucralfate were on order. -On 9/22/24 medications were discontinued (no documentation as to why). Review of the resident's MAR and TAR dated 9/15/24 showed: -Amlodipine was given at 11:07 A.M. (outside of the 6:00 A.M. to 10:00 A.M. plus one hour). -Atorvastatin (used to lower the amount of cholesterol in the blood) was given at 11:07 A.M. (outside of the 6:00 A.M. to 10:00 A.M. plus one hour). Review of the resident's MAR and TAR dated 9/24/24 showed: -Atorvastatin was given at 11:20 A.M. (outside the 7:00 A.M. to 10:00 A.M. plus one hour). -Duloxetine (used to treat depression and anxiety) was given at 11:20 A.M. (outside the 7:00 A.M. to 10:00 A.M. plus one hour). -Hydrocodone was given at 11:20 A.M. (outside the 7:00 A.M. to 10:00 A.M. plus one hour). -NOTE: The facility was not able to print a copy of the actual timestamp medications were given, this information was verified with Medical records. During an interview on 9/24/24 at 10:00 A.M. the Administrator said: -The facility received two deliveries a day from the Pharmacy. -The resident should not have run out of medications. -The resident went out to the hospital because he/she did not have pain medications. -The resident had went out for a family visit prior to going to the hospital. -While at the hospital the resident had tested positive for Cocaine use. -This was conveyed to the facility from the hospital prior to the resident returning to the facility via telephone call. -There was no discharge paperwork or documentation from the hospital. -The physician was notified and discontinued the resident's medications until he/she evaluated him/her as he/she had just started service with the facility. -There should have been documentation in the resident's chart but there was not. During an interview on 9/24/24 at 10:30 A.M the Pharmacist said: -The facility received two deliveries a day from the pharmacy there was no reason for a resident to run out of medications. -They had been waiting on a signature from the physician to fill the resident's order. -The facility had just changed physicians on 9/23/24 and maybe this had been the hold up. During an interview on 9/27/24 at 12:00 P.M. the Director of Nursing said: -He/She expected to find an evaluation for a resident to keep medications at bedside. -He/she expected to find an order for a resident to keep medications at bedside. -He/She would expect medication delivery to be made by pharmacy during the next delivery run or by the next day for a medication the resident was already taking. -If a medication was not available, he/she or the charge nurse should have been notified. -Mediations were considered late if they were over one hour past the scheduled time. -They have changed Medical Directors and and it is taking a day or so to get new prescriptions for the residents. -After talking to the pharmacy they have 72 hours to get a script to the residents. -This has been an issue with the Physician signing the script. -The resident had an issue with drugs when he/she went to the hospital so the Dr was holding medications.

Based on interview, and record review, the facility failed to follow physician's orders for obtaining Prothrombin Time (PT: a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder) and International Normalized Ratio (INR: calculated from a PT result and is used to monitor how well the blood-thinning medication is working to prevent blood clots) labs for one sampled resident (Resident #17) on Coumadin (an anticoagulant) out of 19 sampled residents. The facility census was 74 residents. Review of the facility policy titled High Risk Medications Anticoagulants Policy, revised 6/26/24, showed: -Routine labs, including baseline and subsequent labs, shall be ordered for each resident requiring anticoagulation medication. -Results shall be communicated to the physician in a timely manner. -Lab results that are outside the normal limits or target range for the individual resident, but not critical values, shall be communicated to the physician within 24 hours. -Lab results that are considered critical values per facility lab specificity shall be communicated to the physician immediately upon receipt of the critical lab value, but no greater than two hours. 1. Review of Resident #17's Face sheet, with an admission date of 4/3/24 showed the resident: -Had acute embolism and thrombosis (blood clot) of unspecified deep veins of right lower extremity. -Had personal history of other venous thrombosis and embolism. -Had history of Transient Ischemic Attack (TIA: a temporary blockage of blood flow to the brain). -Had history of Cerebral Infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of the resident's Care Plan dated 4/4/24 showed: -The resident had a history of Deep Vein Thrombosis (DVT: A blood clot in a deep vein, usually in the legs). -Monitor laboratory values to monitor/document effect of anticoagulant therapy, report values outside of therapeutic range. -The resident was on anticoagulation therapy. -Anticoagulation labs were ordered and to report abnormal finding to the physician. Review of the resident's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/11/24 showed the resident: -Was cognitively intact. -Had a diagnosis of DVT. -Was on anticoagulation therapy. Review of the resident's Physician's Order Sheet (POS) dated 4/4/24 showed the following physician's order for PT/INR lab draw every Monday and Thursday. Review of the resident's lab results report, dated 9/25/24, showed: -23 missing lab results for PT/INR's from 4/4/24-9/25/24. -3 missing PT/INR lab results from the month of April. -3 missing PT/INR lab results from the month of May. -8 missing PT/INT lab results from the month of June. -2 missing PT/INR lab results from the month of July. -5 missing PT/INR lab results from the month of August. -2 missing PT/INR lab results from September. During an interview on 9/23/24 at 1:22 P.M. the resident said: -The facility was not drawing his/her labs twice per week on a consistent basis. -He/She was supposed to get PT/INR lab draws every Monday and Thursday. -He/She had told staff about the missing lab draws, but he/she could not recall which staff he told. During an interview on 9/25/24 at 12:00 P.M., Agency Licensed Practice Nurse (LPN) D said: -He/She was unaware how often the resident was ordered to get PT/INR labs drawn. -He/She has never noticed a missing PT/INR lab. -He/She was supposed to call the physician with PT/INR results and document in the nurses noted in the electronic medical record. During an interview on 9/25/24 at 1:22 P.M., the Director of Nursing (DON) said: -PT/INR labs should be drawn on the resident twice per week. -Physician should be notified when results are abnormal. During an interview on 9/27/24 at 11:58 A.M., the DON and the Regional Director of Operations (RDO) said: -He/She would expect PT/INR labs to be drawn twice per week if they were ordered to be done twice per week. -He/She would expect lab results back from the lab within 24 hours after being drawn. -He/She would expect staff to communicate with the physician and document in a nursing note if results were not present or abnormal. -He/She assumed that the missing labs were not done, if they were not documented in the lab result section in the electronic medical record.

Based on observation, interview, and record review, the facility failed to provide toenail care or an appointment with a podiatrist for one sampled resident (Resident #17) out of 19 sampled residents. The facility census was 74 residents. A podiatry policy was requested and not provided. 1. Review of Resident #17's Face Sheet showed the resident was admitted to the facility with the following diagnoses: -Morbid obesity. -Dysfunction of lower extremity. Review of the resident's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/11/24 showed the resident: -Was cognitively intact. -Required maximal/substantial assistance with personal hygiene. During an interview on 9/23/24 at 1:22 P.M. the resident said: -He/she had requested to see a podiatrist to care for his/her toenails. -He/she made this request to the previous social worker and the current administrator. -He/she had never seen a podiatrist since being in the facility. -He/she had pain in his/her feet from his/her toenails being so long. -He/she was told months ago by the administrator that he/she would be able to see a podiatrist but never had. Observation on 9/23/24 at 1:30 P.M., showed: -The resident had unkept and untrimmed toenails. -The resident's toenails were long and thick. During an interview on 9/25/24 at 10:36 A.M., Certified Nursing Assistant (CNA) F said: -If a resident requested to see a podiatrist, he/she would report it to the charge nurse. -He/she knew that the resident was wanting and needing to see a podiatrist. -He/she had reported the resident's need to see a podiatrist to the previous social worker and the administrator. During an interview on 9/25/24 at 11:45 A.M., CNA D said: -He/she was aware the resident needed to see a podiatrist. -He/she had reported the need for the resident to see a podiatrist to a charge nurse. -He/she could not recall which charge nurse he/she reported information to. -The Director Of Nursing (DON) also was aware that the resident was needing to see a podiatrist. During an interview on 9/25/24 at 12:00 P.M., Licensed Practical Nurse (LPN) D said: -He/she was aware that the resident needed to see a podiatrist. -He/she reported to the DON the resident needed to see a podiatrist. During an interview on 9/25/24 at 1:22 P.M., the DON, said: -He/she was aware that the resident needed to see the podiatrist. -He/she added the resident to the list to be seen by the podiatrist the next time he/she was at the facility. -He/she thought that the resident had already been seen by the podiatrist. During an interview on 9/26/24 at 11:00 A.M., the Social Services Director said: -He/she was responsible for setting up the resident appointments with the podiatrist. -A resident should be seen by a podiatrist with 48-72 hours of admission into the facility. -He/she was unaware that the resident needed to see a podiatrist. -He/she would have expected if a resident needed to see a podiatrist, it would have been communicated to the charge nurse, the DON, and himself/herself. -He/she would have expected that a nursing note had been made in the resident's electronic medical record of his need to see a podiatrist. During an interview on 9/27/24 at 11:58 A.M., the DON and the Regional Director of Operations (RDO), said: -He/she was aware of the resident needing to see a podiatrist. -When a resident needed to see a podiatrist, the social worker makes the appointment. -He/she would have expected the need for the resident to see a podiatrist be communicated to the social worker. -He/she was unaware why the resident had not seen a podiatrist yet. -The facility had no podiatry notes or nursing notes to provide regarding the resident's need to see a podiatrist.

Based on observation, interview, and record review, the facility failed to ensure communication between the facility and dialysis (a mechanical way to filter the blood and remove waste when the kidneys stop functioning) treatment center was maintained and ongoing to ensure the continuum of care and failed to maintain and implement post dialysis assessment orders to ensure safety for one sampled resident (Resident # 38) out of 19 sampled residents. The facility census was 74 residents. A dialysis policy was requested but not received. 1. Review of Resident #38's Care Plan dated 11/15/22 showed the resident: -Had dialysis three times a week due to End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) -Was to be monitored for any signs and symptoms of infection (redness, swelling, warmth, or drainage) to the access site by facility staff. Review of the resident's Physicians Order Sheet (POS) dated 12/29/23, showed: -Facility staff was to ensure the resident was ready by 10:00 A.M., every Monday, Wednesday, and Friday related to dependence on renal dialysis. -Note: There were no orders for assessment of signs and symptoms of infection at the site of dialysis. -Note: There were no orders for assessment of thrill (A vibration felt above the incision line of the fistula. It's caused by blood flowing through the fistula) and bruit (A whooshing or swooshing sound heard near the fistula incision site. It's caused by the high-pressure flow of blood through the fistula). Review of the resident's Quarterly Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 8/20/24 showed the resident: -Was cognitively intact. -Has renal insufficiency, renal failure, or ESRD. -Was receiving dialysis. Observation on 9/23/24 at 10:00 A.M., showed the resident was out of the facility for dialysis. Observation on 9/25/24 at 10:35 A.M., showed the resident was out of the facility for dialysis. During an interview on 9/25/24 at 12:00 P.M., agency Licensed Practical Nurse (LPN) D said: -He/she was an agency nurse. -He/she worked a couple days a week at the facility. -He/she was unaware of any special orders to complete when the resident returned from dialysis. -The only thing that he/she knew to do upon the resident returning from dialysis was to check and make sure that the resident was not bleeding through his/her dressing and to remove the dressing after 24 hours. -A dialysis communication sheet should be sent with and come back with the resident each time the resident receives dialysis. -The dialysis communication sheets were placed in a binder at the nurse's station, but he/she was unaware of where the location of the binder was. -If the resident failed to return to the facility with the communication sheet, the charge nurse should have called the dialysis company and documented this conversation in a nurses note in the electronic medical record. -The charge nurse was responsible for calling the dialysis company to clarify any new orders that the dialysis company started on the resident. -The dialysis company did not call the facility when the dialysis company initiated new orders. Observation on 9/26/24 at 10:52 A.M., showed: -The resident had an Arteriovenous (AV) Fistula Shunt (An AV fistula is a connection that's made between an artery and a vein for dialysis access) in his/her right arm. -The AV fistula shunt was open to air and not covered. During an interview on 9/26/24 at 11:00 P.M., the resident said: -He/she received dialysis three times per week. -He/she did not recall nurse assessments when he/she returned from dialysis three times per week. During an interview on 9/27/24 at 9:22 A.M., LPN A said: -The facility had a dialysis binder, but it got lost. -He/she was unaware of how long the binder had been missing. -He/she created a new one the day prior. Observation on 9/27/24 at 9:30 A.M., showed: -A new binder was created and at the nurse's station. -No communication forms were in the binder for the resident. -Note: The facility provided dialysis communication forms for: 8/16/24, 8/30/24, and 9/25/24. No other dialysis communication forms could be located for the resident. During an interview on 9/27/24 at 11:58 A.M., the DON and the Regional Director of Operations (RDO), said: -The staff was made aware of changes of condition and new orders from the dialysis center by the dialysis communication form. -The dialysis communication forms were kept in a binder at the nurse's station. -He/she was made aware that the dialysis binder was missing. -He/she was unaware of where the dialysis binder was. -It was expected that if a resident came back from dialysis without a dialysis communication form, the charge nurse was to call the dialysis facility and have the form faxed over to the charge nurse. -It was expected that a resident came back from dialysis with a communication form after every dialysis visit. -It was expected that a dialysis communication form be placed in the dialysis binder each time a resident returned from dialysis. -It was expected that the nursing staff would have completed an assessment of thrill and bruit and infection on residents each time a resident returned from dialysis. -Nursing assessment after a resident returned from dialysis should have been documented in the electronic medical record. -If a resident did not have an order to assess thrill and bruit and assess for infection, it would have been expected that the staff call the physician and get an order. -Treatment administration records and care plans should have included assessment's for thrill, bruit, and signs of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) completed by the pharmacist was reviewed and responded to by the facility physician(s) for two sampled residents (Resident #19 and #45) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's Medication Regimen Review Policy, dated 6/26/24, showed: -Each resident was reviewed at least once a month by a licensed pharmacist. -The MRR was a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. -Review of the medical record was to prevent, identify, and resolve medication-related problems, medications errors and other recommendations. -The pharmacist communicated any irregularities to the facility physician, Director of Nursing (DON), or staff of any urgent needs. -The facility staff acted upon all recommendations according to procedure for addressing medication regimen review irregularities. 1. Review of Resident #19's undated face sheet showed the resident was diagnosed with type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) and gout (a type if arthritis causing buildup of uric acid in the joints). Review of the resident's consultant pharmacist progress note dated 9/2/24 in the Electronic Health Record (EHR) showed: -The consultant pharmacist reviewed the resident's medication regimen. -The pharmacist recommended the physician evaluate the need for a scheduled uric acid level on the Physician's Order Sheet (POS) for therapy monitoring due to the resident's Allopurinol (a synthetic drug used to treat gout) 100 milligrams (mg). Review of the resident's EHR showed no physician's response to the pharmacist's recommendation. Review of the resident's POS dated September 2024 showed: -The resident had an order for Allopurinol 100 mg. -NOTE: There was no order for measuring/monitoring uric acid levels. 2. Review of Resident #45's quarterly MDS dated [DATE], showed: -The resident was moderately cognitively impaired. -The resident's diagnoses included: --Type 2 diabetes. --Epilepsy (a burst of uncontrolled electrical activity between brain cells). Review of the resident's consultant pharmacist progress note dated 9/2/24 in the EHR showed the consultant pharmacist reviewed the resident's medication regimen and provided recommendations for the physician. Review of the resident's EHR, viewed on 9/26/24, showed no physician notes addressing the pharmacist recommendations. 3. During an interview on 9/24/24 at 1:56 P.M., the Director of Nursing said: -He/She received pharmacist recommendations through email. -He/She was unaware they were available in the EHR. -He/She reviewed emails from the pharmacist and talked to the physician about the recommendations. -He/She also talked to the physicians in person. -He/She had no documentation of discussing recommendations with the physician. -When the physicians come in he/she reviewed the pharmacist recommendations with the physicians and told them what the pharmacy recommendations were. -They then made the updates. During an interview on 9/24/24 at 2:06 P.M., the consultant pharmacist said: -He/She had been serving the facility as the consultant pharmacist for ten years. -He/She conducted MRR's every 30 days, usually in the first seven days of the month. -He/She put recommendations into the EHR. -The Physician then went into the EHR to address the recommendations. -He/She ran reports from the EHR that indicated if the physician had seen the new recommendations and their response. -Sometimes the recommendations were not addressed for six months and he/she had to redo the recommendations. During an interview on 9/25/24 at 12:21 P.M., the Administrator said he/she was unable to locate any physician responses for Residents #19 and #45 During an interview on 9/26/24 at 11:16 A.M. the Assistant Director of Nursing (ADON) said: -He/She was not familiar with MRR's yet, and did not have email access. -The pharmacist was able to access the EHR and enter recommendations for the physician. -The physician viewed the recommendations in the EHR. During an interview on 9/27/24 at 11:58 A.M., the DON said: -The pharmacist made recommendations in the EHR. -The physician was able to go in the EHR and document his/her responses. During an interview on 9/27/24 at 11:58 A.M., the Regional Director of Operations (RDO) said if there was no documentation then he/she could not prove it was being done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #51's undated Face Sheet showed he/she was initially admitted on [DATE] and the most recent admission to the facility on 7/25/24 with the following diagnoses: -Heart Failure (HF-disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body) -Chronic Pain Syndrome -Venous Insufficiency (Chronic) (Peripheral) condition in which the veins have problems sending blood from the legs back to the heart. -Cellulitis (an infection of deep skin tissue) of unspecified part of limb. Review of the resident's current Order Summary Report showed a physician's order dated 2/21/24 that the resident may see the dentist. Review of the resident's admission MDS dated [DATE] Section L, Dental, showed no issues with teeth. Review of the resident's Nutrition Assessment -Registered Dietician Evaluation dated 3/16/24 showed: -He/She was on a regular diet and regular consistency. -Resident had his/her own teeth. Review of the resident's Quarterly MDS's dated 6/1/24 and 8/30/24 Section L, Dental, showed the resident had no issues with his/her teeth. During an interview on 9/23/24 2:02 P.M. the resident said: -He/She was unsure the last time he/she saw a dentist. -He/She had missing teeth. -He/She wanted dentures. Observation on 9/23/24 at 2:02 P.M. showed the resident had multiple teeth missing. During an interview on 9/24/24 at 2:44 P.M. the Social Service Director (SSD) said: -He/She was new to the facility. -He/She did the admission contract and would obtain consent forms. -He/She did not know if the resident had seen the dentist. During an interview on 9/25/24 at 11:12 A.M. Licensed Practical Nurse (LPN) B said: -He/She was contract staff. -He/She was not aware of the resident's missing teeth or request to see dentist. During an interview on 9/26/24 at 11:52 A.M. the MDS Coordinator said: -He/She was not aware of the resident's missing teeth. -He/She was not aware the resident wanted to see the dentist. During an interview on 9/26/24 at 1:53 P.M. the SSD said: -The facility had a provider for dental care. -He/She was not aware when dental services had last been provided. -He/She would ask on admission if the resident wanted dental and would obtain the signed consent form. -He/She would receive a list from the dental provider with the residents' names for the next visit. -He/She was not aware the resident had missing teeth. During an interview on 9/27/24 at 8:43 A.M. the SSD said the resident had not seen the dentist since admission. During an interview on 9/27/24 at 11:58 A.M. the DON said: -The dental provider came monthly. -The SSD would obtain consent from residents. -The SSD would fax/email the consents to the dental provider for scheduling. -He/She would expect residents to be seen within two months of admission. -He/She was not aware Resident #51 had missing teeth. -He/She expected a resident with multiple missing teeth on admission would be seen by dental. Based on observation, interview and record review, the facility failed to provide dental services to two sampled residents (Resident #33 and #51) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Dental Services dated as revised on 6/26/24 showed: -The dental needs of each resident were identified through the physical assessment and Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) assessment process and were addressed in each resident's plan of care. -The oral/dental status of the resident would be documented according to assessment findings. -Oral care and denture care would be provided for identified needs and as part of the resident's plan of care. -Referrals to a dental provider were to be made as appropriate. -The Social Services Director maintained contact information for dental service providers. -The facility would assist the resident with making dental appointments and arranging transportation. 1. Review of Resident #33's baseline care plan dated 2/5/21 did not include anything about the resident's teeth. Review of the resident's dental progress note dated 2/13/23 showed: -The resident was interested in dentures. -Four of the resident's teeth were removed. Review of the resident's dental progress note dated 2/16/23 showed: -Four of the resident's teeth were removed. -The fifth tooth was not removed because the resident did not get numb on that tooth. Review of the resident's annual MDS dated [DATE] showed the staff assessed the resident as having no dental issues. Review of the resident's monthly nurse's dental notes dated 4/6/24 showed the staff assessed resident as: -Had his/her own teeth. -Had cavities and/or broken teeth. -Did not have: --Broken or loosely fitted dentures. --Mouth or facial pain. --Discomfort/difficulty with chewing. --Abnormal mouth tissue. --Inflamed/bleeding gums or loose teeth. Review of the resident's dentist's progress note dated 5/1/24 showed: -The resident had one tooth and one root tip on the bottom jaw. -Alveoloplasty (a common dental procedure often performed following a tooth extraction) was needed with maxillary (upper) teeth extractions. Review of the resident's monthly nurse's dental notes dated 5/14/24 and 7/2/24 showed the staff assessed the resident as: -Had his/her own teeth. -Did not have: --Broken or loosely fitted dentures. --Cavities or broken teeth. --Mouth or facial pain. --Discomfort/difficulty with chewing. --Abnormal mouth tissue. --Inflamed/bleeding gums or loose teeth. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Was moderately cognitively impaired. -Had no hearing, speech, or vision impairment. -Was independent with eating and oral hygiene. Review of the resident's care plan revised 7/28/24 showed nothing was included regarding the resident's teeth. Review of the resident's Physician's Order Sheet (POS) dated September 2024 showed a physician's order dated 11/14/22 that the resident may see a dentist. Review of the resident's monthly nurse's dental notes dated 9/6/24 showed the staff assessed the resident as: -Had his/her own teeth. -Did not have: --Broken or loosely fitted dentures. --Cavities or broken teeth. --Mouth or facial pain. --Discomfort/difficulty with chewing. --Abnormal mouth tissue. --Inflamed/bleeding gums or loose teeth. Review of the resident concerns questionnaire dated 9/15/24 showed the resident did not need dental services. Observation on 9/24/24 at 8:58 A.M. showed the resident: -Had multiple missing teeth. -The teeth the resident had were discolored black and/or yellow. -Had multiple teeth that were misaligned and/or were broken. During an interview on 9/24/24 at 8:58 A.M. the resident said: -He/She asked about seeing a dentist at least a month ago. -He/She did not remember who he/she asked about seeing a dentist. -He/She desperately needed to see a dentist. -He/She needed all his/her teeth pulled. During an interview on 9/25/24 at 9:50 A.M., the MDS Coordinator said: -The resident's teeth were in poor condition and needed to be removed. -The resident's teeth were damaged from Lithium (a medication used to treat mood disorders and reduces the amount of saliva in one's mouth which can lead to dental issues such as tooth decay and gum disease). -The comprehensive MDS indicating the resident had no dental issues was inaccurate. -He/She should have included dental needs in the resident's care plan. -They needed to schedule an appointment for the resident because he/she needed to have all his/her teeth removed. During an interview on 9/24/24 at 3:26 P.M., the Social Services Director said: -He/She was new to the facility. -He/She looked at the resident's most recent dental notes (5/1/24). -Nothing was done after the dentist's recommendation (from 5/1/24) for teeth extractions. -The Social Services Director would have been responsible for scheduling the teeth extractions and obtaining transportation. During an interview on 9/27/24 at 11:57 A.M., the Director of Nursing (DON) said: -Nursing staff and Social Services were responsible for assessing the condition of residents' teeth. -They discussed residents' teeth in their daily nurses' meeting. -Nursing would normally obtain an order for the dental procedure that was recommended. -When dental services were needed, they sent an email to the Social Services Director to schedule an outside dental appointment. -They should have followed up with the dental recommendations made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure documentation and monitoring for ongoing hospice care (a type of health care that focuses on comfort care of a terminally ill resident) visits and communication with hospice staff, and failed to obtain pertinent documentation of the delivery of hospice care services for one sampled resident (Resident #42) out 19 sampled residents. The facility census was 74 residents. 1. Review of Resident #42's admission Record showed he/she was admitted on [DATE] and admitted to hospice on 9/11/24 with the following diagnoses: -Dementia (a general term for a decline in mental ability resulting in memory loss) 4/16/24. -Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions) 4/16/24. -Senile degeneration of the brain (also known as Senile dementia- a mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age) 9/12/2024. Review of the resident's hospice communication book had the following documents: -The Long-Term Care/Hospice Coordination of Care Form which showed: --Code Status as Full code. --The resident's room number. --Hospice Diagnosis: Senile Degeneration of the Brain. --The name of the Hospice Company. --Hospice Nurse visits on these days: 1-2 times a week. --Long-Term Care Aide to provide Bath/Shower on these days: 2 times a week. --Hospice Aide to provide Bath/Shower on these days: 2-3 times a week. --Wound care shows N/A. --Dated 9/11/24 by a Registered Nurse (RN). -Sign In sheets showed: --9/11/24 by the RN admission nurse. --9/13/24 (unable to read the signature or title of person). -No other documentation was in the book. -No documentation of any hospice staff seeing the resident after admission to current date of 9/24/24. -No Care Plan in book. -No Physician named. Review of the resident's Physicians Order Summary dated September 2024 showed Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) dated 9/19/24. Review of the resident's DNR showed it was signed by the resident representative on 9/19/24. Review of the resident's DNR showed it was signed by the resident's physician on 9/19/24. During an interview on 9/24/24 at 2:09 P.M., Certified Nursing Assistant (CNA) J said: -He/She knew when a resident went on to hospice from the daily report from off going shift. -A resident's code status was in the resident's chart. -Not sure what information was in a resident's hospice book. -Did not know when the hospice nurse or aide visited the resident. During an interview on 9/27/24 at 11:57 A.M., the Director of Nursing(DON) said: -All information of hospice cares or visits for a hospice resident should be in the resident's hospice book. -The hospice nurse's admission of a resident to hospice should be in the resident's hospice book. -The hospice nurse saw the resident weekly and informed the DON of any changes or updates to the resident before leaving the facility. -The hospice nurse visits and what they did should be in the resident's hospice book. -The hospice aide saw the resident at least weekly and did cares including bathing/showering. -The hospice aide visits should be in the resident's hospice book with what cares were done. -The hospice aide informed the DON of what he/she did and any changes to the resident before leaving the facility. -The hospice staff informed the facility DON of any changes to the resident's care verbally and put it in the hospice book. -The resident's care was coordinated between the hospice staff and facility staff by communicating verbally with the DON and writing it in the resident's hospice book. -The following information should be in the resident's hospice book: --The name of the resident's Physician. --A hospice care plan. --What the resident's cares should be. --The hospice staff that visited the resident with the date and what cares were performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received or were provided education for the pneumococcal (vaccine that protects against the bacteria that causes pneumonia) vaccinations for two sampled residents (Resident #24 and #325) out of five residents sampled for vaccines. The facility census was 74 residents. Review of the facility's policy, Infection Prevention and Control Program, dated 5/7/24 showed: -Residents should have been offered the pneumococcal vaccines recommended by the Centers for Disease Control upon admission, unless contraindicated or had received the vaccinations elsewhere. -Education should have been provided to the residents and or their representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. -Residents would have had the opportunity to refuse immunizations. -Documentation would reflect the education provided and details regarding whether the resident received the immunizations. 1. Review of Resident #24's entry tracking form showed the resident admitted to the facility on [DATE] and was over [AGE] years old. Review of the resident's medical records showed no documentation regarding the resident's pneumococcal vaccine status. 2. Review of Resident #325's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's medical records showed no documentation regarding the resident's pneumococcal vaccine status. 3. During an interview on 9/27/24 at 9:32 A.M., the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) Coordinator said: -The Director of Nursing (DON) was responsible for ensuring the immunizations were done. -Documentation regarding the resident's pneumococcal vaccine status should be charted in the immunization tab in the electronic health record (EHR). -The pneumococcal vaccine should be offered and administered during the resident's first week at the facility if the resident was over 65 or immunocompromised (when one's immune system is weakened, making it harder to fight off infections and diseases). -If the resident declined the pneumococcal vaccine, they should put a progress note in the EHR and the resident should sign the vaccine form saying they declined it. -Education on the risks and benefits of the pneumococcal vaccine was included in the admission packet. During an interview on 9/27/24 at 11:57 A.M., the DON said: -They had a consent form for the administration of the pneumococcal vaccines that should be filled out. -The charge nurses were supposed to offer the pneumococcal vaccines within 72 hours of the resident's admission and administer it if the resident consented. -Documentation regarding the pneumococcal vaccines should be in the resident's EHR. -If the resident declined the pneumococcal vaccines, education provided to the resident regarding the risks and benefits of the pneumococcal vaccines should be documented in the resident's progress notes. -They had handouts for education and declination of pneumococcal vaccines. -He/She spot checked the administration of vaccines. -Their process of offering and administering the pneumococcal vaccines needed some work.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two sampled residents (Residents #24 and #325) out of five residents sampled for vaccines were offered the Coronavirus Disease ((COVID-19) is an infectious disease caused by a virus that causes symptoms of a respiratory illness) vaccine. The facility census was 74 residents. Review of the facility's policy titled COVID-19 Vaccine: Educate and Offer dated 6/26/24 showed: -All residents would be offered the COVID-19 vaccine unless the immunization was medically contraindicated, or the resident had already been vaccinated. -If the resident already received the COVID-19 vaccine, the facility would ask for documentation of the vaccination. -The facility would provide a copy of the package insert for the COVID-19 vaccine being offered. -The facility would maintain copies of any material used to educate residents about the COVID-19 vaccine. -The resident had the option to accept or refuse the COVID-19 vaccine. -The resident would sign the consent form indicating whether they have consented or declined the COVID-19 vaccination. -A copy of the form would be kept in each resident's medical record. -The facility would document in the resident's chart that the resident was provided with education about the benefits and potential risks associated with the COVID-19 vaccine. -The Director of Nursing (DON) would serve as the facility point of contact for ensuring that all residents are educated about and offered the COVID-19 vaccine. 1. Review of Resident #24's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's medical records showed no documentation regarding the resident's COVID-19 vaccine status. 2. Review of Resident #325's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's medical records showed no documentation regarding the resident's COVID-19 vaccine status. 3. During an interview on 9/27/24 at 9:32 A.M., the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) Coordinator said: -The DON was responsible for ensuring the immunizations were done. -Documentation regarding the resident's COVID-19 vaccine status should be charted in the immunization tab in the electronic health record (EHR). -The COVID-19 vaccine should be offered and administered during the resident's first week at the facility. -If the resident declined the COVID-19 vaccine, they should put a progress note in the EHR and the resident should sign the vaccine form saying they declined it. -Education on the risks and benefits of the COVID-19 was included in the admission packet. During an interview on 9/27/24 at 11:57 A.M., the DON said: -They had a consent form for the administration of the COVID-19 vaccine that should be filled out. -The charge nurses were supposed to offer the COVID-19 vaccine within 72 hours of the resident's admission and administer it if the resident consented. -Documentation regarding the COVID-19 vaccine should be in the resident's EHR. -If the resident declined the COVID-19 vaccine, education provided to the resident regarding the risks and benefits of the COVID-19 vaccine should be documented in the resident's progress notes. -They had handouts for education and declination of COVID-19 vaccines. -He/She spot checked the administration of vaccines. -Their process of offering and administering the COVID-19 vaccine needed some work.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment including, but not limited to, unbroken furniture and/or window treatments, clean and comfortable sleeping conditions, and a physical layout of the facility that maximized people with disabilities' independence, met The Americans with Disabilities Act (ADA) requirements, and did not pose a safety risk and/or tripping hazards. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in at least four locations throughout the building. This facility had a census of 74 residents with a licensed capacity of 91 residents at the time of the survey. 1. Observation on 9/24/24 at 11:48 A.M. during the initial facility walk-through inspection showed the plumbing clean out (the access point for a sewer line and is considered a means to access the sewer line for cleaning and unclogging) in the middle of the 300 Hall by resident room [ROOM NUMBER] was missing its cover which allowed for an approximately (app.) ½ inch (in.) deep, 9 in. diameter drop in the floor that someone could catch their foot or walker on. Observation on 9/24/24 between 3:10 P.M. and 3:45 P.M. during a follow-up facility walk-through inspection with the Maintenance Supervisor (MS) showed the 100, 200, and 300 Halls' resident rooms had their numerals in both Arabic and Braille next to their doors. During an interview on 9/24/24 at 3:33 P.M. the MS said that he/she was going to change out the room numbers on the 400, 500, and 600 Halls because those resident rooms only had regular numbers and no Braille. Observation on 9/25/24 between 10:31 A.M. and 1:01 P.M. during another facility follow-up walk-through inspection with the MS showed the following: -The 400, 500, and 600 Halls' resident rooms had regular numbers next to their doors. -In resident room [ROOM NUMBER] there was a four-drawer chest with the front of the 2nd drawer from the top lying inside the drawer itself, and some slats in the window blinds missing. -In resident room [ROOM NUMBER] bed #2 had several long rips in the mattress top. -In resident room [ROOM NUMBER] the inside hinged edge of the bathroom door was cracked and broken towards the bottom to the point of showing that it was a hollow-core door. During an interview on 9/25/24 at 1:04 P.M. the Environmental Services Supervisor (EVS) said the following: -If any Housekeepers, nursing staff, or anyone noticed a damaged mattress they reported it to him/her and they would order a new one. -They had replaced a couple about a month or so ago. -It was the same process for damaged furniture or window blinds, but the MS is included on those too. During an interview on 9/26/24 at 12:53 P.M. the MS said the following: -He/She would order new blinds when reported. -The EVS or Administrator would do the mattresses and furniture. During an interview on 9/26/24 at 2:46 P.M. the Administrator said the following: -The facility should be free from any tripping hazards. -The EVS, or the MS could order any furniture, mattresses, or blinds when needed, they just had to wait for their corporate office to approve it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #40's Face Sheet, undated, showed the resident was diagnosed with dementia (loss of memory, language, problem-solving and other thinking abilities), anxiety disorder (apprehension, tension, or uneasiness that stems from the anticipation of danger) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's quarterly MDS dated [DATE], showed the resident was moderately cognitively impaired. Review of the resident's Electronic Health Record (EHR) Progress Notes, dated 8/26/2024, showed: -There was no documentation of a discharge in the resident's record. -There was no documentation of the ombudsman being notified of a discharge. -Emergency Medical Services (EMS) was called and the resident was sent to the emergency room (ER). -Writer spoke with resident's daughter. 4. During an interview on 9/25/24 at 6:11 A.M., Certified Nursing Assistant (CNA) A said: -The nurses sent residents to the hospital. -He/She did not know who sent the discharge notice. -The nurses contact the resident's family. During an interview on 9/26/24 at 10:34 A.M., LPN A said: -Residents have face sheet and medication list sent with them when they were sent out to the hospital. -The nurse who sent the resident out was responsible for notifying the family and the physician. -The nurse who sent the resident out was also responsible for completing the discharge notice. During an interview on 9/26/24 at 11:16 A.M., the Assistant Director of Nursing (ADON) said: -When residents were sent out to the hospital, they had their face sheet and medication list. -Whoever sent out the resident contacted the ER and notified them the resident was on their way. -Face sheet, medication list, a copy of electronic Medication Administration Record (E-MAR) were sent with the resident. -The charge nurse or the SSD sent the discharge notice with the resident. During an interview on 9/27/24 at 11:58 A.M., the DON said: -When a resident was discharged to the hospital the face sheet and medication list was sent with them. -The charge nurse discharging the resident was responsible for sending that information. -The documents should have been scanned in the documents of the EHR. -A note should be in the EHR progress notes that the family was contacted. -He/She was unsure if the resident's family was notified, he/she went to the hospital. -The SSD was responsible for sending the discharge notice and notifying the Ombudsman. -There was no one in the position in August 2024. -No one else was designated to do those while the position was vacant. During an interview on 9/27/24 at 11:58 A.M., the RDO said: -The charge nurse initiated the discharge notice documents and notified the Ombudsman. -The Social Service Director also would send the discharge notice and notify the Ombudsman depending on the day. -They should be scanned in the EHR under documents. -If the documents were not available then it wasn't done. MO00241127 2. Review of Resident #73's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] and was discharged to a hospital on 8/14/24 with the following diagnoses: -Type 2 Diabetes Mellitus [condition that affects the way the body processes blood sugar (glucose)]. -Severe protein-calorie malnutrition (insufficient intake of protein). Review of the resident's Health Status Note dated 8/14/2024 at 10:04 A.M., showed: -The DON informed the nurse that the resident was requesting to be sent to the emergency room due to his/her physical decline. -The DON said the resident's sister was made aware of decision to transfer to the hospital. -Emergency Medical Technicians (EMT) in facility at that time to transfer to hospital for evaluation/treatment if indicated. During an interview on 9/25/24 at 11:33 A.M., the Administrator said: -He/She could not find any nursing or progress notes of the resident being transferred to the hospital. -He/she could not find the discharge notice and/or the Ombudsman notification of the resident being transferred/discharged to the hospital. During an interview on 9/27/24 09:43 A.M., LPN A said: -When a resident was sent out to the hospital a progress note was written showing: --The reason the resident was sent to the hospital. --Who was notified: physician, family/representative. -He/She did not know if family/representative had to be notified in writing of a transfer or discharge. -He/She did not know who was responsible for sending a written notice. Review of the resident's electronic medical record on 9/27/24 showed no documentation that the resident, family, or representative received written notice of the resident's transfer to the hospital. During an interview on 9/27/24 11:57 A.M., the DON said: -When a resident was discharged from the facility a progress note should be written as to where the resident went and who was notified. -The resident's family/representative should be notified in writing of the resident's discharge to the hospital. Based on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reasons for the transfer in writing and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification for three sampled residents (Residents #33, #73, and #40) out of 19 sampled residents. The facility census was 74 residents. Review of the Facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy dated 5/14/2024 showed: -Any resident transferred or discharged under a Facility-Initiated Transfer or discharge the Facility must: --Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand. --Notify a representative of the Office of the State Long-Term Care Ombudsman. ---A copy of the discharge/transfer notice shall be sent to the Ombudsman at least 30 days in advance of the discharge or as soon as possible. ---In the case of an emergency or immediate discharge, copies shall be sent to the Ombudsman. This notice shall be sent when practicable and a monthly list is acceptable and should include if the resident's return is expected. -The written notice shall include the following information: --Reason for the transfer or discharge. --Effective date of the transfer or discharge. --Location to which the resident is being transferred or discharged , including specific address. --Resident's right to appeal the transfer or discharge. -The Notice of transfer or discharge shall be given at least thirty days prior to the transfer or discharge. -In the case of an emergency or immediate transfer or discharge, the notice shall be as soon as practicable before the transfer/discharge. -Emergency or immediate discharge is permitted if it specifically alleged in the notice that: --Immediate transfer or discharge is required by resident's urgent medical needs. --Or the resident has not resided in the Facility for 30 days. -The Facility shall provide sufficient preparation and orientation to ensure that the resident as a safe and orderly transfer or discharge, including informing the resident where he/she is going and taking steps to minimize anxiety. -Orientation may include explaining to a resident why they are going to the emergency room, other location, or leaving the facility. -Orientation should be documented in the medical record including the resident's understanding regarding the transfer or discharge. 1. Review of Resident #33's discharge assessment dated [DATE] showed the resident discharged to an acute hospital with his/her return anticipated. Review of the resident's medical records showed no discharge notice dated 5/26/24. Review of the resident's entry tracking forms showed the resident returned from the hospital on 6/2/24. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/28/24 showed the resident was moderately cognitively impaired. Review of the resident's discharge assessment dated [DATE] showed the resident discharged to an acute hospital with his/her return anticipated. Review of the resident's medical records showed no discharge notice dated 8/1/24. Review of the resident's entry tracking forms showed the resident returned from the hospital on 8/7/24. During an interview on 9/25/24 at 9:31 A.M., the Administrator said: -The Ombudsman notifications were in the previous Social Service Director's (SSD) emails. -He/She was trying to find out if he/she could retrieve the emails. During an interview on 9/26/24 at 11:19 A.M., the resident said he/she did not receive discharge notices for these hospitalizations. During an interview on 9/27/24 at 8:41 A.M., Licensed Practical Nurse (LPN) A said the charge nurse was responsible for sending the discharge notice when a resident was being sent to the hospital. Review of an email from the Ombudsman sent on 9/27/24 at 11:09 A.M. showed he/she did not receive a list of residents discharged from the facility for August 2024. During an interview on 9/27/24 at 11:57 A.M.: -The Director of Nursing (DON) said: --The charge nurse usually sent the discharge notice. --It should be documented in a progress note when the discharge notice was sent. --The Social Services Director could send the discharge notice on Monday if the charge nurse did not do it on Sunday. -The Regional Director of Operations (RDO) said: --The discharge notice should have been completed and scanned under the documents/miscellaneous tab in the electronic health record. -The Administrator said: --He/she was not aware the notifications of the August 2024 discharges were not made to the Ombudsman. --The Social Services Director was responsible for notifying the Ombudsman of resident discharges, but they did not have a Social Services Director in August 2024. --Nursing should have documented in a progress note when the discharge notice was provided to the resident and/or guardian. -The Regional Clinical Supervisor said the Administrator should have sent the August 2024 discharges to the ombudsman while they had no Social Services Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #14's undated Facesheet showed he/she originally admitted [DATE] with most recent admission 8/8/2024 and was his/her own responsible person. Review of resident's Nursing Progress Note dated 7/23/24 at 2:09 A.M. showed: -He/She wanted to be transported to the hospital via ambulance. -He/She wanted to be sent out to the hospital for further evaluation. Review of the resident's medical record showed no bed hold policy notice dated 7/23/24. Review of resident's Social Service Progress Note dated 7/24/24 at 11:56 A.M. showed: -The resident was admitted to the hospital. -There was no documentation of a bed hold notice. During an Interview on 9/25/24 at 10:30 A.M. the RDO said: -The charge nurse would send the bed hold policy when the resident was sent to the hospital. -The facility had 24 hours to get the bed hold policy to the guardian. -If the charge nurse did not send the bed hold policy with the resident, the SSD would follow up. During an interview on 9/26/24 at 11:52 A.M. the MDS Coordinator said: -Nursing would give the bed hold policy on transfer to the hospital. -The SSD would follow up the next business day and send the bed hold policy if nursing had not sent it at time of transfer. During an interview on 9/27/24 at 11:58 A.M. the DON said: -The Charge Nurse was responsible for sending the bed hold policy. -The SSD would follow up and send the bed hold policy if the Charge Nurse had not provided it. Based on interview and record review, the facility failed to provide a bed hold notification to a resident or resident representative upon transfer or discharge for three residents (Resident #40, #33, and #14) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's Bed Hold Policy, date 11/6/23, showed: -When a resident was admitted to the facility, they received a copy of the bed hold policy from the admission Packet. -When a resident was discharged to the hospital or went on therapeutic leave, the facility provided a a copy of the Bed Hold Policy to the resident or resident representative. -When a resident was admitted following a hospitalization or therapeutic leave, the resident will be admitted to the facility if they continue to require services from the facility and was eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 1. Review of Resident #40's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 6/24/24, showed: -The resident was moderately cognitively impaired. Review of the resident's Electronic Health Record (EHR) Progress Notes, dated 8/26/2024, showed: -Emergency Medical Services (EMS) was called and the resident was sent to the emergency room (ER). -There was no bed hold documentation. During an interview on 9/26/24 at 10:34 A.M., Licensed Practical Nurse (LPN) A said: -The resident went to hospital for slurred speech. -The nurse who sent the resident out was responsible for sending the bed hold policy. During an interview on 9/26/24 at 11:16 A.M., the Assistant Director of Nursing (ADON) said: -When residents were sent out to the hospital, their face sheet and medication list was sent with them. -If they were anticipated to return they were given a bed hold policy. During an interview on 9/27/24 at 11:58 A.M., the Director of Nursing (DON) said: -When a resident was discharged to the hospital the bed hold, was sent with them. -The charge nurse discharging the resident was responsible for sending the bed hold policy. -The documents should have been scanned in the documents of the EHR. -A note should be in the EHR progress notes that the family was provided a bed hold. -He/She was unsure if a bed hold policy was sent with the resident. During an interview on 9/27/24 at 11:58 A.M., the Regional Director of Operations (RDO) said: should bed hold notice be given? -The charge nurse initiated the discharge documents. -The Social Service Director (SSD) also would complete and send the bed hold policy out, depending on the day. -They should be scanned in the EHR under documents. -A bed hold policy should have been issued to the resident. -If the documents were not available then it wasn't done. 2. Review of Resident #33's discharge assessment dated Sunday, 5/26/24 showed the resident discharged to an acute hospital with his/her return anticipated. Review of the resident's medical records showed no bed hold policy notice dated 5/26/24. Review of the resident's entry tracking forms showed the resident returned from the hospital on 6/2/24. Review of the resident's quarterly MDS dated [DATE] showed the resident was moderately cognitively impaired. Review of the resident's discharge assessment dated [DATE] showed the resident discharged to an acute hospital with his/her return anticipated. Review of the resident's medical records showed no bed hold policy notice dated 8/1/24. Review of the resident's entry tracking forms showed the resident returned from the hospital on 8/7/24. During an interview on 9/26/24 at 11:19 A.M., the resident said he/she did not receive bed hold policies for the hospitalizations. During an interview on 9/27/24 at 8:41 A.M., LPN A said the charge nurse was responsible for sending the bed hold policy when a resident was being sent to the hospital. During an interview on 9/27/24 at 11:57 A.M.: -The DON said: --The charge nurse usually sent the bed hold notice. --It should be documented in a progress note when the bed hold policy notice was provided. --The SSD could send the bed hold policy notice on Monday if the charge nurse did not do it on Sunday. -The Regional Director of Operations said the bed hold policy notice should have been completed and scanned under the documents/miscellaneous tab in the electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #51's admission MDS Section L Oral/Dental status dated 3/1/24 showed: -No documentation of any dental concerns. --NOTE: The MDS was not marked to indicate this resident had missing teeth. Review of the resident's Nutrition Assessment -Registered Dietician Evaluation dated 3/16/24 showed: -He/She was on a regular diet and regular consistency. --He/She had his/her own teeth. Review of the resident's Quarterly MDS's dated 6/1/24 and 8/30/24 Section L, Dental, showed no issues with teeth. Review of the resident's undated Care Plan did not show a dental care plan. Observation on 9/23/24 at 2:02 P.M. showed the resident had multiple missing teeth. During an interview on 9/26/24 at 11:52 A.M. the MDS coordinator said: -He/She would look through the resident's chart to obtain information. -He/She was not aware of the resident's missing teeth. -He/She reviewed/updated care plans every 3 months and with changes. During an interview on 9/27/24 at 11:58 A.M. the DON said: -He/She expected the MDS to be correct. -He/She expected the care plan to be individualized. -He/She expected a resident with multiple missing teeth to have his/her dental status identified on the MDS and care plan. -He/She was not aware Resident #51 had missing teeth. -He/She expected a resident with multiple missing teeth on admission to be seen by dental. 3. Review of Resident #19's face sheet, undated, showed: -The resident was admitted to the facility on [DATE]. -Diagnoses included moderate protein-calorie malnutrition (in adequate intake of calories resulting in muscle weakness), diabetes (a disease causing elevated levels of blood sugar, potentially leading to kidney, heart and vision problems), and generalized muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was severely cognitively impaired. -The resident's weight was 133 pounds. Review of the resident's weight record located in the Electronic Health Record (EHR), showed: -On 7/9/2024 the resident's weight was recorded as 126.0 pounds. -On 8/6/2024 the resident's weight was recorded as 161.8 pounds. --This was a weight gain of 22.1 percent (%) in 30 days. --There were no notes addressing the weight change. -On 8/11/2024 the residents weight was recorded as 161.8 pounds. -On 9/7/2024 the resident's weight was recorded as 150.5 pounds. --This was a weight loss of 7.5 % in 30 days. Review of the resident's Physician Order Summary (POS), with order date of 9/19/20, showed the resident was ordered a regular diet. Review of the resident's care plan dated 9/20/24, showed: -The resident was on a regular diet. -The dietician reviewed the resident's chart quarterly to ensure a regular diet was still proper for the resident. During an interview on 9/25/24 at 6:11 A.M., Certified Nursing Assistant (CNA) A said: -He/She was unsure who did the weights on residents. -He/She was unaware if the resident had lost or gained weight. During an interview on 9/25/24 at 6:22 A.M. CNA B said: -He/She was unaware of the resident having weight loss or weight gain. -He/She was unaware if the resident was on supplements. During an interview on 9/25/24 at 7:58 A.M., CNA C said: -The resident was a picky eater and did not like a lot of pasta or gravy. -The resident was given sandwiches if he/she did not like the meal. -He/She was unaware if the resident had a weight loss. -He/She was unaware of a large weight gain. -He/She was unaware if the resident was on any dietary supplements. During an interview on 9/25/24 12:59 at P.M., the Registered Dietician (RD) said: -He/She was aware of the resident's weight issues. -He/She did not believe the resident had actual weight loss and questioned the accuracy of the recent weights. -He/She was unsure of how the weights were taken, either standing, wheelchair, or mechanical lift. -He/She asked staff for a reweigh the resident earlier this week and had not received the weight yet. -He/She believed the resident needed a new baseline weight. -He/She did not feel it necessary to start nutritional supplements until the reweigh was received. During an interview on 9/26/24 at 10:34 A.M., Licensed Practical Nurse (LPN) A said: -He/She was unaware if the resident had a weight loss or gain. -He/She had not seen the resident eat very much. -Nursing staff provided encouragement during meals. -The resident was very picky about his/her food. -Resident's were weighed monthly by nursing staff. -Nursing staff monitored weights and entered them in the EHR. -The EHR indicated a weight loss or gain of five or more pounds. -When there was an indication of a weight loss or gain the nurse called the physician and let him/her know. -The physician would then call the dietician and order a supplement. During an interview on 9/27/24 at 11:58 A.M., the Director of Nursing (DON) said: -He/She was made aware of the resident's weight issues by the charge nurse. -The team also discussed weights at weekly meetings. -The RD reported any issues as well. -Monthly weight changes were triggered when there was a weight difference of five pounds plus or minus in a month. -He/She was aware of the recent weight loss and was going to reweigh the resident but had not done it yet. -The RD checked weights every month and reported weight issues and recommendations to him/her. -The RD was aware the resident had a recent weight loss and asked for the resident to be reweighed. -The RD was aware the resident had a weight gain in August, but was not sure it was accurate. -The RD recommended the resident be in the dining room for meals. -He/She believed the RD ordered a protein shake. -It should have been on the Physician Order Sheets (POS) and care plan. -He/She was aware the RD requested the resident be reweighed, -The resident was reweighed but he/she was unsure if was charted. -The physician should have been made aware of the weight gain and the loss. During an interview on 9/27/24 at 11:58 A.M., the Regional Director of Operations (RDO) said: -The DON should have been aware the resident had weight fluctuations and requested the resident be reweighed to set a new baseline. -The resident should have been put on weekly weights. -Nursing staff weighed the residents and charted it in the EHR. -The charge nurse was responsible for letting the physician know of any weight loss or gains. -The scale should have been calibrated and the resident reweighed. -Weekly weights could be done without a physician order. Based on observation, interview and record review, the facility failed to accurately assess the resident's dental status for two sampled residents (Resident #33 and #51), and failed to accurately assess and implement strategies for unintended weight gain and loss for one sampled resident (Resident #19) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) 3.0, Care Assessment Summary and Individualized Care Plans dated 11/6/23 showed: -The purpose of the policy was to ensure the MDS was completed accurately. -The dental health section of the MDS was to be completed by nursing staff. -The dental health section of the MDS was to be used to document any dental problems. -Section K (swallowing/nutrition status): --Was to be completed by the dietary manager. --Used to assess conditions that affected the resident's ability to maintain adequate nutrition and hydration. --Monitored for triggered weight gains and losses. --Triggered gains or losses were 5% in 30 days, 7.5% in 90 days or 10% in 180 days. --Documented any nutritional approaches. 1. Review of Resident #33's dental progress note dated 2/13/23 showed: -The resident was interested in dentures. -Four of his/her teeth were removed. Review of the resident's dental progress note dated 2/16/23 showed: -Four of his/her teeth were removed. -The fifth tooth was not removed because the resident did not get numb on that tooth. Review of the resident's annual MDS dated [DATE] showed the staff assessed the resident as having no dental issues. Review of the resident's monthly nurse's dental notes dated 4/6/24 showed the staff assessed the resident as: -Had his/her own teeth. -Had cavities and/or broken teeth. Review of the resident's dentist's progress note dated 5/1/24 showed: -The resident had one tooth and one root tip on the bottom jaw. -Alveoloplasty (a common dental procedure often performed following a tooth extraction) was needed with maxillary (upper) teeth extractions. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Was moderately cognitively impaired. -Had no hearing, speech, or vision impairment. -Was independent with eating and oral hygiene. Review of the resident's care plan revised 7/28/24 showed nothing was included regarding the resident's teeth. During an interview on 9/24/24 at 8:58 A.M. the resident said: -He/She asked about seeing a dentist at least a month ago. -He/She did not remember who he/she asked about seeing a dentist. -He/She desperately needed to see a dentist. -He/She needed all his/her teeth pulled. Observation on 9/24/24 at 8:58 A.M. showed: -The resident had multiple missing teeth. -The teeth the resident had were discolored black and/or yellow. -The resident had multiple teeth that were misaligned and/or were broken. During an interview on 9/25/24 at 9:50 A.M., the MDS Coordinator said: -The resident's teeth were in poor condition and needed to be removed. -The resident's teeth were damaged from Lithium (a medication used to treat mood disorders, reduced the amount of saliva in one's mouth which could lead to dental issues such as tooth decay and gum disease). -The annual MDS indicating the resident had no dental issues was inaccurate. During an interview on 9/27/24 at 11:57 A.M., the Director of Nursing (DON) said: -Nursing staff and Social Services were responsible for assessing the condition of residents' teeth. -They discussed residents' teeth in their daily nurses' meeting. -The MDS should accurately reflect the resident's condition at the time of the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #51's undated Face Sheet showed he/she was initially admitted on [DATE] and the most recent admission to the facility on 7/25/24 with the following diagnoses: -Heart Failure (HF-disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). - Chronic Pain Syndrome. -Venous Insufficiency (Chronic) (Peripheral) condition in which the veins have problems sending blood from the legs back to the heart. -Cellulitis (an infection of deep skin tissue) of unspecified part of limb. Review of the resident's admission MDS dated [DATE] showed the staff assessed the resident as having no dental issues. Review of the resident's Quarterly MDS's dated 6/1/24 and 8/30/24 showed the staff assessed the resident as having no dental issues. Review of the resident's Care Plan dated 7/24/24 did not show a Dental care plan. Observation on 9/23/24 at 2:02 P.M. showed the resident had multiple missing teeth. During an interview on 9/23/24 at 2:02 P.M. the resident said: -He/She was unsure the last time he/she saw a dentist. -He/She provided his/her own oral care. -He/She wanted dentures. During an interview on 9/25/24 at 11:50 A.M. LPN D said he/she was not aware of the resident's missing teeth. During an interview on 9/26/24 at 11:52 A.M. the MDS Coordinator said he/she was not aware the resident had missing teeth. During an interview on 9/27/24 at 11:58 A.M. the Director of Nursing (DON) said: -He/She was not aware Resident #51 had missing teeth. -He/She expected a resident with multiple missing teeth to have his/her dental status identified on the care plan.4. Review of Resident #20's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Morbid (severe) obesity (a disorder involving excessive body fat that increases the risk of health problems). -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Acute (sudden onset) and Chronic (persisting for a long time or constantly recurring) respiratory failure (results from inadequate gas exchange by the respiratory system) with hypoxia (low oxygen levels in the body tissues). -Atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls causing obstruction of blood flow) without angina pectoris (severe pain in the chest spreading out to other areas cause by inadequate blood supply to the heart). Review of the resident's admission MDS dated [DATE] showed the resident was frequently incontinent of bladder and bowels. Review of the resident's Health Status Note-skin only evaluation dated 8/22/24 late entry showed -Skin Issue: #001 Location: Coccyx (Back of body above buttocks). Review of the resident's POS dated September 2024 showed: -Weekly skin assessments every day shift every Thursday. -Monitor for signs and symptoms of infection or open areas. -Abrasion to left posterior thigh: --Cleanse with normal saline or wound cleanser. --Pat dry. --Apply Xeroform dressing to wound bed and cover with border gauze dressing. --Every day shift AND as needed for soiled/dislodged. Review of the resident's Hot Rack Notes dated 9/12/24 at 9:34 A.M., showed the nurse assessed the resident's skin and noted: -An abrasion to the left posterior thigh. -Pink colored wound bed, no drainage. -Redness to peri wound (the area around the wound)/surrounding skin. -Redness to the right posterior thigh. -Encouraged the resident to limit time up in wheelchair daily. -Physician was made aware with new treatment order given via telephone. During an interview on 9/23/24 at 11:57 A.M., the resident said he/she had sores on his/her buttocks. Review of the resident's Skin/Wound Note dated 9/24/2024 at 2:24 P.M., showed: -Date of service was 9/19/2024 9:00 A.M. -Wound on back healed today. --Weeks in Treatment: 14. -New open wound on left posterior thigh currently classified as a Category/Stage III (full-thickness skin loss extending into the tissue beneath the skin, forming a small crater). --Date acquired was 9/16/2024. --Cleanse wound with Cleanser - xeroform gauze. --Cover wound with Bordered Gauze. --Change daily and as needed (PRN) for soiling and/or saturation. --Pressure Relief/Offloading: Wheelchair Pressure Redistribution Cushion per Facility Policy/Protocol. Review of the resident's Care Plan showed no interventions for peri cares or wound cares. During an interview on 9/26/24 at 11:52 A.M., The MDS Coordinator said: -He/she got updated information from the facility morning meetings on resident changes and or needs. -A resident's care plan could be updated by the nurse, the MDS Coordinator or the Social Services Director. -He/she went through the care plans every three months and updated them when needed. During an interview on 9/27/24 at 9:41 A.M., Licensed Practical Nurse (LPN) A said: -The Certified Nursing Assistants (CNA)'s let the nurses know if there was anything different or new with a resident. -The nurse assessed the resident. -If the care plan needed to be updated the nurse, Director of Nursing (DON), Assistant DON (ADON), or the MDS Coordinator put the new information in. 5. During an interview on 9/27/24 at 11:57 A.M., the DON said: -The MDS Coordinator was responsible for the overall care plan development. -The care plan should reflect the resident's current condition and plan of care. Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for four sampled residents (Residents #33, #54, #20 and #51) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy titled Comprehensive Care Plans dated as revised on 6/26/24 showed: -The facility staff would develop and implement a comprehensive, person-centered care plan for each resident to meet the resident's needs. -The care plan would include resident-specific interventions. 1. Review of Resident #33's baseline care plan dated 2/5/21 did not include anything about the resident's teeth. Review of the resident's dental progress note dated 2/13/23 showed: -The resident was interested in dentures. -Four teeth were removed. Review of the resident's dental progress note dated 2/16/23 showed: -Four of his/her teeth were removed. -The fifth tooth was not removed because the resident did not get numb on that tooth. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/16/23 showed the staff assessed the resident as having no dental issues. Review of the resident's monthly nurse's dental notes dated 4/6/24 showed the staff assessed resident as: -Had his/her own teeth. -Had cavities and/or broken teeth. Review of the resident's dentist's progress note dated 5/1/24 showed: -The resident had one tooth and one root tip on the bottom jaw. -Alveoloplasty (a common dental procedure often performed following a tooth extraction) was needed with maxillary (upper) teeth extractions. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Was moderately cognitively impaired. -Had no hearing, speech, or vision impairment. -Was independent with eating and oral hygiene. Review of the resident's care plan revised 7/28/24 showed nothing was included regarding the resident's teeth. During an interview on 9/24/24 at 8:58 A.M. the resident said: -He/She asked about seeing a dentist at least a month ago. -He/She did not remember who he/she asked about seeing a dentist. -He/She desperately needed to see a dentist. -He/She needed all his/her teeth pulled. Observation on 9/24/24 at 8:58 A.M. showed: -The resident had multiple missing teeth. -The teeth the resident had were discolored black and/or yellow. -The resident had multiple teeth that were misaligned and/or were broken. During an interview on 9/25/24 at 9:50 A.M., the MDS Coordinator said: -The resident's teeth were in poor condition and needed to be removed. -The resident's teeth were damaged from Lithium (a medication used to treat mood disorders, that reduced the amount of saliva in one's mouth which can lead to dental issues such as tooth decay and gum disease). -The annual MDS indicating the resident had no dental issues was inaccurate. -He/She should have included dental needs in the resident's care plan. 2. Review of Resident #54's admission MDS dated [DATE] showed the following staff assessment of the resident: -Received high risk medications including insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) injections, antianxiety medication (medication to treat anxiety (a psychiatric disorder that involves extreme fear, worry and nervousness)), and antidepressant medication (medication used to treat clinical depression-(a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life)). -Some of his/her diagnoses included diabetes, anxiety disorder, and depression. -Psychotropic drug (any drug that affects brain activities associated with mental processes and behavior) use triggered as a focus area and would be addressed in the resident's care plan. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Received high risk medications including insulin injections, antianxiety medication, and antidepressant medications. -Some of his/her diagnoses included diabetes, anxiety disorder, and depression. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Received high risk medications including insulin injections, antianxiety medication, and antidepressant medication. -Some of his/her diagnoses included diabetes, anxiety disorder and depression. Review of the resident's Physician's Order Sheet (POS) dated September 2024 showed the resident: -Received insulin for diabetes. -Received an antidepressant medication for major depressive disorder. -Received an antianxiety medication for generalized anxiety disorder. Review of the resident's care plan last updated on 9/9/24 showed no care plan for diabetes, insulin, depression, antidepressant medication, anxiety, or antianxiety medications. During an interview on 9/25/24 at 9:50 A.M., the MDS Coordinator said he/she would normally care plan diabetes, insulin, depression, antidepressant medication, anxiety, and antianxiety medications and he/she just missed them when developing the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #14's undated Facesheet showed he/she originally admitted on [DATE] with the most recent admission on [DATE] and had the following diagnoses: -Bilateral primary osteoarthritis (a degenerative disease of the bones and joints) of knee. -Pain in leg unspecified. -Urinary Tract Infection, site not specified. Review of the resident's Nursing Progress Note dated 7/23/24 at 2:09 A.M. showed: -He/She wanted to be transported to the hospital via ambulance. -He/She wanted to be sent out to the hospital for further evaluation. Review of the resident's Social Service Progress Note dated 7/24/24 at 11:56 A.M. showed the resident was admitted to the hospital. Review of resident's Nursing Progress Note dated 9/13/24 at 3:11 P.M. showed he/she was sent to the hospital. Review of the resident's nurses notes dated 9/14/24 at 11:09 A.M. and 9/14/24 at 8:14 P.M. showed the resident was out of the facility at the hospital. Review of the resident's Order Recap Summary dated April 2024 to August 2024 showed: -Diflucan (an antifungal medication) oral 150 milligram (mg) give one tablet at bedtime for yeast for one day dated 7/22/24. -Obtain an urinalysis one time only for pain 7/23/24. -Ceftazidime (an antibiotic) Intravenous Solution, reconstitute 2 gram (gm), use one vial at bedtime for Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system) for three days dated 8/8/24 to 8/11/24. -Cephalexin (an antibiotic) capsule, 500 milligrams (mg) give one capsule three times a day for UTI 9/14/24 to 9/22/24. -Cephalexin capsule, 500 mg give one capsule three times a day for UTI 9/22/24 with no stop date. Review of the resident's Order Recap Summary dated September 2024 showed: -Cephalexin capsule 500 mg give one capsule three times daily for urinary tract infection (UTI). -The MAR was marked to show the medication was unavailable. Review of the resident's care plan showed there was no care plan that addressed yeast, recurrent UTI, or antibiotic or antifungal medication usage. 4. Review of Resident #51's undated Face Sheet showed he/she was initially admitted on [DATE] and the most recent admission to the facility on 7/25/24 with the following diagnoses: -Heart Failure (HF-disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). -Chronic Pain Syndrome. -Venous Insufficiency (Chronic) (Peripheral) condition in which the veins have problems sending blood from the legs back to the heart. -Cellulitis (an infection of deep skin tissue) of unspecified part of limb. -Alcohol Abuse, uncomplicated. Review of the resident's admission MDS dated [DATE] showed: -He/She received as needed (PRN) pain medications. -He/She did not receive non-medication interventions. -He/She had pain present. -He/She had frequent pain. -Pain intensity score was an eight, a very strong pain that made it difficult to do anything including physical activity and conversation. Review of the resident's Quarterly MDS dated [DATE] showed: -He/She received PRN pain medications. -He/She did not receive non-medication interventions. -He/She had pain present. -He/She had frequent pain. -Pain occasionally affected sleep. -Pain occasionally interfered with day-to-day activities. -Pain intensity score was an eight, a very strong pain that makes it difficult to do anything including physical activity and conversation. Review of the resident's Care Plan dated 7/24/24 showed: -He/She had a care plan for chronic pain due to a venous stasis ulcer (caused by problems with blood flow in your veins). -Goal: The resident would not have an interruption in normal activities due to pain through the review date. -Goal: The resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. -Interventions included: --Anticipate the resident's need for pain and respond immediately. --Identify and record previous pain history and management of that pain and impact on function. --Identify previous response to analgesia including pain relief, side effects and impact on function. --Monitor and document for probable cause of each pain episode. Remove/limit causes where possible. -NOTE: The care plan did not show medication interventions, non-pharmacological interventions, refusals of treatment plan with notification to physician of unrelieved pain. Review of the resident's Quarterly MDS dated [DATE] showed: -He/She received PRN pain medications. -He/She did not receive non-medication interventions. -He/She had pain present. -He/She had frequent pain. -Pain occasionally affected sleep. -Pain occasionally interfered with day-to-day activities. -Pain intensity score was an eight, a very strong pain that makes it difficult to do anything including physical activity and conversation. Review of the resident's current Order Summary showed: -Capsaicin (used topically for peripheral nerve pain) external cream, apply to knees topically every morning and at bedtime. -Lidocaine (used as a local anesthetic) external patch apply to skin topically one time a day. -Muscle rub external cream 10-15% (Methol-Methyl Salicylate (liniments) apply to affected joints. -Tramadol (used to relieve moderate to moderately severe pain) 50 mg one tablet every 8 hours as needed for pain. Review of the resident's Nurse Practitioner progress note dated 9/14/24 at 4:59 P.M. showed an order for Tramadol Oral Tablet 50 mg Give one tablet by mouth every 8 hours as needed for pain. During an interview on 9/23/24 at 11:10 A.M. the resident said: -He/She did not feel well and was in pain. -He/She wanted to lay down and be left alone. During an interview on 9/23/24 1:59 P.M. the resident said: -He/She was in pain due to arthritis and cellulitis in his/her legs. -He/She rated his/her pain at a seven. -The pain was in the shoulders, knees, and wounds and it was chronic. -The facility didn't do anything. During an interview on 9/25/24 at 11:12 A.M. the resident said: -His/Her knees were bone on bone. -He/She needed knee injections. -He/She wanted physical therapy. -He/She felt he/she was not receiving the care that was needed. During an interview on 9/25/24 11:13 A.M. Licensed Practical Nurse (LPN) D said: -The resident had an order for a Lidocaine patch and a cream. -The resident did not have an order for controlled medication due to substance abuse history. -The DON would know about the resident's history. During an interview on 9/25/24 at 11:22 A.M. the DON said: -The resident had a history of substance abuse that included street drugs such as [NAME] meth (a highly addictive & dangerous drug with devastating effects on your health). -The resident also drank hard liquor. 5. During an interview on 9/26/24 at 11:52 A.M. the MDS Coordinator said: -He/She attended the clinical meetings when possible, to obtain information to revise care plans. -He/she was responsible to update/revise care plans. -The residents should have individualized care plans. -The residents should have care plans for pain, infections and/or antibiotics. -He/She reviewed/updated care plans every 3 months and with changes. During an interview on 9/27/24 at 11:58 A.M. the DON said: -He/She expected the care plan to be individualized. -He/She expected a resident with multiple missing teeth to have dental issues identified on the MDS and care plan. -He/She was not aware the resident had missing teeth. -He/She expected antibiotics to be on the care plan. -He/She expected the pain care plan to identify sites, types of pain and the plan to address. -He/She expected the care plan to be updated with new orders, antibiotics, referrals, refusals of treatment plan and communication to the provider/physician. -He/She, the ADON and the MDS Coordinator were responsible for updating care plans. Based on interview and record review, the facility failed to notify the resident or the resident representative of meetings for care plan development, review, and revision, for one sampled resident (Resident #67) and failed to update the care plan for falls, pain, and infections for three sampled residents (Resident #33, #14 and #51) out of 19 sampled residents. The facility census was 74 residents. Policies regarding care plan invitations and care plan invitations were requested and not received. 1. Review of Resident #67's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 7/29/24, showed: -The resident was moderately cognitively impaired. -The resident was diagnosed with anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), depression (a low mood or loss of pleasure or interest in activities for long periods of time), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 9/23/24 at 12:34 P.M., the resident said: -He/She was unsure what a care plan was. -He/She could not remember if he/she had been invited to the care plan meeting. -He/She understood the process and confirmed he/she had not been to a care plan meeting in the past. During an interview on 9/25/24 at 6:11 A.M., Certified Nursing Assistant (CNA) A said: -He/She found information about the resident in the care plan. -Residents should be invited to care plan meetings. During an interview on 9/25/24 at 6:22 A.M., CNA B said: -Resident's needs were addressed on the care plan. -He/She believed the resident was invited to care plan meetings. -Unsure if there were care plan meetings as he/she worked nights. During an interview on 9/25/24 at 7:58 A.M., CNA C said: -Residents should get invited verbally to care plan meetings. -He/She was unaware if the resident had one recently. During an interview on 9/25/24 at 9:32 A.M., the Social Service Director (SSD) said: -He/She started this position two weeks ago. -Care plan due date notifications were generated in the Electronic Health Record (EHR). -The MDS Coordinator handled care plan meeting notifications while the facility transitioned between SSD's. -Meeting notifications were mailed out to families, and they were offered by zoom, phone, or in person. -The resident would have received a notice himself/herself, if he/she was his/her own person. -The resident had a care plan update on 4/29/24 and on 7/29/24. During an interview on 9/25/24 at 9:56 A.M., the MDS Coordinator said: -The resident's care plan meeting was not done with the resident present. -The resident's care plan was updated but he/she did not have a meeting. -He/She did not have time to do meetings with residents or resident representatives. -He/She was responsible for MDS's at two buildings and his/her time management needed improvement. During an interview on 9/26/24 at 11:16 A.M., the Assistant Director of Nursing (ADON) said: -He/She started this position about a month ago. -It was his/her understanding that residents were invited to their care plan meetings. During an interview on 9/27/24 at 11:58 A.M., with the Director of Nursing (DON) and the Regional Director of Operations (RDO) the RDO said: -The resident and resident representatives were notified of care plan meetings via the telephone and should be in writing. -Everything should be in writing, even the invites for residents. -The MDS coordinator was responsible for inviting residents to care plan meetings. -Any letters were uploaded into documents in the EHR or in a binder. -Unless there was documentation in the resident's clinical notes then there was no proof the care plan meeting was done. 2. Review of Resident #33's quarterly MDS dated [DATE] showed the resident had not fallen since admission or prior assessment, whichever was more recent. Review of the resident's health status note dated 4/7/24 showed the resident was sent to the hospital emergency department related to his/her altered mental status after a fall. Review of the resident's discharge assessment dated [DATE] showed the resident had two or more non-injury falls since admission or prior assessment, whichever was more recent. Review of the resident's discharge assessment dated [DATE] showed the resident had one non-injury falls since admission or prior assessment, whichever was more recent. Review of the resident's quarterly MDS dated [DATE] showed the resident had one non-injury fall since admission or prior assessment, whichever was more recent. Review of the resident's care plan updated 7/28/24 showed falls and fall-prevention interventions were not included in the care plan. During an interview on 9/25/24 at 9:50 A.M., the MDS Coordinator said: -The resident had declined and had unsteady gait. -The resident had fallen. -He/She should have included falls in the resident's care plan. During an interview on 9/27/24 at 11:57 A.M.: -The DON said: --Falls should have been added to the resident's care plan. --The MDS Coordinator, DON, ADON, and charge nurses should update care plans. --The care plan should be accurate and reflect the resident's current status. -The RDO said: --The charge nurses were educated on how to update care plans. --The MDS Coordinator was responsible overall for ensuring care plans were updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNA). The facility census was 74 residents. Review of the facility Nursing Assistant Training Program Policy dated 5/18/24 showed: -Each nursing assistant shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. -It is the responsibility of the employee to attend/complete mandatory in-service training's to maintain employment status with the facility. -A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review. -Some of the minimum training includes: --Dementia management and care of the cognitively impaired. --Abuse, neglect, and exploitation prevention. --Resident rights and facility responsibilities. --Behavioral health. --Identification of changes in condition. 1. Review of the Facility assessment dated [DATE] showed: -The facility was licensed for 91 beds. -The average number of occupied beds during the previous quarter was 67.8. -The training time required for newly hired CNA's was 8.25 hours which included: --Compliance and ethics training. --Abuse: preventing, recognizing and reporting. --Resident rights. --Sexual harassment for employees. --Workplace violence. --Care of cognitively impaired. --Communicating with older adults with dementia. -Use of the computer training program to complete all or some of the CNA required 12 hours of training. Review of the Employee List showed the following five CNA's were employed for the last 12 months or longer: -CNA B hired on 4/5/2022. -CNA C hired on 5/2/2007. -CNA H hired on 7/6/2023. -CNA K hired on 8/8/2023. -CNA L hired on 7/13/2023. Review of the facility In-Services and Education book for last 12 months dated September 2023 to August 2024 showed: -No competency reviews were found for any of the five listed CNA's during the previous 12 months. -The in-services/education sign-in sheets provided did not include the following required training's during the previous 12 months: --Dementia/Alzheimer care. --Misappropriation. --Behavioral training. -CNA B received one hour of in-service which did not include the above required training's or Abuse and Neglect. -CNA C received ten hours of in-service which did not include the above required training's or Abuse and Neglect. -CNA H received eight hours of in-service which did not include the above required training's or Abuse and Neglect. -CNA K received four hours of in-service which did not include the required above training's Abuse and Neglect. -CNA L was not listed on any of the in-service sign in sheets during the previous 12 months. Requested copies of the computer training for the five listed CNA's from the Director of Nursing (DON) and the Administrator on 9/27/24 and did not receive. During an interview on 9/27/24 at 8:50 A.M., CNA H said: -There were in-service meetings that went over different topics. -In-services were not every month. -Sometimes staff were handed a review sheet to read and sign that he/she read it. -He/She did the computer training's when he/she had time. -He/She was not sure of all the topics that he/she had done. -He/She did not believe he/she had been watched or observed doing resident cares. During an interview on 9/27/24 at 9:13 A.M., CNA J said: -Sometimes staff were handed a review sheet to read and sign that he/she read it. -He/She did the Relias computer training's when he/she had time. -There had been some in person in-services. -He/She has had the Abuse/Neglect, behavioral in-services but not sure of the last time he/she had them or if they were in person or on the computer. During an interview on 9/27/24 at 11:57 A.M., the DON said: -CNA's should receive at least 12 hours of in-services, education and training's a year. -Some of the in-services/education were done through the computer training program. -He/She and the Assistant DON (ADON) could monitor the program. -In-Services, education and training's should include: --Infection Control. --Dementia/Alzheimer care. --Misappropriation. --Behavioral training. --Resident Rights. -In person in-services were held monthly and presented by different facility department heads depending on the subject. -Staff evaluations and competencies should be audited at least quarterly by the DON or the ADON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staffing was posted correctly including the total number and actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), Certified Nursing Assistants (CNA's), and Certified Medication Technicians (CMT's) directly responsible for resident care per shift which could have the potential to affect all residents, staff, and visitors of the facility. The facility census was 74 residents. Requested the facility policy for daily posted staffing and did not receive it. 1. Review of the Facility assessment dated [DATE] showed nursing services required daily was: -1 Director of Nursing (DON) full time days. -4 LPN's. -4 CMT's. -10 CNA's. Observation on 9/23/24 at 10:10 A.M., of the glass case bulletin board in the common area near the 600-hall showed: -Staffing sheets for 9/20/24, 9/21/24, 9/22/24 and 9/23/24. -The staffing sheets showed the names of the staff working for each position. -Did not show the number of hours worked for each staff. -Did not show census for the day. Observation on 9/23/24 at 2:46 P.M., of the main nursing station for the 400, 500, and 600 halls showed: -A white board (a wipeable board with a white surface used for posting information that can be erased and rewritten on) on the wall behind main nurse station showed the following: -24-hour daily nursing hours report. -Date of 7/24/24. -Day shift: --RN 16 hours. --LPN 24 hours. --CMT 24 hours. --CNA 60 hours. -Night shift: --LPN 24 hours. --CMT 24 hours --CNA 60 hours. --One staff doing a 1:1 (a resident needs around the clock supervision). -Did not show the number of staff for each position. -Did not show the census for the day. Observation on 9/23/24 at 2:55 P.M., of the 100, 200, and 300 halls nursing station did not have any posted staffing. Observation on 9/24/24 at 11:02 A.M., of the main nursing station for the 400, 500, and 600 halls showed: -A white board on the wall behind main nurse station showed the following: -24-hour daily nursing hours report. -Date of 7-24-24. -Day shift: --RN 16 hours. --LPN 24 hours. --CMT 24 hours. --CNA 60 hours. -Night shift: --LPN 24 hours. --CMT 24 hours --CNA 60 hours. --One staff doing a 1:1. -Did not show the number of staff for each position. -Did not show the census for the day. Observation on 9/24/24 at 11:05 A.M., of the glass case bulletin board in the common area near the 600-hall showed: -Staffing sheets for 9/23/24 and 9/24/24. -The staffing sheets showed the names of the staff working for each position. -Did not show the number of hours worked for each staff. -Did not show the census for the day. Observation on 9/24/24 at 11:15 A.M., of the 100, 200, and 300 halls nursing station did not have any posted staffing. During an interview on 9/25/24 at 5:58 A.M., the DON said the night shift had: -Two nurses one on each side of the facility. -Four CNA's on the main side 400, 500, and 600 halls. -One CNA on the back side 100, 200, and 300 halls those residents are more independent with own cares. Observation on 9/25/24 at 8:15 A.M., of the main nursing station for the 400, 500, and 600 halls showed: -A white board on the wall behind main nurse station showed the following: -24-hour daily nursing hours report. -Date of 9/24/24. -Day shift: --RN 16 hours. --LPN 24 hours. --CMT 24 hours. --CNA 60 hours. -Night shift: --LPN 24 hours. --CMT 24 hours --CNA 60 hours. --One staff doing a 1:1. -Did not show the number of staff for each position. -Did not show the census for the day. Observation on 9/25/24 at 8:20 A.M., of the glass case bulletin board in the common area near the 600-hall showed: -Staffing sheets for 9/24/24 and 9/25/24. -The staffing sheets showed the names of the staff working for each position. -Did not show the number of hours worked for each staff. -Did not show the census for the day. Observation on 9/25/24 at 8:25 A.M., of the 100, 200, and 300 halls nursing station did not have any posted staffing. Observation on 9/26/24 at 2:15 P.M., of the main nursing station for the 400, 500, and 600 halls showed: -A white board on the wall behind main nurse station showed the following: -24-hour daily nursing hours report. -Date of 9/26/24. -Day shift: --RN 16 hours. --LPN 24 hours. --CMT 24 hours. --CNA 60 hours. -Night shift: --LPN 24 hours. --CMT 24 hours --CNA 60 hours. --One staff doing a 1:1. -Did not show the number of staff for each position. -Did not show the census for the day. Observation on 9/26/24 at 2:20 P.M., of the glass case bulletin board in the common area near the 600-hall showed: -Staffing sheets for 9/25/24 and 9/26/24. -The staffing sheets showed the names of the staff working for each position. -Did not show the number of hours worked for each staff. -Did not show the census for the day. Observation on 9/26/24 at 2:25 P.M., of the 100, 200, and 300 halls nursing station did not have any posted staffing. Observation on 9/27/24 at 9:07 A.M., of the main nursing station for the 400, 500, and 600 halls showed: -A white board on the wall behind main nurse station showed the following: -24-hour daily nursing hours report. -Date of 9/27/24. -Day shift: --RN 16 hours. --LPN 24 hours. --CMT 24 hours. --CNA 60 hours. -Night shift: --LPN 24 hours. --CMT 24 hours --CNA 60 hours. --One staff doing a 1:1. -Did not show the number of staff for each position. -Did not show the census for the day. Observation on 9/27/24 at 9:10 A.M., of the glass case bulletin board in the common area near the 600-hall showed: -Staffing sheets for 9/26/24 and 9/27/24. -The staffing sheets showed the names of the staff working for each position. -Did not show the number of hours worked for each staff. -Did not show the census for the day. Observation on 9/27/24 at 9:15 A.M., of the 100, 200, and 300 halls nursing station did not have any posted staffing. During an interview on 9/27/24 at 9:20 A.M., CNA J said: -Staffing sheets were in the glass case by the 600 hall on the main nurse's station. -Staffing sheets showed the names of the staff working each shift. -Did not think the staffing sheets were on the 100, 200, 300 nursing station. During an interview on 9/27/24 at 9:20 A.M., LPN A said: -Daily staffing sheets were on the bulletin board on the main nurse's station near the 600 hall. -The staffing sheets showed who was working that day. -Not sure if the staffing sheets should have the hours each staff worked or the facility census. -There was a white board behind the main nurses' station that showed the number of hours for each staff position. During an interview on 9/27/24 at 11:57 A.M., the DON said: -The daily staffing sheet was posted daily in the glass bulletin board at the main nurses' station. -The staffing sheet showed the name of the staff working for each nursing position for that day and shift including the RN. -The staffing sheet did not show the total number of hours worked for each position. -The staffing sheet did not show the daily facility census. -The number of hours worked for each nursing position was on the white board behind the main nursing station. -The facility daily census was not on the white board. -There was no staffing posted on the 100, 200, 300 hall nurses' station. -Daily staffing should include the hours for each position and the facility census. These were not on the same form. -The daily staffing should be posted on the 100, 200, 300 hall side of the facility.

Based on observation, interview, and record review, the facility failed to ensure medication carts were locked when staff was not in sight of the cart, failed to ensure medication carts were clean and did not contain other non medical objects, failed to ensure the medication refrigerator's temperature was within temperature range by not checking it daily, failed to ensure nursing staff was counting narcotics at the beginning and end of each shift for three sampled residents, (Resident #61, #42, and #325) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy, Medication Storage Policy, dated 5/18/24 showed: -All drugs and biologicals would have been stored in locked compartments under proper temperature controls. -During a medication pass, medications must be under the direct observation of the person administering medications or locked. -Any discrepancies which could not been resolved must have been reported immediately as follows: -Notify the Director of Nursing (DON), charge nurse, or designee and the pharmacy. -Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted. -Staff may not leave the area until discrepancies were resolved or reported as unresolved discrepancies. -All medications requiring refrigeration were to have been stored in refrigerators located in the medication rooms. -Temperatures were to have been maintained within 36 to 46 degrees Fahrenheit (F). -Charts were to have been kept on each refrigerator and temperature levels were to have been recorded daily by the charge nurse or other designee. -In the event that a refrigerator was malfunctioning, the person discovering the malfunction must promptly report such finding to the Maintenance Department for emergency repair. Review of the facility's policy, Controlled Substance Administration and Accountability Policy, dated 5/14/24 showed: -The facility would have safeguards in place in order to prevent loss, diversion or accidental exposure. -The charge nurse or other designee was to have conducted a daily audit of the required documentation of controlled substances. -Areas without an automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for for 24 hour recording of controlled substance use. -The amount on hand was to have been checked against the amount used daily from the documentation records. -For areas without an automated dispensing system, two licensed nurses account for all controlled substances and access keys at the end of each shift. -Any discrepancy in the count of controlled substances or disposition of the narcotic keys was to have been resolved by the end of the shift during which it was discovered. -Staff may not leave the area until discrepancies were resolved. 1. Observation on 9/25/24 at 7:03 A.M. of the 100/200/300 hall Nurses' medication cart with Licensed Practical Nurse (LPN) B showed: -There was a container of bleach wipes and a bottle of isopropyl alcohol (rubbing alcohol used in cleaning) in the locked narcotic box with the residents' prescribed medications. -There was a pair of used toe nail clippers, a lighter, a box cutter, a computer mouse, and a stapler in a drawer with the residents' prescribed medications. During an interview on 9/25/24 at 7:03 A.M. LPN B said: -There should not have been any other items in with the residents' prescribed medications. -The person who had used the cart was responsible for ensuring it was clean and there were no items that didn't belong in the medication cart. 2. Observation on 9/25/24 at 7:26 A.M. of the Certified Medication Technician's (CMT) medication cart for 100/200/300/ halls with CMT C showed: -The drawers had a brown colored debris in with the residents' prescribed medications. -There was one loose red oblong pill in a drawer with the residents' prescribed medications. During an interview on 9/25/24 at 7:26 A.M. CMT C said: -There should not have been loose pills in the medication cart drawers. -The person who had used the cart was responsible for ensuring it was clean and there were no items that didn't belong in the medication cart. 3. Observation on 9/25/24 at 7:26 A.M. showed: -The night shift nurse (LPN C) left without counting the narcotics in the locked medication drawer with the day shift CMT (CMT C) for the CMT medication cart for the 100/200/300 halls. During an interview on 9/25/24 at 7:26 A.M. CMT C said: -The night shift nurse should have counted the narcotics with him/her before leaving. -There were many blanks where there should have been two signatures verifying the count was correct. -The person coming on shift counts with the off going staff and both of them should have signed at the same time they had counted. -If there was a blank space the DON should have been notified. -He/She had not notified the DON but should have when there were not two signatures. -He/She would count without the second person to count with him/her. During an interview on 9/25/24 at 7:30 A.M. LPN B said: -He/she had told the night shift nurse (LPN C) not to leave before counting with the day shift CMT. -The narcotic count should have been signed by two nurses at the beginning and end of each shift. -The oncoming nurse should have counted with the off going nurse. -There should not have been any blanks. -The DON should have been notified. -He/she knew there were many blanks but had not said anything to the DON. During an interview on 9/25/24 at 7:30 A.M. LPN C declined to be interviewed. Observation on 9/26/24 at 8:20 A.M. showed the night shift nurse (LPN C) left without counting with the day shift CMT. During an interview on 9/26/24 at 8:20 A.M. LPN B said he/she had told the night shift nurse not to leave before counting with the day shift CMT. During an interview on 9/26/24 at 8:20 A.M. LPN C declined to be interviewed. 4. Observation on 9/25/24 at 7:47 A.M. of the medication pass with CMT C showed: -He/She went into a resident's room to administer medications. -He/She left the medication cart unlocked for three minutes while in the resident's room. -The cart was facing outward. -One resident walked by the unlocked cart within two feet of it. Observation on 9/25/24 at 7:51 A.M. of the medication pass with CMT C showed: -He/She went into a resident's room to administer medications. -He/She left the medication cart unlocked for two minutes while in the resident's room. -The cart was facing outward. -One resident walked by the unlocked cart within two feet of it. Observation on 9/25/24 at 7:55 A.M. of the medication pass with CMT C showed: -He/She went into a resident's room to administer medications. -He/She left the medication cart unlocked for two minutes while in the resident's room. -The cart was facing outward. -One resident walked by the unlocked cart within two feet of it. During an interview on 9/25/24 at 7:55 A.M. CMT C said if staff were not in front of the medication cart it should have been locked he/she had forgotten to lock the cart. During an interview on 9/25/24 at 8:30 A.M. LPN B said staff should never leave the medication cart unlocked if they were not directly in front of it. 5. Observation on 9/25/24 at 8:00 A.M. of the September 2024 medication refrigerator log for 100/200/300 hall with LPN B showed: -Out of 24 shifts, 11 shifts showed the temperature was blank, indicating it was not checked. -On 9/14/24 showed there was no thermometer. -There was no documentation from 9/14/24 to 9/23/24. -On 9/24/24 the temperature was recorded at 25.0 degrees Fahrenheit ( F) (below freezing) and the refrigerator's temperature was reset. --There was no documentation the temperature was rechecked. --There was no documentation the maintenance department was notified. -There were more than 10 insulin pens in the medication refrigerator, directions on the box said to keep insulin between 36 to 46 degrees F do not freeze. -One vial of Tuberculin (TB -a bacteria, a skin test for TB injected into the skin) was in the refrigerator, directions said TB was to be stored at 35 to 46 degrees F. -There was no documentation the pharmacy had been notified about the medications that had been at a temperature that was out of range. During an interview on 9/25/24 at 8:10 A.M. LPN B said: -The night shift nurse was responsible for checking the temperature in the medication refrigerator. -There should not have been any days missed. -If the temperature was out of range the nurse should have told the charge nurse. -He/She did not know what to do if the medications had been frozen. -The DON was ultimately responsible for ensuring medications were stored at the correct temperature. 6. Review of Resident #61's Individual Patient Narcotic Record with LPN B showed: -The resident had a Physician's order for Hydrocodone/Tylenol (pain medication) 5/325 milligram (mg) one or two tablets by mouth to be given every six hours as needed. -On 9/22/24 the count was 60. -From 9/22/24 to 9/25/24 10 times two tablets were given for a total of 20 tablets. -The remaining amount documented was 42 tablets (verified by surveyor and LPN B). -60 tablets minus the 20 given should have equaled 40. 7. Review of Resident #42's Individual Patient Narcotic Record with LPN B showed: -The resident had a Physician's order for Lorazepam (used to treat anxiety) 0.5 mg tablet one tablet by mouth every four hours as needed. -On 9/17/24 the count was 15. -On 9/17/24 the medication was given twice. -The remaining amount was 11 (verified by surveyor and LPN B). -The count was corrected by staff to have been 11. -15 minus 2 should have equaled 13. 8. Review of Resident #325's Individual Patient Narcotic Record with LPN B showed: -The resident had a Physician's order for Tramadol Hydrochloride (medication for moderate to severe pain) 50 mg tablet to be given every six hours as needed. -The resident had a second order for Tramadol Hydrochloride 50 mg tablet to be given every six hours. -On 9/20/24 at 12:00 A.M. the record showed the resident received one as needed pill from the nurse and one as needed pill from the CMT. -On 9/25/24 at 6:00 A.M. the nurse gave the resident one scheduled pill and one as needed pill. -LPN B did not know why this had happened. -The DON should have been notified, he/she had not reported anything to the DON. 9. Review of the CMT Narcotic Count sheet dated July 2024 showed: -7/1/24 to 7/8/24 (two shifts per day with two signatures per shift) out of 32 opportunities there were 23 times there were missing signatures. -There were 11 out of 16 shifts with no card count at the end of the shift. -Started with 11 cards, four were added, two were subtracted should have equaled 13, facility showed 11. -7/9/24 to 7/26/26 the narcotic count sheet was missing. -7/27/24 to 7/31/24 out of 20 opportunities there were 11 times there were missing signatures. -There were 7 out of 10 shifts with no card count at the end of the shift. Review of the CMT Narcotic Count sheet dated August 2024 showed: -8/1/24 to 8/30/24 (two shifts per day with two signatures per shift) out of 120 opportunities 55 times there were missing signatures. -There was no documentation for 8/31/24. -There were 23 out of 60 shifts with no card count at the end of the shift. -Started with 11 cards, 12 were added, eight were subtracted should have equaled 15, facility showed 9. Review of the CMT Narcotic Count sheet dated September 2024 showed: -9/1/24 to 9/25/24 (two shifts per day with two signatures per shift) out of 96 opportunities 60 times there were missing signatures. -There were 26 out of 48 shifts with no card count at the end of the shift. 10. Review of the Nurses' Narcotic Count sheet dated July 2024 showed: -7/1/24 to 7/31/24 (two shifts per day with two signatures per shift) out of 124 opportunities 15 times there were missing signatures. -There were 29 out of 62 shifts with no card count at the end of the shift. Review of the Nurses' Narcotic Count sheet dated August 2024 showed: -8/1/24 to 8/31/24 (two shifts per day with two signatures per shift) out of 124 opportunities 12 times there were missing signatures. -There were 14 out of 62 shifts with no card count at the end of the shift. -Started with 15 cards, four were added, 10 were subtracted should have equaled nine, facility showed 10. Review of the Nurses' Narcotic Count sheet dated September 2024 showed: -9/1/24 to 9/25/24 (two shifts per day with two signatures per shift) out of 98 opportunities 16 times there were missing signatures. -There were 13 out of 48 shifts with no card count at the end of the shift. -On 9/25/24 the night shift nurse had pre signed the Narcotic count sheet before the day shift nurse arrived at the facility. 11. During an interview on 9/27/24 at 12:00 P.M. the DON said: -Staff were to keep the medication carts locked if they were not directly in front of it. -Two nursing staff were expected to count the narcotics at the beginning and end of each shift. -The on coming nurse and the off going nurse would count at the same time ensuring the count was correct. -There should not have been any blank spaces, or he/she should have been notified. -The DON and Assistant DON have done audits weekly on the narcotic count sheets. -There should not have been an non medical objects in the medication cart. -The staff member who had used the cart was responsible for ensuring the cart was clean without other objects in it. -Pharmacy also did cart audits. -The night shift charge nurse was responsible for ensuring that the medication refrigerator was within range, every night shift. -If the medication refrigerator was out of range it was expected staff notified the maintenance department so it could be adjusted and the medication did not freeze. -If the medications were out of range then the Pharmacy should have been notified and they would have directed them what to do. -The acceptable temperature range for the medication refrigerator was 36 to 42 degrees F. -The temperature should have been rechecked if it had been adjusted and documented on the temperature log sheet. -The DON, Charge Nurse, and CMT did weekly audits of the temperature on the medication refrigerator.

Based on observation and interview the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to safeguard against foreign material possibly getting into food and/or beverages; failed to keep trash dumpsters lidded; failed to consistently measure and document hot food temperatures at the oven and/or stove, or steam table to ensure they were suitably cooked, and cooked longer if needed, to lessen the chance of bacterial contamination; failed to maintain plastic and/or rubber cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs; failed to store foodstuffs within acceptable temperature parameters; and failed to ensure the proper labeling, refrigeration, and/or disposal of foodstuffs to preserve their freshness, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 74 residents with a licensed capacity for 91 residents at the time of the survey. 1. Observation on 9/23/24 between 9:24 A.M. and 10:10 A.M. during the initial kitchen inspection with the Dietary Manager (DM) showed the following: -The ice machine in the kitchenette off the kitchen proper had a non-sealing gasket on its lid. -The manual can opener had paper debris on the blade. -A red handled spatula in the top utensil drawer that had chips on and around its blade and crumbs in the bottom of its drawer and the middle drawer. -Four of five 50 ounce (oz.) cans of cream of chicken soup on a baker's rack in the Dry Storage (DS) were dented on their sides and/or upper rims and a 6 pound (lb.) 14 oz. large can of black beans on the can dispenser rack was heavily dented on its side -One open 1 gallon (gal.) jug of 13 jugs of soy sauce on a bottom shelf of a rack in the southwest corner of the DS was approximately (app.) 3/5 full and its label read to Refrigerate after Opening for Quality. -The green, beige, white, and red cutting boards by the east window were excessively scored to the point of plastic flaking off. -There were 15 undated jars of 16 oz. grated parmesan cheese in the walk-in refrigerator with plastic trash and a lettuce leaf on the floor, and an undated 4 oz. vanilla ice cream cup and paper trash on the floor of the walk-in freezer. -There were no visible thermometers in the Serving Room refrigerator or either of the walk-ins. Observation on 9/23/24 at 11:48 A.M. during the initial facility Life Safety Code (LSC) outdoor perimeter inspection with the Maintenance Supervisor (MS) showed the north lid of the west dumpster was flipped backward completely. Observation on 9/24/24 at 12:01 P.M. during a follow-up outer perimeter LSC inspection showed the north lid of the west dumpster was flipped backward completely. Observation on 9/24/24 between 12:26 P.M. and 12:43 P.M. showed the following: -There was a red handled spatula in the top utensil drawer that had chips on and around its blade and crumbs in the bottom of its drawer and the middle drawer. -Two remaining 50 oz. cans of cream of chicken soup on the baker's rack in the DS were dented on their sides and/or upper rims and a 6 lb. 14 oz large can of black beans on the dispenser rack was heavily dented on its side. -One open 1 gal. jug of 13 jugs of soy sauce app. 3/5 full on a bottom shelf in the southwest corner of the DS read Refrigerate after Opening for Quality on its label. -The green, beige, white, and red cutting boards by a window were excessively scored. -There were 15 16 oz. undated jars of grated parmesan cheese in the walk-in refrigerator with a lettuce leaf on a bottom shelf and butter pod on the floor. -There was no thermometer in the Serving Room fridge or either of the walk-ins. -The food temperature log sheet for 9/2/24 in a binder by the walk-in refrigerator had temperatures recorded for breakfast and lunch, but none for dinner, and no further days filled out. Observation on 9/25/24 at 9:45 A.M. during another follow-up outer perimeter LSC inspection showed the south lid of the west dumpster was flipped backward completely. During an interview on 9/26/24 at 1:44 P.M. the new DM said the following: -The cooks were responsible for cleaning the walk-in floors. -He/She would expect if a foodstuff read store at a certain temperature on its label that it would be. -Damaged foodstuffs were separated out, they contact the food vendor for a credit, and then they are thrown out. -Damaged food preparation items were brought to their attention by the dietary staff and replaced. -He/She would expect food to be free of foreign substances. -Food temperatures should be taken and recorded when they were done cooking, when they were served, and if a resident complained about it. -Refrigerators and freezers should have extra thermometers inside. -After each meal or meal clean-up the leftover garbage was thrown away, bagged up, and taken outside to the dumpsters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #49's face sheet showed he/she had the following diagnoses: -Colostomy. -Malignant neoplasm of the colon (a cancer of the colon). Review of the resident's Care Plan dated 7/24/24 showed: -He/She had a colostomy due to malignant neoplasm of the colon. -NOTE: the Care Plan did not address EBP. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 8/4/24 showed: -He/She was cognitively intact. -He/She had a colostomy. -He/She had malignant neoplasm of the colon. -The MDS did not address EBP. Review of the resident's POS dated September 2024 showed the following order: -Change the colostomy bag and wafer (the pouching system around the stoma (the opening of the colostomy), use water to clean around the site, pat dry. Cut the wafer to fit the stoma. Change every three days on the night shift and as needed, dated 9/22/24. -There was no order for EBP. Observation on 9/23/24 at 10:47 A.M. showed: -There was no sign for EBP on the resident's door. -There was no isolation cart for PPE. During an interview on 9/25/24 CNA B said: -He/She did stoma cares for the resident. -During cares he/she would wear gloves and a mask. -He/She would not have worn a gown. -There were no masks in the resident's room. -Every resident's room had a box of gloves. During an interview on 9/25/24 at 7:58 A.M. CNA C said: -When he/she did stoma care on the resident he/she would have worn gloves, no mask, no gown. Observation on 9/25/24 at 10:11 A.M. of stoma care showed: -CNA C changed the resident's colostomy bag wearing only gloves. During an interview on 9/26/24 LPN A said: -During colostomy care staff should have worn gloves, a gown, and a face shield. -Supplies were available in central supply. During an interview on 9/26/24 at 11:16 A.M. the Assistant Director of Nursing (ADON) said: -He/She was unsure if the resident should have been on EBP. -He/She used a gown for his/her own protection. -The staff should have been trained on EBP. 6. Review of Resident 41's face sheet showed he/she had the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe).) -Malignant Neoplasm of Bronchus and lung (a cancer that begins in the lungs and often spreads). -Tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea(windpipe) from outside the neck). Review of the resident's care plan dated 6/4/24 showed: -He/She had a tracheostomy and performed own cares. -It did not show he/she had nebulizer treatments. -It did not show he/she was able to administer own breathing treatments. Review of the resident's Discharge Summary MDS dated [DATE] showed: -He/She had Cardiorespiratory conditions (heart and lungs). -He/She had COPD. -He/She had cancer. -No breathing problems was checked. -He/She was receiving tracheotomy cares. Review of the resident's POS dated September 2024 showed the following orders: -Change nebulizer/oxygen tubing every Sunday on night shift, dated 9/19/24. -Oxygen at two liters per nasal cannula (a device that delivers extra oxygen through a tube into your nose) as needed, dated 9/19/24. -Albuterol Sulfate Inhalation Nebulization solution (medication used to prevent and treat wheezing,difficulty breathing,caused by lung diseases) 1.25 milligrams(mg)/3 milliliters (ml) one vial inhale orally via nebulizer every six hours as needed for wheezing, dated 9/22/24. Observation on 9/23/24 at 10:05 A.M. showed: -He/She had a tracheostomy. -His/Her nebulizer mask was on the dirty floor, not in a bag. -There was no date on the tubing. During an interview on 9/23/24 at 10:05 A.M. the resident said: -He/She had a tracheostomy for four years and took care of it himself/herself. -He/She did not think the staff had ever changed out the tubing. -The staff had not provided a bag for the nebulizer. -The staff was supposed to have provided a humidifier for the oxygen. -He/She had asked the nurse several times and still did not have a humidifier. -He/She had not seen the staff ever clean the nebulizer mask. Observation on 9/24/24 at 8:00 A.M. showed: -The nebulizer mask and tubing sitting on a dirty (greasy) plastic cart, not in a bag. During an interview on 9/25/24 at 7:56 A.M. Certified Mediation Technician (CMT) C said: -The resident was able to do his/her own nebulizer treatments. -The tubing for the nebulizer should have been changed out weekly by the night shift CNA's. -The nebulizer mask should have been changed out weekly by the night shift CNA's. -The oxygen tubing, nebulizer mask and tubing should have been in a bag with the date it was changed written on it. -The tubing and mask should not have been on the floor. -Anyone could change the nebulizer mask and tubing. -He/She had seen the tubing and nebulizer on the floor. -He/She did not change the tubing or the nebulizer mask, Observation on 9/25/24 at 8:50 A.M. showed: -LPN B looked into the resident's room and saw the nebulizer mask on the floor. -He/She did not change out the tubing or the nebulizer mask. During an interview on 9/25/24 at 8:50 A.M. LPN B said: -Oxygen tubing or tubing for the nebulizer should have been changed out weekly by the night shift CNA's. -The nebulizer mask and tubing should have been in a bag with the date it was changed out written on it. -Anyone who went in the room should have seen the tubing and mask on the floor and changed it out. Observation on 9/25/24 at 9:00 A.M. showed: -The nebulizer mask and tubing sitting on a dirty (greasy) plastic cart, not in a bag. 7. Observation on 9/25/24 at 7:46 A.M. with CMT C showed: -He/She did not cleanse his/her hands before delivering a resident's medications to him/her. -When the CMT came out of the resident's room he/she reached into the trash and pulled out a piece of paper with his/her bare hands. -He/She did not cleanse his/her hands before continuing medication pass. -He/She went into a different resident's room to deliver medications. -He/She did not cleanse his/her hands when he/she came out of the room and continued medication pass. During an interview on 9/25/24 at 8:00 A.M. CMT C said: -Staff should cleanse their hands before starting medication pass, after the medication pass, and after administering medications to each resident. -He/She should not have reached into the trash without washing his/her hands after. -The DON had provided education on hand washing. During an interview on 9/25/24 at 8:50 A.M. LPN B said: -The Administrator and DON had provided education on hand washing. -Staff should wash their hands before and after medication pass. -Staff should wash their hands after delivering medications to each resident. -The CMT should have washed his/her hands after reaching into the trash. 8. During an interview on 9/27/24 at 9:32 A.M. the Infection Preventionist/LPN said: -Handwashing should have been done before and after doing cares with a resident. -Staff was expected to wash their hands after passing medications after every third resident. -The CMT should have washed his/her hands after reaching into the trash bag. -Residents who had a catheter, feeding tube, or tracheostomy should have had EBP. -There should have been a sign on the door to alert staff EBP was to be used with that resident. -There should have been an isolation bag with PPE hanging on that door. -He/She should have provided education to the staff regarding EBP, he/she had not done this. -He/She had no documentation of infection control training that had been provided to the staff, such as monitoring hand washing. -He/She had not provided any education to staff regarding hand washing. -Oxygen tubing and equipment such as a nebulizer mask should have been changed out on Sundays. -The oxygen equipment should have been changed out by a CNA on Sunday night with a date on the bag that it had been changed. -Even if the resident self-administered nebulizer treatments the staff was responsible for changing it out. -He/She was responsible for ensuring Infection policies were followed by the staff. During an interview on 9/27/24 at 12:00 P.M. the DON, RDO, and Administrator said: -During a medication pass staff should have cleansed their hands before and after the medication pass, and after administering medications to each resident. -The CMT should have washed his/her hands after reaching into the trash. -Anyone with a manmade opening to the body should have been on EBP. -This would have included; catheters, feeding tubes, colostomy, and wounds. -There should have been a sign on the resident's door alerting staff to use EBP with that resident. -There should have been an isolation cart so that staff would have had access to PPE. -EBP should have been documented in the resident's care plan. -They were expected to have worn a gown, gloves, and a mask while providing cares for the resident. -No education had been provided to the staff regarding EBP. -The DON was responsible for ensuring staff was using EBP and had been educated on it. -Oxygen tubing/nebulizer equipment should have been stored in a clean plastic bag even if the resident was self-administering. -Oxygen tubing/nebulizer equipment should not have been on the floor. -The CNA's were responsible for changing the tubing out weekly on the night shift. -The oxygen tubing should have been stored in a clean bag with the date it was changed out written on it. Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility failed to properly screen and follow their policies for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for eight out of nine new employees sampled for TB screening. This practice had the potential to affect all residents, employees, and visitors to the facility. The facility failed to ensure staff practiced Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities example residents with wounds or indwelling medical devices) for one sampled resident (Resident #49) who had a colostomy (a surgical opening into the large intestine), for one sampled resident (Resident #28) who had a supra pubic catheter (a surgically created connection between the bladder and the skin to drain urine from the bladder in individuals with an obstruction of normal urinary flow), and one sampled resident (Resident #20) who had a pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin), failed to ensure staff was educated on EBP, failed to ensure staff were cleansing their hands during a medication pass, and failed to ensure a nebulizer mask ( liquid medicine delivered as a mist that was inhaled through a mouthpiece or mask) was kept in a sanitary condition for one sampled resident (Resident #41) out of 19 sampled residents. The facility census was 74 residents with a licensed capacity for 91 residents at the time of the survey. 1. Observation on 9/23/24 between 9:24 A.M. and 10:10 A.M. during the initial facility Life Safety Code (LSC) kitchen inspection with the Dietary Manager (DM) showed there was a three-sink area, an ice machine, a low-heat chemical dish-washing machine, and a hand-washing sink. During an interview on 9/23/24 at 2:07 P.M. the Administrator said the following: -They had only been working at this facility for about six months and they had not had the chance to go through the whole disaster manual yet. -They could not say if there was a copy of their disaster manual at the nurses' desks. Review of the undated binder from their East Nurse Station entitled Edgewood Manor Disasters Book showed it was full of their residents' admission face sheets only. Observation on 9/24/24 between 3:10 P.M. and 3:45 P.M. during the facility LSC walk-through inspection with the Maintenance Supervisor (MS) showed the following: -The building was equipped with a full fire sprinkler system and had its incoming water supplied by the local water company. -There was a piped fire sprinkler riser room (A dedicated space for fire protection equipment) which served the whole facility's system. -There were housekeeping closets and water heaters throughout the six resident room hallways. -There were at least 54 resident rooms with private or shared bathrooms and sinks. -There was a laundry area with two commercial grade clothes washers. -There were two Shower Rooms, two gender specific public restrooms, and a Beauty Shop with a sink. Review of the facility's binder entitled Edgewood Manor Disaster Manual, last reviewed 2/27/23 and provided by the Administrator, under the heading, Legionnaire - Water Management Program, was a 35-page policy and procedure which showed the following: -The answers to the 2-page Worksheet to Identify Buildings at Increased Risk for Legionella Growth and Spread showed the building was a healthcare facility that housed people primarily older than 65-years overnight and therefore needed a water management program. -The Water Management Facility Documentation Form listed a previous Administrator and Maintenance Supervisor. -The page with the heading Water System Diagram had a written explanation of the water flow throughout the facility, but no schematic, diagram, or flowchart of the facility's water system that indicated areas of risk with the potential likelihood and risk level for each. -There was no facility-specific risk management plan assessment that considered all elements of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed CDC toolkit assessment. -There were sampling results on the water analyzed 8/16/24, but no documentation of any site logbook being maintained with any cleanings, sanitizings, descalings, and/or inspections mentioned. During an interview on 9/26/24 at 12:53 P.M. the MS said the following: -He/She took samples of the facility's water and sent them off to a lab for testing. -He/She was somewhat familiar with the federal requirements. -He/She educated themselves on them by reading their policy and asking the lab questions about it. During an interview on 9/26/24 at 2:46 P.M. the Administrator said the following: -Their MS was responsible for implementing the Legionella program. -He/She believed they were aware of some of the basic requirements. -They had not had a chance to look at all of their policy, however. 3. Review of the facility's policy, Infection Prevention and Control Program, dated 5/7/24 showed: -The designated Infection Preventionist was responsible for oversight of the program and served as a consultant to out staff on infectious diseases, implementing isolation precautions, staff and resident exposures, surveillance, and investigations of exposures of infectious diseases. -See Infection Preventionist Policy. -All staff were responsible for following all policies and procedures related to the program. -A system of surveillance was to have been utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. -The Infection Preventionist serves as the leader in surveillance activities, maintained documentation of incidents, findings, and any corrective actions made by the facility and reported surveillance finding to the facility's Quality Assessment and Assurance Committee. -All staff should have assumed that all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. -Hand hygiene was to have been performed in accordance with the facility's established hand hygiene procedures. -All staff was to have used personal protective equipment (PPE) according to established facility policy governing the use of PPE. See PPE policy. -Licensed staff was to have adhered to safe injection and medication administration practices, as described in relevant facility policies. -All staff would have received training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. -All staff was to have demonstrated competence in relevant infection control practices. -Direct care staff was to have demonstrated competence in resident care procedures established by our facility. -The facility would have conducted an annual review of the infection prevention and control program, including policies and procedures based upon the facility assessment which included any facility and community risk. -Following the review, the infection and prevention control program would have been updated as necessary. The facility did not have a policy for Infection Preventionist. The facility did not have a policy for EBP. The facility did not have a hand washing policy. Review of Resident #28's admission Record showed he/she was admitted with the following diagnoses: -Neuromuscular Dysfunction of the Bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Retention of urine (a condition in which urine cannot empty from the bladder). Review of the resident's Physicians Order Summary (POS) dated September 2024 showed: -Supra Pubic Catheter 20 FR (French scale -a unit of measurement used to size catheters) with a 30 cubic centimeter (cc-a measure of volume in the metric system) balloon (a flexible part of the catheter tip that is inflatable to hold the catheter in the bladder). -Cleanse urostomy (Urinary diversion - a surgically created opening in the abdominal wall through which urine passes) site with wound cleanser twice a day (BID) and as needed (prn); cover with abdominal pad dressing (ABD pad an extra thick primary or secondary dressing used for wounds) two times a day for Prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease). Observation on 9/23/24 at 1:18 P.M., of the resident's room showed: -No posted signage on the door or near the door for EBP precautions. -No isolation cart outside the room for the required Personal Protective equipment (PPE-gowns, gloves, face masks, goggles or face shields) for staff to wear while doing resident cares. Observation on 9/24/24 at 1:15 P.M., of the resident's Suprapubic catheter care and Perineal care (care to the area between the anus and the exterior genitalia) showed: -Certified Nursing Assistants (CNA)'s J, CNA M and Licensed Practical Nurse (LPN) A did not put on the EBP PPE before entering the resident's room. -CNA J and CNA M did not change gloves after the perineal care before changing the resident's bed linen. -CNA J, CNA M and LPN A did not wear the EBP PPE when doing cares for the resident. -No posted signage on the door or near the door for EBP precautions. -No isolation cart outside the room for the required PPE. During an interview on 9/27/24 at 8:50 A.M., CNA H said: -He/She washed his/her hands and put on gloves when entering a resident's room to do any cares. -He/She removed gloves and washed or sanitized his/her hands before putting on clean gloves if he/she touched other items during cares. -He/She removed gloves and washed or sanitized his/her hands and put on clean gloves when going from a dirty body part to a clean body part. -He/She removed gloves and washed his/her hands when finished with resident cares. During an interview on 9/27/24 at 9:13 A.M., CNA J said: -Should wash hands and put on gloves when entering a resident's room to do any cares. -Should change gloves wash or sanitize hands when going from a dirty body part to a clean body part during perineal care. -Should change gloves wash or sanitize hands if he/she touched other items in room during perineal cares. -Should wash or sanitize hands between any glove changes. -He/She did not know what EBP was thought it was an ointment to place on a resident's buttock. -He/She had not received any education pertaining to EBP. -Did not know he/she was supposed to be wearing PPE when caring for any resident with a catheter, colostomy, or tube feeding. -There were no signs showing to wear PPE on resident doors who had catheters, colostomies, or tube feedings. -There were no isolation carts with PPE outside of residents rooms who would require EBP. -Had not worn any type of PPE for residents who may need EBP except for gloves when doing cares. During an interview on 9/27/24 at 9:30 A.M., LPN A said: -He/She thought EBP was an ointment. -Had not received any education on EBP. --When informed what EBP was LPN A said he/she had received education in July 2024 on the online training program when he/she started at the facility. -Would know which residents would need EBP/PPE by looking at the resident's care plan. -EBP/PPE was required if the resident had any type of tubes going into the body. -The facility did not put signs for EBP/PPE on the resident's doors who required it. -The facility did not keep carts with EBP/ PPE in them outside of the resident rooms. -If a resident required the use of EBP/ PPE he/she went to central supply to get the needed items. -He/She did wear PPE while doing Resident #28's Supra pubic catheter care this morning. During an interview on 9/27/24 at 9:40 A.M., the resident said: -LPN A did change his/her Supra pubic catheter dressing this morning. -LPN A did not wear a gown or mask during the cares. 4. Review of Resident #20's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnosis: -Morbid (severe) obesity (a disorder involving excessive body fat that increases the risk of health problems). Review of the resident's POS dated September 2024 showed: -Abrasion to left posterior thigh: Cleanse with normal saline or wound cleanser. Pat dry. Apply Xeroform (a medicated) dressing to wound bed and cover with border gauze dressing every day shift and as needed for soiled/dislodged. 9/12/2024. -Eucerin cream (a brand name of dry skin cream) apply to bilateral lower extremities and shin area every shift for dryness and monitor for signs and symptoms of infection or open area. 8/23/2024. -Weekly skin assessments every day shift every Thursday. 3/28/2024. Observation on 9/23/24 at 11:55 A.M. of the resident's room showed: -No posted signage on the door or near the door for EBP precautions. -No isolation cart outside the room for the required PPE for staff to wear while doing resident wound care. During an interview on 9/23/24 at 11:57 A.M., the resident said: -Had pressure sores on his/her buttocks that wound care saw. -Had a scabbed area on his/her left shin. Observation on 9/26/24 at 10:05 A.M. of the resident's perineal care by CNA G and LPN B showed: -CNA G touched the resident's motorized chair then removed the resident's brief without changing gloves or sanitizing his/her hands and putting on new gloves. -CNA G cleaned the resident's buttock then perineal area without changing gloves or sanitizing his/her hands and putting on new gloves. -CNA G removed gloves and put on new gloves without sanitizing his/her hands. -LPN B removed gloves and sanitized his/her hands, he/she picked up some paper towels that were on the floor and placed in trash, he/she did not wash or sanitize his/her hands. -LPN B left the room to get a larger gown for the resident. -LPN B washed his/her hands on re-entering the room. During an interview on 9/26/24 at 10:30 A.M., CNA G said: -He/She should have changed his/her gloves during perineal cares between dirty and clean areas and if gloves become dirty. -Should have washed his/her hands between glove changes. -Should have washed his/her hands after removing gloves at end of resident cares. Observation on 9/26/24 at 10:34 A.M. of the resident's wound care by LPN B showed: -He/She sanitized his/her hands and put on gloves. -He/She cleansed the small wound on the left posterior (back) thigh and placed the Xeroform on the wound. -He/She did not wash or sanitize his/her hands, he/she changed gloves and placed a bordered gauze dressing over the area. -He/She did not wash or sanitize his/her hands, he/she changed gloves and cleaned the resident's left shin as ordered. -He/She did not wash or sanitize his/her hands, he/she changed gloves and placed barrier cream on the back of the resident's right thigh reddened area. -He/She removed the gloves, did not wash his/her hands then took the trash to the dirty utility room. During an interview on 9/26/24 at 10:45 A.M., LPN B said: -He/She would ask the resident about his/her pain level before starting wound cares. -NOTE: LPN B was needed and the interview was abruptly ended with no other questions or answers asked and answered. 2. Review of the facility's policy titled Tuberculosis Testing dated 6/29/23 showed new employees would receive a two-step Tuberculin Skin Test (TST-used to screen for TB). Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 7/16/24. -Employee B was hired on 6/25/24. -Employee C was hired on 5/29/24. -Employee D was hired on 8/27/24. -Employee E was hired on 6/25/24. -Employee G was hired on 4/17/24. -Employee H was hired on 8/6/24. -Employee J was hired on 7/2/24. Review of the above employees' employee files showed employees A, B, C, D, E, G, H, and J did not have any TSTs completed. During an interview on 9/24/24 at 3:46 P.M., the Human Resources Director said: -He/She started working at the facility at the end of July 2024. -He/She asked the Director of Nursing (DON) to make sure the employee TSTs were completed. During an interview on 9/25/24 at 1:19 P.M., the Administrator said: -They were supposed to be doing TSTs on new employees when they were in orientation at another facility owned by the same company. -He/She thought it was being done there but it was not. -The TSTs should have been done prior to hire. During an interview on 9/27/24 at 11:57 A.M., with the DON present, the Regional Director of Operations (RDO) said: -The TSTs were supposed to be administered on the employee's first day of orientation at another facility, which was their human resources hub. -The TSTs were supposed to be read 48 hours after administration at this facility where the DON was supposed to print the form, read the TST and sign the form. -The TST had to be read before the employee worked on the floor. -The second-step of the TSTs were to be given at the facility they were working at within 21 days of the first TST being read. -The second-step TST was the responsibility of the DON. -They just got a Human Resources Director for this facility in July 2024, so the responsibility of TB screening will shift to the Human Resources Director.

Based on interview and record review, the facility failed to designate one or more individuals with the required primary professional training as an Infection Preventionist (IP) for the facility's Infection Prevention control program. The facility census was 74 residents. The certifications were requested for all employees who were certified in the IP program and were not received at the time of exit. 1. Review of the Centers for Disease Control (CDC) online IP course showed: -The Minimum Data Set (a federally mandated assessment tool completed by facility staff for care planning) Coordinator had completed 15 of the 26 modules for the CDC IP course. -He/She worked 15 hours a week as the IP. During an interview on 9/27/24 at 9:32 A.M. the MDS Coordinator said: -He/She had started the IP course a couple of years ago. -He/She had not finished the IP course. -He/She was not certified in the IP program. -He/She worked 15 hours a week as the IP. During an interview on 9/27/24 at 12:00 P.M. the Director of Nursing (DON) said: -He/She had completed the IP program training and had the certification. -The Administrator had also completed the IP program training and had the certification. -The MDS Coordinator had not completed the IP program training and was not certified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent misappropriation of approximately $1100.00 cash, taken from a wallet in a safe, which belonged to one sampled resident (Resident #1) out of seven sampled residents. The facility census was 55 residents. On 8/23/24, the facility Administration was notified of the past noncompliance which occurred on 8/1/24. Facility staff were educated on abuse and neglect policy, resident funds policy, resident rights policy and resident trusts policy. The resident's money was returned to him/her. The locks on the safe was changed and only necessary personal have access to the new code. The deficiency was corrected on 8/9/24. Review of the facility's Resident Rights policy, revised on 7/5/23 showed: -A resident had the right to manage his/her financial affairs and the facility could not require resident to deposit their personal funds with the facility. -Upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of a resident deposited with the facility. Review of the facility's Abuse and Neglect policy, revised on 6/12/24 showed: -It was the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames. -Misappropriation of resident property was the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent including; identity theft, theft of money from bank accounts; theft of money from a resident; unauthorized or coerced purchases on a resident's credit card or resident's funds. -The facility would develop operational policies and procedures for screening and training employees, protection of residents and for the prevention, identification, and reporting of abuse, neglect, mistreatment and misappropriation of property. -The facility would identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property was likely to occur. 1. Review of Resident #1's admission Record face sheet showed he/she was admitted to the facility on [DATE], readmitted on [DATE] and was was his/her own financial responsible party. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 8/4/24, showed he/she was cognitively intact. Review of the facility's Administrator/RN Investigation dated 8/8/24 showed: -On 8/1/24 the resident stated to the Director of Nursing (DON) his/her wallet was missing. -When the EVS (Environmental Services) manager was doing laundry that morning, the wallet was found in a nightgown in the dirty laundry. -He/She stated he/she came to the Administrator's office, but the Administrator was out. -He/She then gave the walled to the social worker, who took the wallet to the business office and placed it in the safe. -The social worker stated he/she was told there was $1500.00 in the wallet, but he/she did not have anyone count it with him/her and just placed it in the safe. -The Administrator was told by the social worker that the wallet had been found in the laundry and had been placed in the safe. -On 8/8/24 the resident asked for his/her wallet to be returned. -The business office manager retrieved the wallet from the safe and checked the wallet to find there was no money inside the wallet. -He/She and the social worker went to the Administrator's office and told him/her there was no money in the wallet. -The Administrator called the local Police Department and Police Officer A came and took all the information they had about the missing money. -The police officer said that due to the leather material of the wallet, he/she could not fingerprint it. -It was reported to the DON by the van driver that the resident had lost his/her wallet and had around $1500.00-$1800.00 in it. -The social worker stated the DON had said there was $1500.00 in the wallet, but the DON said he/she did not say that. -When the wallet was found in the laundry, the EVS manager called the van driver, who was taking the resident for an appointment, and let him/her know the wallet had been found with the money in it. -The van driver stated the resident told him/her there was $500 in the wallet. -The regional district manager spoke with the resident and he/she stated there had been $1860.00 in the wallet. -Since nobody had counted the money and several different amounts had been stated, the resident was interviewed again. The regional district manager told the resident he/she would get his/her money back, but needed to confirm that he/she had that much cash. -The resident was not able to provide any ATM receipts or bank statements. -The resident gave the regional district manager permission to call his/her bank to check the resident's withdrawals and balance. -The resident's withdrawals totaled $1100.00 taken from the account. The resident agreed to this amount, which was given back to him/her and he/she signed a receipt for it. Review of the social worker's written statement dated 8/8/24 showed: -He/She was given report from the DON that the resident was missing a wallet with approximately $1500.00 in it. -On 8/8/24 he/she received the resident's wallet from the EVS manager, who found it in the laundry. -Once he/she received it, he/she placed it in the safe in the business office. -At the time, he/she was also doing business office duties, however any time he/she accessed the safe, the money was still in the wallet. -He/she did not count the money, but it appeared a substantial amount upwards to $1000.00 to $1500.00. -When the wallet was obtained from the safe on 8/8/24, the money was missing. -He/She and the business office manager obtained the wallet from the safe, and then immediately reported to the Administrator. Review of the EVS manager's written statement dated 8/8/24 showed: -On 8/1/24 at approximately 10:00 A.M. he/she was working in the laundry room at the facility. -While sorting clothes, he/she discovered a men's wallet in the pocket of a gown. -He/She opened it and found it belonged to Resident #1. -It contained a substantial amount of cash money. -He/She did not count it, but estimated the amount to be about $1000.00. -The Administrator was away from his/her desk, so he/she gave it to the social worker. Review of the maintenance manager's written statement dated 8/8/24 showed: -He/She access the safe initially with a key as the pad code was unknown. -After accessing the safe with the key, a new code was put in place and the safe was placed in the business office for the previous business office manager. They keys were placed in the safe box. -Since then, he/she had not accessed the safe in any manner. Review of the business office manager's undated written statement showed: -On 8/8/24, he/she received a request that the resident wanted his/her money. -He/She went to the social worker who told him/her the resident had to sign a form for his/her money. -He/She went to the business office to get the wallet and when he/she picked it up, looked inside. -There was no money. -He/She went back to the social worker and showed him/her, and then the two of them went to inform the Administrator. Review of the Administrator's written investigation report dated 8/12/24 showed: -On 8/1/24 the resident stated his/her wallet was missing to the DON. -When the EVS manager was doing the laundry that morning, the wallet was found in the dirty laundry. -The EVS manager stated he/she came to his/her office, but he/she was not in the office, so he/she gave it to the social worker. -The social worker stated he/she took it to the business office and placed it in the safe. He/She stated he/she was told there was $1500.00 in the wallet. He/she did not count the money; just placed it in the safe. -He/she was told by the social worker it had been found in the laundry and placed in the safe. -The resident was admitted to the hospital on [DATE] and returned to the facility on the night of 8/7/24. -When the business manager went to the safe and got the wallet out, he/she saw there was no money in the wallet. He/She told the social worker and they came to his/her office and stated the money was missing from the wallet. -He/She called the local Police Department. Police Officer A took all the information they had about the missing money. He/she said due to the type of material that the wallet was made of, he/she could not fingerprint it. The wallet was leather with a textured pattern on it. -He/She had the business office manager, the maintenance manager and the EVS manager wrote statements. -It was reported to the DON by the van driver that the resident had lost his/her wallet and it had $1500.00 to $1800.00 in it. -The social worker stated there was $1500.00, but the DON did not say that. -When the wallet was found in the laundry, the EVS manager called the van driver who was driving the resident to an appointment to tell him/her the wallet was found and the money was in it. --The van driver stated the resident told him/her there was $500 in the wallet. -The regional district manager spoke with the resident and he/she stated there had been $1860.00 in the wallet. -Since nobody had counted the money and several different amounts had been stated, the resident was interviewed again. The regional district manager told the resident he/she would get his/her money back, but needed to confirm that he/she had that much cash. -The resident was not able to provide any ATM receipts or bank statements. -The resident gave the regional district manager permission to call his/her bank to check the resident's withdrawals and balance -The resident's withdrawals totaled $1100.00 taken from the account. The resident agreed to this amount, which was given to him/her and he/she signed a receipt for it. During an interview on 8/22/24 at 10:40 A.M., the regional district manager said: -Nobody could say how much money was in the wallet. -He/She and the administrator called, with the resident's permission, to his/her bank and found from 7/24 to 8/24 the resident had withdrawn $1100.00 -That amount was all he/she was able to verify. -They replaced the money to the resident and had him/her sign that he/she had received it. -Now he/she and the business office manager were the only ones who had the code for the safe. During an interview on 8/22/24 at 11:00 A.M., the EVS manager said: -He/She found the wallet in the laundry. -He/She took it to the social worker. -He/She saw there was a considerable amount of money, but did not count it. -He/She understood the wallet was put in the safe. During an interview on 8/22/24 at 1:15 P.M., the maintenance director said: -He/She never saw the wallet until the business office manager took it out. -He/She had access to the business office, but did not have access to the safe. During an interview on 8/23/24 at 7:55 A.M., the Administrator said: -The social worker said the EVS manager found the wallet in the laundry and brought it to him/her. -The social worker said he/she put the wallet in the safe. -Nobody counted the money. -When the resident returned from the hospital, he/she wanted his/her wallet. -The office manager went to get it and came to him/her because the money was missing. -Different people stated there were different amounts of money. -He/she, the regional district manager and the resident were present and they called the bank to find out how many cash withdrawals the resident had made. -The resident had made three withdrawals, totaling $1100.00, so the facility replaced that. -He/She, the social worker and the office manager had access to the safe. -The police talked to them and said they could not fingerprint the wallet, and that was all they could do. They were told a detective might call, but nobody ever did. -He/She was responsible for getting money back to the residents, but everything was transferred to the business office and the business office had gotten a new safe. -The business office manager was the only one with access to the safe currently. During an interview on 8/23/24 at 11:25 A.M., the business office manager said: -He/She got a message from a nurse that the resident wanted his/her wallet. -He/She went to the social worker who said the resident's wallet should be in the safe. -He/She went in the office and took the wallet out and took it back to the social worker because there was nothing in it. -He/She and the social worker went to the Administrator's office. -The Administrator asked who had seen it last and he/she started an investigation. -The EVS manager did not have access to the safe. -The maintenance director had access to the office door and the safe code. He/she did say he/she had to go in the office and clean. -The regional district manager said to get a new safe and nobody should know the code. -There was now a new safe in his/her office and only he/she knew the code. During an interview on 8/27/24 at 4:45 P.M., the social worker said: -On Thursday, 8/8/24, staff reported the resident said his/her wallet was in the safe and there was a substantial amount of money in it. -That morning the wallet was found in the laundry by the environmental services. -The EVS manager handed him/her the wallet, but did not count it. -He/She notified the Administrator it was found and showed him/her the wallet. -The Administrator told him/her to put it in the safe in the business office. -The dietary manager went with him/her to put it in the safe and it was placed in the safe. -The dietary manager did not have access to the safe; he/she was a witness. -At the time he/she was assisting the business office manager with resident trusts since he/she was a new employee. -The following day, he/she left the facility early to go out of town. -The last time he/she saw the wallet was when he/she put it in the safe. -The business office manager got the wallet out of the safe the following Thursday and realized the money was missing. -They notified the Administrator immediately that the money was missing. -The police, state agency and regional district manager were notified. -Upon investigation, the money was replaced by the facility. MO00240263

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to preserve one sampled resident's (Resident #3) dignity when agency Certified Nurses Aide (CNA) B slapped the resident's hand and made inappropriate comments to the resident while he/she provided incontinence care out of seven sampled residents. The facility census was 77 residents. On 4/18/24, the Administrator were notified of the past noncompliance (PNC) for an incident that occurred on 4/4/24. The facility administration had all staff including agency staff in-serviced on abuse and neglect, customer services, resident rights and dignity. The deficiency was corrected on 4/5/24. Review of the facility's policy for Resident's Rights dated 6/29/23 showed: -Every resident had the right to be treated with dignity and respect. -All staff should speak to all residents with dignity and respect. 1. Review of Resident #3's Facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Schizoaffective disorder, bipolar type-(a mental condition that causes loss of contact with reality and mood problems along with periods of very high moods followed by very low moods). -Paranoid schizophrenia-(a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 2/8/24 showed he/she: -Was not cognitively intact. -Had little pleasure in doing things along with feeling bad about himself/herself nearly every day. -Had trouble falling asleep or sleeping too much, feeling tired/having little energy, and thoughts of self-harm several days during a two-week period. -Showed behavioral symptoms not directed at others such as screaming, rummaging, and disruptive sounds. -Was wheelchair bound. -Was dependent on facility staff for toileting/hygiene, showers/baths, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. -Was dependent on facility staff for rolling left to right, sit to lying, chair/bed to chair transfers, and tub/shower transfers. -Was dependent on facility staff to wheel his/her wheelchair 50 feet with two turns. -Was dependent on facility staff to wheel his/her wheelchair 150 feet in a corridor or similar space. -Was always incontinent of urine and stool. Review of the resident's Nursing Care Plan dated 11/27/23 showed: -He/she had a self-care deficit being totally dependent on facility staff for daily needs. -He/she required assistance of one to two staff members to assist with incontinence care. -The facility staff was to encourage the resident to participate in his/her cares to the fullest extent possible with each interaction. -The facility staff was to encourage the resident to use his/her call light for assistance. -He/she had behavior problems including obsessively yelling for help from the facility staff even when the care had just been provided. -The facility staff was to anticipate and meet the resident's needs. -The facility staff was to provide opportunity for positive interactions, attention, etc., with the resident including stopping and talking with him/her frequently throughout the day and during cares. -The facility staff was to educate the resident on successful coping and interaction strategies while encouraging the resident and supporting him/her and the family. -The facility staff was to explain all procedures/cares to the resident before starting them and allow the resident to adjust to changes in care. -The facility staff was to intervene as necessary to protect the rights and safety of the resident and others. -The facility staff was to approach and speak to the resident in a calm manner, diverting attention and removing the resident from any vulnerable situations. -The facility staff was to administer the resident's medications which helped to curb negative behaviors, as ordered by the physician. -The facility staff was to review the resident's behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. -The facility staff was to monitor the occurrences of the negative behaviors and document them per facility direction. Review of the resident's Nurse's Notes dated 4/4/24 at 5:11 P.M., showed: -Agency CNA A came to the Facility Administrator and stated that Agency CNA B slapped Resident #3's hand and stated don't touch me to the resident. -The Facility Administrator asked the resident what happened and he/she stated, he/she slapped his/her hand and he/she told him/her don't hit me bitch.' -A head to toe assessment was attempted however the resident said, No. It was my hand. -The Facility Administrator further interviewed the resident who stated that he/she was not hurt and he/she was not scared to be in the facility. -The resident's family was present during part of the investigation and was notified at that time. -The resident's physician was notified as well. Review of Agency CNA A's written statement dated 4/4/24 showed: -Between 11:45 A.M., and 12:00 P.M., he/she went to Agency CNA B to ask him/her to assist with changing Resident #3. -He/she informed Agency CNA B the room was a mess because the resident had a bowel movement to which Agency CNA B appeared to be upset about the mess. -Agency CNA A and Agency CNA B transferred the resident into his/her bed to get him/her cleaned up. -Agency CNA A turned around to get the wipes and heard a slapping sound. -When Agency CNA A turned around, he/she saw Agency CNA B slap the resident's hand and tell the resident not to touch him/her. -The resident then said, Don't hit me, bitch. -Agency CNA A then went and told the nurse and Abuse Coordinator who was the Facility Administrator. Review of the Facility Administrator's undated Investigation Summary showed: -Agency CNA A came to him/her and stated that Agency CNA B slapped Resident #3 on his/her hand and stated, Don't touch me. -When the resident was asked what happened, he/she stated the CNA slapped him/her and he/she told him/her, 'Don't hit me bitch. -The Facility Administrator asked Agency CNA B if he/she had hit the resident and Agency CNA B said that he/she wouldn't do that. -The Facility Administrator then walked Agency CNA B out of the building. -A head to toe assessment was attempted on the resident, however the resident refused as it only involved his/her hand. -The resident then stated that he/she was not harmed and the slap did not hurt, nor was he/she scared. Review of the resident's Psychosocial Post-Incident Impact Questionnaire dated 4/4/24 at 12:43 P.M., showed: -The resident was the victim in the incident. -He/she did feel safe. -He/she did not feel that he/she needed to speak with someone else. -He/she did have at least one staff member that he/she felt safe to share his/her thought/feelings with if needed. -He/she had no after-effects from the incident. -He/she did not have any other needs or items that he/she wanted to address after the incident. During an interview on 4/15/24 at 1:19 P.M., Agency CNA A said: -He/she heard the resident yelling and went to check on him/her. -The resident was seated in his/her wheelchair and had feces all over him/her and on the floor. -The resident stated that he/she tried to get to the bathroom but did not make it there in time. -Agency CNA A asked Agency CNA B for help in cleaning up the resident. -Agency CNA A told Agency CNA B that it was a mess in the room as there was feces even on the floor. -Agency CNA B immediately seemed to get a bad attitude about the situation, however he/she agreed to come help. -After they got the resident into the bed to get him/her cleaned up, Agency CNA A turned to get the wipes an immediately heard a slapping sound. -He/she turned around and saw Agency CNA B slap the resident on his/her hand and said. Don't touch me! I don't' like you! -Immediately after cleaning the resident up, he/she went to tell the Facility Administrator what had happened. -The Facility Administrator then made Agency CNA B leave the facility. During an interview on 4/15/24 at 2:45 P.M., the resident said: -He/she did get slapped, but was not hurt. -He/she felt safe in the facility. -He/she was not afraid. -When asked how he/she felt about Agency CNA B, he/she stated, I was not impressed by him/her. That is all I have to say. During an interview on 4/18/24 at 1:40 P.M., Agency CNA B said: -He/she never slapped the resident's hand. -The resident at one point, went to grab ahold of his/her hand and there was feces on the resident's hand. -When the resident made a motion to grab his/her hand so he/she blocked his/her hand and there could have been a slapping sound because of that. -He/she believed that when he/she blocked the resident's arm, he/she might have said, I don't like this!, referring to the messy situation. -He/she never told the resident he/she did not like him/her. During an interview on 4/23/24 at 2:00 P.M., the Facility Administrator said: -He/she would have expected the agency staff member to maintain the residents' dignity at all times. -He/she would have expected the agency staff member to make no derogatory comments to any residents. -He/she would have expected the agency staff to have been well educated in maintaining the resident's dignity and rights. MO00234201

Based on observation, interview and record review, the facility failed to ensure the safety and protective oversight for one sampled resident (Resident #5) who left the faciity on 2/15/24 around 5:02 P.M., without the knowledge of the facility staff and was gone overnight from the facility out of 10 sampled residents. The facility resident census of 62 residents. On 2/27/24, the Administrator were notified of the past noncompliance (PNC) for an incident that occurred on 2/15/24. The facility administration was notified on 2/16/24 of the resident's elopement and facility investigation of the resident elopement immediately begun on 2/16/24. In-services were provided to staff who were involved and to all staff related to resident's visual monitoring (Face checks) every hour or at least every two hours to ensure the safety and protective oversight supervision for all resident at the facility on 2/16/24 and 2/17/24. The deficiency was corrected on 2/17/24. Review of the facility's Elopement Protocol revised on 1/19/22 showed: -An elopement will be defied as anytime a resident is missing for the facility or there is a possibility that the resident has left the facility without appropriate supervision and their whereabouts are unknown. -The first person aware of an elopement will call a Code White to the area of the believed elopement, if known. -Page all units to search room to room for the resident. All rooms, closets, bathrooms, and work areas are to be searched. -The administrator is to be called immediately. Review of the facility's Intensive Monitoring/Visual Checks revised on 6/30/23 showed: -Face checks for all resident on each unit will be monitored by visual checks at least every two hours or may be provided more intensive monitoring every hour. -Special units will not be left unattended at any time. -Upon hire, Licensed and registered Nurse (RN) will require to review, agree and sign the nurse census call-in protocol, signed form should be placed in employee fill. -Certified Nursing Assistant (CNA) can provided direction to monitor the resident in a timely manner at the discretion of administration for medical or behavioral decomposition. -Document of face checks monitoring will be done in electronic medical record under task. 1. Review of Resident #5's admission Face Sheet showed he/she had the following diagnoses: -Paranoid Schizophrenia (a long-term mental health condition where you may see, hear or believe things that are not real and person experiences paranoia that feeds into delusions and hallucinations, it's common for them to feel afraid and unable to trust others) -Disorganized schizophrenia (is associated with symptoms like disorganized speech, thinking, and behavior). -Seizures (is sudden uncontrolled body movement). -Has a Public Administrator (PA) as a guardian. Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/2/23, showed he/she was cognitively intact. Review of the resident's Care Plan revised on 12/10/23 showed: -He/she was at risk for elopement: --Complete elopement assessment on admission, readmission and quarterly. --Face checks/intensive monitoring will be completed per facility protocol revised on 9/22/22. -The resident was independent with activities of daily living. --Facility staff to provided protective oversight and assist where needed. Review of the resident's Certified Medication Technician (CMT) Medication Administration Record (MAR) date 2/15/24 showed the last dose of medication was given to the resident was at 4:00 P.M. Observation/review of the facility's Video Surveillance dated 2/15/24 showed: -On the 300 hallway at 5:02.39 P.M. below the video time stamp had written live and a person detected. -The resident was wearing a red sweatshirt or jacket, black pants and shoes was seen walking toward the end of 300 hall to the exit door. -At 5:02.54 P.M., the resident in the red sweatshirt was at the end of hallway and turned toward right then was out of site (that was location of the keypad, which required a code to be enter before anyone could exit the out that door). -The video time showed 5:02.58 P.M. and then the video skips to 5:03.35 P.M. -At 5:03.35 P.M., the exit door was opened and closed and can be slightly heard on the video. Review of the resident's guardian email to the facility dated on 2/16/24 at 8:24 A.M. showed: -The Deputy PA had received a phone call from the resident's family member the morning of 2/16/24 around 7:42 A.M., explaining that the resident had showed up to his/her house on the evening of 2/15/24 around 10:00 P.M. and the resident was asleep at their home. Family member was hoping to have the resident picked up to go back to the facility before he/she left his/her house. -He/she had not received any phone calls from the facility that the resident had eloped. -He/she was just double checking with the facility that in fact the resident had eloped the night before and how to get the resident back to the nursing home. -Phone calls were attempted to contact the facility with no answer and the PA office was unable to leave voice mail at 8:02 A.M., 8:12 A.M. and 8:15 A.M. Review of the resident's Transfer to Hospital Note dated 2/16/24 at 10:35 A.M., showed the resident arrived back to the facility with the Administrator and Activities Director at approximately 10:31 A.M. on 2/16/24. Review of the resident's Incident Note written by the Regional Facility Advisor Nurse dated 2/16/24 at 3:41 P.M. showed: -The facility received a call from resident's guardian around 9:17 A.M., that he/she had received a call from the resident's family member that the resident had showed up at the family members' house between 10:30 P.M. and 10:45 P.M. on 2/15/24. -The immediate response from staff was to check the resident's room for verification of the missing resident, and the resident's room was checked, and the resident was not found. Review of the facility Investigation dated 2/16/24 at 12:53 P.M. showed: -On 2/15/24 the resident had eloped. -The facility staff were notified of the resident elopement on 2/16/24 at 9:17 A.M. -At 9:17 A.M. the resident's guardian had notified the MDS's Coordinator that, the resident's family member had called the guardian to inform him/her the resident had showed up on his/her doorstep at around 10:00 P.M. on the evening of 2/15/24. -Resident noted on facility camera system at 5:00 P.M. to 5:10 P.M. walking back and forth to exit door on the 300 halls where the resident had resided on. -Resident noted to wear a red jacket on with dark colored trouser and his/her gloves in his/her hands. The resident then noted what it looks like to be trying to enter door code in the keypad. -Resident was eventually able to enter code and exit out the door. -Conclusion of the investigation documented that the resident eloped form facility by entering a code into the exit door on 300 halls. During the facility investigation the following findings were noted: --CMT A who was scheduled to complete face check form 5:00 P.M. to 7:00 P.M. during 7:00 A.M. to 7:00 P.M. day shift, did not notify the charge nurse that the resident was not in the facility. -Off going/oncoming charge nurse did not make facility rounds to ensure all residents were in the building at change of shift. -CMT B who was scheduled for 7:00 P.M. to 7:00 A.M. shift to administer medication and document facility face check, did in fact noted that the resident was not in the facility because he/she was unable to administer the resident's medications that was due at bedtime. The CMT was unable to locate the resident to complete face checks. -The evening/night CMT did not notify the charge nurse that the resident could not be located. -Charge nurse on duty 7:00 P.M. to 7:00 A.M. shift, did not complete midnight census round checks to see if resident was in the facility to be counted on the resident census. -Maintenance supervisor did not ensure facility door codes were changed weekly per policy. Review of the Activities Director's written Witness Statement dated 2/16/24 showed he/she had talked to the resident near the 100,200, and 300 nursing station, right around 4:45 P.M. to 5:00 P.M., before Activities Director had left for the day on 2/15/24. During an interview on 2/26/24 at 3:23 P.M., Activities Director said the last time he/she saw the resident on 2/15/24 was around 4:45 P.M. to 5:00 P.M. around the 300-nursing station area. Review of CMT C's written Witness Statement dated 2/16/24 showed the resident told him/her the resident decided to leave the facility to go somewhere. The resident had walked to the store then got on a bus. During an interview on 2/26/24 at 3:38 P.M., CMT C said: -On 2/16/24 he/she arrived at the facility for day shift and made round on assigned resident. He/she notice the resident was not in his/her room at that time. -Later he/she had went to give the resident his/her morning medication and he/she was not in his/her room. -CMT C did not report that resident was not in his/her room at that time to anyone. During an interview on 2/27/24 at 9:18 A.M., CMT A said: -He/she last saw the resident around 4:00 P.M. for his/her last dose of afternoon medication. -He/she had saw the resident in passing after the medication pass. -He/she did not remember seeing the resident prior to leaving the facility at end of his/her shift change. -He/she was not aware of the resident having history of wandering or exit seeking behaviors. The resident would have the ability to enter a code to door if he/she knew the code. -He/she was assigned to pass medication on the 100, 200, 300 and 400 unit. -After he/she had completed medication pass, he/she would be station himself/herself back onto the 100, 200 and 300 unit nursing station area. -He/she tries to make walking rounds on the resident every one to two hours. -The facility does not have assigned staff member to remain or station continuous supervision or monitoring of the 100, 200, and 300-unit residents at all times. -If he/she were not able to locate the resident, he/she should had notified the charge nurse immediately. -For CMT shift change, if oncoming staff on time would complete a walk through and give report. -He/she did not complete shift change walk-through or report with on coming staff member on 2/15/24. Review of CMT B's written Witness Statement dated 2/16/24 showed when he/she went to the resident's room to pass medication, he/she noticed the resident was not in his/her room. During an interview on 2/27/24 at 9:39 A.M., CMT B said: -He/she was not aware the resident had left the building. -He/she had not seen the resident during his/her shift. -He/she did not get shift change report and had to obtain the keys for medication cart from the secured keypad medication room. -He/she began medication administration for all residents in the facility. -Did not have CNA coverage for 100, 200, 300 unit when he/she had to pass medication on the skilled unit. The unit was left without a staff member station on that unit. -The resident was not in his/her room when tried give the resident his/her medication. -CMT B thought the resident was out smoking or visiting with peers. -He/she looked for the resident again and did not find him/her and then look in computer record to see if the resident was out of the building. Sometime the resident's electronic chart does not have most current/correct information about the resident. -CMT B had completed medication administration between 10:00 P.M. and 11:00 P.M. -He/she went completed the night shift sitting at nursing station on the 100, 200 and 300 unit. During an interview on 2/27/24 at 9:58 A.M., LPN B said: -The CMT was responsible for provided or assisting resident with any cares, passing medication and face checks on assigned resident for 100, 200 and 300 units. -He/she went back to the 200, 300 unit around 5:00 P.M. to obtain blood sugars and did not see the resident at that time. Review of LPN A's written Witness statement dated 2/16/24 showed: -He/she had arrived at the facility on 2/15/24 (evening) at approximately during the resident smoke break time. -At no time did he/she recall seeing the resident. During an interview on 2/27/24 at 10:38 A.M., LPN A said: -100, 200 and 300 hallways were all independent residents that were able to provide their own cares and transfer themselves without staff assistance. -When he/she arrived at the facility the day shift nurse was busy with family members. And waited for nurse to give shift change report. -He/she did not receive any report of any resident missing or not in the building. -Night nursing staff were responsible for completing the midnight resident census. -He/she would normally complete around 2:00 A.M. -He/she did not complete a walk-through of all residents during night shift. -All night staff were supposed to check on assigned resident to include face checks and report if they were not able to locate a resident. During an interview on 2/27/24 at 2:23 P.M., the Administrator said: -He/she had completed the elopement investigation and found: -The facility staff had not been changing the door code per facility policy of every week. -Facility staff did not complete resident face checks per facility policy to ensure the safety of the resident and protective oversight. -He/she would expect facility staff to notify the charge nurse and the Administrator of any resident not found during rounds. During an interview on 2/28/24 at 1:55 P.M., Deputy PA said: -Their office had received a phone call from the resident family member on the morning of 2/16/24 who said the resident had arrived at his/her door step on the evening of 2/15/24 around 10:00 P.M The resident had slept the night at the family member's home. -On 2/16/24 the PA office had emailed the facility to ask if the resident was at the facility or was missing. -Later that morning he/she had received a phone call from the facility saying the resident had left the facility and the facility administration would make contact with the family member to transport back to the facility. -The PA office would expect the facility to ensure the protective oversight of the resident safety and know where the resident was while a the facility. -He/she would expect the facility to notify the PA office if the resident was not able to be located or if there was a change of condition. Complaint# MO 00231972

Based on interview and record review the facility failed to prevent further potential abuse for one sampled resident (Resident #1) when an alleged incident of abuse was not reported immediately to the Administrator or designee and Certified Nurses Aide (CNA) A continued to work his/her shift after the allegation was made. There were five sampled residents. The facility census was 71 residents. Review of the facility's policy titled Abuse and Neglect Policy dated 1/5/23 showed: -Physical abuse was categorized as purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practice, such as; --Dealing with aggressive residents. --Reporting allegations without fear of reprisal. -Employees and vendors are required immediately to report any occurrences of potential mistreatment including alleged violations. -If such incidents occur after hours the Administrator or designee and Director of Nursing (DON) or designee will be notified at home or by cell phone and informed of any such incident. -Employees of this Facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by the Administrator. Review of the facility's policy titled Administrative Investigation dated 7/5/22 showed: -The Administrative Investigation will consist of any pertinent information describing the situation including: --The names of all staff and residents involved. --The root cause of the incident. --The recommendations from the investigation including the facts that prove or disprove the alleged situation occurred. --The plan of correction or action by the Administrative staff. --All statements attached from residents and staff involved and any training or education that the Administration feels needs to be provided to staff or residents to ensure education has been provided to prevent further similar situations. -The Administrative Investigation will also include a review of the resident's record to ensure that the documentation reveals: --That the legal guardian was notified. --The physician was made aware. --The resident was fully assessed. --Interventions and physician's orders were followed. --The resident was reevaluated and the Plan of Care was updated to reflect the change in medical or behavioral status. -Documentation of the Behavior Emergency in the Administrative Investigation will include evaluation of the resident's behavior including: --Consideration for precipitating events or environmental triggers. --Other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible. --Identifying or attempting to identify the root causes of the behaviors and revising the plan of care. 1. Review of Resident #1's face sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration or intellectual capacity and function, and impairment of control of memory, judgement, and impulses. -Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 7/9/23 showed: -The resident was cognitively intact. -The resident had not exhibited any behaviors during the seven day look back period. -The resident currently used tobacco. Review of an undated incident statement completed by CNA A showed: -The resident was attempting to go out to smoke. -The resident was aware that he/she was not allowed to smoke at 3:00 A.M. -He/she tried to redirect the resident, but the resident became upset and threw a coffee in his/her face. -He/she could not see due to the coffee in his/her face and lost sight of the resident. -He/she thought when he/she turned around that he/she may have bumped the resident. -The resident then started going off and explained the situation to the charge nurse. Review of an undated incident report completed by the facility's Administrator showed: -The incident occurred on 8/4/23. -The incident that was investigated was an allegation of Staff-to-Resident abuse. -Immediately upon entrance to of the facility on 8/4/23 the resident approached the Administrator and had asked to review the cameras due to an incident that occurred between him/her and CNA A. -The resident reported that he/she had been struck by CNA A. -CNA B had been standing nearby when the resident reported this and stated That's not what happened. -CNA B then explained to the Administrator that he/she had been a witness to the alleged incident. -CNA B explained that the resident had tried to force his/her way through the door to go out to smoke. -CNA A then stood up in front of the door to redirect the resident from pushing the door open. -The resident then stood up, CNA A walked to the side of the resident as the resident was losing his/her balance and assisted the resident back into his/her wheelchair. -CNA B had also added that the resident had thrown coffee at CNA A. -Nursing staff performed a head-to-toe assessment of the resident which was unremarkable. -The resident continued to ask about reviewing the cameras. -The Administrator explained to the resident that the camera system was inoperable at that time. -The resident thought this was unacceptable. -Interventions put in place after the incident included: --New cameras had been installed throughout the building. --There was a subscription needed for the cameras to work and the plan would be bought by the end of the month. --Smoking materials and equipment would be in locked storage and distributed by staff at each smoke break and collected at the end of each smoke break. -The incident had been reviewed by the Interdisciplinary Team (IDT) with no further action needed. -The incident report did not include the root cause of the incident, no record of the guardian or physician notification, any evaluation of the resident 's behaviors and/or triggers, when the Administrator had been notified of the event, and what was done with CNA A during the investigation. Review of an incident statement dated 8/14/23 completed by CNA B showed: -The incident occurred the early morning of 8/4/23. -He/she had come in the morning of the incident and could hear some residents trying to open the door to the smoking area. -CNA A had stated to the residents that no residents could go out to smoke at that time. -The resident was already upset and stood up from his/her wheelchair. -CNA A was already positioned in front of the door to prevent the resident from pushing the door open. -It looked as if the resident was going to lose his/her balance so CNA A moved to the side of the resident and assisted the resident back into his/her wheelchair. During an interview on 8/29/23 at 10:45 the Administrator said: -The incident had occurred in the early morning. -He/she was unsure if the resident had intentionally threw the coffee at the resident due to the resident's diagnosis of Parkinson's disease. -The staff on duty had tried to prevent the resident from going outside. -The resident was not hit. -There were multiple witnesses of the event. -A part of the issue was that the residents attempt to go outside to smoke all throughout the day and not only at the designated smoking times. During an interview on 8/29/23 at 11:52 A.M. the resident said: -CNA A hit him/her. -He/she had gone up to the front desk because he/she wanted to go outside. -CNA A did not let him/her go outside and pulled him/her back from the door. -After he/she was pulled away from the door he/she poured coffee onto CNA A. -After pouring the coffee on CNA A that was when CNA A hit him/her in the ear. -The impact of the injury did not break skin, but his/her ear hurt for a few days after the incident. -This was the first altercation he/she had with CNA A. -CNA A did not have an issue with or have any altercations with the other residents. -The facility told him/her that the cameras had not been working at the time of the facility. -No one had come to talk with him/her after the altercation occurred. -He/she was not scared on CNA A. -He/she thought there was an additional witness, Hall Monitor A. During an interview on 8/29/23 at 12:37 P.M. Hall Monitor A said: -He/she only saw the end of the altercation. -CNA A did not hit the resident. -The resident threw coffee at CNA A. During an interview on 8/29/23 at 12:41 P.M. CNA A said: -The resident threw coffee at him/her. -He/she was trying to prevent the resident from going outside. -He/she only wrote up a report for the investigation and nothing else was done. -He/she thought the only witness to the altercation was CNA B. -He/she reported everything to the charge nurse on duty. -He/she knew that any allegation of abuse needed to be reported to the Administrator or DON. -The incident occurred at 3:00 A.M., nobody else was in the building besides the nurse to report the incident. During an interview on 8/29/23 at 12:49 P.M. CNA B said: -The incident occurred early in the morning. -The resident was trying to go outside to smoke, but it was not a designated smoking time at the time of the incident. -He/she was not provided with any education after the altercation occurred. During an interview on 8/29/23 at 1:28 P.M. CNA C said: -Any allegation of abuse needed to be reported immediately to the Administrator or DON. -He/she thought there was a two hour window in which the abuse allegation needed to be reported to the Administrator and then the Administrator would have 24 hours to complete the investigation. -There had been an in-service completed about a week prior regarding abuse. During an interview on 8/29/23 at 1:30 P.M. Certified Medication Technician (CMT) A said: -Any allegation of abuse needed to be reported immediately to the charge nurse, DON, and Administrator. -There was not a specific time frame in which abuse needed to be reported, that it just needed to be reported immediately. -He/she had been in-serviced about a month ago, or less, regarding abuse. During an interview on 8/29/23 at 1:37 P.M. Registered Nurse (RN) A said: -Staff were responsible for reporting any allegation of abuse to the DON or Administrator immediately. -The person completing the investigation was responsible for reporting to the State Agency. -There was not a specific time frame for reporting allegations of abuse. -Human Resources (HR) was responsible for abuse/neglect education upon hire of each employee. -He/she was unsure what the facility policy was related to investigating any allegation of abuse, but would follow whatever the policy said if he/she needed to investigate the allegation. During an interview on 8/29/23 at 1:37 P.M. the Administrator and the MDS Coordinator said: -The abuse allegation had been reported around 8:00 AM on 8/4/23. -He/she would have expected the staff to have reported the incident before the Administrator entered the building. -CNA A was still working in the building upon arrival to the facility and continued to work while the investigation was ongoing. -The investigation was wrapped up almost instantly because of the verbal statements received from the staff. -He/she did not report the allegation to the State Agency because he/she did not think it met the criteria for reporting. -There was no follow-up completed after completing the investigation related to abuse. During an interview on 8/30/23 at 12:55 P.M. the Facility Nurse Advisor said: -Staff are expected to report all allegations of abuse to the Administrator. -The investigation starts immediately after the report. - Depending on the severity of the report, the allegation would then get reported to the State Agency. -He/she thought that regardless of investigation findings any allegation of abuse would need to be reported to the State Agency. -He/she thought that this incident should have been reported to the State Agency. -He/she thought that investigations related to abuse needed to be completed within three days, but would need to look at the policy. -He/she would have expected the staff to have reported the abuse allegation immediately, especially before 8:00 A.M. if the alleged incident occurred at 3:00 A.M. -Any staff who are alleged abusers were to be suspended immediately per policy until the pending the results of the investigation. -CNA A should not have been working on the floor or even in the building after the alleged incident and should not have been in the building while the investigation was ongoing. During an interview on 8/30/23 at 1:34 P.M. the DON said: -The incident happened at the beginning of August. -The Administrator completed the investigation. -The Administrator was responsible for all investigations related to abuse. -He/she was not aware that the Administrator had not been notified of the alleged abuse after it had occurred. -The staff should have notified the Administrator immediately after the incident occurred. -The staff report all allegations of abuse to the Administrator. -The Administrator was responsible for reporting all allegations of abuse to the State Agency. -An investigation related to abuse needed to be completed within three to five days. -He/she was not aware that CNA A had not been suspended after the alleged abuse. -He/she thought CNA A should have been suspended per facility policy pending the completion of the investigation. MO00223647

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate and complete a fall investigation for one sampled resident (Resident #6) out of eight sampled residents. The facility census was 66 residents. Record review of the facility Focus Risk Assessment Plan Scope/Severity for Falls (FRAPSS) dated 7/9/21 showed: -Purpose: --To assess all residents for potential for falls in the facility. --To ensure a comprehensive interdisciplinary plan of care is established for all resident who are identified for increase risk of falls. --To identify precipitating factors for fall risk and to be proactive in implementing interventions to prevent or reduce the incident of further falls. 1. Record review of Resident #6's admission Record showed he/she was admitted on [DATE] with the diagnoses of cerebrovascular disease (refers to a group of conditions that affect blood flow and the blood vessels in the brain), vascular 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), and alcoholic cirrhosis of the liver. Record review of the resident's medical record showed no documentation of a fall risk assessment. Record review of the Resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 4/23/23 showed the resident: -To have moderate cognitive impairment. -Unable to perform ambulatory assessment and wheelchair bound due to terminal illness. -No documentation of any history of falls. Record review of the resident's undated Care Plan showed: -The resident was at low risk for falls. -The resident will remain free of falls through review date of 5/16/23. -Last assessment and revision was on 3/1/23. Record review of the resident's Progress Note dated 5/21/23 at 9:39 A.M. showed: -The resident was found by the writer on the floor. -Resident was alert, with his/her eyes open and attempting to answer questions of how the fall occurred. -Resident stated, I slid out of bed and did not hit my head. -Staff assisted the resident from the floor with a two man lift while the resident rested on a blanket. -Resident was assessed for new injuries and possible fractures and none found. -Calls were placed to pertinent parties and to the facility Administrator. -Resident was presently on hospice care (end of life care) . Record review of the resident's Progress Note dated 5/21/23 at 9:55 A.M. showed: -Call placed to the resident's hospice provider to inform them of the resident's fall this morning and spoke to the hospice nurse who will call the resident's responsible parties. -Hospice nurse has noted the resident's fragile appearance. -His/her oxygen saturation was 83% (normal range is between 95 to 100%), -His/her blood pressure was 82/67( normal blood pressure is 120/80, low blood pressure is anything below 90/60). -The resident was alert with confusion and his/her head of bed was elevated. He/she was feeding self a snack of jello. -The resident had a oxygen canister in place at 2 liters per minute per nasal cannula (tube in the nose). -Hospice nurse to pursue doctor's orders to provide oxygen concentrator for resident. NOTE: Requested fall investigation from the Director of Nursing (DON) on 5/24/23 at 12:00 P.M. A fall investigation was not provided at the time of exit. During an interview on 5/24/23 at 10:49 A.M., Certified Nursing Assistant (CNA) A said: -The night shift had just been in and changed the resident before shift change at 7:00 A.M. -During rounds at shift change is when he/she found the resident on the floor. -The resident said he/she was trying to get to his/her TV when he/she fell. -He/she noticed the resident had not been eating well and was declining two days prior to the fall. During an interview on 5/24/23 at 1:59 P.M., the DON said: -He/she had been told the resident was not doing well. -He/she was working as a charge nurse that day and assessed the resident for injuries after his/her fall. -He/she did not initiate a fall investigation or neurological checks after the fall. -He/she said another nurse was supposed to start the documentation, although the DON was the charge nurse. -He/she agreed it was ultimately his/her responsibility (to complete the fall investigation) since he/she was the charge nurse and the DON. -The resident being found on the floor was considered a fall. During an interview on 5/31/23 at 4:03 P.M., the Medical Director said: -He/she expects a fall investigation to be initiated within 24 hours. -He/she expects documentation to be initiated when the fall happens. -Neurological checks should have been initiated at that time. -Even when a resident is on hospice, (fall) protocol should be initiated. -When the resident fell on 5/21/23, a fall investigation should have been initiated by or before 5/22/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one sampled resident (Resident #2) received dialysis services (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood), out of eight sampled residents. The facility census was 66 residents. Record review of the facility Dialysis Policy dated 3/18/22 showed: -Ensure that residents who require dialysis receive such services as ordered by physician. -The facility will ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. -The facility will ensure that each resident receives care and services for the provision of hemodialysis (blood is pumped out of the body to an artificial kidney machine, and returned to the body by tubes that connect the patient to the machine) and/or peritoneal dialysis (the inside lining of the patient's own belly acts as a natural filter. Wastes are taken out by means of a cleansing fluid called dialysate, which is washed in and out of the patient's belly in cycles) consistent with professional standards of practices including: --Ensure resident has transportation to and from an off-site certified dialysis facility for dialysis treatments. 1. Record review of Resident #2's admission Record showed he/she was admitted [DATE] with diagnoses of end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) and anemia (a condition in which your blood has a lower-than-normal amount of red blood cells or hemoglobin) in chronic kidney disease (the kidneys are damaged and can ' t filter blood the way they should. This damage can cause wastes and fluid to build up in the body). Record review of the resident's May 2023 Order Summary showed: -Dialysis Monday, Wednesday and Friday at 3:15 P.M. dated 5/17/23. -Dialysis Monday, Wednesday, and Friday every day shift Monday, Wednesday and Friday for dialysis therapy at 3:15 P.M. dated 5/17/23. Record review of the resident's Progress Notes dated 5/10/23 at 5:30 P.M. showed he/she was admitted to the facility on this Wednesday. NOTE: No documentation in the resident's hospital discharge records to indicate the last time the resident received dialysis while in the hospital. Record review of the resident's Progress Notes dated 5/10/23 at 9:24 P.M. showed the resident placed a 911 call to be transferred back to the hospital with complaint of excess pain and unable to wait for staff intervention. Record review of the resident's Progress Notes dated 5/11/23 at 11:06 A.M. showed the resident was re-admitted to the facility on this Thursday. NOTE: No documentation in the resident's hospital discharge records from 5/10-5/11/23 to show the resident received dialysis while in the hospital. Record review of the resident's Progress Notes dated 5/12/23 at 2:09 P.M. showed: -The dialysis center was contacted to set up dialysis. -The resident re-admitted for dialysis and to start on Monday 5/15/23. -Paperwork related to transportation to be completed on 5/15/23. -Facility to transport to dialysis on 5/15/23. NOTE: No documentation in the resident's medical record the last time the resident received a dialysis treatment. Record review of the resident's Progress Notes dated 5/12/23 at 2:37 P.M. showed: -Resident requested to be sent to the hospital for dialysis. -Transported via Emergency Medical Services to the hospital for dialysis. Note: 5/12/23 is Friday, as per physician orders a dialysis day. Record review of the resident's Progress Notes dated 5/17/23 at 9:42 A.M. showed the resident was re-admitted to the facility on this Wednesday. NOTE: No documentation in the resident's hospital discharge records from 5/12-5/17/23 to indicate the resident received dialysis while in the hospital. Record review of the resident's Progress Notes dated 5/18/23 showed: -The resident was seen by the Nurse Practitioner. -No documentation related to the resident's dialysis treatments and/or any potential missed treatments. Record review of the resident's Progress Notes dated 5/19/23 at 9:21 P.M. showed: -No dialysis recorded for this date, Friday. -The resident contacted Emergency Services to be transferred to the hospital. Record review of the Resident's Progress Notes dated 5/23/23 at 3:42 P.M. showed the resident was readmitted to the facility. NOTE: No documentation in the resident's hospital discharge records from 5/19-5/23/23 to indicate the resident received dialysis while in the hospital. Record review of the resident's medical record from 5/10/23 - 5/23/23 showed no documentation the resident received dialysis treatments or was transported to the dialysis treatment center. During an interview on 5/24/23 at 2:05 P.M., the resident said: -He/she was due to go to dialysis on 5/24/23 at 3:00 P.M. -He/she did not know who was transporting him/her to dialysis. During an interview on 5/24/23 at 2:05 P.M., Licensed Practical Nurse (LPN) B said: -The discharging facility was to ensure transportation was set up before the resident was admitted to the facility. -Transportation did not show up to transport the resident to dialysis. -He/she was unsure what to do or who to contact if the resident's transportation to dialysis did not show up when expected. -He/she was unsure who to notify or if he/she would contact the resident's physician if the resident was not able to be transported to dialysis as expected. -The facility is ultimately responsible for ensuring the resident gets to dialysis. During an interview on 5/24/23 at 2:33 P.M., the Administrator said: -Transportation for dialysis is set up by the facility. -He/she was not sure who was responsible for setting up the resident's transportation needs. -If there were concerns, the facility would transport the resident to dialysis. -He/she expects transportation and coordination for dialysis to be done immediately upon admission. -He/she expects no residents to miss dialysis unless they refused. During an interview on 5/24/23 at 3:09 P.M., the Director of Nursing (DON) said: -He/she was not sure who was responsible for setting up the resident's transportation needs. -The last day the resident was to go to dialysis, the resident was sent to the hospital. -The resident has not made it to any dialysis appointments since admitted to the facility. He/she was not sure why the resident had not made it to his/her dialysis appointments. -It is not the fault of the facility since the resident was not transported as the van was in the shop for repairs at some point. (No date known) -The van was the alternative mode of transportation if the resident's primary transportation did not arrive to take the resident to his/her appointments. During an interview on 5/24/23 at 3:21 P.M., the Social Worker said: -Transportation was to be set up by Social Services from the hospital. -He/she was not sure who was responsible for setting up the resident's transportation needs. -He/she expects the discharging facility to ensure dialysis is set up before the resident is admitted . During an interview on 5/24/23 at 3:23 P.M., LPN A said: -The resident's appointment and transportation was set up by the dialysis center. -On 5/19/23 the van driver refused to take the resident to dialysis. -It was his/her understanding the van driver would not take the resident to dialysis because the resident's wheelchair was too big for the transport van. -The facility did not transport the resident to dialysis on 5/19/23 when the van driver refused to transport. -It was his/her understanding the resident did not have transportation set up for dialysis during his/her stay with the facility. -It was his/her understanding the facility van driver was supposed to take the resident to his/her dialysis appointments if the primary transportation did not arrive. -No documentation of the incident was recorded in the electronic medical record. During an interview on 5/24/23 at 10:13 A.M., Certified Nursing Assistant (CNA) A said: -The resident is always willing to go to dialysis and never refuses. -On Monday 5/23/23 the resident wanted to go to dialysis, but nobody showed up to take the resident. -He/she had the resident ready to go and in the front lobby waiting. During an interview on 5/24/23 at 10:23 A.M. the CNA B said: -There have been concerns about a third party picking up residents for dialysis in the past. -In the past when a third party has not showed up to pick up a resident, the facility van driver has called to have the third party to pick up the resident. -If a resident doesn't get picked up he/she will go to the nurse in charge and the DON. During an interview on 5/31/23 at 4:03 P.M., the Medical Director said: -The resident has returned to the hospital for unknown reasons. -He/she expects a resident to be able to continue the same dialysis schedule in place prior to admission. -Most of the time, the discharging facility already has a dialysis chair reserved and transportation in place. -Social Services from both facilities should be working together to ensure coordination of dialysis and transportation is in place. -The facility should not have taken the resident without ensuring dialysis and transportation was in place. -If there was not a dialysis chair already reserved for the resident, he/she is not sure why the facility would accept the admission of the resident. -He/she was not aware of the resident missing any dialysis. -When a resident has missed a dialysis appointment, he/she will order labs to be done immediately to ensure the resident remains stable. MO00218718

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document that a transfer of the resident was necessary for two sampled residents (Resident #23 and #26) who were transferred to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy revised 7/12/22 showed when a resident was transferred or discharged , the reason for the transfer/discharge must be documented in the resident's medical record. 1. Record review of Resident #23's Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) tracking records (records of admission/discharge) showed he/she was discharged , return anticipated on 10/21/22. Record review of the resident's medical record showed the reason for the resident's discharge on [DATE] was not documented. Record review of the resident's MDS tracking records showed he/she was readmitted to the facility from an acute care hospital on [DATE]. 2. Record review of Resident #26's progress note dated 1/24/23 showed: -He/she had been hospitalized post unwitnessed fall. -There was no documented assessment of the resident's condition/injuries or specific reason for his/her transfer to a hospital other than unwitnessed fall. Record review of the resident's MDS tracking records showed he/she was discharged , return anticipated on 1/24/23. Record review of the resident's MDS tracking records showed he/she was readmitted to the facility from an acute care hospital on 1/27/23. 3. During an interview on 2/9/23 at 1:23 P.M. Licensed Practical Nurse B said: -If a resident needed to be transferred/discharged , he/she would assess the resident first. -He/she would document what happened with the resident and his/her assessment of the resident in the resident's medical record. During an interview on 2/9/23 at 2:05 P.M. the Director of Nursing said: -Residents' medical records should include documentation of what occurred with the resident, an assessment of the resident's condition, and the reason for the resident's transfer/discharge. -The licensed nurse caring for the resident at the time of transfer/discharge was responsible for completing the needed documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of the bed hold policy for two sampled residents (Resident #23 and #26) who were transferred to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy revised 7/12/22 showed: -When a resident was transferred to the hospital or other location the facility must provide to the resident or their representative a written copy of the bed hold policy. -This notice must be given at the time of transfer. -For emergency transfers the bed hold notice must be given within 24 hours of transfer. -If the emergency transfer was to a hospital, the facility may send a copy of the bed hold policy to the resident in the hospital if a hospital representative such as a social worker. 1. Record review of Resident #23's Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) tracking records (records of admission/discharge) showed he/she was discharged , return anticipated on 10/21/22. Record review of the resident's medical record showed the bed hold policy for the discharge on [DATE] was not documented. Record review of the resident's MDS tracking records showed he/she was readmitted to the facility from an acute care hospital on [DATE]. 2. Record review of Resident #26's progress note dated 1/24/23 showed: -He/she had been hospitalized post unwitnessed fall. -There was no documented assessment of the resident's condition/injuries or specific reason for his/her transfer to a hospital other than unwitnessed fall. Record review of the resident's MDS tracking records showed he/she was discharged , return anticipated on 1/24/23. Record review of the resident's MDS tracking records showed he/she was readmitted to the facility from an acute care hospital on 1/27/23. 3. During an interview on 2/7/23 Resident #23's and Resident #26's written notifications of the bed hold policy being given to the resident and/or the resident's representatives were requested from the Administrator on 2/7/23 and had not been provided at the time of the survey exit on 2/9/23. During an interview on 2/9/23 at 1:23 P.M. Licensed Practical Nurse B said he/she did not have any part in providing a bed hold policy to resident being transferred or discharged . During an interview on 2/9/23 at 2:05 P.M. the Director of Nursing said: -When a resident transferred to a hospital they or their representative were to be given a bed hold policy. -Bed hold policies were provided to residents or resident representatives as soon as was practicable.

Based on interview and record review, the facility failed to complete comprehensive falls investigations, determine a root cause (main cause) for the resident's falls and revise the resident's care plan following a fall for one sampled resident (Resident #26) out of 17 sampled residents. The facility resident census was 66 residents. Record review of the facility Focused Risk Assessment Plan Scope/Severity for Falls (FRAPSS) policy revised 7/9/23 showed: -The purpose of the policy included identifying precipitation factors for fall risk and to be proactive in implementing interventions to prevent or reduce further falls. -Residents will be assessed using the FRAPSS including in an acute situation where a resident has had a fall. -The FRAPSS assessment guide measures areas of precipitating factors, history of previous falls, sensory deficits, medications and resident compliance. -The resident will be assessed by a Licensed Nurse and after the assessment is completed the resident will be scored accordingly and placed on the scope and severity level which outlines the plan of care and is denoted by different colors. -Nursing interventions will be individualized and addressed on the care plan for the resident. 1. Record review of Resident #26's falls care plan revised 10/28/22 showed: -Desired outcomes that the resident would be free of falls, free of minor injury and would not sustain serious injury. -Interventions included floor mat next to bed and bed I lowest position when in bed, review information on past falls and attempt to determine cause of falls, record possible root causes (main reasons) for falls, record possible root causes and alter/remove any potential causes if possible. -No care plan revisions regarding or mention of the resident's falls the resident experienced following 10/28/23. Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool required to be completed by facility staff for care planning) dated 1/17/23 showed: -He/she was severely cognitively impaired. -He/she had two or more non-injury falls since his/her last MDS assessment. Record review of the resident's incident progress note dated 1/24/23 showed: -The resident was transferred to hospital post unwitnessed fall. Next of kin notified. -There was no documented assessment of the resident's condition/injuries or specific reason for his/her transfer to a hospital other than unwitnessed fall. Record review of the resident's incident progress note dated 2/1/23 showed: -The licensed nurse was notified that the resident fell out of his/her wheelchair. -He/she was assisted back into his/her wheelchair. -No injury was noted. Record review of the resident's Hot Rack Notes (A specialized assessment progress note entered for 72 hours following a resident's event or change in condition) dated 2/2/23 at 9:08 A.M. showed: -He/she had a non-injury fall out of his/her wheelchair. -He/she refused assessment. -He/she denied pain. -He/she was found lying on the floor mat one time. -He/she said he/she could do what he/she wanted. -He/she moved all extremities (arms and legs) and refused care. -There was no further information in the resident's medical record related to the resident's falls on 2/1/23 and 2/2/23. Record review of the resident's falls investigations requested from the Administrator and received on 2/7/23 showed: -No falls investigation for the resident's fall on 1/24/23. -No falls investigation for the resident's fall on 2/1/23. -No falls investigation for the resident's fall on 2/2/23. During an interview on 2/8/23 Certified Nursing Assistant (CNA) E said: -The resident was often found on his/her mat next to his/her bed which was kept in the lowest position. -He/she told the charge nurse when he/she would find the resident on his/her mat next to his/her bed. During an interview 2/9/23 at 1:23 P.M. Licensed Practical Nurse (LPN) B said: -The resident was often found on his/her mat next to his/her bed. -The resident liked to be on the mat and could tell nursing staff when he/she got on his/her mat intentionally. -If the resident was found on the floor and said he/she wanted to be on his/her mat and got on his/her mat intentionally, he/she would not start any kind of notifications for a falls investigation. -If the resident could not say how he/she ended up on the mat, he/she would consider that a fall and would notify the Director of Nursing (DON), the physician and the resident's family. During an interview on 2/9/23 at 2:05 P.M. the DON said: -Each resident fall required a complete falls investigation with identification of a root cause for the resident's fall. -Each resident fall required a review and revision of the resident's care plan. -For each fall, the charge nurse was to notify him/her of the resident's fall and he/she was responsible for ensuring a completed falls investigation and for notifying the MDS/Care Plan Coordinator of the resident's fall. -The MDS/Care plan Coordinator was responsible for revising resident's care plans after each fall. -Residents' medical records should include documentation of what occurred with the resident, an assessment of the resident's condition, and the reason for the resident's transfer/discharge. -The licensed nurse caring for the resident at the time of transfer/discharge is responsible completing the needed documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after hemodialysis (a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments by having a licensed nurse assess the dialysis site for one sampled resident (Resident #49) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility policy entitled Dialysis dated 11/28/17 and revised 3/18/22 showed: -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. -Ongoing assessment and oversight of the resident before and after dialysis treatments. -Coordination of Physician Services between Nursing Home and Dialysis facility. -For a resident that received dialysis, the nursing home staff must immediately contact and communicate with the attending physician/practitioner, resident/resident representative, and designated dialysis staff regarding any significant changes in the resident's status related to clinical complications or emergent situations that would impact the dialysis portion of the care plan. -These situations might have included to but are not limited to changes in cognition or sudden unexpected decline in condition, dialysis complications such as bleeding, hypotension (low blood pressure), or adverse consequences to medication or therapy, or other situations. -The nurse would check the resident's circulation by palpating pulses away from the vascular access; capillary refill in the fingers would be observed, assessed fingers for numbness, tingling, altered sensation, coldness, pale color in affected extremity. -The nurse would monitor Bruit (the abnormal sound generated by turbulent flow of blood in an artery) and Thrill (a vibration felt upon palpation of a blood vessel) every shift and documented in the Treatment Administration Record (TAR). -The nurse would palpate the vascular access to feel for a thrill or vibration that indicated arterial and venous blood flow and patency. -The nurse would auscultate the vascular access with a stethoscope to detect a bruit or swishing sound that indicated patency. -After dialysis, the vascular access would be assessed for any bleeding or hemorrhage. -The vascular access would be assessed for signs and symptoms of infection such as redness, warmth, tenderness, purulent (consisting of, containing, or discharging pus) drainage, open sores, or swelling. -The vascular access would be assessed for blebs (ballooning or bulging) that might indicate an aneurysm (abnormal bulge or ballooning in the wall of a blood vessel) that could rupture and cause bleeding. -The assessment findings would be documented, any interventions and resident responses, resident teaching, and the resident's level of understanding. 1. Record review of Resident #49's Transfer/Discharge Report showed: -He/she was readmitted to the facility on [DATE]. -He/she had diagnoses of End Stage Renal Disease (the stage of kidney impairment that is irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life) and dependence on renal dialysis. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 11/13/22 showed: -He/she was cognitively intact. -He/she had no symptoms of mood disturbance. -He/she had no behavioral symptoms, including that he/she did not reject care. -He/she received dialysis. Record review of the resident's care plan dated 11/15/22 showed: -He/she had end stage kidney disease and went to dialysis three times a week on Monday, Wednesday, and Friday. -He/she would have no signs/symptoms of complications from dialysis. -Staff were to monitor/document/report as needed any signs/symptoms of infection to his/her access site (shunt); redness, swelling, warmth or drainage. Record review of the resident's TAR's dated 11/13/22 to 2/8/23 showed no documentation for staff to monitor for the thrill, bruit, signs of infection, or bleeding. Record review of the resident's Order Summary Report dated 2/7/23 showed: -Dialysis on Monday, Wednesday, and Friday facility to transport. -Asses bruit and thrill every morning and at bedtime related to end stage renal disease order dated 2/6/23. -No order to monitor for swelling, pain, redness, or drainage of the vascular access site every shift. During an interview on 2/8/23 at 1:46 P.M., Registered Nurse (RN) A said: -He/She would check for the thrill and bruit every shift. -He/She would monitor for signs of infection every shift. -These would be done once a day or every shift. -An order to asses just the thrill and bruit would not be acceptable. -This monitoring would be started as soon as the resident was admitted . -These assessments would be charted on the TAR. During an interview on 2/9/25 at 9:18 A.M. the resident said facility staff were not assessing his/her dialysis site. Observation on 2/9/26 at 9:18 A.M. showed the resident's dialysis shunt was uncovered and had no swelling, pain, redness, or drainage. During an interview on 2/9/23 at 9:21 A.M. Licensed Practical Nurse (LPN) A said: -When the dialysis site was assessed for infection and bleeding it should be documented in the computer. -If there were any abnormalities in the dialysis site it would be documented in a nurses noted. -The nurse that admitted or readmitted the resident was responsible for entering in the admission orders. -When the resident returned from the dialysis facility he/she reviewed the dialysis communication paperwork for any new orders. -He/she also assessed the dialysis site for any signs of complications upon the residents return. Record review of the resident's monitoring and assessment of the dialysis site showed: -On 2/9/23 LPN A was not able to find any documentation that the resident's dialysis site had been assessed or monitored. During an interview on 2/9/23 at 2:04 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) A, said: -He/she expected the dialysis site would be monitored for thrill, bruit, bleeding, and signs of infection. -He/she expected this monitoring would be documented on the residents TAR and this charting would done each shift. -When the resident returned from the hospital all the orders from the hospital would be put in the electronic medical records. -If the resident returned from the hospital with no orders the nurse would inform him/her and contact the doctor to get the correct orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #60), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 17 sampled residents. The facility census was 66 residents. Record review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: -Trauma-informed care shifts the focus from What's wrong with you? to What happened to you? -A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - in order to provide effective health care services with a healing orientation. -Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors. -Trauma-informed care seeks to: --Realize the widespread impact of trauma and understand paths for recovery; --Recognize the signs and symptoms of trauma in patients, families, and staff; --Integrate knowledge about trauma into policies, procedures, and practices; and --Actively avoid re-traumatization. 1. Record review of Resident #60's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had a diagnosis of PTSD, dated 3/29/22. Record review of the resident's care plan, initiated on 12/2/21 and revised on 12/20/22 showed: -No identification the resident had a diagnosis of PTSD or had experienced trauma. -No staff interventions to address the resident's PTSD, history of trauma and need for trauma informed care. -No identification of/interventions for supportive mental health services to address his/her diagnosis of PTSD and history of trauma. Observation on 2/5/23 at 10:28: A.M. showed: -The resident had down cast eyes and a furrowed brow. -He/she spoke in a low voice volume and did not maintain eye contact. During an interview on 2/5/23 at 10:28 A.M. the resident said: -The facility was not helping him/her at all with PTSD. -He/she had panic attacks. -He/she did not sleep well at night. -He/she was miserable from it. During an interview on 2/9/23 at 11:56 A.M. the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning)/Care Plan Coordinator said: -He/she had not been aware the resident had a diagnosis of PTSD. -He/she had not included the resident's past trauma or diagnosis of PTSD in the resident's care plan. During an interview on 2/9/23 at 2:13 P.M. the Director of Nursing (DON) said: -The resident's care plan should have included trauma informed care. -The MDS Coordinator was responsible for ensuring trauma informed care was addressed for residents with a history of trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dental services for one sampled resident (Resident #7) with teeth in poor repair out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received. 1. Record review of Resident #7's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 12/17/21 showed the resident: -Was cognitively intact. -Had teeth in good repair. Record review of the resident's annual MDS dated [DATE] showed the resident: -Was cognitively intact. -Was independent with Activities of Daily Living (ADLs-grooming, hygiene, self-care). -Was edentulous or had broken/fragmented teeth. Record review of the resident's care plan dated 12/16/22 showed the resident was independent with self-care and staff would monitor. Observation and interview on 2/5/23 at 7:45 A.M. showed: -The resident had all front lower teeth broken off at the gum line. -The resident said he/she was not in pain from the broken teeth. -He/she would like to have the teeth pulled to get lower dentures. -He/she was still able to eat and drink with no issues. Record review of the resident's electronic medical record on 2/7/23 showed no information related to dental services. During an interview on 2/9/23 at 10:11 A.M. Certified Nurses Assistant (CNA) A said: -He/she had not noticed the resident's teeth were in bad repair. -He/she would notify the charge nurse if a resident had teeth in bad repair. During an interview on 2/9/22 at 1:14 P.M. Licensed Practical Nurse (LPN) B said: -The Social Services Designee (SSD) was responsible for setting up dental services for the resident. -He/she was not aware the resident had teeth in bad repair. During an interview on 2/9/23 at 2:10 P.M. the Director of Nursing (DON) said: -Nurses were responsible for following up on teeth in bad repair and obtaining an appointment. -The SSD was responsible for routine dental care. -If the MDS showed the resident's teeth were in bad repair upon assessment, the nurse was responsible for setting up services to have the resident's teeth repaired. -The SSD was unavailable for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #68's Entry and Discharge MDS's showed: -The resident entered the facility on 1/21/22 and was discharged on 11/14/22 with return to the facility not anticipated. -The resident was admitted to another Skilled Nursing Facility (SNF) on 11/15/22. Record review of the Transfer/Discharge report that was sent to the Ombudsman, dated 2/5/23 showed: -The Ombudsman's Office was not notified of the 11/14/22 discharge until 2/5/23. -The resident was discharged to an acute care hospital. -The notification did not have documentation of the address where the resident was discharged to. 5. During an interview on 2/7/23 at 2:45 P.M. the Administrator said: -Social Services was responsible for notifying the Ombudsman of resident transfers and discharges on a monthly basis. -The Social Services Designee (SSD) was not at the facility that week and was unavailable for interview. -He/she was unable to locate any documentation of monthly Transfer/Discharge reports so he/she sent a Transfer/Discharge report to cover the past year to the Ombudsman's Office on 2/5/23. Based on interview and record review, the facility failed to provide notice to the resident and/or the resident's representative in writing of the residents transfer to an acute care hospital for two sampled residents (Resident #23 and #26), and to provide a notice of facility-initiated transfers and discharges within 30 days of discharge and the location to which the resident was discharged to the Office of the State Long Term Care (LTC) Ombudsman for one sampled resident (Resident #68) who was transferred on an emergency basis to an acute care hospital, out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave policy, revised 7/12/22 showed: -Transfer referred to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. -Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community when return to the original facility is not expected. -Residents who are sent emergently to the hospital are considered facility-initiated transfers because the resident's return is generally expected. -Before any resident was transferred or discharged under a facility-initiated transfer or discharge the facility must: --Notify the resident and resident's representative of the reason for the transfer or discharge in writing and in a manner they understand. --Notify a representative of the Office of the State LTC Ombudsman at least 30 days in advance of the discharge or as soon as possible. --In the case of an emergency or immediate discharge copies shall be sent to the Ombudsman's Office. This notice shall be sent when practicable. A monthly list is acceptable and should include whether or not the resident's return is expected. -The written notice shall include the following information: --The reason for the transfer or discharge. --Effective date of the transfer or discharge. --Location to which the resident is being transferred or discharged , including the specific address. --Resident's right to appeal the transfer or discharge notice to the Department of Health and Senior Services (DHSS) within 30 days of receipt of the notice and the address to which the request shall be sent. --If the resident files an appeal, they can remain in the facility unless and until a hearing official finds otherwise. --The name, address, e-mail, and telephone number of the designated regional long-term care ombudsman office. --For residents with developmental disabilities, the mailing address, e-mail, and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities. --For residents with mental disorders or related disabilities, the mailing address, e-mail, and telephone number of the agency responsible for the protection and advocacy of individuals with mental disorder. 1. Record review of Resident #23's Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) tracking records (records of admission/discharge) showed he/she was discharged , return anticipated on 10/21/22. Record review of the resident's medical record showed the reason for the resident's discharge on [DATE] was not documented. Record review of the resident's MDS tracking records showed he/she was readmitted to the facility from an acute care hospital on [DATE]. 2. Record review of Resident #26's progress note dated 1/24/23 showed: -He/she had been hospitalized post unwitnessed fall. -There was no documented assessment of the resident's condition/injuries or specific reason for his/her transfer to a hospital other than unwitnessed fall. Record review of the resident's MDS tracking records showed he/she was discharged , return anticipated on 1/24/23. Record review of the resident's MDS tracking records showed he/she was readmitted to the facility from an acute care hospital on 1/27/23. 3. On 2/7/23 Resident #23's and Resident #26's written notifications of transfer were requested from the Administrator and had not been provided at the time of the survey exit on 2/9/23. During an interview on 2/9/23 at 1:23 P.M. Licensed Practical Nurse B said he/she did not have any part in providing a transfer or discharge letter to residents being transferred or discharged . During an interview on 2/9/23 at 2:05 P.M. the Director of Nursing said: -When a resident transferred to a hospital they or their representative were to be given a written discharge notice. -Written discharge notices were provided to residents or resident representatives as soon as was practicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident had a Pre-admission Screening/Resident Review (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment) level II when the DA-124 (PASRR) Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a level II PASRR screening was required) showed that the resident had a qualifying psychiatric condition as required, for three sampled residents (Resident #15, #23, and #60) out of 17 sampled residents. The facility census was 66 residents. Record review of facility policy entitled PASRR Assessments and DA 124 A&B dated 4/16/2017 and revised 7/9/2021 showed: -PASRR assessment was to develop a plan of care that showed continuity from previous history of behaviors and placement. -Upon the resident's admission to the facility and upon the facility receiving the PASRR, the Customer Service Consultant would make a copy of the PASRR with the clinical history of previous behavior and services provided. -The Customer Service Consultant would give a copy of the PASRR to the Director of Nursing (DON), Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) Care Plan Coordinator, and the Social Services Director (SSD). -The DON, SSD, and MDS/Care Plan Coordinator would meet and developed a plan of care that showed continuity from previous history of behaviors and placements. -The plan of care would holistically address the resident's needs to assist in reaching and maintaining their highest level of mental and psychosocial functioning. -The PASRR would be utilized as an instrument to assist the facility in maintaining as much as possible, previous treatment modalities that were effective in the resident's life prior to placement at this facility. -The PASRR would be a guide in developing an assessment that would assist in the continuity of care and services in the best interest of the resident. -The MDS Coordinator would ensure that all recommendations made in the PASRR were addressed in the care plan. -The DA-124 A/B/C Forms would be completed by the MDS Coordinator as needed. -In the event the facility was without an MDS Coordinator, the DON/Assistant Director of Nursing (ADON) would complete. 1. Record review of Resident #15's DA-124 dated 8/3/15 showed he/she had the following medical diagnoses: -Schizophrenia (a psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday life). -Mood disorder (a variety of conditions characterized by a disturbance in mood as the main feature). -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). -Medical diagnosis that required a level II PASRR performed. Record review of the resident's DA-124 dated 4/16/2021 showed the following medical diagnoses: -Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). -Medical diagnosis that required a level II PASRR be performed. Record review of the resident's admission record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Personality Disorder (conditions in which an individual differed significantly from an average person, in terms of how they think, perceive, feel or relate to others). -Bipolar Disorder ((formerly called manic-depressive illness or manic depression) was a mental illness that caused unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). -Schizoaffective disorder (a mental condition that caused loss of contact with reality and mood problems). -Mood disorder due to a known physiological condition with depressive features. -Major depressive disorder. -Antisocial personality disorder (a condition characterized by repetitive behavioral patterns that were contrary to usual moral and ethical standards and caused a person to experience continuous conflict with society). Record review of the resident's admission MDS dated [DATE] showed the resident had the following medical diagnoses: -Schizophrenia. -Depression. During an interview on 2/8/23 at 12:25 P.M., the MDS Coordinator said: -He/she had only been in position for six months. -The DA-124 was done within seven days from admission. -The DA-124 told you if a level II PASRR needed to be done. -The resident had a medical diagnoses that required a level II PASRR to have been done, and it was not done. -He/she was unsure why a level II PASRR was not done, but it should have been done. -He/She was responsible for ensuring the level II PASRR was performed when it was required. During an interview on 2/9/23 at 2:04 P.M., the DON said: -He/she expected a resident that had a diagnosis of Schizophrenia would have a level II PASRR performed. -MDS and Social Services were responsible for completing the level II PASRR. -He/she expected any resident that needed a level II PASRR would have one completed. -The recommendations from the level II PASRR should be incorporated into the residents care plan. 2. Record review of Resident #23's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had diagnoses of Schizophrenia. Record review of the resident's care plan revised on 12/17/22 showed: -No mention of his/her diagnosis of Schizophrenia. -No goals or interventions to address continuity of care, history of behaviors and treatment modalities that were effective in the resident's life prior to placement in the facility. Observation on 2/5/23 at 10:46 A.M. showed: -The resident was seated in the activity area by a television. -He/she had an angry grimace facial expression with a furrowed brow and appeared to be preoccupied. -He/she mumbled incoherently. Observation on 2/7/23 at 11:32 A.M. showed: -He/she was seated on his/her bed in his her room. -He/she mumbled incoherently. 3. Record review of Resident #60's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Major Depressive Disorder, Recurrent Depression. -Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). Record review of the resident's care plan, revised on 12/20/22 showed: -No identification the resident had a diagnosis of PTSD or had experienced trauma. -No staff care plan interventions to address his/her PTSD, history of trauma and need for trauma informed care. -No identification of or interventions for supportive mental health services to address his/her diagnosis of PTSD and history of trauma. Observation on 2/5/23 at 10:28: A.M. showed: -The resident had down cast eyes and furrowed eyebrows. -He/she spoke in a low voice volume and did not maintain eye contact. During an interview on 2/5/23 at 10:28 A.M. the resident said: -The facility was not helping him/her at all with PTSD. -He/she had panic attacks and did not sleep well at night and was miserable from it. 4. During an interview on 2/6/23 at 12:56 P.M. the level II PASRR was requested for Resident #15, Resident #23, and Resident #60 from the DON and they were not provided. During an interview on 2/8/23 at 12:25 P.M., the MDS Coordinator said: -He/she had only been in the position for six months. -The DA-124 was done within seven days from admission. -The DA-124 showed if a level II PASRR needed to be done. -Resident #15 had a medical diagnoses that required a level II PASRR be performed. -The level II PASRR was not performed. -The level II PASRR should have been performed. -He/She was responsible to ensure that the level II PASRR was performed when it was required. During an interview on 2/9/23 at 11:56 A.M. the MDS/Care Plan Coordinator said: -He/she was responsible for completing the PASRR for all residents. -Resident #23's Schizophrenia diagnosis was an indicator a level II PASRR needed to be completed. -He/she had not been aware Resident #60 had a diagnosis of PTSD. -He/she had not obtained or completed a level II PASRR for Resident #60. -He/she had not included Resident #60's past trauma or diagnosis of PTSD in his/her care plan. During an interview on 2/9/23 at 2:13 P.M. the DON said: -The MDS Coordinator was responsible for completing the residents PASRR. -The resident's care plan should have included his/her diagnosis of PTSD and trauma informed care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #61's annual MDS dated [DATE] showed the resident: -Was moderately cognitively impaired. -Felt the following activities were very important: listening to music, going outside, and doing his/her favorite activities. -Felt the following activities were somewhat important: access to pets and religious activities. Record review of the resident's Care Plan last updated 11/30/22 showed no care plan for activities. 4. During an interview on 2/9/23 at 11:57 A.M. the MDS Coordinator said: -He/she was responsible for developing all the residents' care plans, including each resident's Activity Care Plan and used the Activity Interview for Daily and Activity Preferences assessments for developing the plans. -All residents should have an Activities Care Plan. During an interview on 2/9/23 at 12:19 P.M. the Life Enhancement Director said: -He/She was responsible for completing the activity assessments, which were completed annually and quarterly. -The MDS Coordinator used the activity assessments to develop individualized Activities Care Plans. -Each resident should have an individualized Activities Care Plan, including Residents #64, #58, and #61. During an interview on 2/9/23 at 2:10 P.M. the Director of Nursing (DON) said: -The MDS Coordinator used input from individual resident assessments to develop care plans. -All residents should have an individualized activity care plan, including Residents #61, #64 and #58. Based on interview, and record review, the facility failed to develop activity care plans that were comprehensive, individualized and represented the resident's current interests and needs for three sampled residents (Resident # 64, #58, and #61) who were dependent upon staff to meet their activity needs out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Comprehensive Care Plans and Baseline Care Plans policy and procedure, revised 1/19/22 showed: -The facility must develop a comprehensive care plan within 14 days of admission for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. -A licensed nurse that has been designated by the facility administration will coordinate each assessment with the appropriate participation of health professionals. The Interdisciplinary Team (IDT) will be responsible for the Minimum Data Set (MDS a federally mandated assessment instrument completed by facility staff for care planning)/Care Planning process and shall include but is not limited to the MDS/Care Plan Coordinator, Social Services, Dietary, Therapy staff, Activities, and various nursing staff. -The facility will use the current Resident Assessment Instrument (RAI helps nursing home staff gather information on a resident's strengths and needs which are addressed in the individualized care plan) User [NAME] as a reference to help the IDT look at residents holistically, as individuals for whom quality of life and quality of care are mutually significant and necessary. Record review of the facility's Activities policy and procedure, revised 2/26/21 showed Section F of the MDS comprehensive assessment will be reviewed on all residents to ensure the facility identifies the resident's interests and needs and has a plan in place for individual 1:1 and self-directed activities. 1. Record review of Resident #64's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that include: -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -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, judgment, and impulses) with behavioral disturbance. -Unspecified mood disorder (a variety of conditions characterized by a disturbance in mood as the main feature). Record review of the resident's admission MDS, dated [DATE] showed: -The resident's activity preferences were obtained primarily from the resident. -Activities identified as somewhat important to the resident included: --Having newspapers, magazines and books. --Listening to music. --Being around animals. --Keeping up with the news. --Doing things in groups of people. --Going outside for fresh air when the weather was good. --Participating in religious services. Record review of the resident's Comprehensive Care Plan, dated 2/1/23 showed the resident did not have an Activity Care Plan to meet his/her individual activity and psychosocial needs. 2. Record review of Resident #58's admission Record showed he/she was admitted to the facility on [DATE] and had diagnoses that include: -Unspecified dementia without behavioral disturbance. -Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). -Mood disorder. -Anxiety. Record review of the resident's Comprehensive Care Plan, dated 8/8/22 showed the resident did not have an Activity Care Plan to meet his/her individual activity and psychosocial needs. Record review of the resident's Activity Interview for Daily and Activity Preferences, dated 8/9/22 showed: -Activity preferences were primarily obtained from the resident. -It was very important for the resident to go outside to get fresh air when the weather was good. -It was somewhat important for the resident to listen to music, keep up with the news, do things with groups of people, engage in favorite activities, and attend religious services. Record review of the resident's admission MDS, dated [DATE] showed: -Activity preferences were primarily obtained from the staff. -Daily activity preferences were doing things with groups of people and participating in favorite activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #1's admission MDS dated [DATE] showed: -The resident had no cognitive impairment. -It was very important to the resident to have family/close friends involved in his/her care. Record review of the resident's care plan dated 1/31/23 showed: -The resident had a guardian (family member) to assist with making decisions for the resident. -The resident would like to have input in his/her decision making with his/her care as much as possible. During an interview on 2/5/23 at 10:35 A.M. the resident said: -He/she had not been invited to a care plan meeting. -He/she would like to be involved in his/her care plan meeting to go over his/her care at the facility. Record review of the resident's medical record on 2/8/23 showed no information regarding his/her care plan meetings. 4. During an interview on 2/7/23 at 11:55 A.M. the MDS Coordinator said no care plan meetings had been held for the residents. During an interview on 2/9/23 at 11:57 A.M. the MDS Coordinator said: -He/she was responsible for setting up care plan meetings. -The care plan meetings were held with the resident, residents' responsible party, the Social Services Designee (SSD), Activity staff, and himself/herself. -Care plan meetings were completed quarterly. -He/she had started in June 2022 and had not had care plan meetings for any of the residents and/or family members. -He/she had been focusing on other audits. During an interview on 2/9/23 at 2:10 P.M. the Director of Nursing (DON) said: -The care plan meetings were the responsibility of the MDS Coordinator. -He/she was not involved in the care plan meetings. -Residents and family members should be invited to attend care plan meetings. Based on interview and record review, the facility failed to the extent practicable, to include residents and/or their representatives in the care planning process and to conduct care plan conferences to include resident/resident representative participation for three sampled residents (Residents Resident #61, #60 and #1) out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received by the facility. 1. Record review of Resident #61's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/22/22 showed the resident: -Was moderately cognitively impaired. -Felt it was very important to have family involved about discussions of his/her care. Record review of the resident's care plan revised 11/22/22 showed he/she had a guardian (family member) to assist with decision making. During an interview on 2/5/23 at 6:00 A.M. the resident said: -He/she had not been invited and was not aware of care plan meetings. -He/she would like to be involved in his/her care planning to go over his/her care at the facility. Record review of the resident's medical record on 2/7/23 showed no information regarding his/her care plan meetings. 2. Record review of Resident #60's annual MDS dated [DATE] showed he/she was cognitively intact. During an interview on 2/5/23 at 7:11 A.M. the resident said: -He/she was not invited to his/her care plan meetings. -He/she would like the facility to include him/her in his/her care plan meetings. Record review of the resident's medical record on 2/7/23 showed no information regarding his/her care plan meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide individualized activities for three sampled residents (Resident #61, #64 and #58) out of 17 sampled residents; and to provide daily activities for the residents who would like to participate in scheduled activities. The facility census was 66 residents. Record review of the facility's Activities policy revised 2/26/21 showed: -All residents in the facility were provided an ongoing program designed to meet, in accordance of their comprehensive assessment, their interests and their physical, mental and psycho-social well-being. -If a resident required more intensive interventions for activities, one on one activities would be provided based on their specific needs. -The activity calendar would be placed on all units and would include activities that were appropriate for the population that met specific needs, cognitive impairments, and interests. -The Life Enrichment Director would monitor large group, small group, one on one activities and self-directed activities. -The residents' activity participation would be completed daily. 1. Record review of Resident #61's admission Record showed: -The resident had a diagnosis of Cerebral Palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination). -The resident was a younger than other residents in the facility. Record review of the resident's Activity Participation dated 8/2022 and 9/2022 showed no activity participation. Record review of the resident's Quarterly/Annual Participation Review dated 9/15/22 showed the resident liked doing daily activities including bingo, church, parties, crafts, games, nail care, bowling games, watching television and snacking. Record review of the resident's Activity Participation dated 10/2022 and 11/2022 showed no activity participation. Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/22/22 showed the resident: -Was moderately cognitively impaired. -Felt the following activities were very important: listening to music, going outside, and doing his/her favorite activities. -Felt the following activities were somewhat important: access to pets and religious activities. Record review of the resident's Care Plan last updated 11/30/22 showed no care plan for activities. Record review of the resident's Activity Participation dated 12/2022 showed: -On 12/1/22 the resident played bingo. -On 12/12/22 the resident played the vintage arcade machine. Record review of the resident's Activity Participation dated 1/2023 showed the resident went out on a day outing and saw a movie. During an interview on 2/5/23 at 6:00 A.M. the resident said: -The facility did not have many activities. -He/she would like to have activities to do at the facility. -He/she was younger and did not want to play bingo. -He/she would watch television sometimes because there were no activities here that he/she liked. -He/she really loved bowling. Observation on 2/6/23 at 2:47 P.M. showed the resident playing the vintage arcade game in the common area. Observation on 2/6/23 at 2:49 P.M. showed bingo was being played in the main dining room and seven residents were in attendance. 2. Record review of the facility activity calendar dated 2/7/23 showed the following activities: -Grooming and haircuts. -Money and mail. -Christmas bingo. Observation on 2/7/23 showed no activities were being conducted between 8:03 A.M. and 3:30 P.M. Record review of the facility activity calendar dated 2/8/23 showed the following activities: -Money and mail. -Arts and crafts. -Kindle fire reading. -Painting nails. Observation on 2/8/23 showed no activities were being conducted between 8:03 A.M. and 3:30 P.M. 3. During an interview on 2/9/23 at 9:51 A.M. Certified Nurses Assistant (CNA) C said: -There were not many activities for the residents. -He/she saw one activity this week being completed which was bingo. -Resident #61 would play bingo or do some arts and crafts when offered. During an interview on 2/9/23 at 10:11 A.M. CNA A said: -There were not many activities for the residents to participate in. -Sometimes, he/she had seen nails being painted. -Resident #61 played the vintage arcade game often. During an interview on 2/9/23 at 10:27 A.M. CNA B said: -He/she had only seen an exercise class being done this week for the residents. -There were not many activities for the residents. -There were many activities that could be done with the residents but there was not much going on for them here. -The facility staff did take independent residents out to dinner or shopping. -Resident #61 was younger than everyone here and would benefit from one on one or age group activities for him/her. He/she would benefit from a specialized program. During an interview on 2/9/23 at 12:19 P.M. the Life Enrichment Director said: -He/she was responsible for the facility activity program. -There should be three group activities scheduled each day. -The residents should have meaningful activities on a daily basis. -On Monday, resident rules were gone over with the residents. -The facility did hair/grooming and some residents liked to have their hair done. -He/she counted hair/grooming as an activity. -Haircuts, passing out money and mail, were not really an activity. -There were board games out for the residents to play. -He/she did not get to do all the activities on the activity calendar. -An exercise class was held on 2/8/23 but the rest of the activities were not completed. -Resident #61 liked to play bingo and go on facility outings. The resident was younger and needed an individualized activity program. During an interview on 2/9/23 at 2:10 P.M. the Director of Nursing (DON) said: -The Life Enrichment Director was responsible for assessing the residents' individual activity needs and preferences. -Daily activities should be provided for the residents and participation should be documented in the residents' electronic medical record. -Hair/grooming were not a normal activity. -Activities should be completed per the activity schedule. 4. Record review of Resident #64's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that include: -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -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, judgment, and impulses) with behavioral disturbance. -Unspecified mood disorder (a variety of conditions characterized by a disturbance in mood as the main feature). Record review of the resident's progress notes showed there were no Activity Participation notes covering the period of 12/16/22 through 12/25/22. Record review of the resident's admission MDS, dated [DATE] showed: -The resident: --Had adequate hearing without aids and adequate vision without corrective lenses. --Was usually understood and could usually understand others. --Was moderately cognitively impaired. --Was independent in most Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting). -Activity preferences somewhat important to the resident included: --Having newspapers, magazines and books. --Listening to music. --Being around animals. --Keeping up with the news. --Doing things in groups of people. --Going outside for fresh air when the weather was good. --Participating in religious services. Record review of the resident's progress notes showed there were no Activity Participation notes from 12/26/22 through 2/1/23. Record review of the resident's Comprehensive Care Plan, dated 2/1/23 showed he/she did not have an Activity Care Plan to meet his/her individual activity and psychosocial needs. Record review of the resident's progress notes showed no Activity Participation notes from 2/2/23 through 2/7/23. Observation on 2/5/23 at 7:41 A.M. and 11:22 A.M. showed the resident was lying in bed. Observation on 2/6/23 at 1:19 P.M., 2:50 P.M. and 3:21 P.M. showed the resident was lying in bed. Observation on 2/7/23 at 10:18 A.M. showed the resident was lying on his/her roommate's bed. Observation on 2/7/23 at 1:45 P.M. and 2:22 P.M. showed the resident was lying in his/her bed. During an interview on 2/9/23 at 10:32 A.M. CNA A said: -Resident #64 stayed to himself/herself. -He/she had tried to encourage the resident to watch TV, but the resident wouldn't stay in the TV room. 5. Record review of Resident #58's admission Record showed he/she was admitted most recently to the facility on 8/8/22 and had diagnoses that include: -Unspecified dementia without behavioral disturbance. -Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). -Mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -Anxiety. Record review of the resident's Comprehensive Care Plan, dated 8/8/22 showed the resident did not have an Activity Care Plan to meet his/her individual activity and psychosocial needs. Record review of the resident's Activity Interview for Daily and Activity Preferences, dated 8/9/22 showed: -Activity preferences were primarily obtained from the resident. -It was very important for the resident to go outside to get fresh air when the weather was good. -It was somewhat important for the resident to listen to music, keep up with the news, do things with groups of people, engage in favorite activities, and attend religious services. Record review of the resident's progress notes showed no Activity Participation notes from 8/9/22 through 11/16/22. The resident's quarterly activity assessment, due 11/2022 was requested but not provided. Record review of the resident's quarterly MDS, dated [DATE] showed the resident: -Had adequate hearing without aids and adequate vision without corrective lenses. -Was able to be understood and could understand others. -Was severely cognitively impaired. -Was mostly independent in ADLs. Record review of the resident's progress notes showed no Activity Participation notes from 11/17/22 through 2/7/23. Observation on 2/6/23 at 1:56 P.M. and 2:51 P.M. showed the resident was lying in bed. Observation on 2/7/23 at 10:22 A.M. showed the resident in the front TV room with his/her head down and eyes closed. Observation on 2/7/23 at 1:40 P.M. and 2:22 P.M. showed the resident was lying in bed. Observation on 2/8/23 at 9:38 A.M., 10:52 A.M., and 2:12 P.M. showed the resident was lying in bed. During an interview on 2/9/23 at 12:19 P.M. the Life Enhancement Director said the resident liked to eat pork rinds and enjoyed visits with his/her family. 6. Observation on the secured unit hall showed: -On 2/5/23 there were no 1:1 or group activities conducted between 5:15 A.M. and 11:45 A.M. (Note: On 2/5/23 the census for the secured hall was 14 residents). -On 2/6/23 there were no 1:1 or group activities conducted between 8:45 A.M. and 3:30 P.M. -On 2/7/23 there were no 1:1 or group activities conducted between 8:25 A.M. and 2:30 P.M. -There was no activity calendar posted on the hall. 7. During an interview on 2/8/23 at 10:36 A.M. the Activity Aide on the secured hall said: -The residents on the hall were a tough crowd. -Only one resident would sometimes go to bingo held outside the secured hall. -Sometimes he/she made residents popcorn while they watched a movie. -He/she had made some residents hot chocolate that morning. During an interview on 2/9/23 at 9:37 A.M. CNA D said: -On the secured hall the residents watched movies for their activities. -He/she had seen the Activity Aide play hip hop music for residents who came out of their rooms. During an interview on 2/9/23 at 10:32 A.M. CNA A said: -He/she had never seen activities being offered to residents on the secured hall except a week and a half ago residents were given popcorn while they watched a movie. -He/she had never seen residents on the hall be taken outside except those who smoked during smoke break times. During an interview on 2/9/23 at 11:03 A.M. Hall Monitor A said: -Residents on the secured hall who didn't smoke were not taken outside. -There were no activities offered on the hall that morning. -The residents on the hall don't want to do activities. They just want to eat, sleep and watch TV. That was all. During an interview on 2/9/23 at 12:19 P.M. the Life Enhancement Director said: -He/she was responsible for documenting activity participation in activity progress notes. -If a resident participated in an activity that should be documented in an activity participation note. -On the secured hall the residents loved movies and popcorn. -Music was sometimes played for residents who were sitting in the TV rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #1's admission MDS dated [DATE] showed the resident: -Had no cognitive impairment. -Had functional limitations of range of motion on upper and lower extremity. -Was wheelchair bound. -Needed extensive assistance with activities of daily living. -Did not receive therapy or range of motion in the look back period. -Had diagnoses that included stroke, left side hemiparesis, depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), hypothyroidism (a condition when the thyroid does not produce enough thyroid hormone), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (COPD lung disease that blocks airflow and makes it difficult to breathe), and glaucoma (high eye pressure). Record review of resident's care plan revised on 1/31/23 showed: -He/she had a contracture (a condition of shortening and hardening of muscles, tendons resulting in deformity and rigidity of joints) of his/her left hand. -He/she wore a splint to his/her left hand. -He/she would remain free of injuries or complications related to the contracture of his/her left hand through the next review date. During an interview on 2/5/23 at 10:46 A.M., the resident said: -He/she was to wear the left hand splint at all times to prevent contracture. -He/she would like another splint for his/her left hand while one was being washed. -He/she had requested therapy/range of motion and had not received any. -He/she was afraid his/her left hand would get more contracted and he/she would get a sore in the palm of his/her hand if not wearing the splint. Observation and interview on 2/5/23 at 10:46 A.M., showed: -There was no splint on the resident's left hand. -The resident's finger were contracted to his/her palm and he/she could not move them independently. -The resident said he/she had not received therapy or range of motion. Observation and interview on 2/6/23 at 1:56 P.M. showed: -There was no splint on the resident's left hand. -The resident said he/she had not received therapy or range of motion. Observation and interview on 2/7/23 at 8:46 A.M. showed: -There was no splint on the resident's left hand. -The resident said he/she had not received therapy or range of motion. During an interview on 2/9/23 at 9:21 A.M. CNA A said: -CNA's were responsible for providing residents with range of motion after evaluated by therapy. -Resident #1 had a left hand contracture and did wear a splint. -Range of motion needs for residents were in the CNA tasks on the computer and the nurse was responsible for putting care tasks in the computer. During an interview on 2/9/23 at 9:23 A.M. CNA B said: -CNA's were responsible for providing residents with range of motion after evaluated by therapy. -Resident #1 had a left hand contracture and wore a splint. -Range of motion needs for residents were in the CNA tasks on the computer and the nurse was responsible for putting care tasks in the computer. During an interview on 2/9/23 at 10:14 A.M. LPN A said: -Nursing was responsible for Passive Range of Motion (PROM the ROM that was achieved when an outside force exclusively causes movement of a joint and is usually the maximum range of motion that a joint can move. Usually performed when the patient is unable or not permitted to move the body part) for residents. -ROM and PROM should be on the treatment record and CNA tasks. -Nursing and the Director of Nursing (DON) were responsible for updating the medical record for ROM and PROM orders. -He/she was not aware that Resident #1 was wanting therapy. -He/she was not aware the resident's left hand splint was not on. During an interview on 2/9/23 at 2:10 P.M. the DON said: -The facility did not have a restorative program. -CNA's were responsible for completing ROM with the residents. -If a resident needed PROM this should be determined from a therapy evaluation and referral for restorative therapy. -Resident #61, Resident #2, and Resident #1 had limited ROM and should have a restorative program. Based on observation, interview and record review, the facility failed to ensure restorative services were provided to maintain, improve, or prevent decline in Range of Motion (ROM the range on which a joint can move) for three sampled residents (Resident #61, #2 and #1) out of 17 sampled residents. The facility census was 66 residents. A policy was requested but not received by the facility. 1. Record review of Resident #61's admission Record showed: -The resident had a diagnosis of Cerebral Palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination). -Quadriplegia (paralysis of all four extremities and usually the trunk). Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/22/22 showed the resident: -Was moderately cognitively impaired. -Had limited lower extremity ROM. -Had no limitations of ROM to the upper extremities. Record review of the resident's care plan revised 11/30/22 showed the resident: -Had Activity of Daily Living (ADL-bathing, grooming, dressing) deficits due to disease processes and diagnoses. -Would maintain his/her level of function through the next review date. Observation and interview on 2/5/23 at 6:00 A.M. showed: -The resident was in his/her electric wheelchair. -The resident's fingers were contracted downward into the palm of his/her right hand. -The resident said he/she was not receiving ROM for his/her hand. He/she would like to have ROM on his/her hand. 2. Record review of Resident #2's admission Record showed the resident had the following diagnoses: -Stroke. -Hemiplegia/hemiparesis (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain). Record review of the resident's admission MDS dated [DATE] showed the resident: -Was cognitively intact. -Had limited ROM to the upper and lower extremities on one side of his/her body. Record review of the resident's care plan revised 7/6/22 showed the resident: -Had left sided hemiparesis. -Would remain free of complications or discomfort related to his/her diagnosis. Observation and interview on 2/7/23 at 12:27 P.M. showed: -The resident's left hand was contracted and all fingers were in his/her palm. -The resident could not flex his/her hand open. -The resident's left leg could not extend outward at the knee. -He/she did not have a splint device to flex out his/her fingers. -The resident said he/she had not received ROM for his/her limitations and would like to have ROM services. 3. During an interview on 2/9/23 at 10:11 A.M. Certified Nurses Assistant (CNA) A said: -The facility did not have a restorative program for ROM for the residents. -They did have one in the past but restorative services had not been done for the residents for at least a year. -Resident #61 and Resident #2 both had contractures. During an interview on 2/9/23 at 10:27 A.M. CNA B said: -Resident #61 and Resident #2 had issues with ROM. -He/she was unaware of a restorative therapy program for the residents. -He/she had been a restorative aide in the past and felt both residents would benefit from a restorative program. During an interview on 2/9/22 at 1:14 P.M. Licensed Practical Nurse (LPN) B said: -The facility used to have a staff member completing restorative services for the residents. -He/she had not seen a restorative aide completing ROM for residents since last summer. -Resident #61 and Resident #2 did have limitations from ROM including contractures. -Neither resident had a splint or device to flex out their fingers from touching their hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident's #15 admission record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Quadriplegia (paralysis of all four limbs) cervical vertebrae 5-7 (C5-C7 neck bones from the top) complete. -Spinal Stenosis (narrowing of the spinal canal) Thoracic (chest abdominal) region Record review of the resident's admission MDS dated [DATE] showed: -A Brief Interview for Mental Status (BIMS) score of 15 which meant the resident was cognitively intact with no memory issue. -Had an indwelling catheter. Record review of the residents Medication Review Report showed a physician order dated 1/19/23 to change the supra pubic catheter every two months and as needed on every night shift starting on 1/19/23. Record review of the resident's Treatment Administration Record (TAR) dated January 2023 showed: -The supra pubic was due to be changed on 1/19/23. -The 1/19/23 was left blank. During an interview on 2/5/23 at 10:28 A.M. the resident said his/her supra pubic catheter was to be changed and had not been changed. During an interview on 2/8/23 at 12:03 P.M., LPN B said: -When the doctor gave an order to change the supra pubic catheter it should have been done. -If the order was not marked as performed on the TAR with an X and the nurse's initials, then the care was not performed. During an interview on 2/8/23 at 2:20 P.M., LPN A said: -A supra pubic catheter would be changed as ordered by the doctor. -It was unacceptable to have a supra pubic catheter and no orders to have it changed with a time frame. -If the doctor gave an order to change the supra pubic catheter, then the catheter should have been changed. -When the catheter was changed it would be documented on the TAR by the nurse. -If the TAR had a blank spot on it, then the catheter was not changed. During an interview on 2/9/23 at 2:04 P.M., the DON said: -Residents with a supra pubic catheter would have orders on how often the catheter would be changed. -He/she expected physician's orders to be followed and if an order was given to change a supra pubic catheter, the catheter should be changed. -There should be documentation on the TAR of the catheter being changed. -If the TAR was blank, the catheter was not changed. MO00213360 Based on observation, interview, and record review, the facility failed to maintain catheter (a tube inserted into the bladder to drain urine) bags (the urine collection device) and tubing (the clear tubing extending from the end of the catheter to the collection bag) off the floor for two sampled residents with catheters (Resident #26 and #27); to ensure a physician's order with a diagnosis for one sampled resident's catheter (Resident #26); and to ensure one sampled resident (Resident #15) had his/her suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) changed per the physician's order out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Urinary Catheter Care policy, revised 2/26/21 showed: -The facility would ensure urinary catheters were maintained to prevent infection. -Residents with urinary catheters would have a physician's order for the catheter, care of the catheter and the diagnosis for the catheter. -Make sure that the urinary drainage bag did not touch the floor. Record review of facility policy titled Suprapubic Catheter Care dated 4/16/2017 and revised 9/17/2021 showed a supra pubic catheter would be changed every four to ten weeks or as ordered by the primary care physician. 1. Record review of Resident #26's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/17/23 showed he/she did not have a caterer. Observation on 2/5/23 at 5:23 A.M. of the resident showed: -He/she was lying in his/her bed. -His/her bed was in its lowest position to the floor and a fall safety protection mat was on the floor next to the resident's bed. -His/her catheter urine collection bag was on the end of his/her mattress. -His/her catheter tubing was touching the mat next to his/her bed. Observation on 2/5/23 at 6:54 A.M. of the resident showed: -He/she was lying in his/her bed. -His/her bed was in its lowest position to the floor and a fall safety protection mat was on the floor next to the resident's bed. -His/her catheter urine collection bag was lying directly on the floor next to his/her bed. -His/her catheter tubing was touching the mat nest to his/her bed. Observation on 2/6/23 at 1:35 P.M. of the resident showed: -He/she was lying in his/her bed. -His/her bed was in its lowest position to the floor and a fall safety protection mat was on the floor next to the resident's bed. -His/her catheter urine collection bag was without cover and was on the floor next to his/her bed. -His/her catheter tubing was on the mat next to his/her bed. Record review of the resident's current physician's orders dated 02/2023 showed no physician's order for the resident to have an indwelling catheter. Observation on 2/7/23 at 11:35 A.M. of the resident showed: -He/she was seated on his/her bed. -His/her bed was in its lowest position to the floor and a fall safety protection mat was on the floor next his/her bed. -His/her catheter tubing was on the floor. Observation on 2/8/22 at 10:43 A.M. showed the resident refused observation of his/her catheter care. During an interview on 2/8/23 at 10:43 A.M. Certified Nursing Assistant (CNA) E said: -The resident had a regular catheter that was inserted into his/her urethra. -Catheter bags and tubing were to be kept off the floor. -This was hard to do because the resident's bed was kept in the lowest position close to the floor to prevent falls. During an interview on 2/9/23 at 1:23 P.M. Licensed Practical Nurse (LPN) B said: -Nursing staff were to keep resident's catheter bags and tubing off the floor. -This was difficult to do with the resident because his/her bed was kept low. During an interview on 2/9/22 at 2:05 P.M. the Director of Nursing (DON) said: -The resident's catheter bag and tubing was to be kept off the floor and off his/her mat. -He/she would consider use of a leg bag (a smaller catheter bag that attaches to the leg with straps and had shorter tubing and would fit under clothes allowing normal daily activities) to help keep his/her catheter bag and tubing off the floor. -There needed to be a physician's order for the resident's catheter. 2. Record review of Resident #27's admission MDS dated [DATE] showed he/she had an indwelling catheter. Observation on 2/5/2 at 5:24 A.M. showed: -He/she was laying in his/her bed. -His/her catheter tubing was on the floor. Observation on 2/5/23 at 6:37 A.M. showed: -He/she was laying in his/her bed. -His/her catheter tubing was on the floor. Observation on 2/6/23 at 1:49 P.M. showed: -He/she was seated in his/her wheelchair in the main entry/lobby. -His/her catheter tubing was on the floor. During an interview on 2/8/22 at 10:46 A.M. CNA E said: -The resident's catheter tubing and bag were sometimes on the floor. -When he/she saw the resident's catheter tubing or bag on the floor, he/she got them off the floor right away. During an interview on 2/9/23 at 1:23 P.M. LPN B said the nursing staff were to keep the resident's catheter bag and tubing off the floor. During an interview on 2/9/23 at 2:05 P.M. the DON said: -Catheter bags and tubing were to be kept off the floor. -He/she expected staff to correct this right away when they saw a resident's catheter bag or tubing on the floor.

Based on observation and interview, the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), Certified Medication Technicians (CMT's), and Certified Nursing Assistants (CNA's) directly responsible for resident care per shift and the resident census. The facility census was 66 residents. 1. Observation on the following dates, and times showed posted staffing did not include actual hours worked for RN's, LPN's, CMT's, and CNA's and did not include the resident census: -On 2/5/23 at 5:24 A.M. - On 2/6/23 at 10:43 A.M. -On 2/7/23 at 10:08 A.M. -On 2/8/23 at 12:16 P.M. During an interview on 2/9/23 at 2:04 P.M. the Director of Nursing (DON) said: -He/she did not know who was responsible for posting staffing hours and resident census. -He/she did not know where staffing hours and census was posted in facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #47's Face Sheet showed he/she as admitted to the facility 7/10/20, with diagnoses including: -Schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). -Major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). -Dementia ( 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). -Delusions (a false belief or judgment about external reality, held despite incontrovertible evidence to the contrary, occurring especially in mental conditions). -High blood pressure. -Pain. -Urine retention (a condition in which you are unable to empty all the urine from your bladder). -Resident had a guardian. Record review of the resident's quarterly MDS dated [DATE] showed: -The resident's cognitive score was 14, which indicated he/she had no cognitive incapacities. -The resident was independent with all areas of activity of daily living. -The resident had no behaviors, mood changes or psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality)/delirium ( a mental state in which you are confused, disoriented, and not able to think or remember clearly) during the look back period. Record review of the resident's Pharmacy Progress Notes/Recommendations showed: -On 12/1/22 at 1:10 P.M. Finasteride (a drug used to reduce the amount of testosterone (hormone) produced by the body) had instructions to please add instructions for Glove Prior to Administration if of Childbearing Age. -On 12/1/22 at 1:11 P.M. Tamsulosin (A drug used to treat urinary problems) had instructions to please add to instructions Give with Food or a snack. Record review of the resident's Physician orders dated 2/23 showed: -Finasteride Tablet 5 milligram (mg) order did not have glove prior to administration if of childbearing age. -Tamsulosin HCI Capsule 0.4mg order did not have give with food or a snack. 4. Record review of Resident #62's Face Sheet showed he/she was admitted to the facility 3/31/22 with diagnoses, including: -Schizophrenia. -Anoxic brain damage (lack of oxygen to the brain). -Pulmonary embolism (blood clot in lung). -Cardiac arrest (sudden, unexpected loss of heart function, breathing and consciousness). -Bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). -The resident was responsible for self. Record review of the resident's quarterly MDS dated [DATE] showed: -The resident's cognitive score was 15, which indicated he/she had no cognitive incapacities. -The resident needed extensive one person assist in all areas of activities of daily living with exception of meal intake he/she needed set-up assistance. -The resident had no mood, behaviors or psychosis/delirium during the look back period. Record review of the resident's Pharmacy Progress Notes/Recommendations dated 5/4/22, 6/1/22, 7/1/22, 8/2/22, 9/6/22, 10/3/22, 11/1/22, 12/1/22, 1/3/23, and 2/3/23 showed: -Please add to Tamsulosin instructions Give with Food-Do Not Crush on POS/MAR. Record review of the residents Physician orders dated 2/23 showed Tamsulosin 5 mg tablet did not have Give with Food-Do Not Crush instructions. Based on interview and record review, the facility failed to ensure monthly pharmacy Medication Regimen Reviews (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications) were completed and in the resident's medical record for five sampled residents (Resident's #37, #49, #47, #62, and #34) out of 17 sampled residents. The facility census was 66 residents. Record review of facility policy titled Monthly Drug Regimen Review dated 7/5/22 showed: -The nurse/Director of Nursing (DON) will forward the pharmacists recommendations to the attending physician within 48 hours of receiving the recommendation. The nurse/DON will document the date and time that the physician was notified of the recommendation. -It the attending physician does not respond to the recommendation with 7 days, the nurse/DON will follow up with the physician to obtain orders if necessary. -The attending physician will indicate if they agree or disagree with the recommendation made by the Licensed Pharmacist. If the physician does not agree with recommendation, the physician will be asked to document the reason on the resident's clinical record. 1. Record review of Resident #37's Transfer/Discharge Report showed he/she was admitted to the facility 5/29/21 with the following diagnoses: -Anemia (a decrease in hemoglobin in the blood to levels below the normal range). -Essential Hypertension (high blood pressure). -Hyperlipidemia (high levels of lipids in the blood). Record review of the residents Pharmacy Progress Notes/Recommendations dated 6/1/22 showed to please add to instructions for Carvedilol (used to treat high blood pressure and heart failure) Check Pulse and cardiac hold parameters on Physician Order Sheet (POS)/Medication Administration Record (MAR). Record review of the residents Pharmacy Progress Notes/Recommendations dated 7/1/22, 9/6/22, 10/3/22, 11/1/22, 12/1/22, and 1/3/23 showed to please add to instructions for Carvedilol Check Pulse and cardiac hold parameters on POS/MAR. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by the facility staff for care planning) dated 1/17/23 showed: -The resident's Brief Interview for Mental Status (BIMS) score was unable to be completed to resident's nonverbal condition. -The resident required one-two person assistance in activities of daily living. -The resident had no behaviors, mood changes or psychosis/delirium during the look back period. Record review of the resident's order Summary Report dated 2/7/23 showed: -Carvedilol 25 milligram (mg) 1 tablet via Gastrostomy-Tube (G-tube a tube inserted through the wall of the abdomen directly into the stomach) every morning and at bedtime related to Essential Hypertension (high blood pressure). -No parameters for pulse or blood pressure to hold medication noted. 2. Record review of Resident #49's Pharmacy Progress Notes/Recommendations dated 7/1/22 showed to please add to Duloxetine (used to treat depression and anxiety) Delayed Release (DR) instructions Swallow whole - Do Not Crush Contents of Capsule on POS/MAR. Record review of the resident's Pharmacy Progress Notes/Recommendations dated 8/2/22 showed to please add to Duloxetine DR instructions Swallow whole - Do Not Crush Contents of Capsule on POS/MAR. Record review of the resident's Pharmacy Progress Notes/Recommendations dated 9/6/22 showed: -Please add to Duloxetine DR instructions Swallow whole - Do Not Crush Contents of Capsule -Please add to Pantoprazole DR (Protonix used for heartburn, acid reflux and gastro-esophageal reflux disease (GERD)) Do Not Crush on POS/MAR. Record review of the resident's Pharmacy Progress Notes/Recommendations dated 10/3/22 showed to please add to Duloxetine DR and Pantoprazole DR instructions Swallow whole - Do Not Crush Contents of Capsule on POS/MAR. Record review of the resident's Transfer/Discharge Report showed the resident was readmitted to the facility 11/2/22 with the following diagnoses: -End Stage Renal disease (ESRD is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). -Hemiplegia (paralysis of one side of the body) and Hemiparesis (another term for hemiplegia) following Cerebral Infarction (stroke) affecting left non-dominate side. Record review of the resident's quarterly MDS dated [DATE] showed: -The resident's BIMS score was 15 which indicated he/she had no cognitive impairment. -The resident was independent in activities of daily living. -The resident had no mood, behaviors or psychosis/delirium during the look back period. Record review of the resident's Pharmacy Progress Notes/Recommendations dated 12/1/22 showed: -Please add to Duloxetine DR, Ferrous Sulfate (supplement) and Pantoprazole DR instructions Swallow whole - Do Not Crush Contents of Capsule on POS/MAR. -Please add cardiac monitoring parameters Check BP/Pulse to instructions on POS/MAR for Hydralazine (used to treat high blood pressure). Record review of the resident's Pharmacy Progress Notes/Recommendations dated 1/3/22 showed: -Please add cardiac monitoring parameters Check BP/Pulse to instructions on POS/MAR for Hydralazine. -Please add to Duloxetine DR, Ferrous Sulfate and Pantoprazole DR instructions Swallow whole - Do Not Crush Contents of Capsule on POS/MAR. Record review of the resident's Order Summary Report dated 2/7/23 showed: -Duloxetine Capsule Delayed Release Particles 30 mg give 30 mg by mouth at bedtime for depression. -Ferrous Sulfate 325 (65 Fe) mg give 325 mg by mouth two times a day for anemia. -Pantoprazole Sodium Tablet Delayed Release 40 mg give 40 mg by mouth one time a day for GERD -Hydralazine Tablet 25 mg give 25 mg by mouth every 8 hours for High blood pressure. -NOTE: No blood pressure or pulse parameters for Hydralazine order. -NOTE: No swallow whole-do not crush contents of capsule on orders for Duloxetine DR, Ferrous Sulfate, or Pantoprazole DR. 5. Record review of Resident #34's admission Record showed he/she was admitted to the facility on [DATE]. Record review of the resident's Pharmacy Review Note dated 7/1/22 showed: -The resident currently has a seizure disorder (a hyperexcitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of muscles). -The resident currently receives Levetiracetam 750 mg three times per day. -Please evaluate for the need for a scheduled levetiracetam level (laboratory test) for therapy monitoring. Record review of the resident's Pharmacy Review Note dated 8/2/22, 9/6/22, and 10/3/22 showed to please follow up on recommendations for 8/2/22 for therapy monitoring. Record review of the resident's significant change MDS dated [DATE] showed the resident: -Was cognitively intact. -Had a diagnosis of seizure disorder. Record review of the Pharmacy Review Note dated 11/3/22 and 12/1/22 showed to please follow up on recommendations for 8/2/22 for therapy monitoring. Record review of the resident's care plan revised 12/19/22 showed the resident had a seizure disorder. Record review of the Pharmacy Review Note dated 1/3/23 showed to please follow up on recommendations for 8/2/22 for therapy monitoring. 6. During interview on 2/9/23 at 12:42 P.M., Licensed Practical Nurse (LPN) A said he/she was not aware of who was responsible for MMR responses. During an interview on 2/9/22 at 1:14 P.M. LPN B said: -He/she did not complete any pharmacy requests or reviews. -The DON was responsible for completing all pharmacy recommendations. During interview on 2/9/23 at 2:04 P.M., the DON said: -He/she just found out about MMR's. -He/she should have received MMR's monthly. -He/she or the charge nurse would be responsible to send MMR's to physician. -He/she or the charge nurse would be responsible to follow up with physician for MMR responses. -He/she and the MDS nurse would be responsible for MMR completion audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #47's Face Sheet showed he/she was admitted to the facility 7/10/20, with diagnoses that include: -Schizophrenia( disorder that affects a person's ability to think, feel, and behave clearly). -Major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). -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). -Delusions (a false belief or judgment about external reality, held despite incontrovertible evidence to the contrary, occurring especially in mental conditions). -High blood pressure. -Pain. -Urine retention (a condition in which you are unable to empty all the urine from your bladder). -Resident had a guardian. Record review of resident's care plan revised on 12/21/21 showed: -The resident received psychotropic medications. -The resident would be free of adverse reactions through the review date. -The resident did not have a behavioral care plan. Record review of resident's psychiatric physician visit dated 6/28/22 showed to monitor the resident's mood, behaviors and side effects of psychotropic medication use. Record review of the resident's quarterly MDS dated [DATE] showed: -The resident's cognitive score was 14 which indicated he/she had no cognitive incapacities. -The resident was independent with all areas of activity of daily living. -The resident had no behaviors, mood changes or psychosis/delirium during the look back period. Record review of the resident's physician order dated 2/23 showed: -Olanzapine Tablet (an antipsychotic primarily used to treat schizophrenia) 5 mg by mouth one time a day. -No behavior monitoring order. -No adverse reaction monitoring order. During an interview 2/9/23 at 9:21 A.M. Certified Nursing Assistant (CNA) A and B said: -Nursing would let the CNA's know of behaviors and side effects to look for and to report any changes to the charge nurse. -He/she was not aware of any behaviors to monitor for Resident #47. During interview 2/9/23 at 10:14 A.M. LPN A said: -Psychotropic drug use, behavior and side effect monitoring were located in the resident's treatment record. -Nurses and the DON were responsible for putting monitoring orders in the resident's medical chart. -He/she knew to look in the resident care plan for non-pharmacological interventions and behaviors. -He/she did not know why Resident #47 did not have behavior or side effect monitoring. During Interview 2/9/23 at 2:04 P.M. the DON said: -Behavior and medication side effect monitoring should be done daily by nursing staff. -Behavior and medication side effect monitoring should be included in the resident's medical record, on resident's treatment record, and in the residents care plan. -CNA's had access to the resident's modified version of care plans to know what behaviors and side effects to look for. -CNA's were in-serviced on Mondays and Fridays related to Get to know new residents. Based on interview and record review, the facility failed to ensure a Pro Re Nata (PRN-as needed) antianxiety medication (a controlled substance medicine that calm and relax people with excessive anxiety, nervousness, or tension) was not ordered for more than fourteen days without physician assessment for one sampled resident (Resident #34); to ensure the physician responded to a pharmacist recommendation related to a antipsychotic medications (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis) for one sampled resident (Resident #7); and to adequately monitor for adverse consequences with use of psychotropic medication (medication that affects how the brain works and causes changes in mood, awareness, thoughts feelings and behavior) and adequately monitor behaviors with use of psychotropic medications on one sampled resident (resident #47) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's PRN Antipsychotic and Psychotropic Medication policy revised 7/5/22 showed PRN orders for antianxiety medications were limited to fourteen days and must be reordered by the attending physician documenting and explaining why the physician believed the medication needed to be continued. Record review of the facility Monthly Drug Regimen Review policy revised 7/5/22 showed: -The pharmacist would review the drug regimen of each resident at least monthly and report, in writing, any irregularities. -The nurse or Director of Nursing (DON) would forward the pharmacist recommendations to the attending physician within 48 hours. -If the physician did not respond back within seven days, the DON would follow up with the physician. -The attending physician would indicate if he/she agreed or disagreed with the recommendation. -If the physician disagreed with the recommendation, the physician would document the reason in the medical record. A policy was requested on psychotropic medications (medications which affect psychic function, behavior, or experience) and not received from the facility. Record review of the facility policy titled Comprehensive Care Plans and Baseline Care Plans dated 1/19/22 showed the facility must develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. Record review of #34's significant change Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/25/22 showed the resident: -Was cognitively intact. -Had a diagnoses of Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Did not receive anti-anxiety medication over the last seven days. Record review of the resident's Order Summary Report showed the following physician's order dated 12/22/22 for Lorazapam concentrate (medication used to treat anxiety) 2 milligram/milliliters (mg/ml)-give 0.25 ml by mouth PRN for increased anxiety and/or agitation with no stop date. Record review of the resident's care plan revised 12/19/22 showed the resident had a long history of multiple mental illnesses. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Did not receive anti-anxiety medication over the last seven days. During an interview on 2/9/22 at 1:14 P.M. Licensed Practical Nurse (LPN) B said: -PRN anti-anxiety medications were ordered by the physician. -He/she was unaware a stop date was needed and/or reevaluation by the resident's physician for continued use. During an interview on 2/9/23 at 2:10 P.M. the DON said: -PRN anti-anxiety medications should only be used for fourteen days. -There were some that were longer after being assessed by the physician. -Each PRN anti-anxiety medication should have a stop date. 2. Record review Resident #7's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Received antipsychotic medications seven out of the last seven days. -Had a diagnosis of schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). Record review of the resident's Pharmacy Review Note dated 8/2/22 showed: -The resident received Risperidone 3 mg three times per day and Risperidone microspheres 50 mg intermuscular (IM-injection) every fourteen days. -Please evaluate the need for a Fasting Lipid Panel (FLP-laboratory testing for cholesterol levels) for therapy monitoring. Record review of the Pharmacy Review Notes dated 9/2/22, 10/3/22, 11/2/22 and 12/1/22 showed to please follow up on recommendations for 8/2/22 for therapy monitoring. Record review of the resident's care plan dated 12/16/22 showed the resident needed the staff to administer medications as ordered and to monitor for side effects of medications. Record review of the Pharmacy Review Notes dated 1/3/23 and 2/3/23 showed to please follow up on recommendations for 8/2/22 for therapy monitoring. Record review of the resident's electronic medical record on 2/7/23 showed no FLP laboratory orders. During an interview on 2/9/22 at 1:14 P.M. LPN B said: -He/she did not complete any pharmacy requests or reviews. -The DON was responsible for completing all pharmacy recommendations. During an interview on 2/9/23 at 2:10 P.M. the DON said: -He/she was unaware of the process for pharmacy recommendations. -He/she had learned about pharmacy recommendations and the need of a physician response this week. -The charge nurse and/or himself/herself were responsible for completing pharmacy recommendations to ensure they were acted upon. -The pharmacy recommendations should be sent to the physician the day they were received. -He/she was responsible for all follow up with the physician.

Based on observation, interview and record review, the facility failed to refrigerate opened condiment containers; to prevent grease build-up on the inner range hood vent; to properly thaw potentially hazardous raw meat and to maintain the meat in a safe temperature zone, and to date opened, shelved, out-of-box food items. This deficient practice of not handling foods appropriately could potentially, promote microorganisms and bacterial growth which could adversely affect the health and well-being of the residents and staff who partook of the meals prepared by the dietary staff. The facility census was 66 residents at the time of the survey. 1. Observations on 2/5/23 between 7:03 A.M. and 8:18 A.M. in the kitchen, showed the following: -At 7:03 A.M., there was no dietary staff in the kitchen. -At 7:04 A.M., the food preparation sink contained two, ten pound, sealed, cooked packages of Beef Bottom Round Pot Roast that had a label and inscription on it that read, Keep Refrigerated. There was no water in the sink and the food items felt warm to the touch with no running water flowing over the meat. -At 7:07 A.M., the Dietary [NAME] (DC) A came into the kitchen and started his/her work shift. -At 7:12 A.M., the DC removed the meat from the food preparation sink and relocated it to the refrigerated walk-in unit. -There were three separate, 15-gallon, unmarked and undated containers filled with a white and a brown substance and a box with a white substance. -The stove burner grates and the back of the stove were black and had black, crusted debris attached to them. -The range hood exhaust baffles (metal corrugated/wavey-like filters) and vent had a an appearance of a greasy film covering them. -A one gallon jug of Bar-B-Que sauce approximately 1/4 full that read refrigerate after opening on the label, located on a bakers rack in the kitchen. -A 32 ounce container of lemon juice sauce approximately 1/3 full that read refrigerate after opening on the label, located near the spices in the kitchen. -The range hood baffle filters and vent over the range/stove top had a film of grease on them. -In the dry good storage room on the shelf were five individual (unboxed and unlabeled) bags of cake-like, powder-mixes. -In the dry good storage room on the shelf were 14 individual (unboxed and undated) bags of cereal. During an interview on 2/5/23 at 7:35 A.M., DC A said: -He/she worked the previous afternoon/evening shift and placed the Pot Roast in the food preparation sink before he/she finished his/her shift at 8:00 P.M. to thaw it out over the nighttime. -He/she usually thawed out the next day's menu meat item overnight in order to give the Dietary Manager an option to change the menu items for the next day, if there was not enough of the main course to serve the residents. -He/she does not remember when he/she was in-serviced last about thawing out meat items. -The exhaust hood and filters were cleaned by an outside vendor and had not been cleaned for some time. -The Maintenance Director usually contacts the facility's vendor to service the range hood and for its inspection. -He/she was unaware that the bulk, powder items stored under the spices required labeling and dating. -He/she was unaware that the B-B-Q sauce and the lemon juice required refrigerating after their opening. During an interview on 2/6/23 at 10:25 A.M., the Maintenance Director said: -The exhaust hood and filters were cleaned by an outside vendor semi-annually. -Maintenance usually cleaned the exhaust hood and filters in-between times if they need cleaning. -If the dietary staff sees equipment needing cleaning more often, they should contact the maintenance or housekeeping department for them to attend to the desired equipment. 2. Observations on 2/6/23 at 3:40 P.M. in the kitchen, showed: -Three, ten pound tubes of raw hamburger thawing in the food preparation sink. -There was no water running on top of them. -One of the tubes still had frost covering the plastic wrapping while the other two tubes of hamburger were without any frost and cool to the touch. During an interview on 2/9/23 at 9:35 A.M., the Dietary Manager said: -He/she would have expected the DC A to thaw out meat items in the refrigerated walk-in unit 24 to 48 hours in advance of its preparation. -He/she would in-service the Dietary Cooks about meat thawing techniques and refrigerating food items that need refrigerating. -He/she usually stores the grocery items from the delivery trucks and was in a hurry about placing the cake mix and cereal bags on the shelves without dating them. -Usually maintenance would contact the cleaning service for the range hood baffles and vents. -The opened sauce and juice containers should have been stored in the refrigerated walk-in cooler but would discard it immediately. Record review of the 2013 edition of the MO Food Code chapter 3-501.18, showed, (A) A food specified in 3-501.17(A) - (C) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). Review of the 2013 edition of the Missouri Food Code, Chapter 4-601.11, showed, Equipment FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch, and the FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. Record review of the 2013 edition of the Food and Drug Administration (FDA) Food Code chapter 3-501.13, showed, Except as specified in (D) of this section, potentially hazardous food shall be thawed: (A) Under refrigeration that maintains the food temperature at forty-one degrees Fahrenheit (41°F) or less; or (B) Completely submerged under running water: (1) At a water temperature of seventy degrees Fahrenheit (70°F) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of ready-to-eat food to rise above forty-one degrees Fahrenheit (41°F), or (4) For a period of time that does not allow thawed portions of a raw animal food requiring cooking as specified under 3-401.11(A) and (B) to be above forty-one degrees Fahrenheit (41°F), for more than four (4) hours including: (a) The time the food is exposed to the running water and the time needed for preparation for cooking, or (b) The time it takes under refrigeration to lower the food temperature to forty-one degrees Fahrenheit (41°F). Record review of the 2013 edition of the FDA Food Code 3-501.17 showed, (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Record review of the 2013 edition of the FDA Food Code Chapter 4-601.11, showed, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Record review of the 2013 edition of the FDA Food Code Chapter 4-602.11, showed, Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the 2013 edition of the Food and Drug Administration (FDA) Food Code, Chapter 6-501.12, showed, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. Review of the 2013 edition of the Food and Drug Administration (FDA) Food Code, Chapter 6-501.14, showed, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. Review of the dietary's cleaning schedule (undated) showed the kitchen microwave oven, serving carts, and food preparatory countertops were to be cleaned daily. Review of the 2013 edition of the FDA Food Code, Annex Chapter 6-3(F)(3)(b), showed, (i) Thawing must be monitored and controlled to ensure thoroughness and to prevent temperature abuse. Improperly thawed meat could cause insufficient cure penetration. Temperature abuse can cause spoilage or growth of pathogens. (ii) Meat must be fresh. Curing may not be used to salvage meat that has excessive bacterial growth or spoilage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment in one resident room by allowing a toilet to be in disrepair and unusable for a period of approximately two months making the residents in that room to utilize the shower room out in the hallway. This deficient practice had the potential to affect any residents who resided in that room. The facility census was 61 residents with a licensed capacity for 66 residents. 1. Observations with the Administrator on 12/5/22 at 2:41 P.M. showed the following: -In the double-occupancy resident room [ROOM NUMBER] there was a sign on the bathroom door which stated, Do Not Use - Toilet is broken. -Inside the bathroom there was a sign on the toilet tank which stated, Do Not Use - Toilet is broken. -The nearest shower room with a working toilet was approximately 59 feet away from the doorway of room [ROOM NUMBER]. -Currently, Residents #1 and #2 resided in resident room [ROOM NUMBER]. Record review of Resident #1's Quarterly Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by facility staff for care planning) dated 10/7/22, showed the resident was able to make himself/herself understood, was able to understand others, and was assessed as a resident who was alert and oriented as evidenced by the resident having a Brief Interview for Mental Status (BIMS - A screening used to assist with identifying a resident's current cognitive level and to help determine if any interventions needed to occur) score of 15 out of 15 which indicated he/she was cognitively intact. The resident required staff assistance with tolieting and used a wheelchair for mobility. During interviews on 12/5/22 between 12:53 P.M. and 3:02 P.M., Resident #1 said the following: -He/she was currently staying in bed A of room [ROOM NUMBER]. -The toilet in his/her room had been in disrepair and unusable for about two months. -The toilet's not working was an inconvenience for him/her because if he/she needed to go to the bathroom at night he/she had to activate the call light, wait for help into his/her wheelchair, wheel down the hallway to the shower room to use that toilet, then wheel clear back to his/her room. -He/she had reported the broken toilet when it was first noticed about two months ago but he/she could not remember who it was he/she notified. During interviews on 12/5/22 between 11:13 A.M. and 2:13 P.M. the Administrator said the following: -He/she terminated the previous Maintenance Director because of a lack of follow-through and just not meeting job expectations. -He/she was not aware of the toilet in room [ROOM NUMBER] being in disrepair and unusable. During an interview on 12/5/22 at 3:07 P.M. Licensed Practical Nurse (LPN) A stated that he/she thought that the toilet in room [ROOM NUMBER] had been working the previous weekend or two. MO-00210039

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one sampled resident (Resident #3) was free from abuse when on 10/27/22, Resident #2 struck Resident #3 in his/her right eye causing redness, out of 6 sampled residents. The facility census was 161 residents. Record review of the facility abuse and neglect policy, dated 9/17/21, showed: -Physical abuse was the purposeful beating, striking, wounding or injuring of any resident. -The facility was committed to protecting residents from abuse by anyone including other residents. 1. Record review of Resident #2's facesheet showed he/she admitted to the facility 6/23/22 with the following diagnoses: -Bipolar disorder (a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). -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). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning) NOS (Not otherwise specified). -Diffuse Traumatic Brain Injury (widespread brain injury). Record review of Resident #2's care plan, dated 6/23/22, showed: -He/she had manifestation of behaviors related to his/her mental illness that may create disturbances that affect others. -Interventions included: --Staff were to assist the resident in addressing the root cause of change in his/her behavior or mood as needed. --If he/she were disturbing others, staff were to encourage him/her to go to a more private area to voice concerns or feelings to assist in decreasing episodes of disturbing others. Record review of Resident #2's care plan, dated 8/21/22, showed: -He/she had a potential to be verbally aggressive toward other residents related to ineffective coping skills and poor impulse control. -Interventions included: --Staff were to analyze key times, places, circumstances, triggers and what deescalated behavior and then document. --Staff were to assess and anticipate the resident needs, coping skills, and support system. --Staff were to assess the resident's understanding of a situation and allow time for him/her to express self and feelings toward the situation. Record review of Resident #2's care plan, dated 9/16/22, showed: -He/she had the potential to be physically aggressive toward other residents related to poor impulse control. -Interventions included: --Staff were to analyze key times, places, circumstances, triggers and what deescalated behavior and then document. --Staff were to assess and address contributing sensory deficits, resident needs. --Staff were to provide physical and verbal cues to alleviate anxiety, give positive feedback, assisted in verbalization of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff member when agitated. --He/she was educated to allow staff time to move another resident out of the way. Record review of Resident #3's facesheet showed he/she admitted [DATE] with the following diagnosis: -Cerebral Palsy (a disability resulting from damage to the brain before, during, or shortly after birth and outwardly manifested by muscular incoordination and speech disturbances). -Depression. -Psychosis. Record review of Resident #3's care plan, dated 6/28/22, showed: -He/she had the potential to be verbally aggressive with other residents. Interventions included: --Staff were to analyze key times, places, circumstances, triggers and what deescalated behavior and then document. --Staff were to assess and anticipate the resident needs, coping skills and support system. --Staff were to assess the resident's understanding of a situation and allow time for him/her to express self and feelings toward the situation. Record review of Resident #3's care plan, dated 8/16/22, showed: -He/she had a history of reporting or demonstrating mood indicators related to his/her overall condition. -Interventions included: --Assisting the resident in developing or providing a program of activities. --Staff were to monitor his/her mood to determine if problems seemed to be related to external causes. Record review of Resident #2's progress note, dated 10/15/22, showed: -He/she was in the middle of the hall when another resident attempted to pass and was unable to. -He/she took his/her hand and forcibly shoved and pushed the other resident. Record review of Resident #2's progress note, dated 10/18/22, showed: -He/she was upset with another unnamed resident, because that resident was trying to speak with him/her. -The Administrator informed the resident that he/she may not get along with everyone and should utilize the staff as a resource. Record review of Resident #2's progress note, dated 10/27/22, showed: -He/she struck Resident #3 on the right side of the face with a closed fist after feeling annoyed Resident #3 was talking too much. -He/she had told Resident #3 to leave him/her alone and Resident #3 did not, he/she hit Resident #3. -He/she was separated from Resident #3. -He/she was moved to a locked unit and instructed to stay away from Resident #3 to prevent further issues. Record review of Resident #3's progress note, dated 10/27/22, showed: -He/she was struck on the right side of the face by Resident #2 with a closed fist. -He/she was hit because he/she annoyed Resident #2 by talking to much. -He/she was given a ice pack as a precaution. Record review of the facility investigation, dated 10/27/22, showed: -On 10/27/22 Resident #2 and Resident #3 had a physical aggression incident. -At 1:00 P.M., Resident #2 had entered the dining room and told Resident #3's lunchmate to shut up. -Resident #3 told Resident #2 to leave his/her lunchmate alone and to shut up. -Resident #2 told Resident #3 to mind his/her business. -Resident #3 again told Resident #2 to shut up and to leave his/he her lunchmate alone. -Resident #2 then struck Resident #3 three times in the right eye. -Resident #3 had redness around the right away that went away in about 35 to 40 minutes. -Resident #2 and Resident #3 were separated and brought to the Administrator. -Resident #2 said, I hit Resident #3 because Resident #3 would not leave him/her alone. -Resident #3 said, Resident #2 hit him/her for no reason. -The incident was behavioral, Resident #2 was moved to the locked secured unit away from Resident #3. -Local law enforcement was notified. -The incident was not a result of abuse, was not preventable and was not a previous ongoing problem. -The Administration in Training written statement read: At 1:00 P.M., he/she was taking the cart from the locked unit to the dining room and saw Resident #2 hit Resident #3 in the face. Resident #2 said Resident #3 was talking to much. During an interview on 11/15/22 at 5:07 P.M., the Administrator in Training said: -He/she was passing trays in the dining room when he/she first heard what sounded like a hit. -He/she looked over and watched Resident #2 hit Resident #3 in the face two more times. -He/she stopped what he/she was doing, ran over and stopped Resident #2 from striking Resident #3 again, and asked Resident #2 why he/she hit the other resident. -Resident #2 said Resident #3 was talking too much. -He/she took Resident #2 to the Administrator office. -Resident #3 did not look like he/she had any injury other than redness to his/her face. -The two other Certified Nurses Aides (CNA) were in the dining room passing juices and dealing with other residents. During an interview on 11/15/22 at 5:43 P.M., Resident #2 denied he/she had hit anyone and said he/she did not remember. During an interview on 11/15/22 at 5:46 P.M., Resident #3 said: -Resident #2 had hit him/her in the face with a punch and it hurt. -He/she did not know why Resident #2 had hit him/her. -He/she was scared of Resident #2 and just wanted him/her to stay away from him/her. During an interview on 11/15/22 at 5:50 P.M., CNA A and CNA B said: -Resident #2 and Resident #3 were table mates and had been getting along. -Resident #3 had a tendency to get loud and Resident #2 does not like it. During an interview on 11/15/22 at 2:40 P.M., the Director of Nurses (DON) and the Administrator said: -Abuse was to willfully cause harm to another resident and was anytime a resident physically hurt or injured another with intent to do bodily harm. -The incident between Resident #2 and Resident #3 was by definition of intent and was abuse. -The Administrator did not believe Resident #2 intended to harm Resident #3; but Resident #2 had intended to strike out at Resident #3. MO00209070

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications per physician's orders for one sampled resident (Resident #4) out of 6 sampled residents. The facility census was 61 residents. 1. Record review of Resident #4's facesheet showed he/she admitted [DATE] with the following diagnoses: -Diabetes (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). -Hypertension (HTN- high blood pressure). -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). Record review of the resident's Order Summary Report showed Pancrelipase delayed release capsule (a medication containing enzymes needed for the digestion of proteins, starches, and fats) 10,000-32,000 unit, give two capsules by mouth with meals scheduled three times daily dated [DATE]. Record review of the resident's [DATE] Physician's Order Sheet (POS) showed: -Pancrelipase delayed release capsule 10,000-32,000 unit, give two capsules by mouth with meals for enzyme scheduled three times daily. -Staff documented 9 indicating to refer to Progress Notes 32 out of 50 opportunities. Record review of the resident's [DATE] Progress Notes showed: -On [DATE] at 9:30 A.M. staff documented Pancrelipase delayed release capsule 10,000-32,000 unit, give two capsules by mouth with meals for enzyme, waiting on pharmacy to send, ordered on [DATE]. -On [DATE] at 12:34 P.M. and 4:14 P.M. staff documented Pancrelipase delayed release capsule 10,000-32,000 unit, give two capsules by mouth with meals for enzyme, waiting for pharmacy to send. -On [DATE] at 10:37 A.M., 11:19 A.M., and 4:54 P.M., and on [DATE] at 9:19 A.M., 12:04 P.M., 4:59 P.M. staff documented Pancrelipase delayed release capsule 10,000-32,000 unit, give two capsules by mouth with meals for enzyme medication on reorder from pharmacy, charge nurse notified. -On [DATE] at 8:34 A.M., 4:53 P.M., and 4:54 P.M. and on [DATE] at 4:36 P.M. staff documented Pancrelipase delayed release capsule 10,000-32,000 unit, give two capsules by mouth with meals for enzyme, on order. -On [DATE] at 7:30 A.M., 12:34 P.M., and 4:10 P.M., on [DATE] at 9:17 A.M., 11:14 A.M., and 4:02 P.M., on [DATE] at 7:24 A.M., 11:13 A.M., and 4:01 P.M. staff documented Pancrelipase delayed release capsule 10,000-32,000 unit, give two capsules by mouth with meals for enzyme medication on reorder from pharmacy, charge nurse notified. -On 11/14//22 at 12:50 P.M. (two separate entries) and 5:33 P.M., and on [DATE] at 4:27 P.M. staff documented Pancrelipase delayed release capsule 10,000-32,000 unit, give two capsules by mouth with meals for enzyme on order. -On [DATE] at 8:10 A.M., 12:19 P.M., and 4:41 P.M., on [DATE] at 7:59 A.M., and 12:22 P.M. staff documented Pancrelipase delayed release capsule 10,000-32,000 unit, give two capsules by mouth with meals for enzyme medication on reorder from pharmacy, charge nurse notified. --NOTE: No documentation in the resident's medical record that the Director of Nursing (DON) or the resident's physician were notified of the resident's medication not being available. During an interview on [DATE] at 5:22 P.M., the resident said: -He/she did not want things to get worse as he/she was planning to return to the community. -The facility had not provided his/her medication for digestion. -He/she had complained to the nursing staff and said he/she needed the medication. During an interview on [DATE] at 1:45 P.M., Certified Medication Technician (CMT) A said: -The resident had not had the medication available. -He/she had called the pharmacy every other day and the pharmacy would say they would send and then say it was not due out. -He/she had told the charge nurse. -The facility protocol was to call the pharmacy when a medication was not on hand. -The nurse was to report to the physician. During an interview on [DATE] at 1:50 P.M., the Director of Nurses (DON) said: -The CMT was expected to follow up with pharmacy when an ordered medication was not available for a resident and tell their charge nurse. -The charge nurse was then responsible to alert the DON of why the medication was not available. -About two weeks ago the facility paid out of pocket for the medication because the resident insurance would not pay for it. -Additionally the facility had ordered house stock of a generic similar medication during times the medication was unavailable. -He/she was unsure why the house stock was not provided. -The pharmacy had several times sent the resident a dose for a single day and then indicate they were waiting on insurance. -He/she would contact the physician and ask about an alternative medicine. During an interview on [DATE] at 1:55 P.M., Licensed Practical Nurses (LPN) A said: -The expectation if a resident did not have medication was to call pharmacy and find out why and place a note in the the resident progress notes and then contact to the physician. -He/she was unaware of why the resident did not have the pancrelipase and the CMT had not reported it to him/her. During an interview on [DATE] at 2:35 P.M., CMT B said if a resident had not received medication a note should be placed in the MAR, the DON should be contacted and the pharmacy called. During an interview on [DATE] at 2:40 P.M., the DON and the Administrator said: -The resident preferences and concerns should have been evaluated. -The pharmacy should have been contacted and the physician notified. -The night nurse should have caught the medication was not available on the night audit. During an interview on [DATE] 3:00 P.M., LPN C said: -Currently working as the night nurse and was responsible for auditing the resident charts. -He/she had not audited the resident chart and reviewed his/her MAR. -He/she had been going in alphabet order by resident name for the resident chart audit. During an interview on [DATE] 10:45 A.M., Pharmacy Tech A said: -No prescriptions were found in the computer for the resident's medication pancreliipase. -The pharmacy never received a prescription order, therefore it was never filled. -There were canceled or expired prescriptions in the computer for the medication. MO00209246

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #20's Face Sheet showed he/she: -Was admitted to the facility on [DATE]. -Had diagnoses which included: --History of brain hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain). --Other lack of coordination. --Hemiplegia (paralysis) and hemiparesis (slight paralysis/weakness) affecting the right side of the body following brain hemorrhage. --Generalized muscle weakness. --Retention of urine. Record review of the resident's Care Plan updated 10/24/19 showed: -The resident had an indwelling supra-pubic catheter (a sterile tube surgically inserted into the bladder through the lower abdomen to drain urine). -The resident required staff assistance with all Activities of Daily Living (ADL) tasks due to mobility issues related to hemiplegia of right side, including proper placement of his/her catheter bag below the level of his/her bladder. -The resident's catheter collection bag should be stored inside a protective dignity pouch. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Had an indwelling catheter. -Had functional limitations in range of motion on his/her upper and lower extremities on one side. -Required total assistance (full staff performance) with toilet use, including managing his/her catheter. Record review of the resident's March 2020 Physician's Orders Sheet (POS) showed he/she had a supra-pubic catheter due to a diagnosis of retention of urine. Observation on 3/2/20 at 1:15 P.M. showed two Certified Nursing Assistants (CNAs) assist the resident with transferring from his/her wheelchair to bed at the resident's request. During the transfer, his/her catheter bag was hooked low on the bed frame and was not placed in a privacy bag. Observation on 3/2/20 at 2:31 P.M., 2:56 P.M., on 3/4/20 at 2:01 P.M., and on 3/5/20 at 10:50 A.M. showed the resident lying in bed watching television. His/her catheter bag was hanging low on his/her bed frame and was not in a privacy bag. 3. Record review of Resident #37's Face Sheet showed he/she: -Was admitted to the facility on [DATE]. -Had diagnoses which included: --Multiple Sclerosis (a progressive disease causing damage to nerve cells in the spinal cord and brain characterized by numbness, severe fatigue, and impairment of speech, muscle coordination, and vision). --Generalized muscle weakness. --Kidney disease. --Retention of urine. Record review of the resident's annual MDS dated [DATE] showed he/she: -Had an indwelling catheter. -Required extensive assistance from staff in all areas of ADL. Record review of the resident's Care Plan updated 2/5/20 showed he/she: -Had a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine). -Needed assistance in all areas of Activities of Daily Living (ADLs), including bed mobility, toilet use (catheter care), and positioning. Record review of the resident's March 2020 POS showed he/she had a Foley catheter due to a diagnosis of retention of urine. Observation on 3/2/20 at 9:43 A.M. showed the resident lying in bed. His/her catheter bag was hanging on the bed frame and was not in a privacy bag. Observation on 3/3/20 at 1:01 P.M. showed the resident sitting up in bed with the head of the bed inclined and watching television. His/her catheter bag was hanging on the bed frame and was not in a privacy bag. Observation at 3/4/20 at 8:32 A.M. showed the resident sitting in the bed with the head of the bed elevated. He/she was eating breakfast and watching television. His/her catheter bag was hanging on the bed frame and was not in a privacy bag. Observation on 3/4/20 at 12:21 P.M. showed the resident asleep in bed. His/her catheter bag was hanging on the bed frame and was not in a privacy bag. Observation on 3/5/20 at 10:30 A.M. showed the resident sitting up in bed with the head of the bed elevated, watching television. His/her catheter bag was hanging on the bed frame and was not in a privacy bag. 4. During an interview on 3/2/20 at 1:27 P.M., CNA F said the resident's catheter bag should be in a dignity bag. CNA E verbally agreed with CNA F. During an interview on 3/5/20 at 9:21 A.M., Licensed Practical Nurse (LPN) D said: -The resident's catheter bag should always be kept in a privacy bag. -He/She went into the resident's room to place the resident's catheter bag in a privacy bag. During an interview on 3/5/20 at 10:38 A.M., CNA C said that catheter bags should always be kept in a privacy/dignity bag. During an interview on 3/5/20 at 10:40 A.M., Registered Nurse (RN) A said: -Catheter bags should always be kept in a privacy/dignity bag, and this included when a resident was in bed. -The privacy/dignity bags were somewhat flimsy and broke or fell off easily and would often go missing. During an interview on 3/5/20 at 2:09 P.M., the ADON and Regional Nurse said privacy/dignity bags should always be used to cover catheter bags, both when residents were in bed and when they were out of bed. Based on observation, interview and record review, the facility failed to ensure residents' dignity by not placing a privacy bag over the catheter bag for three sampled residents (Residents #6, #20, and #37) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #6's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, pneumonia, stroke, seizures, dysphagia (difficulty swallowing), high blood pressure, history of urinary tract infection and neurogenic bladder (lack of bladder control) with urinary retention. Record 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 3/3/20, showed he/she: -Was alert, but had cognitive difficulty and memory problems. -Was totally dependent on staff for transfers, mobility, bathing, dressing, toileting and grooming. -Was incontinent and used a catheter for urination. Observation on 3/5/20 at 9:07 A.M., showed the resident was resting in his/her bed with his/her eyes closed. The resident's bed was in a low position and his/her catheter bag was not in a privacy bag. The resident was resting comfortably with no signs or symptoms of pain or discomfort. During an interview on 3/05/20 at 2:09 P.M., Assistant Director of Nursing (ADON) said the resident's catheter bag should always be kept in a privacy bag. -He/She went into the resident's room to place the resident's catheter bag in a privacy bag.

Based on interview and record review, the facility failed to obtain an authorization from for the facility to hold and manage resident funds for one sampled resident(Resident #31) and to implement a system to ensure receipts were retrieved by the Business Office, after the resident's family member withdrew money from the resident's fund account, for expenses. This practice potentially affected one resident out of four residents sampled for the purpose of reviewing the resident fund's process at the facility. The facility census was 48 residents. 1. Record review of the authorization forms showed the absence of a signed authorization for Resident #31. During an interview on 3/2/20 at 12:41 P.M., the Business Office Manager (BOM) said: - Resident #31 signed up for the account in September of 2019. -The resident was physically and mentally unable to sign the authorization form. -The resident's family member is the Durable Power of Attorney (DPOA- a trusted person who a resident may choose to act in that resident's place for medical care and finances if that resident became mentally incapacitated). -He/she (the BOM) forgot to have the DPOA sign the authorization form. Record review of the resident's account, showed: -The resident's relative withdrew $100 on 12/9/19. -There were not receipts in the record to show if the funds were used on behalf of the resident. During an interview on 3/2/20 at 2:40 P.M., the BOM said: -The resident's relative withdrew $100 on 12/9/19. -They did not bring back receipts to show what he/she bought for the resident. -He/she (the BOM) made the relative aware of the need for his/her office to have receipts. -To date no receipts have been returned, the relative may have forgotten.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the code status (instructions on what to do in case of cardiac or respiratory arrest) for one sampled resident (Resident #146) was transcribed to the resident's Physician Order Sheet (POS) out of of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #146's Face Sheet showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including brain injury, neck fracture, right femur fracture, left shoulder fracture, respiratory failure, dysphagia (difficulty swallowing), pneumonia, gastronomy (a tube that is placed directly into the stomach for long term administration of food, fluids, and medications) and tracheostomy (the surgical formation of an opening into the trachea through the neck especially to allow the passage of air). Record review of the resident's Hospital Discharge Record dated 2/26/20, showed hospital physician discussed with the resident's responsible party the resident's code status and the resident was to be a full code (a person will allow all interventions needed to get their heart started in case of cardiac or respiratory arrest). Record review of the resident's Physician's Telephone order dated 2/27/20, showed re-admit orders showing the resident was a Full Code. Record review of the resident's Physician's Order Sheet (POS) dated March 2020 showed the resident was admitted on [DATE]. The POS showed there was no documentation showing the resident's code status. During an interview on 3/5/20 at 9:21 A.M., Licensed Practical Nurse (LPN) D said the resident's code status was supposed to be on the resident's POS. After looking at the resident's POS dated March 2020, he/she said that he/she would correct this on the resident's current POS. During an interview on 3/05/20 at 12:10 P.M., Assistant Director of Nursing (ADON) said: -He/she typically was responsible for transcribing physician's orders onto the resident's POS. -They will usually compare the POS with the resident's Medication Administration Sheet (MAR) and Treatment Administration Sheet (TAR) to ensure all of the orders match and are correct, then they compare it to the last months MAR/TAR and POS. -Any new orders that are written are added to the current POS and they send the telephone orders to the pharmacy so they can be added to the following months POS, MAR, and TAR. -For the last two months, he/she had not been able to follow up and the responsibility was delegated to other nurses. -After looking at the resident's Physician's Telephone Orders and POS's, he/she said that the print out of the resident's current POS was completed and it was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the care plans were comprehensive and updated to reflect the current status with interventions needed for one sampled resident (Resident #1) with and indwelling catheter (Foley catheter, a sterile tube that is inserted into the bladder to drain urine) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #1's admission Face Sheet showed he/she had been admitted to the facility on [DATE] with diagnoses of: -Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity), Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunnelling). -Chronic Kidney Disease (gradual loss of kidney function). Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 12/2/19 showed he/she: -Was alert, and had no cognitive difficulty and memory problems. -Was totally dependent on staff for transfers, mobility, bathing, dressing, toileting and grooming. -Was incontinent at times and used a Foley catheter for urination. -Had a Stage IV pressure ulcer upon admission. Record review of the resident's undated Baseline Care Plan, Under special Care instruction showed: -The resident had a Foley catheter. -The Foley catheter size was an 18 French (fr, size of the tube) with a 30 centimeters (cc) balloon (the amount fluid needed to inflate the balloon to hold catheter in place). -Had a check mark by to provide supportive devices such as a catheter. -No instruction on care of the Foley catheter. -Did not have check mark in the box to follow protocol to care for the items marked in special care instructions. Record review of the resident's Bowel and Bladder Care Plan dated 12/5/19 showed: -The resident required a Foley catheter for wound healing. -Staff were to provide assistance with hygiene, emptying catheter bag as well as clothes management. -Care staff and nursing staff were to observe the resident's urinary output for signs of infections, such as dark color, strong odor, heavy sediment, and were to update the physician as needed. -No interventions related to the type of Foley catheter or the size of the resident catheter and how the facility staff are to care for his/her catheter. Record review of the resident's care plans dated 12/5/19 showed he/she did not have a care plan for his/her Foley catheter. Record review of the resident's progress note dated 12/8/19 showed: -The resident's Foley catheter had been changed due to it not draining and the resident's complaints of burning. -New order from the resident's physician's Nurse Practitioner (NP) for a Foley catheter size 16 fr with 10 cc balloon. Record review of the resident's Bowel and Bladder Care Plan updated on 12/8/19 showed: -Urinalysis (UA) with Culture and Sensitivity (urine sample checking for infections) if indicated. -No documentation related to change in catheter size. Record review of the resident's Treatment Administration Record (TAR) dated 12/1/19 to 12/31/19 showed: -Foley catheter care every shift. -Foley catheter size of an 18 fr with a 30 cc balloon and to be change monthly for leakage. -Change Foley catheter collection bag weekly on Wednesday. Record review of the resident's nurses progress notes dated 2/18/20 showed he/she: -Had been sent to hospital for evaluation and treatment on 2/17/20. -Returned with treatment for urinary tract infection (UTI, an infection in any part of your urinary system) of Keflex (antibiotic) 500 milligram (mg) two times a day for seven days. Record review of the resident's Physician's Order Sheet (POS) and TAR dated 3/1/20 to 3/31/20 showed: -Foley catheter care every shift. -Foley catheter size of an 16 fr with a 10 cc balloon and to be change monthly for leakage. -Change Foley catheter collection bag weekly on Wednesday. Observation on 3/2/20 at 2:00 P.M. of the resident's catheter site showed: -No redness noted. -The skin was sticking together from the cream used for his/her groin irritation per Registered Nurse (RN) A. -The catheter bag had been placed in a privacy bag and was hanging on the lower left bedrail. During an interview on 3/5/20 at 10:31 A.M., Certified Nursing Assistant (CNA) C said: -CNAs review care plan interventions; the care plans are available to CNAs in the care plan books. -Care plans have handwritten updates as they are needed, then all of the changes are incorporated into an updated (typed) document every six months or sometimes more often if needed. Observation on 3/5/20 at 11:15 A.M. of the resident's Foley catheter care with Assistant Director of Nursing (ADON) showed the resident had a Foley catheter and the size on the tube showed it was a 16 fr with a balloon could hold from 5 cc to 15 cc of fluid. During an interview on 3/5/20 at 12:30 P.M., the MDS Coordinator said: -He/she relied on gathering information on resident needs and changes from nursing staff and therapy at morning meetings every Monday through Friday at 9:15 A.M. -Care plans should be accurate, comprehensive, and reflect resident needs and conditions, and include interventions that are specific to resident needs. During an interview 03/05/20 at 1:43 P.M., ADON and Regional Nurse said: -It was expected care plans be comprehensive, reflect current conditions of the resident and the needs of residents. -Would expect to had a comprehensive care plan for resident's with a Foley catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure equipment for maintaining or improving range of motion was available for one sampled resident (Resident #20) out of 13 sampled residents. The facility census was 48 residents. Record review of Resident #20's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -History of brain hemorrhage (an emergency condition in which a rupture blood vessel causes bleeding inside the brain). -Other lack of coordination. -Hemiplegia (paralysis) and hemiparesis (slight paralysis/weakness) affecting the right side of the body following brain hemorrhage. -Generalized muscle weakness. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/8/20 showed he/she had functional limitations in range of motion on his/her upper and lower extremities on one side. Record review of the resident's February 2020 Physician's Order Sheet (POS) showed discontinue skilled Occupational Therapy (OT) and continue splinting order. Record review of OT progress notes dated 2/18/20 showed: -Resident received OT services through 2/18/20 due to right side hemiplegia. -Staff training was completed to carry on the following orthotic program: resident will tolerate right resting hand/wrist orthotic for 4 - 6 hours with good joint/skin integrity. Record review of the resident's Care Plan dated 2/19/20 showed: -The resident had range of motion and mobility deficiencies related to hemiplegia of his/her right side. -Discontinue skilled OT. -Continue splinting order. Record review of the resident's February 2020 Treatment Administration Record (TAR) showed no documentation by the facility staff related to the resident's orthotic program. Record review of the resident's March 2020 POS showed: -The resident's splinting order to continue the resident's orthotic program was not transcribed to the current POS as previously ordered by the resident's physician. -No documentation by the resident's physician to discontinue the splinting order/orthotic program. Record review of the resident's March 2020 TAR showed no documentation by the facility staff related to the resident's orthotic program. Record review of the resident's nursing notes dated 2/19/20 through 3/5/20 showed no documentation by the facility staff that the resident was assisted with his/her orthotic device. Observation on 3/2/20 showed: -9:20 A.M.: The resident entered his/her room with staff pushing his/her wheelchair. No hand splint was observed in the resident's hand or anywhere in the resident's room. -9:29 A.M.: The resident was sitting in his/her wheelchair in the common area of the facility. No hand splint was observed in the resident's hand. -1:15 P.M.: The resident was sitting in his/her wheelchair in his/her room waiting for staff to assist him/her with getting into bed. No hand splint was observed in the resident's hand or anywhere in the resident's room. -2:09 P.M.: The resident was transferred into his/her bed by two Certified Nursing Assistants (CNAs). Before, during, and after the transfer, no hand splint was observed in the resident's hand or anywhere in the resident's room. -2:56 P.M.: The resident was lying in his/her bed. No hand splint was observed in the resident's hand or anywhere in the resident's room. Observation on 3/3/20 showed: -8:40 A.M.: The resident was sitting in his/her wheelchair in the common area of the facility near the doors where the sun was shining in. He/she showed the Activities Director (AD) the fingernails of his/her right hand, which had a contracture (a condition of shortening and hardening of the muscles, characterized by flexion and fixation). The AD reminded the resident that they had just trimmed his/her fingernails to keep them from injuring the palm of his/her hand due to the contracture. No injury or issue was observed. No hand splint was observed in the resident's hand. -10:58 A.M.: The resident was observed going outside with other residents onto a closed patio with assistance of staff pushing his/her wheelchair. No hand splint was observed in the resident's hand. Observation on 3/4/20 showed: -2:01 P.M.: The resident was lying in bed watching television. No hand splint was observed in the resident's hand or anywhere in the resident's room. Observation on 3/5/20 showed: -8:49 A.M.: The resident was observed sitting in his/her wheelchair in the common area of the facility. No hand splint was observed in the resident's hand. -10:50 A.M.: The resident was lying in bed watching television. No hand splint was observed in the resident's hand or anywhere in the resident's room. During an interview on 3/5/20 at 8:49 A.M., the resident nodded his/her head up and down to indicate yes when asked if he/she had a splint or sponge to put into his/her right hand to help keep it from being a tight fist. The resident shook his/her head left and right to indicate no when asked if he/she still used the splint. The resident also shook his head left and right to indicate no when asked if he/she would let staff assist him/her with using the splint. During an interview on 3/5/20 at 10:31 A.M., CNA C said: -The resident has a hand splint and he/she had seen it a couple of times, but not recently. -He/she knew the resident did not like to wear it. -He/she did not know where it was kept or if it was still available. -If a resident had a therapy or physician's order for a splint, CNAs should make sure it is used by the resident or at least offered. During an interview on 3/5/20 at 10:34 A.M., Registered Nurse (RN) A said: -The resident did have a device for his/her hand contracture that was fitted to him/her by therapy. -He/she had not seen the resident wear the splint for a while, but could not recall how long it had been. -About a month ago, he/she remembered the resident had the splint for his/her hand but could not find it. He/she talked to the therapy department at that time to see if it was in their area but it was not. -The resident had moved from one area of the facility to his/her current room a couple of months ago and sometimes items would get misplaced during moves. -The splint was blue on the outside with a foam piece that fit into the resident's hand. During an interview on 3/5/20 at 10:37 A.M., CNA C said: -He/she had found the splint in the resident's room inside a drawer of a small dresser where the resident's television sat. -If there was a physician's order for the splint, it should be used or at least offered to the resident. -If the resident refused to use it, staff should document that. During an interview on 3/5/20 at 10:59 A.M., the Director of Rehabilitation said: -Information related to residents' therapy needs was communicated between the therapy department and facility nursing staff during morning meetings each Monday through Friday. -The resident's splint was a resting splint, which meant that it was used to prevent further contracture or deformity. It was not a functional splint, which would be used to regain functional use of the hand. -The resident's splint should be used at night while the resident was resting with less activity to interrupt wearing it. He/she would communicate this to nursing staff to ensure this was understood. -If ongoing use of the splint was ordered by the Registered Occupational Therapist (OTR) and the physician, it should be followed by facility nursing staff. -Staff should document the use or refusal to use the splint and communicate issues with the resident using the splint to the therapy department as needed. During an interview on 3/5/20 at 12:10 P.M., the Assistant Director of Nursing (ADON) said: -He/she typically competed the transcription of physician's orders onto the next month's POS, unless delegated to other nursing staff when needed. -This responsibility had been delegated to another nurse for the last two months. -The new POS should be checked against the current POS to ensure that they match, and any new orders should also added. -When the new month's completed POS was sent from the pharmacy, it should be re-checked to ensure accuracy. During an interview on 3/5/20 at 1:55 P.M., RN A said: -He/she reviewed the March 2020 Medication Administration Record (MAR) and March 2020 TAR and neither showed a physician's order or any documentation related to the resident's orthotic splint. During an interview on 3/5/20 at 2:09 P.M., the ADON and the Regional Nurse said: -Physician's orders should be transferred from the current month's POS to the next month's POS by the ADON or the nurse delegated to complete that task. -If a resident had a physician's order to continue using a hand splint after OT services were discontinued for maintenance, it was expected that the splint would be available and staff would follow the order to assist the resident with using it. -Use of the hand splint for ongoing maintenance by nursing staff should be documented on the TAR. -If the resident refused to use the splint, this should be circled on the TAR and a description documented on the back of the TAR and in nursing notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #15's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Lack of coordination. -Generalized muscle weakness. Record review of the resident's quarterly MDS dated [DATE] and 12/31/19 showed he/she: -Was cognitively intact. -Required physical assistance of one person to transfer from one surface to another. -Was not stable to transfer from surface to surface without staff assistance. -Had impairment in upper extremity (shoulder, elbow, wrist, or hand) movement on one side. -Had no impairment in lower extremity (hip, knee, ankle, or foot) movement. -Used a wheelchair for mobility. Record review of the resident's care plan dated 2/10/20 showed no documentation related to the resident's lower extremity weakness or the need to use a mechanical lift (a mechanism that lifts and transfers a person from one place to another using a sling secured to a hydraulic lift) for transfers. Observation on 3/2/20 at 8:43 A.M. showed: -The resident was sitting on the side of the bed with his/her feet on the floor. -CNA E was in the room wearing gloves, and was preparing to use the mechanical sit-to-stand lift to assist the resident with transferring from his/her bed to the wheelchair. -No other staff was in the resident's room. -CNA E moved the lift in front of the resident and placed the sling around the resident's back and under his/her arms, then hooked the loops on the sling to the rings on the lift. -CNA E asked the resident if the sling was comfortable and felt secure, and the resident said yes. -CNA E assisted the resident with getting his/her feet in the right place on the footpad of the lift. -CNA E did not fasten the safety belt of the sling around the resident. -With the resident holding onto the hand bars on the lift, CNA E used the remote control of the lift to slowly lift the resident into a standing position. -The sling appeared to pull light under the resident's armpits, but he/she said it felt fine. -CNA E rotated the resident in the lift clockwise and pushed the lift forward to position the resident over the seat of the wheelchair. -CNA E walked behind the resident to ensure that he/she was placed over the seat of the wheelchair, and made sure the wheels were in a locked position. -CNA E then walked back to the front side of the lift (out of arm's reach of the resident) and lowered the resident into the seat of the wheelchair. -CNA E unhooked the sling from the lift and removed the sling from behind the resident. Observation of 3/4/20 at 8:54 A.M. showed: -CNA E was in the resident's room, wearing gloves, with the mechanical sit-to-stand lift near the resident's bed. -No other staff was in the resident's room. -The resident was sitting on the side of the bed with his/her feet on the floor. -CNA E moved the lift in front of the resident and placed the sling around the resident's back and under his/her arms, then hooked the loops on the sling to the rings on the lift. -CNA E assisted the resident with getting his/her feet in the right place on the footpad of the lift. -CNA E asked the resident if the sling felt comfortable and the resident said yes. -CNA E did not fasten the safety belt of the sling around the resident. -With the resident holding onto the hand bars on the lift, CNA E used the remote control of the lift to slowly lift the resident off of the bed to a standing position. -CNA E rotated the lift clockwise and pushed the lift forward to position the resident over the seat of the wheelchair. -CNA E checked the placement of the resident over the seat of the wheelchair and the wheelchair wheels appeared to be in a locked position. -CNA E then stepped back to the front of the lift (out of arm's reach of the resident) and lowered the resident into the seat of the wheelchair. -CNA E unhooked the sling from the lift and removed the sling from behind the resident. During an interview on 3/5/20 at 8:16 A.M., the resident said: -Staff have used the mechanical sit-to-stand lift to assist him/her with transfers since he/she has lived at this facility. -He/she has felt comfortable (no pain) when the lift was used unless staff left her in the standing position for too long. That had rarely happened and he/she told staff and they lowered her down to a surface. He/she could not remember when this had happened or how many times. -He/she felt secure when the lift was used and had never been afraid of slipping out of the sling. 3. During an interview on 3/5/20 at 8:34 A.M., CNA C said: -If a resident uses a mechanical lift, that should be documented in the care plan. -The resident has used a mechanical sit-to-stand lift since he/she has worked at the facility, but that had only been a few weeks. -There should always be two staff present to assist a resident with any transfers using a mechanical lift. -Staff do not always ensure that two staff are present when transferring residents using the mechanical sit-to-stand lift. -New CNAs are trained to use mechanical lifts by watching other staff complete mechanical lift transfers a couple of times. During an interview on 3/5/20 at 9:28 A.M., the Assistant Director of Nursing (ADON) said: -If a resident uses a mechanical lift, that should be documented in the care plan. -There should always be two staff present to assist a resident with any transfers using a mechanical lift. During an interview on 3/05/20 at 11:45 A.M., Licensed Practical Nurse (LPN) D said when transferring a resident with a sit to stand lift, they should fasten the safety belt so the resident is more safely transferred. During an interview on 3/5/20 at 12:39 P.M., the MDS Coordinator said: -If a resident used mechanical lift for transfers most of the time, the MDS should show that the resident needed assistance from at least two staff during transfers. -If a resident used mechanical lift for transfers most of the time, that information and interventions specific to the resident's needs should be care planned. -If a resident had lower extremity impairment, this should be reflected in the MDS assessment and the care plan. -Information related to the functional needs of a resident was gathered at care plan meetings. -Information related to resident care was gathered at care plan meetings and also communicated among the nursing department, therapy department, other facility department leaders, and the MDS Coordinator at morning meetings every Monday through Friday. -Any change in resident condition or support needs should be communicated by nursing or therapy to the MDS Coordinator in morning meetings. -MDS assessments should be comprehensive, accurate, and reflect the current needs and conditions of residents. -Care plans should be comprehensive, accurate, reflect the current needs and conditions of the resident, and include specific supports and interventions needed by that resident. During an interview on 3/5/20 at 2:09 P.M., the ADON and Regional Nurse said: -There should always be two nursing staff present to assist a resident with any transfer using a mechanical lift. -The safety belt of the mechanical lift sling should always be fastened prior to completing the transfer for the safety of the resident. -MDS assessments should be comprehensive, accurate, and reflect the current needs and conditions of residents. -Care plans should be comprehensive, accurate, reflect the current needs and conditions of the resident, and include specific supports and interventions needed by that resident. Based on observation, interview and record review, the facility failed to ensure a safe transfer for two sampled residents (Residents #38 and #15), and to ensure the accuracy of assessments and care planning related to safe transfer for one sampled resident (Resident #15) out of 13 sampled residents. The facility census was 48 residents. 1. Record review of Resident #38's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including anxiety, muscle spasms, deformity of the lower leg, and cervical spondylosis (wear and tear affecting the spinal disks in your neck). Record 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 2/4/19, showed he/she: -Was cognitively intact. -Needed limited assistance with bathing, dressing, toileting, and transferring. -Was not stable to transfer from surface to surface without assistance. -Used a wheelchair to mobilize. Record review of the resident's Care Plan, updated 1/6/20, showed he/she was at risk for falls related to unsteady balance and medications. It showed the resident is non-ambulatory and had falls with and without injury. Interventions showed the resident was not to transfer without assistance. The care plan did not show how the resident transferred with assistance. Observation on 3/03/20 at 9:21 A.M., showed the resident was sitting up in bed. Certified Nursing Assistant (CNA) D and CNA B were already in the resident's room after performing incontinence care and both were wearing gloves. CNA D and CNA B lowered the resident's bed and assisted him/her to a sitting position on the side of his/her bed. There was a stand up mechanical lift in the resident's room that the CNAs pulled in front of the resident. The CNAs assisted the resident to place his/her feet on the footpad. The CNAs then attached the sling, which went behind the resident's back and under his/her arms, to the lift. There was a safety belt that the CNAs did not secure-they did not attach the belt closure and left the belt loosely hanging. CNA D controlled the lift while CNA B assisted with positioning the resident in his/her wheelchair. CNA D moved the lift out of the room while CNA B put the footrests on the resident's wheelchair and placed him/her feet on them. CNA D gloved and made the residents bed. CNA B then put a new bag in the resident's trash then washed his/her hands. During an interview on 3/03/20 at 9:29 A.M., CNA D said: -They were supposed to put the safety belt around the waist of the resident when using stand up lift. -They should fasten the belt to ensure the resident's safety and their safety, but he/she forgot to fasten it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a physician's order for a resident to self-administrator his/her medications; to assess the resident ability to be able to self-administer medication and to ensure to update the resident respiratory care plan to reflect current health status for one sampled resident (Resident #33) out of 13 sampled resident. The facility census was 48 residents. 1. Record review of Resident #33 admission Face Sheet showed he/she was readmitted to the facility on [DATE] with diagnoses of: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Congestive Heart Failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). -The resident was his/her own responsible person. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 2/3/20 showed he/she: -Had diagnosis of COPD. -Was mildly cognitively impaired. -He/she was able to make his/her needs known. -Did not indicate the resident had oxygen while resident. Record review of the resident's COPD Care Plan dated 8/7/19 showed: -The resident had the potential at risk complication respiratory distress related to COPD. -He/she required oxygen as ordered. -Nursing staff were to provide medication as physician's ordered. -Nursing staff were to monitor the resident's lung sounds and oxygen saturation via pulse oximetry as ordered by the resident physician's. -Did not indicate the resident had nebulizer breathing treatment as needed for COPD. -Did not indicate the resident may self-administration his/her nebulizer treatment or nursing assessment for the resident's ability to self-administer medication. -Did not indicate the resident may keep nebulizer medication at his/her bedside. Record review of the resident's Physician's Progress Note dated 2/27/20 showed; -The resident had complaint of cough, chest congestion and night sweats for the past several days. -The physician's assessment of the resident showed he/she had pulmonary (lung) congestion and coarse crackles in the lungs. -The resident plan included: -Resident had lab work ordered and a chest x-ray. -Nursing staff were to continue to monitor the resident's pulmonary status. Record review of the resident's Physician's Order Sheet (POS) dated 3/1/20 to 3/31/20 showed: -A physician's order for the resident to be given DuoNeb (breathing treatment medication, two medicines work together to help open the airways in the lungs) 2.5-0.5 milligrams per 3 milliliters (mg/ml) inhale, one vial via nebulizer every six hours as needed for COPD. -No physician's order for the resident to provide his/her own breathing treatment or to keep medication in his/her room. Record review of the resident's medical record showed no documentation of the resident's ability to self-administer medication. During observation and interview on 3/02/20 at 3:23 P.M., the resident said: -He/she has had respiratory issue of a cold for last five days. -The facility nursing staff had been monitoring his/her lungs sounds. -On 3/1/20 he/she had wheezing in his/her lungs. -He/She had been performing his/her own breathing treatment. -Observation of his/her nebulizer machine with tubing attached was located on the sink counter in the resident's bathroom. Observation and interview 3/3/20 at 10:40 A.M. of the resident room showed: -Observation of his/her nebulizer machine with tubing attached located on the sink counter in the resident's bathroom. -He/she had one unopened vial of DuoNeb medication next to the nebulizer machine. -The resident said normally the nursing staff setup the breathing treatment, but since he/she had been having shortness of breath the nursing staff had left one vial in his/her room just in case he/she had shortness of breath during the night, then the resident could provide his/her own treatment right away. Observation 3/4/20 at 12:45 P.M. of the resident room showed: -His/her nebulizer machine, tubing and mask on the sink counter in the resident's bathroom. -He/she had one unopened vial of DuoNeb medication next to the nebulizer machine. During an interview on 3/5/20 at 12:55 P.M., Registered Nurse (RN) A said: -He/She was not aware of any resident providing their own breathing treatment at this time. -The resident had an as needed physician order for his/her breathing treatment, but he/she did not have a physician's order for self-administration of medication at this time. During an interview 03/05/20 at 1:43 P.M., Regional Nurse, Assistant Director of Nursing (ADON) said: -They were not aware of any resident at this time providing their own administration of medication. -Would expect to for the resident to have a physician's order to keep medication at bedside and to self-administer any type of medication. -Would expect nursing staff to ensure to have a physician's order for the resident to self-administer of breathing treatments if required. -Would not be normal nursing practice for the resident to provide own breathing treatment without nursing monitoring. -The facility nursing staff need to be able to assess the resident's lung sounds before and after a breathing treatment. -Would expect to see detail comprehensive care plan related breathing treatment and COPD.

Based on observation, interview and record review, the facility failed to ensure a dead mouse and mouse droppings (the excrement of certain animals, such as rodents, sheep, birds, and insects) were removed from the kitchen furnace room for three days of the survey. This practice potentially affected one non-resident use area. The facility census was 48 residents. 1. Observations on 3/2/20 at 8:29 A.M., 3/3/20 at 10:23 A.M. and 3/4/20 at 8:27 A.M., showed the presence of a dead mouse and mouse droppings in the kitchen furnace room. During an interview on 3/3/20 at 10:22 A.M., the Maintenance Director said he/she did not know about the dead mouse in the kitchen furnace room. During an interview on 3/4/20 at 8:28 A.M., the Dietary Manager (DM) said he/she had not seen the mouse and the mouse droppings in the dietary furnace room. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under §§ 7-202.12, 7-206.12, and 7-206.13; Pf and (D) Eliminating harborage conditions. 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the PREMISES at a frequency that prevents their accumulation, decomposition, or the attraction of pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to do the following: maintain the fan in Resident #33's room free of a heavy buildup of dust; maintain the backing support of the shower chair free of large rips, failed to maintain the shower mat in the 500 Hall shower room free of rips and tears which caused it to be not easily cleanable; failed to maintain the brakes of the wheelchairs that belonged to Residents #45 and #25 in working order; and failed to maintain the restroom ceiling vent in resident room [ROOM NUMBER] free of a heavy buildup of dust. This practice potentially affected at least 40 residents who used or resided in those areas. The facility census was 48 residents. 1. Observations with the Environmental Services Director and the Maintenance Director on 3/3/20, showed the following: - At 8:58 A.M., there was a heavy buildup of dust on the fan in Resident #33's room. - At 9:00 A.M., Resident #33 said facility staff had not cleaned his/her fan. - At 9:00 A.M., The Environmental Services Director said the fan absolutely needed to be cleaned. - At 9:18 A.M., there was a 2 foot (ft.) long rip in the back support of the 500 Hall shower chair. - At 9:20 A.M., Certified Nurse's Assistant (CNA) A said that shower chair has been like that for about one month. - At 9:21 A.M., there were five ripped areas of 1 inch (in.) or more in the shower mat, which made it (the shower mat) not easily cleanable. - At 9:48 A.M., the left brake of Resident #45's wheelchair did not hold the left wheel firmly, when it was pressed down. - At 9:49 A.M., the Maintenance Director confirmed the observation of the left brake not holding the left wheel firmly. - At 11:24 A.M., there was a heavy buildup of dust on the ceiling vent in resident room [ROOM NUMBER]. Observation on 3/5/20 at 9:44 A.M., with CNA B of the left brake of Resident #25's wheelchair showed that the brake did not firmly hold the left wheel in place when engaged. During an interview on 3/5/20 at 9:45 A.M., CNA B acknowledged the observation and said he/she would report it to the Maintenance Director. Record review of the maintenance request book, showed that from 2/8/20 through 3/5/20, there was nothing written about wheelchairs in there. During an interview on 3/5/20 at 9:05 A.M., CNA A said: -He/she had not used the shower mat in the past and did not know about the tears within the shower mat. -He/she would report damaged equipment to the Maintenance Director so the Maintenance Director could order a replacement for the backing of the shower chair, because the Maintenance Director was in charge of ordering new or replacement equipment. During an interview on 3/5/20 at 9:18 A.M., the Assistant Director of Nursing (ADON) said the CNAs should check the brakes when the clean the wheelchairs at night and report to the Maintenance Director if the brakes were not working at the time. During an interview on 3/5/20 at 9:23 A.M., the Maintenance Supervisor said the damaged shower chair should have been reported to him/her by the nursing staff. During an interview on 3/5/20 at 9:24 A.M., the Maintenance Director said it is both the job of nursing staff and Maintenance staff to check the wheelchairs, and once they find something, they should write that in the maintenance book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the medication refrigerator temperature was monitored and maintained within the appropriate range for the refrigerated medications and vaccines. The refrigerator temperature was 52 degrees Fahrenheit (°F) Affecting a total of 85 medications including insulin, vaccine, antipsychotics and anti-anxiety medications. Two sampled residents (Resident #1 and #2) had been given medication out of that refrigerator that day. There were 13 sampled and 8 supplemental residents. The facility census was 48 residents. Record review of the manufacturers package insert for Desmopressin AC (used to increase urine concentration and decrease urine production) revised in July 2007 showed: -Store in refrigerator between 36 °F and 46 °F. Record review of the Manufacturers package insert from AbbVie Inc revised in August 2017 showed: -Store Dronabinol (marinol used to stimulate the appetite and decrease nausea) in a cool place such as in a refrigerator, at a temperature between 46 °F and 59°F . -Do not freeze marinol capsules. Record review of Omnicare 2016 Insulin storage recommendation showed: -Unopened insulin should be stored in the refrigerator between 36°F and 46 °F. Record review of Manufacturers package insert for Risperdal (an antipsychotic. It is used to treat schizophrenia, bipolar disorder, and irritability associated with autism) revised in July 2007 showed: -The entire dose pack should be stored in the refrigerator between 36°and 46°F and protected from light. -If refrigeration is unavailable, Risperdal can be stored at temperatures not exceeding 77°F for no more than 7 days prior to administration. -Do not expose un-refrigerated product to temperatures above 77°F. Record review of the Center for Disease Control and Prevention (CDC) storage and handing of Vaccine reviewed April 15, 2019 showed: -Store all other routinely recommended vaccines in a refrigerator between 35°F and 46°F. -The desired average refrigerator vaccine storage temperature is 40°F. -Exposure to temperatures outside these ranges may result in reduced vaccine potency and increased risk of vaccine-preventable diseases. -The vaccine must be stored in a refrigerator which is monitored daily to ensure the correct temperature of 35°F and 46°F is maintained. 1. Record review of Resident #1's face sheet showed he/she had been admitted to the facility on [DATE] with a diagnoses of: -Type II Diabetes Mellitus (the body ' s ability to produce or respond to the hormone insulin is impaired). -Diabetic chronic kidney disease (gradual loss of the kidneys ability to filter blood like they should, which can cause wastes to build up in your body). Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 12/2/19 showed he/she: -Was alert and had no cognitive difficulty or memory problems. -Had received seven injections during assessment period. -Had a diagnosis of Diabetes. Record review of the resident's Physician's Order Sheet (POS) dated 3/1/20 to 3/31/20 showed he/she had a physician's order for Desmopressin AC, 4 micrograms (mcg) /milliliter (ml) inject 0.5 milligrams (mg) Subcutaneous (sub-q under the skin) every 12 hours for diagnosis of diabetes. Observation on 3/3/20 at 9:10 A.M. during medication pass showed Licensed Practical Nurse (LPN) B: -Checked the resident's order of Desmopressin AC, 4 mcg/ml inject 0.5 mg sub-q every 12 hours for diagnosis of diabetes. -Obtained the medication from the medication cart drawer, and then drew up 0.5 mg of medication in a syringe. --The medication was supposed to be stored in the refrigerator not the medication cart. -Injected the medication into the resident's left arm without difficulty. 2. Record review of Resident #2's face sheet showed he/she had been admitted to the facility on [DATE] with diagnoses of: -Benign Prostatic Hyperplasia (BPH An enlarged prostate gland can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder). -Malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was alert but had cognitive difficulty. -Was able to make his/her needs known. -Had no weight gain or loss. Observation on 3/3/20 at 2:28 P.M. of the medication room with Certified Medication Technician (CMT) A showed the medication refrigerator was pad locked and the temperature log sheet on the front had no temperature recorded. During an interview on 3/3/20 at 2:28 P.M., CMT A said: -The CMT's monitor for out dated medications and cleanliness of the medication room and the over counter medications. -The licensed nursing staff monitor and check the locked medication refrigerator. -The licensed nursing staff were the only staff that have keys for the medication refrigerator. Observation on 3/4/20 at 12:30 P.M., of the unlocked medication refrigerator with LPN B showed: -The refrigerator door was open. -The items were wet and water was dripping. -The thermometer read at 52 °F and was rising. -LPN B was not aware the medication refrigerator was not working properly. -The temperature log located on front of the refrigerator had no temperature documented for March 2020. -LPN B said monitoring of the medication refrigerator had been the responsibility of the night shift nursing staff. During an interview on 3/4/20 at 12:38 P.M. LPN B said he/she had contacted his/her supervisor and the maintenance director to obtain a new refrigerator. Observation on 3/4/20 at 12:38 P.M., of medication stored in the medication refrigerator showed: -Resident #1, had one opened bottle of Desmopressin (used for diabetes) 4 mcg/ml with an opened date of 2/26/20 (to be given every 12 hours). -Resident #2 had two-medication cards of Marinol 2.5 mg (one with nine pills and the other card with 30 pills). -Two boxes with one syringe in each box of Risperdal 37.5 mg inject one syringe every two weeks. -One vial of Ativan (for mood disorder, anxiety). -Two vials of Levemir insulin 100 U/ml vial. -One vial of Humalog Mix insulin 75-25 ml. -One vial of Lantus insulin 100 Unit (U)/ml -Two vials of Novolog 100 unit/ml. -Ten vials of Novolin N insulin 100 U/ml. -Three vials of Lispro Insulin U100. -Two vials of Tuberculin purified protein derivative, 5 tuberculin units (TU) per test dose of 0.1 ml. -Nine vials of Pneumococcal Vaccine (polyvalent Pneumovax 23). -45 syringes of Afluria Quad (flu vaccine- 2019-20) 0.5 ml). -Five syringes of Hepatitis B vaccine. During an interview on 3/4/20 at 12:40 P.M. LPN B said: -He/she did not check the refrigerator temperature on the morning of 3/4/20. -He/she had accessed the locked refrigerator to obtain Resident #1's medication. -He/she had given Resident #1 his/her Desmopressin AC injection on the morning of 3/4/20. -The medication was still cool to touch when he/she took it out of the medication refrigerator. -He/she did not feel any dripping water that morning. -The night shift nursing staff were responsible for checking and recording the refrigerator temperatures. During an interview 3/4/20 at 12:48 P.M., the Assistant Director of Nursing (ADON) said: -He/she had a different form for recording refrigerator temperatures. -Neither of the forms had temperatures documented. -Temperatures were to be documented on the temperature log by night shift nursing staff. During an interview on 3/4/20 at 2:41 P.M., the Administrator, Regional Nurse and ADON said the facility's pharmacy had been contacted and he/she was told two licensed nurses were to destroy the following medications due to the refrigerator temperatures being out of the recommended range: -Influenza vaccine (Afluria Quad). --40 syringes were destroyed. -The facility had kept 5 to review with pharmacy when they arrive on site. -Hepatitis B vaccine. --Five syringes were destroyed. -Resident #1's one open vial of Desmopressin. -Ativan. --The facility had destroyed one vial. -Pneumococcal Vaccine. --The facility had destroyed nine vials. -Tuberculin PPD. --The facility had destroyed two vials. -The insulin had not been affected and was not destroyed. -The temperature logs were kept in the nurses Treatment Administration Record (TAR). Record review on 3/4/20 at 2:45 P.M., of the facility's medication refrigerator log sheet for March 2020 that was in the nurses TAR showed: -No temperatures were documented on 3/1/2020 and 3/2/2020. -A temperature of 40°F was documented on 3/3/20. During an interview on 3/5/20 at 2:11 P.M., the ADON and Regional Nurse said: -Monitoring of medication rooms and medication refrigerators were the responsibility of all nursing staff. -He/she expected night shift nursing to document the medication refrigerator temperatures nightly. -He/she expected all nursing staff who accessed the medication refrigerator, they should monitor the refrigerator temperatures to ensure they are within recommended range.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #20's Face Sheet showed he/she: -Was admitted to the facility on [DATE]. -Had diagnoses which included: --History of brain hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain). --Other lack of coordination. --Hemiplegia (paralysis) and hemiparesis (slight paralysis/weakness) affecting the right side of the body following brain hemorrhage. --Generalized muscle weakness. --Retention of urine. Record review of the resident's Care Plan updated on 10/24/19 showed: -The resident had an indwelling supra-pubic catheter. -The resident required staff assistance with all Activities of Daily Living (ADL) tasks due to mobility issues related to hemiplegia of right side, including: --Proper placement of his/her catheter bag below the level of his/her bladder. --Transfers to and from his/her wheelchair and bed. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Had an indwelling catheter. -Had functional limitations in range of motion on his/her upper and lower extremities on one side. -Required total assistance (full staff performance) with toilet use, including managing his/her catheter. -Required extensive assistance from at least two staff when transferring between bed and wheelchair. -The resident was only able to stabilize with staff assistance during transfers between bed and wheelchair. Record review of the resident's March 2020 POS showed the resident had a supra-pubic catheter (a sterile tube surgically inserted into the bladder through the lower abdomen to drain urine) due to a diagnosis of retention of urine. Observation on 3/2/20 at 9:29 A.M. showed the resident sitting in his/her wheelchair in the common area of the facility. The resident's catheter bag was secured under his/her wheelchair and was in a privacy bag. The privacy bag was touching the floor. Observation on 3/2/20 at 1:15 P.M. of the resident's transfer from his/her wheelchair to bed showed: -CNA E and CNA F were already in the resident's room with a mechanical lift (a mechanism that lifts and transfers a person from one place to another using a sling secured to a hydraulic lift) to assist the resident with transferring. -CNA E took gloves from his/her pocket and put them on, then touched the mechanical lift to move it out of the way. -CNA F put on gloves from a box on the counter, then touched a bedside table to roll it out of the way. -While wearing the same gloves, CNA E picked up the remote control to the resident's bed and moved the bed lower to assist with the transfer. -With contaminated gloved hands, CNA E unhooked the resident's catheter bag from under his/her wheelchair and hooked it low onto the bedframe close to where the resident was sitting with room for movement from the wheelchair to the bed. -With contaminated gloved hands, CNA F pushed the resident's wheelchair to a better transfer position by the bed. -Both CNAs then noticed that there was no mechanical lift sling under the resident so they would need to transfer him/her manually into the bed. -With contaminated gloved hands, CNA E got a clean washable bed pad from a side table and placed it in the middle of the resident's bed. -With contaminated gloved hands, both CNAs assisted the resident to rise from his/her wheelchair, balance, and pivot around to sit on the side of the bed while each supported the resident under each arm. -With contaminated gloved hands, CNA E assisted the resident with swinging his/her legs up onto the bed and the laying down. -With contaminated gloved hands, CNA E took off both of the resident's shoes. -With contaminated gloved hands, CNA E used the remote control to the resident's bed to lift the bed back up to a medium height. -With contaminated gloved hands, CNA F moved the resident's wheelchair to another part of the room. -With contaminated gloved hands, CNA E rolled the resident onto his/her left side and checked the resident's brief, which was clean and dry. -CNA F moved to the left side of the bed and CNA E to the right side of the bed. With contaminated gloved hands, both CNAs assisted the resident with removing his/her pants for comfort in bed. -CNA E carefully moved the resident's catheter bag and tubing through the leg of his/her pants as they were removed, then hung the catheter bag low on the bedframe. The catheter bag was not placed in a privacy bag. -CNA E asked the resident if he/she wanted to put on a hospital gown and he/she nodded his/her head up and down to indicate yes. -CNA E removed his/her gloves and held them in one hand. With the other hand, he/she touched the resident's right ear to look at something, then turned and opened the resident's door with the hand that was empty. He/she did not sanitize or wash his/her hands. -With contaminated gloved hands, CNA F pulled the sheet and blankets up over the resident's legs and abdomen. -CNA E returned to the room carrying a folded hospital gown. -CNA E took gloves from his/her pocket and put them on without being observed to wash or sanitize hands. -Both CNAs stood on each side of the resident's bed and removed his/her shirt and put the hospital gown on him/her. -CNA F removed his/her gloves, disposed of the gloves in the trash bin, and washed his/her hands with soap and water. He/she dispensed paper towels with his/her elbow, dried his/her hands, turned the water faucet off with the paper towel, and threw the paper towel into the trash bin. -Wearing the same gloves, CNA E picked up the resident's clothing and placed into a clear bag, then picked up the remote control to the resident's bed and elevated the head of the resident's bed to about 30 degrees. -CNA E removed his/her gloves, disposed of the gloves in the trash bin, and washed his/her hands with soap and water. He/she dispensed paper towels with his/her elbow, dried his/her hands, turned the water faucet off with the paper towel, and threw the paper towel into the trash bin. -CNA E took one glove from his/her pocket and put it on one hand. With his/her gloved hand, he/she removed trash bag from trash bin, picked up the bag of clothing, then opened the door with the ungloved hand and left the resident's room after making sure he/she was comfortable. During an interview on 3/2/20 at 1:27 P.M., CNA F said the only things he/she would do differently during the transfer process were: -It was best to transfer the resident using the mechanical lift, but staff had not placed the sling under the resident earlier that day, so they could not. -The resident's catheter bag should be placed in a privacy bag. During an interview on 3/2/20 at 1:29 P.M., CNA E said the only thing he/she would do differently during the transfer process was having the transfer the resident manually instead of using the mechanical lift. Observation on 3/2/20 at 2:09 P.M. showed the resident lying in bed watching television. His/her catheter bag was secured low on the bedframe. The catheter bag was not in a privacy bag and it was touching the floor. Observation on 3/2/20 at 2:56 P.M. showed the resident lying in bed watching television. His/her catheter bag was secured low on the bedframe. The catheter bag was not in a privacy bag and it was touching the floor. Observation at 3/5/20 at 10:50 A.M. showed the resident lying in bed watching television. He/she said he/she was comfortable with no issues. His/her catheter bag was secured low on the bedframe. The catheter bag was not in a privacy bag and it was touching the floor. 5. Record review of Resident #32's Face Sheet showed he/she: -Was admitted to the facility on [DATE]. -Had diagnoses which included: --COPD. --Respiratory Failure (a breathing condition characterized by low oxygen levels, high carbon dioxide levels, and deterioration of the airways to the lungs). --Asthma (a breathing disorder that causes the airway to swell and produce thick mucus). --Heart Failure (severe failure of the heart to function properly). --Intellectual disabilities. Record review of the resident's Care Plan dated 8/27/19 showed: -The resident required oxygen therapy related to a history of respiratory failure with interventions that included: -Encourage and remind the resident to keep the oxygen in place, including when he/she was in bed, as he/she had a tendency to remove the oxygen while sleeping. -Provide medications as ordered and encourage compliance with using nebulizer treatments and inhalers. Record review of the resident's March 2020 POS showed: -Oxygen - administer three liters per minute (l/m) via nasal cannula (an oxygen delivery tube with two small prongs that fit into the nostrils) to keep oxygen saturation (a measurement of how much oxygen the blood carries in comparison to its full capacity) above 90%. -Albuterol Sulfate Inhalation Solution (a medication that is inhaled using a nebulizer (a device used to administer medication to people in the form of a mist inhaled into the lungs) to treat and prevent symptoms such as wheezing and shortness of breath) - inhale one vial per nebulizer every two hours as needed for chronic lung disease. Observation on 3/3/20 at 8:43 A.M. showed: -The resident was sleeping in bed with the oxygen concentrator running at 3 l/m. The resident was wearing the nasal cannula. -A nebulizer sat on a small dresser next to the head of the resident's bed, not running, with the tubing and mask lying directly on the top of the cluttered dresser and partially covered with a shirt. No storage bag for the nebulizer tubing and mask was observed. Observation on 3/3/20 at 11:19 A.M. showed: -The resident was not in his/her room. The oxygen concentrator was off and the tubing was partially lying on the concentrator machine and partially on the floor. No storage bag for the oxygen tubing and nasal cannula was observed. -A nebulizer sat on a small dresser next to the head of the resident's bed, not running, with the tubing and mask lying directly on the top of the cluttered dresser and partially covered with a shirt. No storage bag for the nebulizer tubing and mask was observed. Observation on 3/3/20 at 1:05 P.M. showed: -The resident was not in his/her room. The oxygen concentrator was off and the tubing with the nasal cannula attached was wound around the humidifier bottle on the concentrator machine. Neither the tubing nor the nasal cannula were stored in a bag and no storage bag was observed. -A nebulizer sat on a small dresser next to the head of the resident's bed, not running, with the tubing and mask lying directly on the top of the cluttered dresser and partially covered with a shirt. No storage bag for the nebulizer tubing and mask was observed. Observation on 3/4/20 at 10:00 A.M. showed: -The resident was asleep in bed. The oxygen concentrator was running at 3 l/m and the oxygen tubing and nasal cannula were laying on the floor next to the bed. -A nebulizer sat on a small dresser next to the head of the resident's bed, not running, with the tubing and mask lying directly on the top of the cluttered dresser and partially covered with a shirt. No storage bag for the nebulizer tubing and mask was observed. Observation on 3/4/20 at 12:22 P.M. showed: -The resident was not in his/her room. The oxygen concentrator was off and the tubing was partially lying on the concentrator machine and partially on the floor. -On the top of a small dresser near the oxygen concentrator at the foot of the resident's bed was a gallon-size plastic zip-close bag among many other various items. There was writing on the bag that said, O2 (oxygen) cannula 2/2/20. The bag was empty. -A nebulizer sat on a small dresser next to the head of the resident's bed, not running, with the tubing and mask lying directly on the top of the cluttered dresser and partially covered with a shirt. No storage bag for the nebulizer tubing and mask was observed. Observation on 3/4/20 at 1:30 P.M. showed: -The resident was not in his/her room. The oxygen concentrator was off and the tubing was partially lying on the concentrator machine and partially on the floor. -On the top of a small dresser near the oxygen concentrator at the foot of the resident's bed was a gallon-size plastic zip-close bag among many other various items. There was writing on the bag that said, O2 (oxygen) cannula 2/2/20. The bag was empty. -A nebulizer sat on a small dresser next to the head of the resident's bed, not running, with the tubing and mask lying directly on the top of the cluttered dresser and partially covered with a shirt. No storage bag for the nebulizer tubing and mask was observed. Observation on 3/5/20 at 8:35 A.M. showed: -The resident was sleeping in bed with the oxygen concentrator running at 3 l/m. The resident was wearing the nasal cannula. -On the top of a small dresser near the oxygen concentrator at the foot of the resident's bed was a gallon-size plastic zip-close bag among many other various items. There was writing on the bag that said, O2 (oxygen) cannula 2/2/20. The bag was empty. -A nebulizer sat on a small dresser next to the head of the resident's bed, not running, with the tubing and mask lying directly on the top of the cluttered dresser and partially covered with a shirt. No storage bag for the nebulizer tubing and mask was observed. 6. During an interview on 3/5/20 at 10:45 A.M., CNA C said: -Oxygen tubing, cannulas, and masks should be bagged when not in use and should not be on the floor. -Catheter bags and tubing should not touch the floor. -Staff should wash or sanitize hands before providing any kind of care to a resident where they will touch the resident, before putting on gloves, after removing gloves, any time hands or gloves are visibly soiled, and any time something is touched that could be unclean before continuing to provide care to a resident. During an interview on 3/5/20 at 10:33 A.M., Registered Nurse (RN) A said: -All tubing for any type of oxygen support, including nasal cannulas and masks, should be bagged when not in use and should never be on the floor. -There are not always plastic bags available, so nursing staff need to go to dietary to get new plastic zipper bags to use for bagging oxygen tubing, cannulas, and masks. -CNAs and nurses should always put the oxygen equipment in bags if they see it is not bagged. -Catheter bags should not touch the floor. -Staff are trained to sanitize or wash hands before any resident care, before and after glove changes, and when hands are visibly soiled. If a staff is in doubt about whether they should change gloves and/or sanitize hands. During an interview on 3/5/20 at 2:09 P.M., the ADON and the Regional Nurse said: -It was expected that staff wash hands: --Prior to and after resident care. --Before, between, and after glove changes. --If hands or gloves are visibly soiled. -Catheter bags should not touch the floor. -Oxygen tubing, nasal cannulas, mouthpieces, and masks should be stored in a dated bag when not in use and should not touch the floor. -If a CNA saw oxygen equipment on the floor, it was expected that they tell a nurse and the nurse should discard the equipment and replace it. -If a nurse saw oxygen equipment on the floor, it was expected that they should discard it and replace it 2. Record review of Resident #1's admission Face sheet showed he/she had been admitted to the facility on [DATE] with diagnoses of: -Pressure ulcer of sacral region, Stage 4 (Wound that's near lower back area and wound stages that extends all the way into the muscle, bone, or tendons). -Chronic Kidney Disease (gradual loss of kidney function). Record review of the resident's admission MDS dated [DATE] showed he/she: -Was alert, and had no cognitive difficulty and memory problems. -Was totally dependent on staff for transfers, mobility, bathing, dressing, toileting and grooming. -Was incontinent at times and used a catheter for urination. -Had a Stage 4 pressure wound upon admission. Record review of the resident's Physician's Order Sheet (POS) and Treatment Administration Record (TAR) dated 3/1/20 to 3/31/20 showed: -Foley catheter (is a sterile tube that is inserted into your bladder to drain urine) care every shift -Foley catheter size of a 16 French (fr, size of the tube) with a 10 cubic centimeters (cc) balloon (is the amount fluid needed to inflate the balloon to hold catheter in place) was to be changed monthly. -Change Foley catheter collection bag weekly on Wednesday. Observation on 3/5/20 at 10:00 A.M., of the resident's catheter care by Certified Nursing Assistant (CNA) A showed: -CNA A washed his/her hands upon entry of the resident's room and then applied gloves to his/her hands. -Used one wipe at a time for the resident's catheter care. -After CNA A finished catheter care, he/she pulled up the resident's bed sheets while wearing the same soiled gloves. -He/she then removed soiled gloves and emptied the resident's trash, removing it from the resident's room. -CNA A then returned to the resident's room to wash his/her hands with soap and water. During an interview on 3/5/20 at 10:15 A.M., CNA A said: -He/she should have washed his/her hands before he/she left the resident's room. -He/she should not have touched the resident's bed linens with soiled gloves. -He/she should have removed his/her gloves and washed his/her hands before handling the resident's bed sheets. During an interview on 3/5/20 at 1:04 P.M., the ADON and Regional nurse said: -He/she would expect care staff and nursing staff to perform hand hygiene before and after cares. -He/she would expect staff to remove gloves, wash hands, and put on clean gloves between a dirty and a clean process and then remove gloves and wash their hands after the care. -Staff should wash their hands upon entering the resident's room and apply gloves. -Staff should wash their hands before exiting the resident's room. -Staff should not touch linens or any items with soiled gloves or soiled hands. 3. Record review of Resident #33's Chronic Obstructive Pulmonary Disease (COPD, chronic lung damage which makes it difficult for your lungs to absorb enough oxygen) care plan dated 8/7/19 showed: -The resident had a potential complication of respiratory distress related to COPD. -He/she required oxygen as ordered. -Nursing staff were to provide medications as ordered. -Nursing staff were to monitor lung sounds and oxygen saturation via pulse oximetry (a test used to measure the oxygen level (oxygen saturation) of the blood) as ordered by the resident physician. -Did not indicate the resident had nebulizer breathing treatment as needed for COPD. Record review of the resident's admission Face Sheet showed he/she was readmitted to the facility on [DATE] with diagnoses of: -COPD. -Congestive Heart Failure (CHF, is a chronic progressive condition that affects the pumping power of the heart muscles). Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Had diagnosis of COPD. -Was mildly cognitively impaired. -He/she was able to make his/her needs known. -Did not indicate the resident had oxygen while resident. Record review of the resident's POS dated 3/1/20 to 3/31/20 showed an order for DuoNeb (breathing treatment medication, two medicines work together to help open the airways in your lungs) 2.5-0.5 milligram (mg)/3 milliliter (ml) inhale, one vial via nebulizer every 6 hours as needed for COPD. Record review of the resident's medical record showed he/she had a recent influenza A swab and it came back negative. Observation on 3/2/20 at 3:23 P.M., showed the resident's nebulizer machine with tubing attached located on the bathroom sink counter and the tubing and mask was uncovered. Observation 3/3/20 at 10:40 A.M. of the resident's room showed: -The resident's nebulizer machine with tubing attached was located on the bathroom sink counter and the tubing and mask were uncovered. -He/she had one unopened vial of DuoNeb medication next to the nebulizer machine. During an interview on 3/3/20 at 10:40 A.M. the resident said: -Normally the nursing staff setup the breathing treatment, but since he/she had been having shortness of breath the nursing staff had left one vial. -Just in case he/she had shortness of breath during the night, then the resident could provide on treatment right away. Observation on 3/4/20 at 12:45 P.M. of the resident's room showed his/her nebulizer machine, tubing and mask not covered laying on the bathroom sink. During an interview on 3/5/20 at 9:38 A.M., CNA A said: -The resident's O2 tubing and nebulizer tubing should be stored in plastics bags when not in use. -The night shift staff were responsible for changing the tubing weekly. During an interview on 3/5/20 at 1:43 P.M., the Regional Nurse and ADON said: -He/she would expect nursing staff to ensure the resident's nebulizer tubing and face mask were stored in a plastic bag when not in use. Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented to ensure no cross contamination was performed when two sampled residents' catheter bags (a flexible tube inserted through a narrow opening into the bladder, drains into a collection bag for removing fluid from the body) were on the floor (Resident #6 and #20); to ensure proper hand hygiene during catheter care for one sample resident (Resident #1) and during the transfer of one resident (Resident #20); to ensure proper storage of breathing tubing and masks when not in use for two sampled resident residents (Resident #32 and #33); and to include the following in its waterborne illness plan: a risk assessment of where opportunistic waterborne pathogens (e.g. Legionella sp. (a form of pneumonia, caused by the bacterium Legionella pneumophila found in both potable and nonpotable water systems, Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, and fungi) could grow and spread in potential areas of water stagnation; an accurate description of where the water enters into the facility; text flow diagrams of where the pipes from the various hot water heater were directed to; how the facility would react to changes in water quality such as water main breaks and construction; and the members of facility's Water Management program team in the facility's waterborne illness prevention plan. This practice potentially affected all residents and facility staff. The facility census was 48 residents. 1. Record review of Resident #6's Face Sheet showed he/she was admitted on [DATE] with diagnoses including respiratory failure, pneumonia, stroke, seizures, dysphagia (difficulty swallowing), high blood pressure, history of urinary tract infection and neurogenic bladder (lack of bladder control) with urinary retention. Record 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 3/3/20, showed he/she: -Was alert, but had cognitive difficulty and memory problems. -Was totally dependent on staff for transfers, mobility, bathing, dressing, toileting and grooming. -Was incontinent and used a catheter for urination. Observation on 3/5/20 at 9:07 A.M., showed the resident was resting in his/her bed with his/her eyes closed. The resident's bed was in a low position and his/her catheter bag was touching the floor. The resident was resting comfortably with no signs or symptoms of pain or discomfort. During an interview on 3/5/20 at 9:21 A.M., Licensed Practical Nurse (LPN) D said: -The resident's catheter bag should always be kept below the resident's waist and should never be placed in his/her lap or touching the floor. -He/she went into the resident's room to pick the resident's catheter bag up off of the floor. During an interview on 3/5/20 at 2:09 P.M., the Assistant Director of Nursing (ADON) said the resident's catheter bag should always be kept below the resident's waist and off of the floor. 7. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification letter dated 6/2/17, showed: -The facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit. -The toolkit should contain the following: text and flow diagrams, identify areas where Legionella could grow and spread, that the team has conducted a water program review at least annually, as stated. -The annual review should: 1) be implemented; 2) record findings and updates; 3) record participants; and 4) be submitted to the Executive Director. Observation throughout the facility during the survey dated 3/2/20 through 3/5/20, showed eight vacant rooms in the facility, with the increased risk of harmful bacteria growth in the unused sinks located in those rooms. Record review of the facility's undated Legionella/Waterborne Illness plan, showed the absence of the following: - A risk assessment of where (vacant resident rooms) opportunistic water pathogens could grow and spread. - A flow diagram which described where the water came into the building and the routes from the various water heaters throughout the facility, to the various halls. - A plan on what corrective actions the facility would implement in response to a water main break and construction. - A plan for specific actions that would be taken in response to a Legionella sp. Positive water sample. -The members of the water management team. During an interview on 3/5/20 at 9:52 A.M., the Interim Administrator said: -Diagrams were needed to show where water came into the building. -That the reaction to a water main break or construction would need to be in the plan as well as specific actions that would be implemented, if there was a Legionella sp. -Members of the water management team should be listed in the plan.