Based on interview, and record review, facility staff failed to report an allegation of abuse for one resident (Resident #1) out of five sampled residents, within in two hours to the administrator and the state agency (Department of Health and Senior Services). The facility census was 65.1.Review of the facility's Abuse policy, dated 01/10/2024, showed time period to report allegations of abuse and neglect establishes two-time limits for the reporting of reasonable suspicion of a crime, depending on the seriousness.-Serious Bodily Injury-two-hour limit: If the events first cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than two hours after forming the suspicion.-All others-Within 24 hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming suspicion.3. Review Resident #1's Face Sheet, dated 07/09/25, showed staff assessed the resident with a history of falling, cardiac pacemaker, muscle weakness, reduced mobility and Chronic Obstructive Pulmonary Disease (COPD). Review of the Facility's Investigation titled Investigation on Incident R/T Staff Vs. Resident #1, dated 07/16/25, showed the Director of Nursing (DON) documented he/she spoke with staff and residents regarding allegations of abuse on the early morning hours of 07/16/25. The investigation included the written statements of staff present during the incident as follows -On 07/16/25 Certified Medication Technician (CMT) E documented he/she witnessed CMT C and Certified Nurse Aide (CNA) B physically restrain the resident to take the resident back to his/her room. The CNA held the resident's arms down and the CMT held the resident's legs together and up, so CNA D could propel the resident in his/her wheelchair, back to his/her room. CMT E and CNA B picked the resident up and threw the resident on his/her bed. -On 07/16/25 CNA D documented he/she observed CNA B hold the resident's hands down and the resident said let me go, I'm not going to hit you. CNA B then said he/she was not going to let the resident go and told the resident, Try to get lose Motherfucker. CMT C then bent down and said to the resident, Now go ahead and punch me Motherfucker. CNA D documented he/she observed CNA B and CMT C pick the resident up under his/her arms, where his/her feet were off the ground and throw the resident into his/her bed. Review showed the investigation did not contain documentation the facility notified the Department of Health & Senior Services about this allegation of abuse within the required two hours. During an interview on 07/23/25 at 12:35 P.M., Registered Nurse (RN) A said he/she went to the resident's room to talk to him/her the morning of the incident. RN A said the resident told him/her, he/she had been cussing at the staff and the staff were cussing at him/her. RN A said if staff cussed at the resident, it would be abuse. RN A said he/she reported to the DON and administrator that the resident said staff cussed at him/her. He/She said the facility has two hours to report abuse, or allegations of abuse to the state. RN A said he/she thought the state had been notified. During an interview on 07/24/25 at 8:02 A.M., CNA D said he/she saw both CNA B and CMT C call the resident a Motherfucker and was holding the resident down against his/her will. CNA D said RN F was right outside the resident's room. CNA D said he/she exited the resident's room and told RN F what he/she observed. CNA D said RN F reported the incident to the Assistant Director of Nursing (ADON) when he/she came in. CNA D said he/she told RN F he/she felt it was abuse and RN F agreed it was abuse, he/she would have to report to management, and they would have to report it to state. What time was that? During an interview on 07/24/25 at 8:28 A.M., CMT E said he/she went into the resident's room and observed CNA B and CMT C pick the resident up where his/her feet were off the ground and threw the resident down on his/her bed, because his/her bed had already been lowered all the way to the ground. CMT E said he/she also heard the resident report to RN A the staff had cussed at him. During an interview on 07/24/25 at 8:43 A.M., RN F said CNA D reported to him/her that CNA B and CMT C called the resident Motherfucker and threw the resident into bed. RN F said he/she reported to the ADON and the ADON said he/she would report it to state. During an interview on 07/24/25 at 11:10 A.M., the ADON said he/she would say CNA D's witness statement alleges abuse. The ADON said he/she forwarded the CNA D's statement to the administrator. The ADON said he/she did not know that all allegations of abuse had to be reported to the state health agency within two hours. The ADON said CNA D later asked if it had been reported to the state, so he/she contacted the DON, and the DON said the incident had been investigated and handled appropriately. During an interview on 07/24/25 at 1:04 P.M., the DON said when he/she arrived at the facility, the administrator had taken all the statements. The DON said he/she then read the statement. The DON said he/she would consider it abuse if a staff cussed at a resident. The DON said he/she spoke with ownership and the administrator and because our investigation showed it was unsubstantiated, we decided it did not have to be reported to state. The DON said he/she was not aware allegations of abuse had to be reported to state within two hours, if the facility already unsubstantiated the allegation of abuse in its investigation. During an interview on 07/24/25 at 2:05 P.M., the administrator said he/she considers staff cussing at a resident to be abuse. The administrator said the ADON told him/her a staff member alleged abuse. The administrator said he/she had two hours to complete the investigation. The administrator said he/she did not report it to state, because his/her investigation did not show abuse. The administrator said he/she was halfway aware to report to state, like he/she has reported things in the past, he/she knew were not factually accurate. Incident #2570225

Based on interview and record review facility staff failed to ensure one resident (Resident #1) remained free from significant medication errors when staff administered Resident #2's Fentanyl (an copied drug used in the treatment of severe pain) patch to Resident #1. The facility census was 85. The administrator was notified on 3/12/25 of past Non-Compliance, which occurred on 2/27/25 when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 3/10/25. 1. Review of the facility's Medication administration general guidelines policy, undated, showed staff are to verify medication is correct three times before administering the medication. Residents are identified before medication is administered. Medications supplied for resident are never administered to another resident. Review of the facility's Medication error policy, undated, showed staff are to report the administration of the wrong medication being administered to a resident. Medications should be administered per physician's orders. When a medication error has occurred update the physician and responsible party immediately via telephone with the medication error. Follow all new physician orders in regards to the medication error. Obtain a set of vital signs immediately. Staff are to complete a medication error report and turn into the Director of Nursing (DON) office. Review of the facility's Performing the five rights policy, undated, showed staff are to, for safety, check the five rights three times. Take out the patient's medication drawer or bin and place it alongside the medication administration record (MAR) sheet containing the drug orders. Verify that the patient name on the drawer corresponds to the name on the MAR sheet. Count the number of medications to be administered at the particular time. The five rights for medication administration are right drug, right dose, right route, right time, and right patient. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/21/25, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of Congestive Heart Failure; -Received a scheduled pain regimen; -Had pain occasionally. Review of the residents care plan, dated March 2025, showed the resident was at risk for pain and utilized acetaminophen related to a history of pain. Staff are directed to give the medication as ordered. Review of the resident's Physician's Order Sheet (POS), dated March 2025, showed the POS did not contain an order for a Fentanyl patch. Review of the resident's nurses note, dated 2/27/25 at 12:17 P.M., showed staff documented they found Resident #2's fentanyl patch on the resident. Staff assessed the resident, removed the Fentanyl patch, and filled out a medication error report for placement of a Fentanyl patch to the incorrect resident. Staff contacted the physician and received orders to remove the Fentanyl patch and monitor the resident's vitals signs every 15 minutes for two hours. During an interview on 3/12/25 at 11:41 A.M. the DON said nurses are responsible for administering Fentanyl patches. If a nurse has a medication error they are expected to assess the resident and call the doctor. He/She said they are also responsible for contacting the resident's family. The nurse is expected to follow the doctors orders and make a nurses note. He/She said the nurse made a medication error by administering Resident #2's Fentanyl patch to Resident #1. The nurse noticed the error after about 30 minutes and removed the patch and reported to the him/her immediately. The DON said he/she contacted the doctor and was told to do 15 minutes checks with vital signs for two hours. He/She said LPN D filled out a medication error report and made a nurses note. He/She said LPN D was educated on the spot about medication administration and the five rights He/She said all staff were inserviced on 3/10/25. During an interview on 3/12/25 at 2:32 P.M., the physician said staff contacted his/her office and let them know about the medication error. During an interview on 3/18/25 at 7:50 A.M., LPN D said he/she normally works nights but worked a day shift that day. He/She said he/she was not used to the fast past of day shift and was trying to keep up. He/She said he/she made a to do list which included the fentanyl patch for Resident #2. He/She went to Resident #1's room and applied the patch and said he/she did not find the existing patch and though it may have fallen off. He/She said it wasn't until about 30 minutes later when he/she went to chart he/she realized the medication error. He/She said he/she immediately let the DON know and went down to remove the patch and assess the resident. He/She said the doctor was called and instructed to do 15 minute checks for two hours. He/She said he/she notified family of the error and made progress notes in the resident's chart. He/She was educated on the five rights of medication and medication administration. MO00250265

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for three residents (Resident #27, #47, and #61) out of 22 sampled residents. The facility census was 87. 1. Review of the facility's policy titled Care Planning Policy and Procedure, revised 01/17/18, directed staff to: -Ensure the resident and family participate in the resident's care quarterly and annually to ensure there is continuity of care; -Care plan will be developed upon admission, updated quarterly, annually, with any significant change, and in accordance with the individual's needs; -Care plan will be updated as needed. Review of the facility's policy titled Falls, revised 10/05/23, directed staff to: -Care plans with individualized interventions post fall; -The Interdisciplinary Team (IDT) will evaluate the fall prevention plan of care for residents at risk for falls; -Following a resident fall appropriate interventions are implemented, and the care plan updated. 2. Review of Resident #27 Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/05/24, showed staff assessed the resident as: -Cognitively intact; -Depended on staff for transfers; -Requires maximum assistance with bed mobility; -Uses a wheelchair; -No falls since the prior assessment. Review of the resident's Physician's Orders Sheet (POS), dated 05/13/24 showed: -May have overhead trapeze to aide in repositioning with a start date of 04/02/23; -Air mattress to bed with a start date of 04/09/24. Review of the resident's nurse note, dated 04/09/24, showed the resident fell out of bed at 3:00 P.M. when his/her leg slipped off the bed. New intervention for bilateral floor mats beside his/her bed placed. Review of the resident's nurses note, dated 05/10/24, showed the resident rolled out of bed at 7:50 A.M. Observation on 05/13/24 at 10:48 A.M., showed the resident in bed on a low air loss mattress with a trapeze over head. Observation on 05/14/24 at 8:29 A.M., showed the resident in bed without floor mats next to the bed. Observation on 05/14/24 at 10:42 A.M., showed the resident in bedwithout floor mats next to the bed. He/She moved himself/herself in his/her bed with the trapeze bar. Observation on 05/14/24 at 2:14 P.M., showed the resident in bed. Observation showed there were not fall mats on the floor next to the bed. Observation on 05/15/24 at 7:41 A.M., showed the resident in bed on a low air loss mattress with an overhead trapeze and without floor mats next to the bed. Observation on 05/15/24 at 9:30 A.M. showed Certified Nurse Assistant (CNA) I, CNA K, and CNA/Restorative Aide (RA) J performed a mechanical lift transfer on the resident. Review of the resident's care plan, revised 02/22/24, showed the care plan did not contain direction for trapeze use, mechanical lift transfer, and fall interventions placed. During an interview on 05/13/24 at 2:20 P.M., the resident said he/she had a fall from bed a month ago when his/her leg slipped off the bed. During an interview on 05/16/24 at 10:37 A.M., the Director of Nursing (DON) said he/she was aware of the intervention discussed for fall mats to be placed on 04/09/24 but the resident and family member refused. The DON said he/she did not have a note about the refusal and should have documented that. 3. Review of Resident #47's Annual MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Dependent on staff for ADL's and transfers; -Not able to ambulate; -Not at risk for pressure ulcers. Review of the resident's POS, dated 05/13/24 showed an order for air mattress to bed with a start date of 04/09/24. Observation on 05/13/24 at 11:40 A.M., showed the resident in his/her wheelchair with a mechanical lift pad under him/her. Observation on 05/14/24 at 8:31 A.M. and 2:14 P.M., showed the resident in his/her wheelchair with a mechanical lift pad under him/her. Observation on 05/15/24 at 7:38 A.M., showed the resident in his/her wheelchair with a mechanical lift pad under him/her. Observation on 05/16/24 at 8:44 A.M., showed the resident in his/her wheelchair with a mechanical lift pad under him/her. Review of the residents care plan, revised 04/25/24, showed the resident care plan did not contain direction for the use of low air loss mattress or mechanical lift. 4. Review of Resident #61's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Diagnosis of a seizure (uncontrolled movements of the body) disorder. Review of the resident's face sheet, undated, showed an admission date of 10/01/21 with a diagnosis of unspecified convulsions. Review of the resident's POS, dated 05/13/24, showed staff were directed to administer: -Keppra (a medication given to treat seizures) 750 milligrams (mg) twice a day for seizures; -Naloxone (a lifesaving medication) 4mg per nares as needed for low blood pressure with convulsions/seizures. Review of the resident's care plan, revised 03/27/24, showed it did not contain directions for seizures/convulsions. 5. During an interview on 05/16/24 at 8:47 A.M., CNA I said he/she does not have access to the computer to look at the care plans. CNA I said he/she talks to the Care Plan Coordinator (CPC) or the charge nurse with questions regarding a resident's care. CNA I said he/she would expect a care plan to be individualized for each resident. During an interview on 05/16/24 at 8:47 A.M., CNA K said he/she does not have access to the computer to look at the care plans. CNA I said he/she talks to the CPC or the charge nurse with questions regarding a resident's care. CNA K said he/she would expect a care plan to be individualized for each resident. During an interview on 05/16/24 at 8:47 A.M., CNA J said he/she has access to the computer to look at the care plans as he/she works in therapy. CNA J said he/she would expect a care plan to be individualized for each resident. CNA J said he/she would expect a care plan tocontain a low air loss mattress, trapeze, how much assistance a resident need, how they transfer such as using a mechanical lift, if the resident walks or uses a wheelchair. He/She said the care plan should direct staff on how to care for each resident. During an interview on 05/16/24 at 8:54 A.M., CNA I said the administrator told him/her there were printed care plans in a binder at the nurse's station. CNA I said he/she was not aware of this. During an interview on 05/16/24 at 8:55 A.M., Registered Nurse (RN) U said care plans are printed and kept in binders at the nurse's station. RN U said the CPC is responsible for updating them and the staff do not do updates. RN U said a resident's care plan should be individualized to show staff how to take care of a resident. RN U said he/she would expect the care plan to address low air loss mattress', trapeze, mechanical lift to transfer, certain medications, and diagnosis that are relevant such as seizures. During an interview on 05/16/24 at 9:00 A.M., Certified Medication Technician (CMT) E said the CPC is responsible for updating the care plans. CMT E said he/she was not sure if he/she had access on the computer to look at care plans. CMT E said he/she was not aware there were printed copies at the nurse's station. CMT E said care plans should be individualized for each resident. CMT E said resident care plans should address how much assistance a resident need for care, how the resident transfers, if the resident needs a mechanical lift, and special equipment such as a trapeze or low air loss mattress, and any diagnosis such as seizures staff need to be aware of. During an interview on 05/16/24 at 9:07 A.M., the CPC said he/she is responsible to complete and update the care plans but does not do the MDS's. The CPC said he/she is the only one who updates care plans. The CPC said he/she did not get any training on care plans and has learned on his/her own. The CPC said care plans are updated quarterly, annually, and as needed with a change in condition. The CPC said when a new order is obtained that should be on the care plan, he/she relies on the nurse who got the order to tell him/her verbally. The CPC said he/she does not have a report he/she can pull from the computer to look for new orders. The CPC said the facility staff have a meeting each morning as well where they discuss resident changes, and he/she updates the care plan accordingly. The CPC said once he/she updates the care plan in the computer he/she prints a new copy and replaces the old one in the binders at the nurse's station. The CPC said care plans should be individualized and accurate as they direct the resident's care. The CPC said a care plan should have how much assistance a resident needs. The CPC said a care plan should also have certain medications such as antidepressants, antipsychotics, antianxiety, and anticoagulants. He/She said the care plan should also have certain diagnosis that place a resident at risks staff may need to know about such as seizures, and falls. The CPC said if a resident has a fall a new intervention should be placed and the care plan updated with that intervention. During an interview on 05/16/24 at 10:37 A.M., the DON said the CPC is responsible to complete and update all of the care plans. The DON said care plans should be completed upon admission and updated quarterly, annually, and with any changes as needed. He/She said the nursing staff are responsible to verbally communicate or leave a note regarding any new orders to the CPC so he/she can update the care plan as needed. The DON said the facility staff also have a meeting each morning to discuss resident changes and the CPC should update the care plans accordingly with thing they discuss. The DON said once the CPC updates the care plan then the CPC should print a new copy and place in the binders at the nurse's station for the staff. The DON said a care plan should be accurate, individualized, and able to direct the staff on how to care for a resident. The DON said he/she would expect thing such as a mechanical lift transfer, trapeze, wheelchair, walker, low air loss mattress, the amount of assistance a resident needs, any fall interventions put in place, certain at risk meds, and diagnosis such as seizures on the care plan. During an interview on 05/16/24 at 2:45 P.M., the administrator said the CPC is responsible to update the care plans on each resident. The Administrator said he/she is not sure what training the CPC has had, but he/she has access to online seminars from their company, a corporate consultant, and Quality Improvement Program for Missouri (QUIPMO) if he/she has questions. The administrator said care plans should be updated quarterly, annually, and as needed with changes. The administrator said care plans should be accurate and individualized for each resident. The administrator said the care plans serves as a guide for staff on how to care for the resident. The administrator said all staff have access to a paper copy of the care plan in the binders at the nurse's station. The administrator said he/she was not aware not all the staff knew they had paper copies, and he/she plans to educate them. The administrator said care plans should have things on them such as mechanical lift transfer, oxygen, trapeze, wheelchair, walker, low air loss mattress, the amount of assistance a resident needs for any care, any fall interventions put in place, certain at risk meds, and diagnosis such as seizures.

Based on interview and record review, facility staff failed to perform Criminal Background Checks (CBC), and Employee Disqualification List (EDL) checks in accordance with facility policy for six (Licensed Practical Nurse (LPN) M, Nursing Assistant (NA) N, Certified Nursing Assistant Technicain (CMT) O, Laundry Aid U, Dietary Aid R, Dietarty Aid T) out of ten sampled staff. The facility census was 87. 1. Review of the facility CBC policy, undated, showed: -All applicants for employment must have a CBC submitted a minimum of two days prior to date of hire, -All offers of employment are contingent on a satisfactory report, -No applicant may be offered a position prior to checking the State EDL. 2. Review of LPN M's personnel record showed a hire date of 6/9/2023. Review showed the facility requested and received the CBC results on 6/30/2023 (21 days after hire). Review showed staff documented the EDL check on 6/29/2023 (20 days after hire). 3. Review of NA N's personnel record showed a hired date of 4/20/2024. Review showed the facility requested and received the CBC results on 5/15/2024 (25 days after hire). The EDL check was performed on 5/15/2024 (25 days after hire). 4. Review of CMT O's personnel record showed a hire date of 1/3/2024. The record showed a CBC was requested and received on 5/15/2024 (133 days after hire). 5. Review of Laundry Aid U's personnel record showed a hire date of 4/1/2024. The record showed a CBC was requested and received on 5/15/2024 (45 days after hire). The EDL check was performed on 5/15/2024 (45 days after hire). 6. Review of Dietary Aid R's personnel record showed a hire date of 2/20/2024. The record showed a CBC was requested and received on 5/15/2024. The EDL check was performed on 2/23/2024. 7. Review of Dietary Aid T's personnel record showed a hire date of 6/21/2023. The record showed a CBC was requested and received on 5/15/2024 (329 days after hire). The EDL check was performed on 8/23/2023 (63 days after hire) During an interview on 5/16/2024 at 1:55 P.M., the Human Resources Manager said there is a lot of documentation missing for the CBC's. He/She apologized and said he/she has looked everywhere and cannot find them. He/she said he/she realizes policy had not been followed. He/she is onboarding a new HR Manager and will ensure he/she is trained in the process according to policy. During an interview on 5/16/2024 at 2:00 P.M., the Corporate Administrator said he/she does not have the policy memorized but can look it up. He/She said he expects staff to follow the policy. During an interview on 5/16/2024 at 2:04 P.M. the administrator said he/she expects staff to follow the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of resident transfers to the hospital for five residents (Resident #4, #47, #61, #77 and #84) of 22 sampled. The facility census was 87. The facility did not provide a policy for Ombudsman notification of resident transfers to the hospital. 1. Review of Resident #4's medical record showed the resident transferred to acute care for pneumonia on 04/12/24. The record did not contain documentation staff notified the Ombudsman of the resident's transfer and readmitted on [DATE]. 2. Review of Resident #47's medical record showed the resident: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. Review of the facility's monthly resident transfer log sent to the Ombudsman showed the log did not contain documentation of staff notification to the Ombudsman of the resident transfer for the dates of: -04/04/24 through 04/05/24; -04/30/24 through 05/01/24; -05/03/24 through 05/08/24. 3. Review of Resident #61's medical record showed the resident: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. Review of the facility's monthly resident transfer log sent to the Ombudsman showed the log did not contain documentation of staff notification to the Ombudsman of the resident transfer for the dates of: -03/24/24 through 03/28/24; -05/15/24 through 05/15/24. Review of the facility's notification to the Ombudsman showed did not contain documentation March 2024 logs were sent to the Ombudsman; 4. Review of Resident #77's medical record showed the resident: -Transferred to the hospital on [DATE] for a fracture or possibility of a fracture. The record did not contain documentation staff notified the Ombudsman of the resident's transfer; -Transferred to on 03/29/24 for a head injury. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. 5. Review of #84's medical record showed the resident transferred to the hospital on 4/4/24 for changes in mental status and aggressive behavior. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. 6. During an interview on 05/15/24 at 11:46 A.M., the Director of Nursing (DON) said he/she is not sure who does the written notification to the Ombudsman when a resident is discharged or transferred from the facility. During an interview on 05/15/24 at 10:00 A.M., the Social Service Director (SSD) said he/she does not notify the Ombudsman when a resident is sent out that day. The SSD said he/she sends a monthly log to the Ombudsman either by fax or email at the end of the month. The SSD said he/she thought the requirement was for the notification to be monthly. During an interview on 05/15/24 at 1:49 P.M., the administrator said he/she does not have written notices to the Ombudsman and the SSD is responsible to do this. During an interview on 05/16/24 at 8:55 A.M., Registered Nurse (RN) U said he/she is not sure who is responsible to notify the Ombudsman when a resident is discharged or transferred from the facility. During an interview on 05/16/24 at 2:45 P.M., the administrator said the SSD is responsible to complete written notification to the Ombudsman when a resident is discharged or transferred from the facility. The Administrator said notification should be given to the Ombudsman with each resident discharge or transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide written information to resident's and/or the responsible party of the bed hold policy at the time of transfer to the hospital on eight residents (Resident #2, #4, #47, #61, #76, #77, #84, and #340) out of 22 sampled residents. The facility census was 87. 1. Review of the facility's policy titled Hospital Transfer and Bed Hold Policy, undated, showed if the physician orders his/her patient to be transferred to the hospital, the family or responsible part will be notified and arrangements made. In the event a resident is transferred to a hospital, a copy of the policy with be sent with them. 2. Review of Resident #2's Discharge/Return Anticipated Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/24, showed the resident discharged to the hospital. Review of the resident's medical record, showed the resident returned to the facility on [DATE]. Review showed the medical record did not contain a bed hold agreement. Review of the resident's Discharge/Return Anticipated MDS, dated [DATE], showed the resident discharged to the hospital. Review of the resident's medical record, showed the resident returned to the facility on [DATE]. Review showed the medical record did not contain a bed hold agreement. 3. Review of Resident #4's Discharge MDS, dated [DATE], showed the resident transferred to acute care for pneumonia on 04/12/2024 as an unplanned discharge with return anticipated. Review of the residents Quarterly MDS, dated [DATE], showed the resident readmitted on [DATE]. Review of the resident's medical record showed the record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 4. Review of Resident #47 Annual MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment. Review of the resident's medical record showed the resident: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 5. Review of Resident #61's Significant Change MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment. Review of the resident's medical record showed the resident was: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 6. Review of Resident #76's Discharge/Return Anticipated MDS, dated [DATE], showed the resident discharged to the hospital. Review of the resident's medical record showed the resident returned to the facility on [DATE]. Review showed the record did not contain a bed hold agreement. 7. Review of Resident #77 admission MDS, dated [DATE], showed staff assessed the resident as cognitively independent. Review of the resident's medical record showed the resident: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 8. Review of #84's Significant Change MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the medical record showed this resident transferred on 04/04/2024 to the hospital for mental status changes and aggressive behavior. Review showed the record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 9. Review of Resident #340's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's medical record showed the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 10. During an interview on 05/15/24 at 10:00 A.M., the Social Service Director (SSD) said he/she does not do the bed holds and thinks the Director of Nursing (DON) takes care of those. During an interview on 05/15/24 at 11:46 A.M., the DON said when a resident is transferred or discharged the nursing staff give them a copy of the bed hold policy, but they do not get it signed or keep a copy of this. During an interview on 05/15/24 at 1:49 P.M., the administrator said he/she does not have any signed bed holds and nursing staff are responsible to do this. During an interview on 05/16/24 at 8:55 A.M., Registered Nurse (RN) U said he/she is not sure who completes the bed holds when a resident is discharged or transferred from the facility. During an interview on 05/16/24 at 10:37 A.M., the DON said nursing only sends a copy of the bed hold policy with the resident upon discharge or transfer. The DON said the SSD is responsible to complete a written notification to the Ombudsman. The DON said he/she is not sure the facility has any signed bed holds and he/she is not sure who is responsible to do that. The DON said a bed hold should be done with every discharge or transfer from the facility. During an interview on 05/16/24 at 2:45 P.M., the administrator said nursing staff are responsible to complete a bed hold when a resident is discharged or transferred. The Administrator said he/she was not sure if the facility kept a signed copy of the bed holds given to the resident. During an interview on 05/16/24 at 2:45 P.M., the corporate administrator said the facility should have a signed copy of a bed hold given. He/She said a resident should have the opportunity to sign a bed hold with any discharge or transfer from the facility. The corporate administrator said he/she is not sure why the facility does not have signed copies of the bed holds given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, staff failed to maintain a professional standard of care, when facility staff failed to document the dosage of insulin administered to three residents (Resident #2, #59 and #71) of 22 sampled residents. The facility census was 87. 1. Review of the facility's Eight Rights of Medication policy, dated 05/2023, showed staff are instructed to ensure when staff administer medications: -Right individual; -Right medication; -Right dosage; -Right route; -Right time; -Right documentation; -Right reason; -Right to refuse. 2. Review of the facility's Medication Administration policy, undated, showed staff should ensure the correct medication doses administered to the resident. 3. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/25/24, showed staff assessed the resident as follows: -Insulin injections seven days of the seven day look back period; -Diagnosis of Diabetes. Review of the resident's Physician Order Sheet (POS), dated May 2024, showed an order directed staff to administer Lispro (insulin) 100 unit (u)/milliliters (mL) subcutaneous pen, one unit subcutaneous (insertion of medications beneath the skin either by injection or infusion) three times per day, inject insulin lispro blood sugar divided by 30 minus 3 for insulin dosage. Do not give if resident eats less then 50% of meal. Review of the resident Medication Administration Record (MAR), dated May 2024, showed staff documented they administered Insulin Lispro and did not document the dosage they administered on: -May 1st at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 2nd at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 7th at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 8th at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 9th at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 14th at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; 4. Review of Resident #59's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Insulin injections seven days of the seven day look back period; - Diagnosis of diabetes. Review of the resident's POS, dated May 2024, showed: - Insulin Lispro (U-100) Insulin 100 unit/mL pen, 12 units subcutaneous before meals; - Insulin glargine (U-100) 100 unit/mL pen, 25 units subcutaneous daily at bedtime. Review of the resident's MAR, dated May 2024, showed staff document they administered the residents Insulin Lispro and did not document the dosage of insulin they administered for: - May 1st at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 2nd at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 3rd at 11:30 A.M., and 4:30 P.M.; - May 4th at 11:30 A.M., and 4:30 P.M.; - May 5th at 11:30 A.M., and 4:30 P.M.; - May 6th at 6:30 A.M., and 11:30 A.M.; - May 7th at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 8th at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 9th at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 10th at 6:30 A.M., and 4:30 P.M.; - May 11th at 11:30 A.M., and 4:30 P.M.; - May 12th at 4:30 P.M.; - May 13th at 4:30 P.M.; - May 14th at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 15th at 6:30 A.M., and 11:30 A.M. Review of the resident's MAR, dated May 2024, showed staff document they administered the Insulin glargine and did not document the dosage they administered for: - May 1st at 8:00 P.M.; - May 2nd at 8:00 P.M.; - May 3rd at 8:00 P.M.; - May 4th at 8:00 P.M.; - May 5th at 8:00 P.M.; - May 6th at 8:00 P.M.; - May 8th at 8:00 P.M.; - May 9th at 8:00 P.M.; - May 10th at 8:00 P.M.; - May 11th at 8:00 P.M.; - May 12th at 8:00 P.M.; - May 13th at 8:00 P.M.; - May 14th at 8:00 P.M. 5. Review of Resident #71's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Insulin injections six days of the seven day look back period; -Diagnosis of Diabetes. Review of the resident's POS, dated May 2024, showed: -Insulin Lispro 100 unit/mL subcutaneous pen, one unit subcutaneous three times per day, inject insulin lispro blood sugar divided by 30 minus 3 for insulin dosage. Do not give if resident eats less then 50% of meal. Review of the resident's MAR, dated May 2024, showed staff documented they administered the residents Lispro Insulin and did not document the dosage they administered for: -May 1st at 7 A.M. and 11 A.M.; -May 2nd at 11 A.M.; -May 3rd at 7 A.M. and 11 A.M.; -May 5th at 7 A.M. and 11 A.M.; -May 6th at 7 A.M. and 11 A.M.; -May 7th at 7 A.M.; -May 8th at 7 A.M. and 11 A.M.; -May 9th at 7 A.M., 11 A.M. and 4 P.M.; -May 10th at 7 A.M. and 11 A.M.; -May 11th at 7 A.M.; -May 12th at 7 A.M.; -May 13th at 7 A.M. and 4 P.M.; -May 14th at 7 A.M. and 4 P.M. Review showed the MAR did not contain documentation of the dosage of insulin administered to the resident for the 23 administrations documented. 6. During an interview on 05/15/24 at 10:38 A.M., the Director of Nursing (DON) said staff do not document the amount of insulin given, the orders are put in the system and it calculates how much to give based off the resident's physician's order. Staff do not document in the computer actual units given, just that staff gave what the calculator said to give. The DON said he/she does not know how to see the dosage administered to the residents. The DON said there is no way to print the dosage of insulin administered to the residents. The DON said corporate said the medication program has a place to add the dosage of insulin administered, but it had not been set up on the facility's program. During an interview on 05/15/24 at 11:15 A.M., Certified Medication Technician (CMT) E said there is no spot on the MAR for how many units are given for sliding scale insulin, for set doses it says to give the amount and shows administered in the chart, but there is no place to document the number that was actually given. CMT E said this can lead to numerous things, the resident's blood sugars could bottom out, or they could be given too much; and if they are sent out to the hospital we would not be able to easily tell them how much insulin they received. During an interview on 05/15/24 at 11:15 A.M., Licensed Practical Nurse (LPN) G said there is no place to chart units given in the chart, it could lead to medication errors, or blood sugar issues if staff can not tell how many units were given or not, and we would not be able to track if the right amount was actually given. During an interview on 05/15/24 at 11:46 A.M., Assistant Director of Nursing (ADON) said staff should write down the amount of insulin given. Staff should make sure the resident's name, medication, date, route, time and dosage is documented at administration. The ADON said staff should have documented the dosage they gave, without documenting the dosage given, there is no way to tell if there is medication errors. During an interview on 05/16/24 at 12:07 P.M., CMT H said he/she did not the document insulin dosages he/she administered to residents on the computer, until yesterday. The CMT said he/she can not look back to the MAR and see what dosage of insulin had been given, just that it had been given. During an interview on 05/16/24 at 1:53 P.M., the DON said he/she does expect staff to document the amount of insulin they administer to residents.

Based on observation and interview, facility staff failed to properly maintain the temperature of hot foods at or above 120 degrees Fahrenheit (ºF) at the time staff served hall trays to six residents (Residents #13, #45, #75, #59, #42 and #77) of 22 sampled residents. Facility staff failed to maintain hold temperatures of 135 ºF, while on the steam table, during food service. Failure to maintain hold temperatures on steam table has the potential to affect all residents served in the main dining room. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed: -Avoid holding foods in danger zone temperatures which are between 41 ºF and 135 ºF; -Cooking Fresh, Frozen, or canned fruits and vegetables to a hot holding temperature of 135ºF prevents the growth of pathogenic bacteria that may be present in, or on these foods; -Does not identify the expectation of temperature for food at time of service. 2. Observation on 05/14/24 at 11:53 A.M., showed Dietary Aide (DA) B served Resident #13 a hall tray. At the time of service, the resident's broccoli was at 108 ºF. Observation showed the DA failed to offer to reheat the resident's tray. During an interview on 05/14/24 at 10:42 A.M., the resident said he/she always eats in his/her room and the food is always cold. The resident said the facility used to have a heat cart for the hall trays, but it broke and the facility never got a new one. 3. Observation on 05/14/24 at 12:06 P.M., showed DA B delivered Resident #45 a hall tray. The temperature of the food at time of service was, pork loin 113 ºF and broccoli 111 ºF. Observation showed the DA failed to offer to reheat the resident's tray. 4. Observation on 05/14/24 at 12:07 P.M., showed DA B delivered Resident #75 a hall tray. The temperature of food at time of service was, pork loin 118 ºF, cornbread 117 ºF and broccoli 101 ºF. Observation showed the DA failed to offer to reheat the resident's tray. 5. Observation on 05/14/24 at 12:33 P.M., showed DA B delivered Resident #59 a hall tray. The temperature of the food at time of service was, cornbread 116 ºF and broccoli 116 ºF. Observation showed the DA failed to offer to reheat the resident's tray. 6. Observation on 05/14/24 at 12:47 P.M., showed DA B delivered Resident #42 a hall tray. The temperature of food at time of service is, cornbread 112 ºF and broccoli 119 ºF. Further observation showed the DA failed to offer, to reheat resident's tray. 7. Observation on 05/14/24 at 12:49 P.M., showed DA B delivered Resident #77 a hall tray. The temperature of food at time of service was, cornbread 109 ºF. Further observation showed the DA failed to offer to reheat the resident's tray. 8. During an interview on 05/13/24 at 2:12 P.M., Resident #2 said he/she eats in his/her room and his/her food is not cold sometimes, it is cold all the time. During an interview on 05/14/24 on 10:03 A.M., Resident #71 said he/she always eats in his/her room. The residents said the food is always cold when he/she gets it. During an interview on 5/15/24 at 10:21 A.M., the administrator said food on room trays should be served at 120 ºF. During an interview on 05/16/24 at 10:17 A.M., Nurse Aide (NA) F said a few residents have complained about the hall trays being cool. The NA said he/she usually brings the tray back to dietary and dietary warms the tray up, or fixes the resident a fresh tray. During an interview on 05/16/24 at 10:26 A.M., the Wound Nurse said he/she has heard residents complain about the food being cold. The Wound Nurse said staff should reheat a resident's food, if it is cold. During an interview on 05/16/24 at 11:00 A.M., the Dietary Manager (DM) said he/she has had complaints about hall trays being cold. The DM said food has to be 120 ºF, or above at the time it is served to resident. The DM said he/she had received some complaints from residents about cold food. The DM said he/she usually addresses these concerns in the morning meetings with department heads, but they have not been having morning meetings this week. 9. Observation on 05/13/24 at 12:06 P.M., showed DA B served lunch to residents in the main dining room. The temperatures taken from the steam table showed, beef stroganoff was 120 ºF, green beans were 122 ºF, pureed beef stroganoff was 120 ºF, pureed green beans were120 ºF. Observation showed the DA served six more residents from the steam table through 12:30 P.M., after the temperatures were taken by the DA at 12:06 P.M. During an interview on 05/13/24 at 12:30 P.M., DA B said he/she does not normally serve the food from the steam table, a cook did not come in today and that is why he/she is serving the food off the steam table. 10. Observation on 5/14/24 at 12:48 P.M., showed [NAME] R served residents pork with gravy, sweet potatoes, broccoli and corn bread with butter. Observation showed the temperature of the pork was 124°F, broccoli was 126°F, and sweet potatoes were 132°F on the steam table. During an interview on 5/14/24 at 12:54 P.M., [NAME] R said he/she did not check food temperatures before or during the lunch meal service. The cook said he/she thought food should be held at 175 degrees, but that was just a guess. The cook said he/she did not know the holding temperature for food, since no one ever told him/her. [NAME] R said he/she received some training from another cook but the training was not good. During an interview on 5/14/24 at 1:45 P.M., DA S said food temperatures on the serving line should be 160 degrees and if anything was below 130 degrees he/she would tell someone. DA S said he/she did not know how kitchen staff made sure residents who received room trays were getting warm food. During an interview on 5/14/24 at 2:14 P.M., the DM said foods on the serving line should be held at 120 degrees F. The DM said kitchen staff serve food from the steam table to room trays as quickly as they can and it usually took less than 20 minutes to pass room trays. The DM said three residents complain about cold food regularly but there were no food complaints at the last resident council meeting. The DM said new cooks were trained by other kitchen staff. The DM said he/she did not document new staff training. During an interview on 5/15/24 at 10:21 A.M., the administrator said the DM was responsible for kitchen functions. The administrator said the cook was responsible for making sure food temperatures were maintained. The administrator said he/she could not remember what temperature food needed to be held at during meal service.

Based on observation, interview, and record review, facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Facility staff failed to provide effective training to dietary staff related to kitchen ware washing/sanitation. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed dishwashing machines use either heat or chemical sanitization methods. Manufacturer's instructions must always be followed. Review of the manufacturer's label which was affixed to the front of the dish machine showed wash and rinse temperatures 120 degrees Fahrenheit (F), minimum. Review of the low temperature dish machine operation guidelines, which were mounted on the wall on the clean side of the dish machine showed: -Water temperature should be between 120 and 140 degrees F; -Special notes when using this machine; -Wash minimum temperature, 120 degrees F; -Final rinse temperature minimum, 140 degrees F. Observation on 05/14/24 at 9:55 A.M., showed DA B ran a load of dishes through the dish machine. Observation showed the machine thermometer indicated a temperature of 110 degrees F during the rinse cycle. Observation on 05/14/24 at 10:23 A.M., showed DA B washed a sheet pan in the dish machine. Observation showed the rinse temperature was 115 degrees F. Observation on 05/14/24 at 1:18 P.M., showed DA T ran a load of dishes through the dish machine. Observation showed the highest temperature indicated on the machine thermometer was 112 degrees F. Observation on 05/14/24 at 1:57 P.M., showed [NAME] R ran two table steam pans through the dish machine. Observation showed the highest temperature indicated on the machine thermometer was 110 degrees F. During an interview on 05/14/24 at 10:20 A.M., DA B said he/she did not check the dish machine temperature before or during use. DA B said he/she only paid attention to the temperature if it was not hot enough. DA B said the water was hot enough. DA B said he/she was not sure what the dish machine water temperature should be. During an interview on 05/14/24 at 10:26 A.M., DA B said the dietary manager told him/her facility chemicals were made to work at any temperature, but the dietary manager liked the machine temperature to be at 120 or above. During an interview on 05/14/24 at 1:18 P.M., DA T said he/she did not know what temperature the dish machine should reach. During an interview on 05/14/24 at 1:57 P.M., [NAME] R said he/she did not know what the dish machine temperature was supposed to be. [NAME] R said he/she was trained by another cook within the past month and his/her training did not cover the dish machine temperature. 2. Review of the facility's Food Service policy, undated, showed clean and sanitize work surfaces, including cutting boards and food-contact equipment (e.g., food processors, blenders, preparation tables, knife blades, can openers and slicer's) between uses and consistent with applicable code. Review of the three compartment sink procedures, which were mounted on the wall above the three-compartment sink showed users were instructed to allow items to soak for two minutes. Review of the sanitizer directions for use showed: -Clean the equipment in the normal manner; -Immerse equipment in the sanitizing solution for at least two minutes and allow the sanitizer to drain. Observation on 05/14/24 at 9:54 A.M., showed the sanitizer compartment of the three-compartment sink contained two large tubes of ground meat submerged in water. Observation on 05/14/24 at 10:03 A.M., showed [NAME] R hand washed a large steam table pan, a plastic pitcher, a sheet pan, and a food processor bowl and blade in the first compartment of a three-compartment sink. [NAME] R dipped the items in the rinse sink and placed them on a drain board on the clean side dish machine. [NAME] R did not soak the items in sanitizer. Observation on 05/14/24 at 10:05 A.M., showed [NAME] R added soap to the first compartment of the three-compartment sink. [NAME] R cleaned two steam table pans and rinsed the pans in the second sink. [NAME] R placed the pans on the clean side of the dish machine and did not soak the items in sanitizer. Observation on 05/14/24 at 11:56 A.M., showed DA Q added sanitizer to the third compartment of the three compartment sink. DA Q washed a large pot, two steam pans, a pair of tongs, and a large plastic pitcher in the first sink compartment. DA Q dipped the items in the rinse sink and then dipped the items in the sanitizer. The items were placed on a drain board on the clean side dish machine. DA Q did not soak the items in sanitizer. Observation on 05/14/24 at 2:01 P.M., showed [NAME] R washed two pans in sink one of a three compartment sink, rinsed the pans in sink two, then placed the pans in the sanitizer sink for less than one minute and placed the pans on a drain board on the clean side dish machine. Observation showed [NAME] R then hand washed a food processor blade, lid and steam pan, and rinsed the items. [NAME] R dipped the items in the sanitizer sink and rotated them before he/she removed the items and placed them on a drain board on the clean side dish machine. [NAME] R did not allow the items to remain submerged in the sanitizer solution for two minutes. During an interview on 05/14/24 at 11:52 A.M., [NAME] R said he/she washed dishes in the first sink, rinsed in the second sink and dipped dishes in sanitizer sink. [NAME] R said he/she did not let the dishes soak in sanitizer. [NAME] R said he/she skipped the sanitizer because there was meat in the sanitizer sink. [NAME] R said he/she started about a month ago and never had training or in-services on how to use the three-compartment sink. During an interview on 05/14/24 at 11:56 A.M., DA Q said he/she knew how to use the three-compartment sink and sanitizer and he/she was sanitizing items correctly. During an interview on 05/14/24 at 1:45 P.M., [NAME] S said he/she was trained on the three compartment sink when he/she started about four years ago. [NAME] S said staff were to wash pots and pans in soap of first sink, rinse in second sink and then let items set for 10 seconds in the third sink During an interview on 5/15/24 at 10:12 A.M., Human Resources staff said he/she did not maintain any kitchen staff competency paperwork. He/She said the DM was responsible for kitchen staff competency. During an interview on 5/15/24 at 10:16 A.M., the DM. said he/she put new staff one on one with another kitchen staff member for training. The DM said he/she did not document kitchen staff training. The DM said he/she conducted verbal reviews with new staff and asked if they had questions. The DM said the verbal reviews did not follow a schedule or structure. During an interview on 05/15/24 at 10:21 A.M., the administrator said the DM was responsible for kitchen staff competency. The administrator said dietary aides should look at the dish machine temperature to make sure it's working correctly and the DM should monitor. The administrator said kitchen wares should soak in the sanitizer but he/she could not remember how long.

Based on observation, interview and record review, facility staff failed to thaw frozen food in a manner to prevent potential contamination. Facility staff failed to store frozen food in a manner to prevent potential contamination. Facility staff failed to allow cleansed dishes to air-dry prior to stacking in storage to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed thawing some foods at room temperature may not be acceptable because it may be within the danger zone for rapid bacterial proliferation. Recommended methods to safely thaw frozen foods include: -Thawing in the refrigerator, in a drip proof container, and in a manner that prevents cross-contamination; -Completely submerging the item under cold water (at a temperature of 70 degrees F or below) that is running fast enough to agitate and float off loose ice particles. Observation on 05/14/24 at 9:54 A.M., showed the sanitizer compartment of the three-compartment sink contained two large tubes of ground meat submerged in standing water. Observation showed the water temperature was 108 degrees F when checked with a calibrated metal stem thermometer. Observation on 05/14/24 at 11:11 A.M., showed the sanitizer compartment of the three-compartment sink contained two large tubes of ground meat. Observation showed the water was running over one tube of the meat, which was not completely submerged. Observation on 05/14/24 at 11:34 A.M., showed the sanitizer compartment of the three-compartment sink contained two large tubes of ground meat. Observation showed the water was running over one tube of the meat which was not completely submerged. Observation on 05/14/24 at 11:55 A.M., showed [NAME] S removed two large tubes of meat from the sanitizer sink and placed the meat on the prep counter at room temperature. Observation on 05/14/24 at 12:12 P.M., showed [NAME] S opened the tubes of meat and added the meat to a pan on the stove top for meal service. During an interview on 05/14/24 at 11:49 A.M., [NAME] S said his/her boss just told him/her not to thaw meat by soaking. [NAME] S said ground meat should be thawed under running cold water. [NAME] S said he/she put the meat in water earlier and he/she thought the water was cold. During an interview on 05/14/24 at 2:52 P.M., the DM said meat should be thawed under cold running water in a tub, not in the sanitizer sink. The DM said meat should not be thawed in warm standing water. During an interview on 05/15/24 at 10:21 A.M., the administrator said the DM was responsible for ensuring kitchen staff handled food correctly. The administrator said the cook was responsible for meat thawing meat correctly. The administrator said meat should not be thawed in warm water or in the sanitizer sink. The administrator said meat should thaw in the refrigerator, or in a pan under cold running water. 2. Review of the facility's Food Service policy, undated, showed frozen foods must be maintained at a temperature to keep the food frozen solid. Practices to maintain safe refrigerated storage include monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation. Review of the facility's Refrigeration Temperature Record form showed the form contained a column for recording walk in freezer temperatures but the form did not contain a column to record reach in freezer temperatures. Observation on 05/13/24 at 10:25 A.M., showed the double door reach in freezer contained an internal thermometer which indicated a temperature of 20 degrees F. Observation on 05/14/24 at 9:46 A.M., showed the exterior digital gauge on the reach in freezer indicated a temperature of 10 degrees F. Observation showed the thermometer inside the freezer indicated a temperature of 23 degrees F. Observation on 05/14/24 at 9:57 A.M., showed the interior freezer thermometer indicated a temperature of 24 degrees F. Observation showed the freezer was not opened between 9:46 A.M. and 9:57 A.M Observation on 05/14/24 at 9:57 A.M., showed the reach in freezer contained bread sticks which were soft to firm pressure. Observation on 05/14/24 at 10:06 A.M., showed the reach in freezer temperature was 24 degrees F with a calibrated metal stem thermometer. Observation showed the reach in freezer was not opened between 9:57 A.M. and 10:06 A.M. Observation on 05/14/24 at 1:15 P.M., showed the interior freezer thermometer indicated a temperature of 22 degrees F. Observation on 05/14/24 at 1:57 P.M., showed the exterior digital gauge on the reach in freezer indicated a temperature of 9 degrees F. Observation showed the thermometer inside the freezer indicated a temperature of 22 degrees F. Observation on 05/15/24 at 7:53 A.M., showed the exterior digital gauge on the reach in freezer indicated a temperature of 8 degrees F. Observation showed the thermometer inside the freezer indicated a temperature of 22 degrees F. Observation showed the reach in freezer contained bread sticks which were soft to firm pressure. During an interview on 05/14/24 at 1:15 P.M., DA T said he/she did not know if kitchen staff kept a freezer temperature log. DA T said the reach in freezer outside gauge should be negative and the inside thermometer should be less than zero. DA T said he/she did not know who was responsible for checking the freezer temperature. During an interview on 05/14/24 at 1:45 P.M., [NAME] S said the freezer temperature should be negative 20 on the exterior gauge and he/she did not know what the inside temperature should be. [NAME] S said the dietary aides or maintenance were responsible for keeping the freezer at the correct temperature. During an interview on 05/14/24 at 2:14 P.M., the DM said the reach in freezer should be between 30 degrees F and negative. The DM said the temperature needed to be less than 30 degrees F. The DM said the cook was responsible for maintaining the freezer temperature log. The DM said he/she could not locate the May 2024 reach in freeer temperature log. The DM said he/she did not know the freezer temperature logs did not include the reach in freezer. During an interview on 05/15/24 at 10:21 A.M., the administrator said the cook was responsible for checking the reach in freezer temperatures daily. The administrator said he/she did not know if kitchen staff had a log for freezer temperatures. The administrator said the DM was responsible for ensuring any kitchen logs were being completed. The administrator said freezer temperatures should be at zero degrees F or less. 3. Review of the low temperature dish machine procedures, which were mounted on the wall on the clean side of the dish machine, showed users were instructed to place racks of dishes in a clean, dry area and allow to air dry. Review of the three compartment sink procedures, which were mounted on the wall above the three-compartment sink, showed users were instructed to place items to air dry and not rinse or towel dry. Observation on 05/13/24 at 10:32 A.M., showed eight steam table pans on metal storage shelving were stacked wet. Observation showed three of the pans contained dried food debris. Observation on 05/14/24 at 10:08 A.M., showed the metal storage shelving contained one stack of three pans and two stacks of five pans, which were stacked wet. Observation on 05/14/24 at 2:01 P.M., showed [NAME] R removed clean pans from the dish machine racks and stacked on a service cart, while still wet. [NAME] R wheeled the service cart full of pans to the storage area and placed the pans on the metal storage shelves, while wet. During an interview on 05/14/24 at 1:23 P.M., DA T said kitchen items should not be stacked wet. DA T said the person washing and stacking kitchen items was responsible for making sure items were dry before being put away. During an interview on 05/14/24 at 2:02 P.M., [NAME] R said the pans were not soaking wet and he/she could get a towel and dry the pans. [NAME] R said he/she just cleaned his/her pots and pans and put them away. [NAME] R said he/she started working in the kitchen about a month ago and nobody ever told him/her about air drying kitchen items. During an interview on 05/14/24 at 2:14 P.M., the DM said kitchen items should air dry and staff should not be putting items away wet. During an interview on 05/15/24 at 10:21 A.M., the administrator said whoever put kitchen items away was responsible for making sure the items were dry. The administrator said the DM was responsible for training and monitoring kitchen staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Please refer to BOUB12 This deficiency is uncorrected. For previous examples, please refer to Statement of Deficiencies dated 03/09/2023. Based on observation, interview and record review, facility staff failed to provide a sufficient number of staff members to ensure call lights were answered in timely manner. The facility census was 79. 1. Review of the facility assessment tool, dated February 23, 2023, showed: -Average census of 80-85 residents; -Direct care staff needed for a 24 hour period of time: -Licensed Nurses: 3 to 8; -Certified Medication Technicians (CMT's): 3 to 6; -Certified Nurse Aides (CNA's): 8 to 14; -Resident preferences will be considered with regard to daily schedules, bathing, naps, going to bed and medication times; -As acuity and/or census needs change, staffing levels and assignments will be reviewed through Quality Assessment and Performance Improvement (QAPI) and weekly staffing committee meetings. 2. Review of the facility's Call lights Policy, dated 10/29/18, showed call lights are to be answered promptly. Review of the facility's wireless call light report, dated 4/28/23 at 12:20 A.M. through 4/28/23 at 10:07 A.M. showed: -At 3:24 A.M., room [ROOM NUMBER] with call light response time of 30 minutes with 6 repages; -At 4:39 A.M., room [ROOM NUMBER] with call light response time of 50 minutes with 10 repages; -At 4:49 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 13 minutes with 14 repages; -At 4:50 A.M., room [ROOM NUMBER] with call light response time of 42 minutes with 8 repages; -At 4:51 A.M., room [ROOM NUMBER] with call light response time of 45 minutes with 9 repages; -At 5:00 A.M., room [ROOM NUMBER] with call light response time of 32 minutes with 6 repages; -At 5:01 A.M., room [ROOM NUMBER] with call light response time of 43 minutes with 8 repages; -At 5:42 A.M., Bathroom in room [ROOM NUMBER] with call light response time of 1 hour and 7 minutes with 13 repages; -At 5:51 A.M., room [ROOM NUMBER] with call light time of 34 minutes with 6 repages; -At 5:54 A.M., room [ROOM NUMBER] with call light time of 1 hour and 6 minutes with 13 repages; -At 6:04 A.M., room [ROOM NUMBER] with call light time of 1 hour and 28 minutes with 17 repages; -At 6:25 A.M., room [ROOM NUMBER] with call light response time of 2 hours and 5 minutes with 25 repages; -At 6:31 A.M., room [ROOM NUMBER] with call light response time of 2 hours and 1 minute with 24 repages; -At 6:36 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 42 minutes with 20 repages; -At 6:50 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 39 minutes with 19 repages; -At 6:51 A.M., Bathroom in room [ROOM NUMBER] with call light response time of 1 hour and 26 minutes with 17 repages; -At 7:01 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 28 minutes with 17 repages; -At 7:03 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 21 minutes with 16 repages; -At 7:35 A.M., room [ROOM NUMBER] with call light response time of 54 minutes with 10 repages; -At 7:55 A.M., room [ROOM NUMBER] with call light response time of 35 minutes with 7 repages; -At 7:56 A.M., room [ROOM NUMBER] with call light response time of 35 minutes with 7 repages; -At 8:02 A.M., Bathroom in room [ROOM NUMBER] with call light response time of 30 minutes with 6 repages; -At 8:31 A.M., room [ROOM NUMBER] with call light response time of 58 minutes with 11 repages; -At 8:37 A.M., room [ROOM NUMBER] with call light response time of 59 minutes with 11 repages; -At 9:01 A.M., room [ROOM NUMBER] with call light response time of 35 minutes with 7 repages; 3. Observation on 4/28/23 at 9:28 A.M., showed room [ROOM NUMBER]'s call light initiated at 8:31 A.M., remained unanswered. Observation on 4/28/23 at 9:38 A.M., showed room [ROOM NUMBER]'s call light initiated at 8:37 A.M., remained unanswered. Observation on 4/28/23 at 9:28 A.M., showed room [ROOM NUMBER]'s call light initiated at 9:01 A.M., remained unanswered. Observation on 4/28/23 at 1:07 P.M., showed room [ROOM NUMBER]'s call light initiated at 12:18 P.M., remained unanswered. Observation on 4/28/23 at 1:07 P.M., showed room [ROOM NUMBER]'s call light initiated at 12:19 P.M., remained unanswered. During an interview on 4/28/23 at 3:48 P.M., Resident #6 said call lights sometimes go unanswered for over an hour and he/she needs assistance to go to the bathroom due to weakness. He/She said sitting on the toilet for 30 minutes or more makes his/her bottom sore and it makes it harder for him/her to stand back up. During an interview on 5/1/23 at 1:02 P.M., Licensed Practical Nurse (LPN) B said call lights should be answered in 15 minutes or less in order to prevent accidents such as falls and skin breakdown. He/She was not aware call lights were going unanswered for over 30 minutes and feels some days are better staffed than others, but it has improved. During an interview on 5/1/23 at 1:40 P.M., Certified Nurse Aide (CNA) D said the average time to answer call lights is around 15 minutes and does not know of any that have gone unanswered longer than that or of any resident complaints of long call light times. He/She said there is a monitor at the nurse station that shows the call lights and the staff wear pagers and walkie talkies to alert them when a call light is initiated. CNA D said it depends on who is working on how well the staff are able to get things accomplished in a reasonable time. During an interview on 5/1/23 at 3:12 P.M., LPN C said call lights go unanswered for long periods of time because there is not enough staff. He/She said if call lights are not answered timely, residents could try to self-transfer and fall or develop skin issues related to incontinence. Residents have mentioned long call lights in their monthly meeting as a concern. LPN C said staff wears pagers that alert them when a call light is initiated and are able to look at the monitors to see which rooms are sounding. During an interview on 5/1/23 at 3:41 P.M., the Administrator said staff are expected to use the pagers which which alert them when the resident pushes the light and after so many minutes of sounding will send an alert via email to the corporate office staff. He/She is working with the call light company to have the email alert go to the Administrator and Director of Nursing as well as corporate staff. The Administrator said new staff has been hired, and they continue to advertise. He/she was not aware of the long call light times. MO00217703

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services for one resident (Resident #23) with an indwelling urinary catheter (a drainage tube that is inserted into the urinary bladder, left in place, and is connected to a drainage bag) who had a Urinary Tract Infection (UTI), when staff failed to ensure the resident's catheter drainage bag was kept off the floor, and failed to provide catheter care in a manner to prevent the spread of infection. The facility census was 82. Review of the facility's Catheter Care, Urinary Policy, dated August 2017, showed staff are directed to: -Maintain catheter tubing coiled to gravity, ensure privacy bag intact and ensure catheter tubing does not make contact with the floor; -Provide catheter care every shift; -Identify and document clinical indications for the use of a catheter. 1. Review of Resident #23's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/23/23, showed staff assessed the resident as: -Cognitively impaired; -No physical or verbal behaviors towards others; -Did not reject care; -Dependent on two staff members for bed mobility, dressing, toileting and transfers; -Dependent on one staff member for personal hygiene; -Has an indwelling urinary catheter; -On hospice. -Has diagnoses of Stroke (brain damage from interruption of blood supply), Coronary Artery Disease (disease of the hearts major vessels), and hemiplegia (paralysis of one side of the body). Review of the resident's urinalysis culture, (a test to check for infection in the urine), dated 2/1/23, showed a positive test result for Klebsiella pneumonia (bacteria commonly spread through person-to-person contact or contamination in the environment). Review of the resident's nurse notes dated 1/8/23 through 3/7/23 showed: -On 1/30/23 at 7:25 A.M., a Certified Nurse Aide (CNA) informed the nurse that resident was found to have a large amount of blood in catheter. Spoke with hospice nurse and received order for Urinalysis (UA); -On 1/31/23 at 1:48 P.M., Large amount of blood continued to be noted in the catheter bag. Resident continues to deny any pain. UA sample collected and awaiting results. Will continue to monitor. -On 2/1/23 at 7:47 P.M., UA results received and called to call center; -On 2/2/23 at 2:09 P.M., start Amoxicillin-potassium Clavulanate 875-125 mg (an antibiotic) twice daily for seven days for treatment of UTI. Review of the resident's care plan, dated 1/18/23, showed: -Has a urinary catheter with goal to keep free of complications related to use; -Provide care and change catheter as ordered; -Keep tubing below the level of the bladder; -Maintain a closed sterile system with tubing free of kinks. Observation on 3/5/23 at 2:03 P.M., showed the resident's catheter drainage bag hung from the bed frame and sat on the floor. Observation on 3/6/23 at 8:11 A.M., showed Certified Nurse Aide (CNA) O provided catheter care to the resident. CNA O wiped the resident's bottom with a disposable wipe, and did not change his/her gloves before he/she got a new wipe, from a package of disposable wipes that sat on the nightstand, and wiped the resident's genital area. He/She did not wipe around the catheter site or the tubing. With the same soiled gloves, he/she positioned the drainage bag on the bed frame. He/she removed his/her gloves and did not wash his/her hands before he/she lowered the bed into the lowest position without performing hand hygiene. The catheter drainage bag sat on the floor. Observation on 3/6/23 at 8:53 A.M., showed CNA O and Licensed Practical Nurse (LPN) M provided wound care to the resident. LPN M hung the catheter drainage bag on the bed frame while CNA O lowered the bed to its lowest position. The catheter bag sat on the floor. Observation on 3/7/23 at 1:36 P.M., showed the resident's catheter drainage bag hung from the bed frame and sat on the floor. During an interview on 3/5/23 at 2:03 P.M., the resident's family said the catheter bag often rests on the floor during visits. During an interview on 3/6/23 at 8:30 A.M., CNA O said he/she should have washed his/her hands between glove changes and when going from dirty to clean areas but was trying to hurry because the resident gets agitated sometimes during care and thought he/she cleaned around the tubing. He/she said the catheter or tubing should not rest on the floor or germs could spread. During an interview on 3/8/23 at 9:25 A.M., the hospice nurse and hospice supervisor said the resident has poor intake and fluid consumption with decreased kidney function making him at risk for infection. The hospice nurse said he/she would expect the catheter to be kept off the floor to decrease chances of getting an infection. During an interview on 3/9/23 at 8:14 A.M., Nurse Aide (NA) E said staff are instructed to clean a catheter tubing from the top down using a different wipe for each stroke. He/She said the drainage bag and tubing should never touch the floor or could risk cross contamination (spread of bacteria). During an interview on 3/9/23 at 8:30 A.M., CNA A said catheter drainage bags should not touch the floor for sanitary reasons. He/She said catheter care includes cleaning around the catheter insertion site then up the tubing toward the drainage bag. He/She said gloves should be changed if they are soiled and before putting new gloves on. During an interview on 3/9/23 at 9:14 A.M., CMT B said catheters should go into a dignity bag to keep covered and off the floor. He/She said if catheter bags or tubing touches the floor it could cause cross contamination of germs and cause an infection. He/She said they would not want something touching the floor that was attached to him/her because it's just nasty. During an interview on 3/9/23 at 11:03 A.M., the Director of Nursing said he/she would expect catheter tubing and drainage bags to be kept off the floor at all times or it could contribute to an infection. He/She said staff should always provide catheter care first, if able, before cleaning other areas and should perform hand hygiene between dirty and clean tasks.

Based on observation, interview, and record review, facility staff failed to provide oxygen as ordered by the physician and failed to ensure proper equipment maintenance for one resident (Resident #40). The facility census was 82. 1. Review of the Facility Assessment, updated 2/23/23, showed 25-31 residents per month received oxygen therapy. Oxygen therapy was included in additional competencies in ongoing educational training. Review of the facility's policies showed staff did not provide a policy for oxygen use. Review of the oxygen concentrator operator's manual showed: -This device contains an alarm system which monitors the state of the device and alerts of abnormal operation, loss of essential performance or failures; -Alarm conditions are shown on the LED display; -All alarms are low priority technical alarms. Review of Resident #40's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/23/22 showed facility staff assessed the resident as follows: -Moderate cognitive impairment; -Diagnoses included chronic lung disease, anemia, heart failure, and diabetes; -Received oxygen while a resident. Review of Physician's order dated 07/22/21 showed the physician directed staff to provide Oxygen at two liters per nasal cannula as needed for shortness of breath. May increase oxygen liter flow to maintain saturation greater or equal to 92%. If increase occurs please notify MD. Review of the resident's care plan, reviewed on 12/23/22 showed: -Oxygen as ordered; -Instruct resident to report shortness of breath, weakness, dizziness, chest pain. Review of resident's nurses note, dated 2/1/23 showed the resident used a nasal cannula at night with oxygen at two liters per minute. Observation on 3/05/23 at 11:33 A.M., showed the resident wore a nasal cannula with oxygen at eight liters per minute while in bed. Observation on 3/06/23 at 2:47 P.M., showed the resident wore a nasal cannula with oxygen at eight liters per minute. Observation also showed the red and yellow indicator lights on the oxygen concentrator were lit. Observation on 3/07/23 at 8:00 A.M., showed the resident wore a nasal cannula with oxygen at eight liters per minute while he/she sat on the side of the bed. Observation also showed the red and yellow indicator lights on the oxygen concentrator were lit. Observation on 3/07/23 at 10:54 A.M., showed the resident wore a nasal cannula with oxygen at eight liters per minute while he/she sat in a wheelchair. Observation also showed the red and yellow indicator lights on the oxygen concentrator were lit. During an interview on 3/08/23 at 8:24 A.M., Certified Nursing Assistant (CNA) Q said he/she did not notice the red or yellow lights and did not notice oxygen flow at eight liters per minute and he/she should have noticed. During an interview on 3/07/23 at 3:15 P.M., Licensed Practical Nurse (LPN) R said the resident used oxygen at two liters per minute if needed. LPN R said there was no facility policy to look at every resident every day but he/she tried to look at the residents every day. LPN R also added, he/she should look at oxygen every day but had not looked at the resident's oxygen since last week. LPN R said a red light on the oxygen concentrator indicated the concentrator was not working correctly and anyone that saw the red light should have told a nurse. LPN R also said the resident should have been seen every two hours at a minimum and he/she would expect someone to see the oxygen at eight liters per minute. During an in interview on 3/08/23 at 9:13 A.M., the Maintenance Director said he/she would expect staff to let maintenance know about any device showing warning lights. During an interview on 3/08/23 at 9:55 A.M., the Director of Nursing (DON) said he/she expected nurses to know what's going on with residents and nurses should be checking on oxygen at least once per shift. The DON also said he/she would expect warning lights on the oxygen concentrator to be addressed by any CNA or nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide orders for ongoing assessment after dialysis (the clinical purification of blood as a substitute for the normal function of the kidney), or have a system in place for ongoing assessments or communication with the dialysis clinic for two residents (Resident #17 and #193) who received dialysis. The facility also failed to include dialysis specific assessments and interventions in the residents' care plans. The facility census was 82. 1. Review of Facility assessment, dated 2/23/23, showed an average of two to seven residents on dialysis per week. Additional competencies included ongoing training in dialysis care. Review of the facility's policies showed staff did not provide a policy for on going communication and collaboration with the dialysis facility regarding dialysis care and services. 2. Review of Resident #17's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/25/22, showed facility staff assessed the resident as follows: -Cognitively intact; -Required limited assistance with activities of daily living; -Diagnoses included end stage kidney disease, anemia, heart failure, diabetes, psychotic disorder; -Received dialysis while a resident. Review of the resident's physicians orders, dated 10/19/22 showed an order for hemodialysis three times per week on Monday, Wednesday and Friday at 8:30 A.M. Review of the resident's care plan, reviewed 12/23/22, showed: -Resident will receive hemodialysis as scheduled per physicians orders; -The care plan did not include any specific care interventions related to dialysis. Review of the resident's medical record showed staff did not document they assessed the resident when he/she returned from dialysis treatment. During an interview on 3/06/23 at 2:10 P.M., the resident said he/she went for dialysis three times a week and when he/she returned the nurse did not do an assessment. The resident also said he/she had instances where he/she had to use the call light because his/her dialysis shunt bled after returning from dialysis. 3. Review of Resident #193's Discharge-Return anticipated MDS dated [DATE], showed: -No cognitive assessment data; -Totally dependent for activities of daily living; -No dialysis data. Review of the resident's physicians orders showed: -Order dated 10/19/22 Hemodialysis three times per week on Tuesday, Thursday and Saturday at 2:40 P.M.; -Order dated 12/08/19 Check bruit (a rumbling sound that you can hear with a stethoscope) and thrill (a rumbling sensation that you can feel) at AV shunt (connection between an artery and a vein used for dialysis) every shift; -Order dated 6/26/19 As Needed Emergency intervention for left forearm AV shunt hemorrhage (bleeding): Apply direct pressure and dial 911. Review of the resident's care plan, reviewed on 9/27/22, showed facility staff were directed to observe resident for adverse reactions after dialysis treatment. Review of the resident's medical record showed staff did not document they assessed the resident when he/she returned from dialysis treatment and did not document the AV shunt assessments every shift. Observation on 3/05/23 at 3:03 P.M., showed the resident had a port in his/her right upper chest and a dressing covering the left upper arm. During an interview on 3/05/23 at 3:03 P.M., the resident said he/she had surgery last Thursday to put a dialysis port in his/her right upper chest and remove the catheter from his/her left upper arm. The resident said he/she goes to dialysis three times a week and the nurse checked in on him/her when he/she returned back from dialysis but did not do any formal assessment. 4. During an interview on 3/07/23 at 3:30 P.M., Licensed Practical Nurse (LPN) R said he/she usually always saw Resident #17 come back from dialysis. LPN R said staff did not have orders to check vitals or anything other than routine every two hour checks. LPN R also said he/she was not aware of facility policy on assessing dialysis residents but the nurse is responsible for making sure residents are okay after dialysis. During an interview on 3/08/23 at 8:30 A.M., Certified Nurse Assistant (CNA) Q said he/she was not aware of a formal assessment when a resident returns from dialysis. CNA Q said nursing staff usually brought the residents from the front of the building but sometimes the receptionist brought the resident to their room. CNA Q also said he/she did not check vital signs or shunt site and he/she not aware of facility policy. During an interview on 3/09/23 at 8:44 A.M., CNA T said when a dialysis resident returned from dialysis, staff took them to their room and saw that they were doing okay. CNA T also said CNAs did not do vital signs at the facility. During an interview on 3/08/23 at 9:55 A.M., the Director of Nursing (DON) said the facility did not have written agreements with dialysis providers but probably should have. The DON also said the facility does not have a policy on dialysis resident assessments but she would expect an assessment to be completed when a resident returned from dialysis. During an interview on 3/09/23 at 8:55 A.M., the Administrator said the facility did not have written agreements with dialysis providers. The administrator said he/she would expect the facility to have written agreements covering responsibilities and services. The administrator said he/she did not think there was a facility policy, but when a resident returned from dialysis the charge nurse should assess and document vital signs and the shunt. He/She also said the care plan should include the dialysis schedule, potential side effects, and assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to maintain resident dignity, when staff failed to cover two residents' (Resident #23 and #36) catheter drainage bags (bag that collects urine from the bladder), failed to assist one resident (Resident #39) with dressing in a timely manner resulting in the resident sitting in his/her doorway without clothing on, posted resident care data on the closet doors in view of the hallway for one resident (Resident #37), and staff used the over-head paging system to ask staff to come to the dining room to assist the feeders. The facility census was 82. 1. Review of the facility's Resident Rights policy, dated January 2017, showed: -The facility protects and promotes the rights of each resident in order to provide a dignified life; -The right to be treated with dignity and respect; -The right to personal privacy and confidentiality of his/her personal and medical records. Review of the facility's Abuse Policy and Procedures, dated December 2018, showed: -Each resident has the right to privacy and confidentiality for all aspects of care and services; -Each resident must be provided individualized care with dignity and respect. 2. Review of the facility's Catheter Care policy, dated August 2017, showed it did not contain direction to maintain resident dignity or drainage bag placement on the wheelchair. 3. Review of Resident #23's Significant Change Minimum Date Set (MDS), a federally mandated assessment tool, dated 1/23/23, showed staff assessed the resident as: -Cognitively impaired; -Has an indwelling catheter (tube that drains the bladder). Observation on 3/5/23 at 11:58 A.M., showed the resident sat in the dining room in a reclining wheelchair. Further observation showed his/her catheter urine collection bag hung on the wheelchair uncovered with urine visible to the residents, staff, and visitors in the dining room. 4. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Did not have an indwelling catheter. Observation on 03/6/23 7:50 A.M., showed the resident sat in a reclining wheelchair in the television area. Further observation showed he/she had a catheter drainage bag that hung on the wheelchair with urine visible. Observation on 3/6/23 at 11:25 A.M., showed the resident in a reclining wheelchair in the television area. Further observation showed his/her catheter drainage bag hung on the wheelchair with urine visible. 5. During an interview 3/9/23 at 8:14 A.M, Nurse Aide (NA) E said he/she is not sure what the facility policy is regarding catheter positioning. During an interview on 3/9/23 at 8:30 A.M., Certified Nurse Assistant (CNA) A said catheters should be covered to hide the urine because it is not dignified. During an interview on 3/9/23 at 9:14 A.M., Certified Medication Technician (CMT) B said catheter drainage bags should always be covered when the resident is in the bed and in the wheelchair. He/She said the facility has dignity bags to put the catheters in and not sure why Resident #23 or #36 did not have one in use. He/She said if the catheter bags are not covered then other residents could see the urine and point it out to others. During an interview on 3/9/23 at 11:03 A.M., the Director of Nursing (DON) said catheter drainage bags should be kept in dignity bags to keep the urine covered. He/She said dignity bags over the catheter bags will help maintain the resident's dignity. During an interview on 3/15/23 at 11:08 A.M., the Administrator said catheter drainage bags should be kept in dignity bags to help maintain the resident's dignity. 6. Review of Resident #39's annual MDS, dated [DATE] showed staff assessed the resident as follows: -Required limited assistance from one person with dressing; -Required extensive assistance from one person with mobility, transfers, toileting and personal hygiene; -Impairment one side lower extremity; -Used a wheelchair. Observation on 3/7/23 at 8:28 A.M., showed the resident initiated their call light at 8:06 A.M Further observation showed the resident sat in a wheelchair in the doorway of his/her room without his/her pants on and held their pants in their hand. During an interview on 3/7/23 at 8:30 A.M., the resident said he/she just needed help getting his/her pants on after using the restroom and nobody had come to help. 7. Observation on 3/7/23 at 10:56 AM showed Resident #37's undated Resident Care Status sheet posted on the exterior of the closet door visible to the hallway. Further observation showed the care sheet contained activity of daily living assistance needed, bladder and bowel status, cognition, diet, mobility devices, skin care, communication needs, and fall risk status. During an interview on 3/15/23 at 11:08 A.M., the Administrator said resident care sheets should not be located in view of the hallway and kept behind a closet door to maintain the resident's privacy. 8. Observation on 3/9/23 at 8:03 A.M., showed the facility staff announced on the over-head paging system for staff to come to the dining room to assist the feeders. During an interview on 3/15/23 at 11:08 A.M., the Administrator said staff should never refer to resident's as feeders. He/She said it is undignified.

Based on interview and record review, facility staff failed to keep eight residents (Residents #7, #33, #35, #46, #193, #289, #290 and #291) from going into a negative balance, which allowed the residents to spend another resident's money without written authorization. The facility also failed to obtain written authorization before donating Resident #193's funds to MO Healthnet. The facility census was 82. 1. Review of the facility's policies showed staff did not provide a policy for managing the Resident Trust Account. 2. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 2/28/23 Resident #7's account had a negative balance of $-5.91. 3. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 2/28/23 Resident #33's account had a negative balance of $-11.13. 4. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 1/31/23 Resident #35's account had a negative balance of $-7.37. 5. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 8/31/22 Resident #46's account had a negative balance of $-28.55. 6. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed Resident #193's account had a negative balance on the following dates: -On 10/31/22 the balance was $-24.05; -On 08/31/22 the balance was $-24.03 7. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed Resident #289's account had a negative balance on the following dates: -On 2/28/23 the balance was $-998.00; -On 01/31/23 the balance was $-998.00; -On 12/31/22 the balance was $-998.00; -On 11/30/22 the balance was $-998.00; -On 10/31/22 the balance was $-998.00; -On 09/30/22 the balance was $-998.00; -On 08/31/22 the balance was $-499.00; -On 07/31/22 the balance was $-499.00; -On 06/30/22 the balance was $-499.00; -On 05/31/22 the balance was $-499.00; -On 04/30/22 the balance was $-499.00; -On 03/31/22 the balance was $-499.00. 8. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 10/31/22 Resident #290's account had a negative balance of $-42.80. 9. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 3/31/22 Resident #291's account had a negative balance of $-1,281.00. During an interview on 3/08/23 at 1:55 P.M., the Business Office Manager (BOM) said he/she managed the resident petty cash and posted payments. The BOM said he/she did not review bank statements or trust fund balance reports. During a teleconference on 3/08/23 at 2:05 P.M., the Corporate Controller, administrator and BOM all stated they were not not responsible for reviewing the monthly trust fund balance reports. None of the three could say who was responsible. 10. Review of the Resident Trust Fund Audit Report for the period 1/01/23 through 1/31/23 showed Resident #193 had $19,256.00 transferred to his/her trust account on 1/19/23 and a numbered facility check for $14,440.79 was disbursed on 1/20/23. During an interview on 3/09/23 at 9:22 A.M., the administrator said the resident got a large sum of money and it was supposed to be returned to Social Security. The administrator could not provide any more details. During an interview on 3/09/23 at 11:21 A.M., the BOM said the check for $14,440.79 listed as personal use in the audit report was a check sent to MO HealthNet to keep the resident from exceeding the Supplemental Security Income (SSI) resource limit. The BOM said corporate staff asked her to send the funds to MO HealthNet and he/she did not get authorization from the resident. During an interview on 3/09/23 at 2:42 P.M., the Corporate Controller (CC) said the resident had a Social Security back payment of approximately $40,000 but they should not have paid that much. The CC said the resident received about $19,000 after Social Security recouped overpayment and after paying bills. The CC also said he/she asked facility staff to voluntarily send the money to MO HealthNet and write on the check voluntary payment. During an interview on 3/09/23 at 3:28 P.M., the BOM said he/she did not believe the resident signed a written authorization to send funds to MO HealthNet. The BOM said he/she received an e-mail from the CC asking him/her to send funds to MO HealthNet and was never told he/she needed written authorization from the resident.

Based on interview and record review, the facility failed to provide notification when the resident's trust account reached $200 less than the Supplemental Security Income (SSI) resource limit of $5,301.85 for three residents (Residents #13, #49 and #292). The census was 82. 1. Review of the facility's policies showed staff did not provide a policy covering Medicaid resource limit. 2. Review of the Resident Trust Fund Balance Reports for the period of March 2022 through February 2023 showed Resident #13 had a trust fund balance in excess of the SSI threshold on the following dates: -On 2/28/23 the balance was $5,725.55; -On 1/31/23 the balance was $5,744.30; -On 12/31/22 the balance was $5,563.00; -On 11/30/22 the balance was $5,695.72; -On 10/31/22 the balance was $5,788.10; -On 9/30/22 the balance was $5,720.81; -On 8/31/22 the balance was $5,723.31; -On 7/31/22 the balance was $5,656.02; -On 6/30/22 the balance was $5,598.72; -On 5/31/22 the balance was $5,541.46; -On 4/30/22 the balance was $5,484.11. 3. Review of the Resident Trust Fund Balance Reports for the period of March 2022 through February 2023 showed Resident #49 had a trust fund balance in excess of the SSI threshold on the following dates: -On 2/28/23 the balance was $5,398.62; -On 1/31/23 the balance was $5,269.38; -On 12/31/22 the balance was $5,115.09; -On 11/30/22 the balance was $5,792.32; -On 10/31/22 the balance was $5,661.03. 4. Review of the Resident Trust Fund Balance Reports for the period of March 2022 through February 2023 showed Resident #292 had a trust fund balance in excess of the SSI threshold on the following dates: -On 9/30/22 the balance was $11,714.37; -On 8/31/22 the balance was $8,707.82; -On 7/31/22 the balance was $7,931.99; -On 6/30/22 the balance was $6,975.62; -On 5/31/22 the balance was $6,119.69; -On 4/30/22 the balance was $23,584.71; -On 3/31/22 the balance was $21,617.21; During an interview on 3/08/23 at 1:35 P.M., the Business Office Manager (BOM) said he/she handles resident petty cash and bill posting but corporate staff manages the resident trust fund. The BOM, said corporate staff sent letters to residents or their representatives when a resident was within 200 dollars of the SSI threshold. The BOM said he/she did not have any of the letters on file. During an interview on 3/08/23 at 2:05 P.M., the administrator said there should be copies of SSI resource limit letters on file in the business office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility staff failed to maintain an approved surety bond sufficient to ensure protection of all resident funds. The facility census was 82. 1. Review of the facility's Resident Trust Surety Bond Policy, revised 4/7/17, showed: -The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the secretary to assure the security of all personal funds of residents deposited with the facility; -The facility will maintain a non-canceling escrow agreement which has been filed with and approved by the state to cover the amount of coverage needed for the trust account. Review of the Department of Health and Senior Services bond approved list showed a surety bond and escrow amounts that totaled $78,500. Review of facility's records showed trust fund security as follows: -Bond - $70,000 -Escrow with a current value of $1,062.59 -Escrow with a current value of $2,584.39 -Escrow with a current value of $5,259.14 -Total of current bond and escrow values showed the facility had security coverage totaling $78,906.12. Review of the resident trust account for March 2022 through [DATE], showed an average monthly balance of $ 70,945.65 which requires a surety bond of $106,500.00. The current trust fund ledger amount was $57,294.01. During an interview on on 3/08/23 at 1:35 P.M., the Business Office Manager (BOM) said the trust fund security bond is handled by corporate staff. During an interview on 3/08/23 at 2:05 P.M., the administrator said he/she was actively working with corporate staff to increase the amount of the resident trust fund bond.

Based on observation, interview, and record review, the facility staff failed to serve meals on plates with silverware to residents who received hall trays. The census was 82. 1. Review of the facility policies showed the facility did not have a policy regarding the use of plates and silverware for resident meals served as hall trays. Review of the resident meal tickets, showed 42 residents received their lunch meal as a hall tray. Observation on 3/5/23 at 11:30 A.M., showed dietary aide (DA) AA and DA BB prepare resident lunches for hall tray service. The DAs prepared the meals in disposable Styrofoam containers with plastic ware. The DA also provided drinks for resident lunches in disposable Styrofoam cups with plastic lids. Further observation showed the facility had forty plates and sufficient silverware and cups available for use for the hall tray service. During an interview on 3/8/23 at 2:19 P.M., the dietary manager (DM) said the facility has been using disposable containers, cups, and plastic ware for hall tray service since the beginning of the pandemic. She said the facility does not currently have any residents on precautions, and there is enough plates and silverware to use for the hall tray service. The DM said there is no reason why staff continue to use disposable containers and plastic ware for hall tray service. They should use the plates, cups, and silverware, because it makes the meal nicer and more homelike. During an interview on 3/8/23 at 3:02 P.M., the administrator said the DM is responsible to ensure the meals are served in an appropriate manner that is homelike. He said the facility does not currently have any resident on precautions, but the staff may continue to use the containers to keep the food warm during service. The administrator said it is preferred the residents are served meals with real plates, cups, and silverware.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for six sampled residents (Residents #1, #9, #21, #58, #80, and #193). The facility census was 86. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI OBRA-required Assessment Summary showed assessment time frames as follows: -Entry MDS completion date no later than the 7th calendar day from the resident's entry into the facility and submitted no later than 14 days from the date of entry into the facility; -admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion date; -Quarterly (Non-Comprehensive) MDS completion date not later than ARD + 14 calendar days; -Quarterly assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type; -Discharge Assessment for a resident must be completed no later than 14 days from the date of discharge and submitted by the MDS completion date plus 14 calendar days. -A significant change in status assessment (SCSA) is appropriate when there is a determination that significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments and the resident's condition is not expected to return to baseline in two weeks; -A significant change is any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual's functioning; -A significant change assessment must be completed within 14 days a determination has been made that a significant change in status has occurred and submitted within 14 days of the care plan completion date. Review of the facility's MDS policy, undated, showed: -The facility will, in accordance with state guidelines, complete MDS Assessments; -MDS Assessments will consist of admission comprehensive assessments with Care Area Assessments (CAA) areas, quarterly assessments, and annual assessments for long term residents; -All assessments will be completed on time, per guidelines; -All residents admitting to facility will have an admission assessment completed and all residents discharging from facility will have a discharge assessment submitted. 2. Review of Resident #1's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 11/9/22. Review of the resident's MDS record dated 11/9/22 to 11/23/22 showed the record did not contain a completed or submitted discharge assessment within the required time frame. 3. Review of Resident #9's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 11/21/22. Review of the resident's MDS record dated 11/21/22 to 12/5/23 showed the record did not contain a completed or submitted discharge assessment within the required time frame. 4. Review of Resident #21's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 11/21/22. Review of the resident's MDS record dated 11/21/22 to 12/5/22 showed the record did not contain a completed or submitted discharge assessment within the required time frame. 5. Review of Resident #58's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 10/25/22. Review of the resident's MDS record dated 10/25/22 to 11/8/22 showed the record did not contain a completed or submitted discharge assessment within the required time frame. 6. Review of Resident #80's closed medical record showed the resident: -admitted to the facility on [DATE] and discharged from the facility on 9/12/22 and; -admitted to the facility on [DATE] and discharged from the facility on 11/18/22. Review of the resident's MDS record dated 9/12/22 to 9/26/22 and 11/18/22 to 12/2/22 showed the record did not contain a completed or submitted discharge assessment within the required time frame for either stay at the facility. 7. Review of Resident #193's medical record showed the resident was discharged with return anticipated on 10/31/22. Further review showed the resident returned to the facility on [DATE]. Review of the resident's MDS record showed the record did not contain a completed or submitted entry tracking record within the required time frame. 8. During an interview on 3/9/23 at 9:51 A.M., the MDS nurse said he/she is responsible to complete MDS assessments and has been with the facility doing MDS since September of 2022. He/She said residents admitted to the facility should have an entry, admission and quarterly assessments completed and residents discharged from the facility should have a discharge assessment completed. He/She thought the discharge from Medicare assessment counted as the discharge from facility assessment and is still learning the position requirements. He/She will complete the assessments and submit them as required. During an interview on 3/9/23 at 11:03 A.M., the Director of Nursing (DON) said the MDS nurse is responsible to complete the MDS assessments timely and accurately. Since the MDS nurse is an LPN, the DON signs as completed. He/She was not aware of any late assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical, and nursing needs when staff failed to address the fluid intake limitations for one resident receiving dialysis (Resident #193), failed to address the use of antipsychotic and antidepressants for one resident (Resident #8), and failed to address falls for three residents (Resident #8, #23, and #189). The facility census was 86. 1. Review of the facility's Care Planning policy dated 2022, showed: -The interdisciplinary team (IDT) is responsible for the development of an individualized comprehensive care plan for each resident; -The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/IDT which includes, but is not limited to the following: attending physician, registered nurse who has responsibility for the resident, the dietary manager/dietician, the social services worker, the activity director, the director of nursing (DON), and others as appropriate or necessary to meet the needs of the resident. Review of the facility's Fall Management Guidelines, dated October 2021, showed: -The following elements are in place for the facility to demonstrate satisfactory compliance with the guide: Residents are assessed for risk, Communication system to identify the resident at risk, care planned with individualized interventions post fall, and IDT review; -Following a resident's fall appropriate intervention are implemented and care plan updated/revised. 2. Review of Resident #193's Discharge-Return anticipated Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/31/22, showed: -No cognitive assessment data; -Totally dependent for activities of daily living; -No dialysis data. Review of the resident's physicians orders showed: -Order dated 10/19/22 Hemodialysis three times per week on Tuesday, Thursday and Saturday at 2:40 P.M.; -Order dated 12/08/19 Check bruit (a rumbling sound that you can hear with a stethoscope) and thrill (a rumbling sensation that you can feel) at AV shunt (connection between an artery and a vein used for dialysis) every shift; -Order dated 6/26/19 As Needed Emergency intervention for left forearm AV shunt hemorrhage (bleeding): Apply direct pressure and dial 911. Review of the resident's Medication Administration Record showed an order dated 1/18/23, fluid restriction of 1200 ml daily. Review of the resident's care plan, reviewed on 9/27/22, showed the care plan was not updated and did not include the resident's fluid intake limitations related to dialysis. 3. Review of Resident #8's Annual MDS, dated [DATE], showed facility staff assessed the resident as: -Cognitively impaired; -Diagnosed with anxiety and depression; -Received an antipsychotic, antidepressant and antianxiety medication 7 of 7 days in the look back period; -Dependent on two staff for transfers; -Dependent on one staff for toileting; -Required extensive assistance of two staff for bed mobility; -Had functional limitations in range of motion in both lower extremities; -Is not steady with surface to surface transfers without staff assistance. Review of the resident's fall risk assessment, dated 1/11/23, showed staff assessed the resident as a high fall risk. Review of the resident's nurse notes dated 1/6/23 through 3/7/23 showed staff documented the resident had a fall on 2/8/23, 3/4/23 and 3/6/23. Review of the resident's care plan, reviewed 1/18/23, showed the care plan did not contain new interventions for the falls that occurred on 2/8/23, 3/4/23, and 3/6/23 as directed in the facility policy and did not address the use of antipsychotics, antidepressants or antianxitey medications. 4. Review of Resident #23's Significant Change of Status MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Dependent on two staff for bed mobility, transfers, and toileting; -Had functional limitations in range of motion in both lower extremities; -Is not steady with surface to surface transfers without staff assistance; -Had no falls since prior assessment; -Diagnosed with stroke, hemiplegia (paralyzed on one side of body), and cataracts (cloudy lens of the eye). Review of the resident's fall risk assessment dated [DATE] showed the resident is a high fall risk. Review of the resident's nurse notes dated 1/1/23 through 3/7/23, showed the resident had a fall on 1/13/23 and 2/16/23. Review of the resident's care plan, reviewed 1/18/23, showed the care plan did not contain new interventions for the falls that occurred on 1/13/23 and 2/16/23 as directed in the facility policy. 5. Review of Resident #189's Face Sheet, dated 3/7/23, showed: -admitted to facility on 3/1/23; -Diagnosed with Traumatic subarachnoid hemorrhage without loss of consciousness (bleeding to the brain), compression fracture of second lumbar vertebra (spinal fracture), compression fracture of fifth lumbar vertebra, intervertebral disc degeneration of the lumbar region (arthritis of the spine), Restless legs syndrome (irresistible urge to move the legs) and Sick sinus syndrome (heart rhythm disorder). Review of the resident's fall risk assessment, dated 3/1/23, showed staff assessed the resident as a high fall risk. Review of the resident's nurse notes dated 3/1/23 through 3/7/23 showed staff documented the resident had a fall on 3/4/23 and found walking down the hallway multiple times with no assistive device on 3/5/23. Review of the resident's care plan, dated 3/1/23, showed the care plan did not contain new interventions for the fall that occurred on 3/4/23 or resident's behaviors related to need to be redirected/cued to use his/her assistive device. 6. During an interview on 3/9/23 at 9:51 A.M., the MDS Coordinator said it is his/her responsibility to make sure care plans are up to date. He/She said care plans are updated quarterly, annually and with changes in care. The Coordinator said everyone has access to the care plans. During an interview on 3/9/23 at 11:03 A.M., the Director of Nursing (DON) said care plans should include resident preferences in their care and updated with any changes. He/She said the nurses can update the care plans with changes that include new fall interventions and medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide activity of daily living (ADL) care to meet the basic hygiene needs for six dependent residents (Resident #25, #32, #38, #45, #53, and #75). The facility census was 82. 1. Review of the facility's Showers policy, dated January 2017, showed: -The facility is to offer showers on a bi-weekly basis with requests for more frequent showers granted and addressed via the care plan; -A shower schedule will be maintained at each nurse station for each division reflecting days for each resident's shower to be completed; -Residents right to refuse showers will be respected and addressed via the plan of care; -The charge nurse will forward all completed shower sheets to the clinical nurse managers; -Clinical nurse managers will ensure a shower sheet is received for each shower; -Shower sheets will be kept in the Clinical Managers office for a period of two weeks. Review of policies and procedures provided by the facility showed they did not contain a shower schedule. 2. Review of Resident #25's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/26/22, showed staff assessed the resident as follows: -Cognitively intact; -Did not have behaviors or reject care; -Required help in part of the bathing activity; -Did not require set up or physical help from staff for bathing. Review of the resident's care plan dated 1/7/23, showed the following: -Goals to maintain or improve self-care of bathing; -Accept assistance with bathing; -Did not contain resident preferences for bathing time, days of the week or type of assistance needed. Review of the facility's Certified Nurse Aid (CNA) ADL form, dated January 2023, showed staff documented they only assisted the resident with one bath on 1/31/23 in the 31 day period. Review of the facility's CNA ADL form, dated February 2023, showed staff documented they only assisted the resident with one bath on 2/1/23 in the 28 day period. Observation on 3/5/23 at 2:20 P.M., showed the resident sat in his/her wheelchair with dry skin on his/her arms and dry hair. During an interview on 3/6/23 at 8:04 A.M., the resident said residents are not getting showers. He/She said it has been over a week and residents should not have to wait that long. He/She said they don't like to feel dirty. 3. Review of Resident #32's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance two plus staff with bed mobility; -Totally dependent on two plus staff for transfers; -Required extensive assistance from two plus staff with dressing; -Required one person physical assistance with bathing. Review of the resident's care plan dated 12/12/22 showed staff were directed: -The resident has a self-care deficit and required staff assistance; -The resident has the potential for skin breakdown and required assistance with bathing. Review of the facility's CNA ADL form, dated January 2023, showed staff did not document they assisted the resident with a bath for the month. Review of the facility's CNA ADL form, dated February 2023, showed staff did not document they assisted the resident with a bath for the month. Review of facility shower sheets showed staff documented the resident was given a bath on 12/17/22, 2/22/23, 2/25/23, 3/1/23, and 3/4/23. Observation on 3/5/23 at 10:00 A.M., showed the resident asleep, uncovered to the groin, with food debris on the face and chest. Observation on 3/6/23 at 9:30 A.M., showed the resident in the same clothing and was still covered in food debris. During an interview on 3/6/23 at 9:25 A.M., the resident said he/she had not received more than three showers in the last three months. 4. Review of Resident #38's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance from two plus staff for bed mobility ; -Required extensive assistance from two plus staff for transfers; -Required extensive assistance two plus staff for dressing; -Required assistance from one person for bathing. Review of the resident's care plan dated 1/24/23 showed staff were directed: -The resident has a self care deficit and required staff assistance; -The resident required staff assistance with bathing. Review of the facility's CNA ADL form, dated January 2023, showed staff did not document they assisted the resident with a bath for the month. Review of the facility's CNA ADL form, dated February 2023, showed staff did not document they assisted the resident with a bath for the month. Review of facility shower sheets showed staff documented they only assisted the resident with a bath on 1/10/23 and 2/19/23. Observation on 3/6/23 at 3:30 P.M., showed the resident had soiled clothing on, dry flaking skin, and a heavy facial hair. During an interview on 3/6/23 at 3:40 P.M., the resident said he/she received a shower once a week on Sundays. 5. Review of Resident #45's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Had no behaviors or rejection of care; -Required help in part of the bathing activity; -Required set up help from staff for bathing. Review of the resident's care plan dated 12/19/22 showed goals to: -Maintain or improve self-care of bathing; -Accept assistance with bathing. Review of the facility's CNA ADL form, dated January 2023, showed staff documented they only assisted the resident with one bath on 1/11/23 in the 31 day period. Review of the facility's CNA ADL form, dated February 2023, showed staff documented they only assisted the resident with a bath/shower on 2/1/23, 2/4/23, and 2/11/23, in the 28 day period. Observation on 3/5/23 at 11:06 A.M., showed the resident lay in bed with long facial hair and debris under his/her long fingernails. Observation on 3/6/23 at 7:50 A.M., showed the resident in the dining room with dry skin, dry hair and long facial hair. Observation on 3/7/23 at 8:46 A.M., showed the resident in the hallway with long facial hair, dry skin and dry hair. During an interview on 3/5/23 at 11:06 A.M., the resident said he/she will shave from time to time, but mostly he/she needs the staff to help because he/she gets tired. He/She would like a bath more than every couple of weeks but knows the staff are doing the best they can with how many they have. 6. Review of Resident #53's PPS schedule 5 day MDS, dated [DATE], showed staff assessed the resident as follows: -Required limited assistance from one person for bed mobility; -Required limited assistance from one person for transfers; -Required limited assistance from one person for dressing; -Required set up only for bathing. Review of the resident's care plan dated 2/21/23 showed staff were directed: -The resident has a self-care deficit; -The resident required assistance with bathing. Review of the facility's CNA ADL form, dated January 2023, showed staff did not document they assisted the resident with a bath for the month. Review of the facility's CNA ADL form, dated February 2023, showed staff documented they assisted the resident with a bath on 2/3/23, 2/7/23, and 2/8/23. Review of facility's shower sheets showed staff documented they assisted the resident with a bath on 1/1/23, 1/6/23, 1/9/23,1/30/23, and 2/3/23. Observation on 3/7/23 at 8:04 A.M., showed the resident had unkempt hair with a greasy appearance and had a strong odor. During an interview on 3/7/23 at 8:10 A.M., the resident said sometimes he/she gets help with a bed bath but staff sometimes they don't come back to assist him/her. 7. Review of Resident #75's Quarterly MDS,dated 2/3/23, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Independent with bed mobility, transfers, and dressing; -Required supervision and cuing for bathing. Review of the resident's care plan dated 1/31/23 showed staff were directed: -The resident was at risk for skin breakdown; -The resident was occasionally incontinent; -The resident required encouragement for staff assistance. Review of the facility's CNA ADL form, dated January 2023, showed staff did not document they assisted the resident with a bath for the month. Review of the facility's CNA ADL form, dated February 2023, showed staff did not document they assisted the resident with a bath for the month. Review of facility's shower sheets showed staff documented they only assisted the resident with a bath on 1/6/23 and 2/19/23. Observation on 3/5/23 at 10:00 A.M., showed the resident sat in the hallway alone. The resident had very greasy hair and food stuck in the resident's unkempt beard. The resident had an odor. Observation on 3/6/23 at 9:20 A.M., showed the resident had on the same food soiled clothing as the day before with a strong odor. The resident's hair was greasy and uncombed. Observation on 3/8/23 at 10:00 A.M., showed the resident's clothing had not been changed and the resident remained unclean with a strong odor. During an interview on 3/7/23 at 9:30 A.M., the resident said sometimes if staff are not short handed they assist him/her to shower. 8. During an interview on 3/8/23 at 10:22 A.M., CNA T said residents are supposed to get a shower two times a week but they are too short staffed to get this done. During an interview on 3/8/23 at 10:25 A.M., CNA J said showers are to be two times a week. If residents refuse, they sign off the refusal and try again later. During an interview on 3/8/23 at 10:30 A.M., CNA U said residents are to be showered two times a week per a shower schedule. They try their best but showers don't always get done. During an interview on 3/8/23 at 1:40 P.M., the director of nursing (DON) and the assistant director of nursing (ADON) said showers are to be done two times a week. Some residents refuse, but staff try again later. They monitor the staff to help get showers done. During an interview on 3/9/23 at 11:08 A.M., the Administrator said showers are offered at least twice a week. He/She said the DON is responsible to ensure the showers are being completed. The Administrator said if a complaint comes in related to showers or care issues, he/she will investigate it and follow up with the DON. The DON is responsible to ensure showers are completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure the resident environment remained as free of accident hazards, when facility staff failed to ensure electronic cigarettes were kept secure for two residents (Resident #41, and #53), failed to ensure hazardous chemicals were stored in a safe manner, failed to lock an unattended medication and treatment cart and failed to propel three residents (Residents #28, #20 and #12) in wheelchairs in a manner to prevent accidents. The facility census was 82. 1. Review of the facility's Smoking Policy, dated February 2021 showed: -Any resident who smokes may do so in the designated smoke area for residents; -The designated smoke area is located outside the exit door in the Activity Department for residents; -There will be designated published smoking schedules and at those times will be supervised by a facility staff member; -All cigarette and smoking items (lighters, cigarettes, vaping devices, electronic cigarettes, matches) are to be kept locked at nurse's station when not in use. Having these items in resident rooms is not permitted; -No resident, family member, responsible party, or staff member may smoke in any resident room, or any place within the building. -Electronic cigarettes/vaping devices section says: any resident who uses a vape (electronic cigarette) may do so in their rooms, the Living Rooms, or other private areas away from other residents who do not vape. Residents are not required to turn in vaping devices to staff as they would smoking devices. 2. Review of Resident #41's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/5/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Had no behaviors; -Did not use oxygen. Review of the resident's care plan, dated 1/18/23 showed staff were directed as follows: -The resident is considered an unsafe smoker; -Cigarettes and lighter will be kept at the nurse's station/designated area; -Staff will light cigarette. Review of the resident's Smoking Risk assessment, dated 3/8/23, showed: -Cigarettes and lighter will be kept at the nurse's station/designated area; -Staff will light cigarette; -Considered an unsafe smoker. Observation on 3/5/23 at 11:50 A.M., showed the resident sat in the dining room with a group of residents being served lunch. Further observation showed the resident used his/her vape device with two residents at the same table. Observation on 3/6/23 at 10:49 A.M., showed the resident sat in the TV room and his/her vape device with five other residents present while he/she talked to the Director of Nursing (DON) followed by the Administrator. Observation on 3/8/23 at 10:39 A.M., showed the resident in a wheelchair located in the hallway with a vape device in his/her hand around other residents. 3. Review of Resident #53's PPS 5 day scheduled MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Had no behaviors; -Did not use oxygen. Review of the resident's Smoking Risk assessment, dated 3/8/23, showed: -Cigarettes and lighter will be kept at the nurse's station/designated area; -Staff will light cigarette; -Considered an unsafe smoker. Review of the resident's care plan dated 2/6/23 showed staff were directed as follows: -Resident is considered an unsafe smoker; -Cigarettes and lighter will be kept at the nurse's station/designated area; -Staff will light cigarette. Observation on 3/8/23 at 10:39 A.M., showed the resident used his/her vape device in his/her room with the door open, the vaping material could be smelled from the hallway. 4. Review of the facility's chemical storage policy, undated, showed: -Chemicals utilized are to be stored in their original containers that are distributed by the manufacturer, with the label intact; -All chemicals, when not in use, are stored under lock and key to prevent misuse and ensure safety; -These chemicals are stored off the floor and in a temperature controlled room; -All chemicals are to be accounted for at all times when not in use. Observation on 3/5/23 at 10:46 A.M., showed an open box of shampoo and body wash bottles labeled external use only, avoid contact with eyes, sat on the floor outside a spa room at the end of 500 hallway unattended and accessible to residents. Observation on 3/5/23 at 10:46 A.M., showed a container of disinfectant wipes with the lid partially open sat in the unlocked spa room at the end of 500 hallway. Further observation showed the label read keep out of reach of children. Observation on 3/5/23 at 11:06 A.M., showed one open container of bleach wipes and one closed container of bleach wipes sat in the window sill of Resident #45's room. Further observation showed the label read Hazards to humans, call poison control for treatment advice. Observation on 3/5/23 at 11:54 A.M., showed one open container of disinfectant wipes sat on a table at the entrance way to the dining room accessible to residents. Further observation showed a group of residents sat waiting for lunch in the area. During an interview on 3/9/23 at 11:03 A.M., the DON said hazardous chemicals such as bleach wipes, should be kept locked when not in attendance. He/She said chemicals should not be kept out or residents with dementia that do not know better could get a hold of them and drink them or put on their skin. He/She did not know the wipes were in resident #45's room. 5. Review of the facility's, Medication Administration General Guidelines, dated May 2020, showed: -During administration the medication cart is kept closed and locked when out of sight of the medication nurse/technician; -The cart must be clearly visible to the personnel administering medications when unlocked. Observation on 3/5/23 at 9:38 A.M., showed one unlocked and unattended medication cart sat at the nurse station near the dining room. Further observation showed three residents sat nearby. Observation on 3/5/23 at 9:42 A.M., showed an unlocked and unattended medication cart sat outside of room [ROOM NUMBER] in the hallway. Further review showed one unidentified staff member and one unidentified resident passed by the cart. Observation on 3/7/23 at 8:20 A.M., showed an unlocked and unattended treatment cart sat in the television room near the dining room. Further observation showed it contained four boxes of insulin pen needles, seven insulin syringes, and four boxes of finger stick devices (device to obtain blood sample). Eight residents were present in the area. Observation on 3/7/23 at 3:36 P.M., showed an unlocked and unattended treatment cart sat in the television room near the dining room. Further observation showed it contained four boxes of insulin pen needles, seven insulin syringes, and four boxes of finger stick devices. Seven residents were present in the area. During an interview on 3/9/23 at 9:14 A.M., Certified Medication Technician (CMT) B said medication carts should always be locked when staff walk away from them. He/She said residents could get into them if left unattended and get hurt on something or take something harmful to them. During an interview on 3/9/23 at 10:24 A.M., Licensed Practical Nurse (LPN) C said medication and treatment carts should always be locked when unattended. He/She said some residents are confused and could take something and get hurt. He/She was not aware the carts were unlocked and does not know why that would happen. During an interview on 3/9/23 at 11:03 A.M., the DON said he/she expects staff to lock all treatment and medication carts when not visible or leaving to give medications. He/She said demented residents that do not know better could get into the cart and take something and get hurt. 6. Review of the facility's Wheelchair Safety policy, undated, showed: -Check foot pedals to be sure they are properly positioned; -Check feet to ensure they are not dragging on the floor or foot twisted before pushing forward. Observation on 3/5/23 at 11:46 A.M., showed an unknown staff propelled Resident #20 in a wheelchair without foot pedals attached. Further observation showed the resident's feet slid on the floor. Observation on 3/5/23 at 12:02 P.M., showed Nurse Aide (NA) E propelled Resident #28 without foot pedals to the dining room from 200 hallway. Further observation showed the bottom of the resident's feet slid on the floor. During an interview on 3/9/23 at 8:14 A.M., NA E said before propelling a resident in a wheelchair, staff should make sure the foot pedals are on. He/She said if the pedals are not on, then the resident's feet could drag the floor and hurt them. He/She did not realize they propelled resident #28 without pedals. Observation on 3/6/23 at 12:10 P.M., showed an unknown staff propelled Resident #12 in a wheelchair without foot pedals on. Further observation showed the resident's feet slid on the floor. During an interview on 3/8/23 at 10:18 A.M., Certified Nurse Assistant (CNA) J said residents should never be propelled without foot pedals in a wheelchair. During an interview on 3/8/23 at 10:22 A.M., CNA T said residents should never be propelled in a wheelchair without foot pedals on the chair. During an interview on 3/8/23 at 10:30 A.M., LPN U said wheelchair foot pedals should be on the chair before a resident is propelled, you should never propel them without the pedals. During an interview on 3/8/23 at 1:40 P.M., the DON and the assistant director of nursing said staff should put the foot pedals on a wheelchair before propelling the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide sufficient staff to meet the needs of the residents. The facility failed to provide showers for six residents (Resident #25, #32, #38, #45, #53, and #75), failed to administer medications in a timely manner for one resident (Resident #191), and failed to ensure call lights were answered in a timely manner. The facility census was 82. 1. Review of the facility assessment tool, dated February 23, 2023, showed: -Average census of 80-85 residents; -Direct care staff needed for a 24 hour period of time: -Licensed Nurses: 3 to 8; -Certified Medication Technicians (CMT's): 3 to 6; -Certified Nurse Aides (CNA's): 8 to 14; -Resident preferences will be considered with regard to daily schedules, bathing, naps, going to bed and medication times; -As acuity and/or census needs change, staffing levels and assignments will be reviewed through Quality Assessment and Performance Improvement (QAPI) and weekly staffing committee meetings. Review of the facility's staffing sheets, dated 2/23/23 through 3/9/23, showed staff documented the average number of direct care staff provided daily as: -7 Certified Nurse Aides for the day shift; -5.6 CNA's for the night shift; -2.7 CMT's for the day shift; -2 CMT's for the night shift; -1.6 Licensed Nurses for the day shift; -1 Licensed Nurse for the night shift. Review of the Resident Census and Conditions of Residents data, dated 3/5/23, showed staff assessed the facility as: -Census of 82; -59 residents required assistance from one to two staff members for bathing; -8 residents as totally dependent on staff for bathing. Review of the facility's Showers policy, dated January 2017, showed staff are to offer showers on a bi-weekly basis with requests for more frequent showers granted and addressed via the care plan. 2. Review of Resident #25, #32, #38, #45, #53, and #75's medical records showed staff did not document the residents received baths twice a week as directed by the facility policy. 3. Observation on 3/5/23 at 2:20 P.M., showed Resident #25 sat in his/her wheelchair with dry skin on his/her arms and multiple flakes in his/her hair. During an interview on 3/6/23 at 8:04 A.M., The resident said it has been over a week since he/she got a shower, and he/she doesn't like to feel dirty. 4. Observation on 3/5/23 at 10:00 A.M., showed Resident #32 in bed with food debris on his/her face and chest. Observation on 3/6/23 at 9:30 A.M., showed the resident in the same clothes as the day before. Further observation showed the resident's clothes covered with food debris. During an interview on 3/6/23 at 9:25 A.M., the resident said he/she has only had three showers in the last three months. 5. Observation on 3/6/23 at 3:30 P.M., showed Resident #38 with soiled clothing, dry skin, and unkempt facial hair. During an interview on 3/6/23 at 3:40 P.M., the resident said he/she only receives a shower once a week. Observation on 3/5/23 at 11:06 A.M., showed the resident lay in bed with long facial hair and debris under his/her long fingernails. Observation on 3/6/23 at 7:50 A.M., showed the resident in the dining room with dry skin, multiple flakes in his/her hair, and long facial hair. Observation on 3/7/23 at 8:46 A.M., showed the resident in the hallway with long facial hair, dry skin, and multiple flakes in his/her hair. During an interview on 3/5/23 at 11:06 A.M., the resident said he/she needs staff to help him/her shave because he/she gets tired. The resident said he/she only receives a bath every couple of weeks, and he/she would like to have one more often. He/She said there is not always enough staff to help him/her. 6. Observation on 3/7/23 at 8:04 A.M., showed Resident #45 with greasy unkempt hair and a foul odor. During an interview on 3/7/23 at 8:10 A.M., the resident said staff sometimes helps him/her with a bed bath, but they don't always come back to help him/her. Observation on 3/5/23 at 10:00 A.M., showed Resident #53 sat in the hallway with greasy hair and food in his/her unkempt facial hair. Further observation showed the resident with a foul odor. Observation on 3/6/23 at 9:20 A.M., showed the resident wore the same food soiled clothes from the day before, had greasy unkempt hair, and had a foul odor. During an interview on 3/7/23 at 9:30 A.M., the resident said sometimes if staff are not short-handed I get a shower. Observation on 3/8/23 at 10:00 A.M., showed Resident #75 wore the same clothes as the day before, and had a foul odor. 7. Review of the facility's Liberal Medication Policy, dated February 2020, showed time specific medications ordered by a physician will have specific times indicated on the Medication Administration Record (MAR). These medications will be given within one hour before or after the specific times labeled on the MAR. Review of Resident #191's MAR, dated March 2023, showed orders for: -Duloxetine (anti-depressant) 60 milligrams (mg) delayed release (DR), daily at 8:00 A.M.; -Potassium Chloride 20 milliequivalents (mEq) at 8:00 A.M.; -Furosemide 40 mg at 8:00 A.M. Observation on 3/7/23 at 11:06 A.M., showed staff administered Duloxetine, Potassium and Furosemide to the resident at 11:06 A.M. More than three hours after the medications were due. 8. Review of the facility's Call lights Policy, dated 10/29/18, showed call lights are to be answered promptly. Review of the facility's wireless call light report, dated 3/5/23 at 12:14 A.M. and 3/5/23 at 12:45 P.M., showed: -room [ROOM NUMBER] call light response of 21 minutes, with 7 repages; -room [ROOM NUMBER] call light response of 30 minutes, with 10 repages; -room [ROOM NUMBER] call light response of 21 minutes, with 7 repages; -room [ROOM NUMBER] call light response of 51 minutes, with 19 repages; -room [ROOM NUMBER] call light response of over an hour, with 20 repages; -room [ROOM NUMBER] call light response of 32 minutes, with 10 repages; -room [ROOM NUMBER] call light response of 22 minutes, with 7 repages; -room [ROOM NUMBER] call light response of over an hour, with 20 repages; -room [ROOM NUMBER] call light response of 56 minutes, with 18 repages; -room [ROOM NUMBER] call light response of 37 minutes, with 12 repages; -room [ROOM NUMBER] call light response of 42 minutes, with 14 repages; -room [ROOM NUMBER] call light response of 1 hour and 32 minutes, with 30 repages; -room [ROOM NUMBER] call light response of 20 minutes, with 6 repages; -room [ROOM NUMBER] call light response of 1 hour and 22 minutes, with 27 repages; -room [ROOM NUMBER] call light response of over an hour, with 22 repages; -room [ROOM NUMBER] call light response of 44 minutes, with 14 repages; -room [ROOM NUMBER] bath call light response of 24 minutes, with 8 repages; -room [ROOM NUMBER] call light response of 29 minutes, with 9 repages; -room [ROOM NUMBER] call light response of 1 hour and 15 minutes, with 25 repages; -room [ROOM NUMBER] call light response of 21 minutes, with 7 repages; -room [ROOM NUMBER] call light response of 1 hour and 15 minutes, with 25 repages; -room [ROOM NUMBER] call light response of 1 hour and 6 minutes, with 22 repages; -room [ROOM NUMBER] bath call light response of 1 hour and 7 minutes, with 22 repages; -room [ROOM NUMBER] bath call light response of 28 minutes, with 9 repages; -room [ROOM NUMBER] call light response of 1 hour and 5 minutes, with 21 repages; -room [ROOM NUMBER] call light response of 1 hour and 18 minutes, with 26 repages; -room [ROOM NUMBER] call light response of 34 minutes, with 11 repages; -room [ROOM NUMBER] call light response of 34 minutes, with 11 repages; -room [ROOM NUMBER] call light response of 50 minutes, with 16 repages; -room [ROOM NUMBER] call light response of 51 minutes, with 17 repages; -room [ROOM NUMBER] call light response of 25 minutes, with 8 repages; -room [ROOM NUMBER] bath call light response of 34 minutes, with 11 repages; -room [ROOM NUMBER] call light response of 59 minutes, with 19 repages; -room [ROOM NUMBER] call light response of 24 minutes, with 8 repages; -room [ROOM NUMBER] call light response of 22 minutes, with 7 repages; -room [ROOM NUMBER] call light response of 39 minutes, with 13 repages; -room [ROOM NUMBER] call light response of 24 minutes, with 8 repages; -room [ROOM NUMBER] call light response of 23 minutes, with 7 repages; -room [ROOM NUMBER] call light response of 25 minutes, with 8 repages; -room [ROOM NUMBER] call light response of 32 minutes, with 10 repages; -room [ROOM NUMBER] call light response of 22 minutes, with 7 repages; -room [ROOM NUMBER] call light response of 21 minutes, with 7 repages; -room [ROOM NUMBER] call light response of 32 minutes, with 10 repages; -room [ROOM NUMBER] call light response of 20 minutes, with 6 repages; -room [ROOM NUMBER] call light response of 23 minutes, with 7 repages; -room [ROOM NUMBER] call light response of 23 minutes, with 7 repages. Observation on 3/5/23 at 2:03 P.M., showed room [ROOM NUMBER]'s call light initiated at 1:31 P.M. remained unanswered. Observation on 3/6/23 at 7:46 A.M., showed room [ROOM NUMBER]'s call light initiated at 6:39 A.M. with multiple repages remained unanswered. Observation on 3/6/23 at 8:18 A.M., showed room [ROOM NUMBER]'s call light initiated at 7:50 A.M. with 9 repages remained unanswered. Observation on 3/6/23 at 12:13 P.M., showed room [ROOM NUMBER]'s call light initiated at 11:09 A.M. with 12 repages remained unanswered. Observation on 3/6/23 at 2:00 P.M., showed room [ROOM NUMBER]'s call light initiated at 1:23 P.M. remained unanswered. Observation on 3/6/23 at 2:02 P.M., showed room [ROOM NUMBER]'s call light initiated at 1:45 P.M. remained unanswered. Observation on 3/7/23 at 8:28 A.M., showed Resident #39 initiated his/her call light at 8:06 A.M., and sat in his/her wheelchair in the doorway of the room with no pants on. During an interview on 3/6/23 at 9:00 A.M., Resident #32 said it takes over an hour for staff to answer his/her call light. The resident said he/she doesn't receive care in a timely manner, and he/she would like to be repositioned more often. During an interview on 3/7/23 at 8:30 A.M., Resident #39 said he/she needs to help to put his/her pants on. He/She said no one ever came to help him/her. During a resident group interview on 3/8/23 at 2:00 P.M., the residents said it takes staff more than thirty minutes to answer call lights on a regular basis. The residents said they have to sit and wait for staff or they have to send someone to get staff to help them. The residents said the staff doesn't check on them unless they use their call lights. Additionally, the residents said it is worse during lunch time. 9. During an interview on 3/9/23 at 8:14 A.M., Nurse Aide (NA) E said he/she doesn't know if the residents receive their showers. The NA said staff answer the call lights as quickly as they can. He/She said if there was more staff the call lights would be answered in a timely manner. During an interview on 3/9/23 at 8:30 A.M. CNA A said the residents are not always receiving showers and baths. The CNA said sometimes the management nurses help if asked. He/She said staff answers the call lights as quickly as they can. He/She said some residents require more time for cares. During an interview on 3/9/23 at 9:14 A.M., CMT B said sometimes the facility only has three to four staff members working during the day shift. The CMT said between medication passes he/she tries to help as much as he/she can. The CMT said it takes longer to get call lights answered if there is not enough staff. He/She said if staff doesn't answer call lights in a timely manner a resident could have an accident and that could cause the resident to feel bad. During an interview on 3/9/23 at 10:24 A.M., Licensed Practical Nurse (LPN) C said staff does the best they can with what they have. The LPN said he/she feels the staff are tired and some overworked but try really hard to provide good care. During an interview on 3/9/23 at 11:03 A.M. the Director of Nursing (DON) said he/she feels the residents needs are met with the staff provided. The DON said he/she would always welcome more staff.

Based on observation, interview and record review, the facility staff failed to maintain a medication error rate of less than five percent (%) when medications were given late. There were 30 opportunities with 3 errors made, for an error rate of 10%. This affected one sampled resident (Resident #191) of six sampled residents. The facility census was 86. 1. Review of the facility's Liberal Medication Policy, dated February 2020, showed: -The purpose is to provide a general guideline to ensure safe and effective administration of medications to accommodate the resident's choice of time for administration, as well as encouraging administration of medications during times when the resident is awake; -Time specific medications ordered by a physician will have specific times indicated on the Medication Administration Record (MAR). These medications will be given within one hour before or after the specific times labeled on the MAR. Review of the Medication Error Policy, undated, showed: -The purpose is to report the administration of the wrong medication being administered to a resident; -Medication should be administered per physician orders; -When a medication error has occurred please update the physician and responsible party via telephone with the medication error; -Complete a medication error report and turn into the Director of Nursing (DON) office. Review of Resident #191's Physician Order Sheet (POS) dated 3/8/23, showed the following medication orders: -Duloxetine (antidepressant) delayed release, enteric coated (DR/EC) 60 milligram (mg) capsule daily; -Potassium Chloride (mineral supplement) 20 milliequivalent (mEq) tablet at 8:00 A.M. and 5:00 P.M.; -Furosemide (to treat fluid retention) 40 mg tablet daily. Review of the resident's Electronic MAR dated 3/1/23 to 3/8/23 showed the following orders: -Duloxetine 60 mg capsule, delayed release, enteric coated daily at 8:00 A.M.; -Potassium Chloride 20 mEq tablet at 8:00 A.M. and 5:00 P.M.; -Furosemide 40 mg tablet daily at 8:00 A.M. Observation on 3/7/23 at 11:06 A.M., showed Certified Medication Technician (CMT) S prepared, administered and documented the following medications were given late: -Duloxetine 60 mg; -Furosemide 40 mg; -Potassium 20 mEq. During an interview on 3/7/23 at 11:15 A.M., CMT S said the resident refuses his medication every morning and will not take them until lunch time. He/She said the nurses have been informed of his/her preference because giving medications late is an error. During an interview on 3/9/23 at 9:14 A.M., CMT B said giving medications late is considered a medication error. He/She said the resident does like to take his/her medications later in the day and the times should be changed to reflect his preferences. He/She does not know why the times have not been changed. During an interview on 3/9/23 at 10:24 A.M., Licensed Practical Nurse (LPN) C said if medications are given outside the time window it is considered a late medication and an error. He/She was not aware of the late administration for the resident. During an interview on 3/9/23 at 11:03 A.M., the DON said he/she is aware the resident refuses his/her morning medications and prefers them later in the day. He/She said the nurses have been asked to get new orders but assumes it has not been done yet. He/She said giving medications late is considered a medication error.

Based on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of two medication storage carts and two of two medication storage rooms. The facility census was 82. 1. Review of the facility's Medication Storage and Labeling Policy, undated, showed staff are directed as follows: - Pharmaceutical medications will be labeled, and stored in accordance with all state of Missouri, and federal guidelines as well as all standards of clinical practice; - Expiration dates must be checked prior to administration. Expired medications are removed from area of care immediately, and disposed of according to facility medication disposal policy, per state and federal guidelines. Review of the facility's Medication Administration General Guidelines policy, dated May 2020, showed: -Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and by persons legally authorized to do so; -Check expiration date on package/container. Many products have specific end-of-use dating defined by the manufacturer. The date opening should be noted on the container/vial of multi-use containers. Review of the Patient information Guide for Budesonide-fomoterol HFA (to treat asthma), dated December 2017, showed patients should discard the inhaler when the counter reaches zero (0) or 3 months after you take it out of the foil pouch, whichever comes first. 2. Observation on 3/7/23 at 7:56 A.M., showed the 200 hallway medication cart contained the following: -An opened, undated budesonide-fomoterol HFA 80 mcg-4.5 mcg aerosol inhaler; -An opened, undated bottle of sodium chloride 5% eye drops (used to treat a swollen cornea). During an interview on 3/9/23 at 9:14 A.M., Certified Medication Technician (CMT) B said eye drops are good for 30 days. He/She said if they are not dated then staff should not use them and should reorder the eye drops. He/She said inhalers are good for 60 days when opened. If the inhalers are not dated then it makes it hard to know if they are still good and they should not use them but reorder instead. During an interview on 3/9/23 at 11:10 A.M., the Director of Nursing (DON) said inhalers and eye drops are good for 30 days when opened. He/She said if the date is not written on them, staff should not use them and reorder a new one. 3. Observation on 3/9/23 at 8:59 A.M., showed the 400 hall medication storage room contained one box of Safety Blood Collection Luer Adapters with an expiration date of 1/7/22. 4. Observation on 3/9/23 at 9:15 A.M., showed the 300 hall medication storage room contained: - Two 1.5 oz bottles of saline nasal spray with an expiration date of 7/22; - Four bottles of 36 count Aspirin (to treat pain) 81 milligram (mg) with an expiration date of 11/22; - One bottle of 60 count Cranberry Supplement 425 mg with and expiration date of 11/22. 5. Observation on 3/9/23 at 9:30 A.M., showed the 200 hall medication cart contained one bottle of milk of magnesium with an expiration date of 10/22. During an interview on 3/9/23 at 8:38 A.M., CMT B said expired medication or damaged medication is to be destroyed. If the medication is a narcotic, the director of nursing assists in the documentation and destruction of the medication. During an interview on 3/9/23 at 9:39 A.M., the administrator said expired or damaged medication should be destroyed. During an interview on 3/9/23 at 9:56 A.M., the Director of Nursing (DON) said damaged or out of date medication should be destroyed or returned to the pharmacy if they will except it.

Based on interview and record review, facility staff failed to implement an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 82. 1. Review of the facility's Antibiotic Stewardship policy, undated, showed: -Antibiotic Stewardship Leaders did not include the Infection Preventionist (IP); -Included a system to monitor antibiotic use included antibiotic use and resistance reports; -Establish minimum criteria for prescribing antibiotics; -Develop facility specific standards for empiric antibiotic use, based on data from the facility; -Review antibiotic appropriateness and resistance patterns on a regular basis; -Provide access to individuals with antibiotic expertise for support staff. During an interview on 3/08/23 at 10:28 A.M., the Infection Preventionist (IP) said he/she just started as the IP in January 2023. The IP said facility staff did not follow formal criteria for starting antibiotics. The IP also said he/she did not get monthly antibiotic use reports from the pharmacy and was not tracking antibiotic use in the facility. During an interview on 3/08/23 at 9:55 A.M., the Director of Nursing (DON) said the IP is responsible for the antibiotic stewardship program. During an interview on 3/09/23 at 8:55 A.M., the Administrator said the IP should be tracking bacteria types and sources within the facility. He/she also said the IP is responsible for tracking antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for four (Residents #8, #38, #40 and #193) of five sampled residents. The facility census was 82. 1. Review of the facility's Resident Pneumococcal Immunization Policy, revised 4/27/17, showed the pneumococcal vaccine will be offered to the residents of the facility. Informed consent must be obtained from the resident or responsible representative noting the benefits and complications or side effects. Review also showed the policy did not contain a timeline for pneumococcal immunization. Review of the U.S. Department of Health and Human Services - CDC, pneumococcal and influenza vaccine timing for adults, dated 4/01/2022, showed the following: -Four types of pneumonia vaccines are acceptable for adults 65 years or older. PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13), PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvanc), PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20), and PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax); -For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) you may administer one dose of PCV15 or PCV20. -Regardless of which vaccine is used (PCV15 or PCV20): - The minimum interval is at least 1 year; - Their pneumococcal vaccinations are complete. 2. Review of Resident #8's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/15/23, showed the resident's pneumococcal vaccination is up to date. Review of the resident's medical record showed: -Most recent admission date of 1/11/22; -Received an unknown type of pneumonia vaccine on 7/30/20; -The record did not contain documentation the resident received, refused, or was offered the current pneumococcal vaccine. 3. Review of Resident #38's Quarterly MDS dated [DATE] showed the resident declined pneumococcal vaccination. Review of the residents medical record showed: -Most recent admission date of 11/8/22; -The record did not contain documentation the resident received, refused, or was offered the pneumococcal vaccine. 4. Review of Resident #40's Quarterly MDS dated [DATE] showed the resident's pneumococcal vaccination is up to date. Review of the resident's medical record showed: -Most recent admission date of 3/15/17; -Received an unknown type of pneumonia vaccine on 5/09/17; -The record did not contain documentation the resident received, refused, or was offered the current pneumococcal vaccine. 5. Review of Resident #193's Discharge-Return anticipated MDS dated [DATE] showed the resident declined pneumococcal vaccination. Review of the resident's medical record showed: -Most recent admission date of 8/25/22; -The record did not contain documentation the resident received, refused, or was offered the pneumococcal vaccine. 6. During an interview on 3/08/23 at 10:28 A.M., the Infection Preventionist (IP) said he/she did not know when the pneumonia vaccine was last offered. The IP said he/she had not seen pneumonia vaccines offered since starting work in the facility in September 2022. The IP said he/she reviewed residents pneumonia vaccine status in the medical record by looking at the date given or refused, and looked for Prevnar 13, Prevnar 23 or others within last five years. The IP also said he/she did not know what a current pneumonia vaccination would look like and assumed any pneumonia vaccine in last five years was current. During an interview on 3/09/23 at 8:55 A.M., the Administrator said the pneumonia vaccine was offered annually, usually around October, and he/she thought it was offered last October. The administrator also said the IP is responsible for tracking resident pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility staff failed to protect, label, and date stored food to prevent cross contamination and outdated use; to ensure the ice machine drained through an air gap; and to perform hand hygiene as often as necessary. Facility staff also failed to test the sanitizing solution according to facility policy and to protect stored dishes, silverware, and plastic ware to prevent contamination. This failure had the potential to affect all facility occupants. The census was 82. 1. Review of the facility's Purchasing and Storage: Facility and Resident Food and Supplies policy, undated, showed the policy did not address the storage of food in the kitchen. Observation on 3/5/23 at 10:05 A.M., of the refrigerator in the kitchenette of the main dining room, showed: - Open package of cream cheese in a zipper storage bag, undated; - Open container of grape jelly, undated; - Three pitchers of juice, not labeled and undated; - Open jar of dill pickles, undated; - Open five pound container of cottage cheese, undated; - Open loaf of bread, undated; - Open package of hamburger buns, undated; - Open container of orange juice, undated. Observation on 3/5/23 at 10:10 A.M., of the pantry in the kitchenette of the main dining room, showed: - One bottle, which contained a brown liquid, not labeled and undated; - Open five pound container of peanut butter, undated; - Six open bags of cereal, undated. Observation on 3/5/23 at 10:35 A.M., of the spice rack, showed: - Open container of coffee creamer, undated; - Open box of corn starch, unprotected and undated; - Open box of salt, unprotected and undated; - Open box of baking soda, unprotected and undated; - Open container of parsley flakes, undated; - Open bottle of browning seasoning, undated; - Open bottle of [NAME] cooking wine, undated; - Open bottle of Worcestershire sauce, undated; - Open bottle of vanilla, undated; - Open bottle of lemon extract, undated; - Open container of thyme, undated; - Open container of seasoning blend, undated; - Open container of chili powder, undated; - Open container of bay leaves, undated; - Open container of garlic powder, undated; - Open container of ground mustard, undated; - Open container of ground basil, undated; - Open container of onion powder, undated; - Open container of Italian seasoning, undated; - Open container of ground nutmeg, undated; - Open container of rubbed sage, undated; - Open container of cinnamon, undated; - Open container of garden seasoning, undated; - Open container of poultry seasoning, undated; - Open container of garlic [NAME] sprinkle, undated; - Open container of ground black pepper, undated. Observation on 3/5/23 at 10:50 A.M., of the dry goods storage area, showed: - Bulk granulated sugar with scoop stored in the sugar; - Bulk flour with scoop stored in the flour; - Open bag of brown sugar stored in zip bag, undated; - Open bag of white cake mix stored in zipper storage bag, undated; - Open bag of croutons stored in zipper storage bag, undated; - Five open bags of cereal stored in zipper storage bag, undated; - Open box of farina, not protected and undated; - Open one gallon container of butter flavored oil, undated; - Open one gallon bottle of white vinegar, undated. Observation on 3/5/23 at 11:00 A.M., of the walk-in refrigerator, showed: - Open loaf of bread, undated; - Three open packs of hamburger buns, undated; - One zipper storage bag of sliced tomatoes, undated; - Open 32 ounce package of sliced turkey breast, undated; - One zipper storage bag of lettuce, undated; - Open 10 pound container of macaroni salad with the lid partially opened, undated; - Open container of potato salad, undated; - Open bag of breaded chicken patties, dated 3/2/23, unprotected; - Open container of grape jelly, undated; - A zipper storage bag contained round sliced meat, not labeled and undated; - Open gallon of milk, with best by date 2/25/23, not dated; - A zipper storage bag of bacon, undated. Observation on 3/5/23 at 10:45 A.M., of the pantry, showed an open five pound container of peanut butter, undated. Observation on 3/6/23 at 10:47 A.M., of dry goods storage area, showed: - Bulk granulated sugar with scoop stored in the sugar; - Bulk flour with scoop stored in the flour; - Open bag of brown sugar, undated; - Open bag of white cake mix, undated; - Two open bags of croutons, undated; - Four individual bowls of cereal, undated. Observation on 3/6/23 at 11:10 A.M., of the walk-in refrigerator, showed: - Two small Styrofoam bowls with lids, which contained a yellow substance, not labeled and undated; - One small Styrofoam bowl with lid, which contained a yellow substance, unlabeled; - Open bag of sliced lunch meat, not labeled and undated; - Open block of white sliced cheese, not labeled and undated; - Open bag of white meat chunks, not labeled and undated; - One gallon ziplock bag with bacon slices, undated; - Open bag of bread slices, undated; - Open bag of hamburger buns, undated; - Open bag of hotdog buns, undated. Observation on 3/6/23 at 11:25 A.M., of the pantry in the kitchenette of the main dining room, showed: - Open bag of corn chips undated; - Three open bags of cereal, undated. Observation on 3/6/23 at 12:55 P.M., of the walk-in freezer, showed: - Bag of brown patties, not labeled and undated; - Bag of pork chops, undated; - Bag of meat dated 1/30/23, unlabeled; - Bag of white meat, not labeled and undated; - Bag of broccoli, undated. Observation on 3/6/23 at 1:00 P.M., of the pantry, showed: - Open bag of spaghetti noodles, not protected and undated; - Open container of broccoli and cheese soup mix, undated; - Open 50 pound bag of long grain rice, undated; - Two open bags of corn chips, undated. During an interview on 3/8/23 at 2:19 P.M., the dietary manager said she is responsible to ensure dietary staff follow kitchen policy and procedures regarding food storage. She said the scoops for bulk food should be stored on a hook on the outside of the storage bin. The scoop should not be stored on top of the food product, because it can contaminate the food. She said food in storage should be protected, labeled, and dated to protect it from contamination and outdated use. The dietary manager said the cooks check the food storage areas daily to make sure food is stored properly, and she checks food storage every once in a while when she is doing inventory. The dietary manager said the facility has a policy for food storage, and the dietary staff have been trained on the policy. During an interview on 3/8/23 at 3:02 P.M., the administrator said the dietary manager is responsible to ensure food is stored correctly. The administrator said the facility has a policy on food storage, and the staff have been trained on the policy. The administrator said it is expected the cooks would check food storage every day and correct any items that are not stored according to policy. The administrator said all stored food should be protected, labeled, and dated, and the scoops for bulk food should be stored protected outside the storage container. 2. Review of the facility's policies and procedures showed the facility did not have a policy regarding the ice machine. Observation on 3/5/23 at 11:10 A.M., showed an ice machine, located in the kitchenette off the main dining room, contained a black substance on the top inside of the ice storage bin door. Observation on 3/6/23 at 10:11:30 A.M., showed the ice machine, located in the kitchenette off the main dining room, did not drain through an air gap. Observation of the ice storage bin inside the ice machine showed a black substance along roof of the storage bin. Observation also showed an accumulation of trash under the ice machine drain pipe which prevented the ice machine from draining properly. Further observation showed a clear sludge type substance hung out of the pipe and onto the trash, and the bottom ¼ inch of the pipe covered with a black substance. During an interview on 3/8/23 at 2:19 P.M., the dietary manager said the facility does not have a policy regarding the ice machine. She said the dietary staff clean the outside of the ice machine and sweep the floor under the machine daily. An outside company cleans the inside and performs maintenance on the machine, but she does not know how often. The dietary manager said the ice machine is used for the residents, and it should drain through an air gap. During an interview on 3/8/23 at 3:02 P.M., the administrator and the maintenance director said maintenance director is responsible to ensure the ice machine is inspected and maintained according to code. The maintenance director checks the ice machine every two months and cleans the filer and coils. He does not check to ensure the air gap is maintained. The administrator and the maintenance director said the facility does not have a policy for the ice machine, but the machine should drain through an air gap according to regulations. 3. Review of the facility's handwashing policy, dated January 2018, showed employees are to wash their hands after touching body parts, handling soiled equipment, when changing tasks, before donning gloves, after engaging in any activity or task which contaminates their hands, and as much as possible during food preparation to remove soil and contamination and to prevent cross contamination. Observation on 3/6/23 at 9:55 A.M., showed [NAME] X prepared food for the resident's lunch. The cook touched his/her facemask with his/her bare hand to the front of the facemask and then touched various food related items. [NAME] X did not wash his/her hands after he/she touched his/her facemask and before he/she touched food related items. Observation on 3/6/23 at 10:18 A.M., showed the activity director (AD) entered the kitchen, touched the ice scoop and sink faucet handle. The AD did not wash his/her hands after he/she entered the kitchen and before he/she touched various kitchen equipment. Further observation showed various dietary staff touched the unsanitized ice scoop and faucet handle. Observation on 3/6/23 at 10:27 A.M., showed Volunteer Y touched his/her hair with his/her bare hands. Further observation showed the volunteer touched the ice scoop and the mouth area of resident cups. The volunteer did not perform hand hygiene after he/she touched his/her hair and before he/she touched the ice scoop and the resident cups. During an interview on 3/8/23 at 2:19 P.M., the dietary manager said the facility has a policy regarding handwashing in the kitchen, and the staff have been trained on the policy. She said it is expected staff would perform hand washing when they enter the kitchen and after touching their hair or face masks. The dietary manager said dietary staff should remind other staff and volunteers to wash their hands as often as necessary. During an interview on 3/8/23 at 3:02 P.M., the administrator said it is expected staff would wash their hands when they enter the kitchen and after they touch their body, to include their hair and face mask. He said the facility has a policy for hand washing in the kitchen, and the staff have been trained on the policy. 4. Review of the facility's Warewashing and Storage policy, dated January 2019, showed: - All dinnerware, utensils, preparation, and service supplies shall be washed and sanitized according to food safety practices and regulatory guidelines; - The dish machine, if low temperature, shall use a detergent, a rinse drying agent, and sanitizer; - Test strips shall be available for the pot sink and low temp dish machine sanitizer. Results shall be checked and recorded daily. Observation on 3/5/23 at 10:30 A.M., showed the dishwasher sanitizer test strips expired in 2022, and the three compartment sink sanitizer test strips expired in 10/2022. Observation on 3/6/23 at 10:00 A.M., showed the dish washing machine used low temperature and sanitizing agent to clean and sanitize the dishes. The manufacturer's instruction label on the dishwashing machine read wash temperature 120° Fahrenheit (F), rinse temperature 120° F, and chlorine sanitizer at 50 parts per million (ppm). Further observations showed the dishwashing area did not contain any sanitizer test strips. During an interview on 3/8/23 at 2:19 P.M., the dietary manager said the dishwashing machine used low temperatures and a sanitizing agent to clean and sanitize the dishes. She said the facility had expired test strips, and they threw them away. She called the outside dishwasher service company, but they have not brought any sanitizing strips to the facility. The dietary manager said she ordered some from the food vendor, but the test strips will not arrive until the next food delivery in a couple days. She said it is expected the staff test the sanitizing solution daily, but they cannot do it without the strips. The facility has a policy for the dishwasher, and the staff have been trained on the policy. During an interview on 3/8/23 at 3:02 P.M., the administrator said the dishwasher uses low temperatures and a sanitizing solution, and the staff should use test strips to test the solution daily. The administrator said the dietary manager should monitor the test strips and order them as needed. He said he was not aware the facility did not have any test strips. The administrator said it is expected staff would tell him, because the test strips can be bought locally. 5. Review of the facility's Warewashing and Storage policy, dated January 2019, showed the policy did not address protecting stored dishes, silverware, and plastic ware. Observation on 3/6/23 at 11:00 A.M., showed: - Two stacks of small plates, two stacks of clear bowls, one stack of small white bowls, and one stack of medium white bowls stored on the bottom shelf of the steam table, not inverted and unprotected; - Plastic ware and silverware stored unprotected on a table near the pantry. During an interview on 3/8/23 at 2:19 P.M., the dietary manager said plates and bowls should be covered when not in use. Silverware should be stored with the handles up, and the bag which contains plastic ware should be closed when not in use. She said the facility had a policy, and the staff have been trained on the policy. During an interview on 3/8/23 at 3:02 P.M., the administrator said the dietary manager is responsible to ensure the dishes are stored in a manner that prevents contamination. He said the facility has a policy, and the staff are trained on the policy. The administrator said it is expected plates, bowls, and silver/plastic ware are stored inverted and protected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to maintain a clean blood glucose meter (device used to obtain a blood sugar reading) between two residents (Resident #49 and #195) and failed to use hand hygiene, change gloves, and wiped multiple times with the same area of a wipe/gauze during perineal care and wound care in a manner to reduce the risk of infection for one resident (Resident #23). Additionally, staff failed to ensure all employees were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per the facility policy for ten out of ten sampled employees (Dietary Aide (DA) G, Certified Nurse Assistant (CNA) H, CNA I, Activities Director, CNA J, Activity Aide (AA) K, DA L, Maintenance Director, Licensed Practical Nurse (LPN) M, and DA N). Facility staff failed to follow infection control protocols, for Coronavirus Disease 2019 (COVID-19), when staff failed to wear facemasks that covered the nose and mouth, failed to implement an infection surveillance program that included tracking of organisms responsible for infections, and failed to review their Infection Prevention and Control Program (IPCP) on an annual basis. The facility census was 82. 1. Review of the Centers for Disease Control and Prevention (CDC) Infection Prevention during Blood Glucose Monitoring and Insulin Administration dated 2/6/13 provided by the facility, showed: -Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared; -An underappreciated risk of blood glucose testing is the opportunity for exposure to blood borne viruses through contaminated equipment and supplies if devices used for testing are shared; -Unsafe practices during assisted monitoring of blood glucose that have contributed to transmission of virus's or have put persons at risk for infection include using a blood glucose meter for more than one person without cleaning and disinfecting it between uses. Review of the facility's Sanitizing Multi-Use Equipment and Surface Area's policy, undated showed: -Sani-cloth (purple top) multi-purpose cleaner and sanitizer will be used for sanitizing multi-use equipment and surface areas; -Sani-cloth will be used per instructions on the packaging; -Sani-cloth is effective on all surface areas, and may be used on equipment including but not limited to lifts, gait belts, tables, medication carts, etc. Review of the G2 glucometer manual, dated 2017, showed: -Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface; -Inspect for blood, debris, dust, or lint anywhere on the meter or lancing device; -To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port; -Do not use glass or household cleaners on the meter or the lancing device; -Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use; -Wipe meter dry or allow to air dry. Review of the Sani-cloth General Guidelines for Use, dated 2022, showed: -Use a wipe to remove visible soil prior to disinfecting; -Unfold a clean wipe and thoroughly wet surface; -Allow treated surface to remain wet for two minutes and let air dry. Observation on 3/7/23 at 7:56 A.M., showed Certified Medication Technician (CMT) F took the blood glucose meter, finger stick device, and alcohol pad into Resident #49's room and placed them on the resident's over bed table. He/She washed his/her hands and placed the glucose meter on the resident's lap. He/She obtained the blood sample and returned the meter to the resident's lap while he/she cleaned the resident's finger of residual blood. The CMT placed the glucose meter on top of the sink in the resident's room, washed his/her hands, placed the glucose meter on top of the medication cart and did not clean the glucose meter. Observation on 3/7/23 at 8:31 A.M., showed CMT F took the same glucose meter from the top of the medication cart, a finger stick device, and alcohol pad into Resident #195's room and placed them on the resident's over bed table. He/She washed his/her hands and placed the glucose meter on the resident's bed. The CMT obtained the blood sample, then placed the blood glucose meter on the over bed table. He/She washed his/her hands, placed the meter on top of the medication cart and did not clean the glucometer. During an interview on 3/7/23 at 9:06 A.M., CMT F said he/she should wipe the meter down with a disinfecting wipe then let it set in the wipe for 30 seconds. He/She said the meter should air dry before using on another resident to decrease risk of infections and he/she was nervous. During an interview on 3/9/23 at 9:14 A.M., CMT B said staff are encouraged to use two glucometers, one to use and one to air dry. He/She said staff are directed to use a disinfecting wipe on the blood glucose meters when finished obtaining a reading and before taking another from a different resident. CMT B said if staff does not clean the blood glucose meters, there is a risk of spreading infection. During an interview on 3/9/23 at 9:51 A.M., the Minimum Data Set (MDS) nurse said glucometers (blood glucose meters) should be cleansed after each resident and before the next resident using a disinfectant wipe and air dry for at least one minute. He/She said failure to clean the glucometer could result in spreading of germs. During an interview on 3/9/23 at 10:24 A.M., LPN C said glucometer's should be cleaned between residents using a disinfectant wipe and air dried at least 30 seconds, then wipe it with a dry cloth. He/She said it would be better if staff would use two meters, one to use and one to air dry. During an interview on 3/9/23 at 11:03 A.M., the Director of Nursing (DON) said glucometer's should be cleansed between residents by the person checking the blood. He/She said disinfectant wipes should be used and the meter air dried before using or risk the spread of infection or germs. 2. Review of the facility's Infection Control and Prevention policy, undated showed: -Observe standard precautions; -Wash hands before and after procedures; -Wash hands before and after resident contact; -Maintain sterility or cleanliness of equipment and working field as necessary; -Wash hands before and after resident contact (i.e. meds, treatments, care) and whenever visibly soiled; -Wash hands or perform hand hygiene after gloves are removed. Review of the facility's Infection Prevention and Control Program, dated August 2021, showed: -Staff must provide hand hygiene before and after contact with resident; -Before performing an aseptic task; -After contact with blood, bodily fluids, visibly contaminated surfaces or after contact with objects in the resident's room; -After removing personal protective equipment (PPE) (e.g. gloves, gown, facemask); -Gloves are to be worn before and after contact with blood or body fluid, mucous membranes, or non-intact skin; -Gloves are to be changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care; -Gloves are to be discarded followed by hand hygiene before leaving a resident's room. Review of the facility's Handwashing/Perineal Care/Incontinent Care in-service training, dated December 2022, showed: -Wash hands, apply gloves and follow standard precautions; -Wash genital area, moving front to back, while using a clean area of the washcloth for each stroke; -Using a clean washcloth, rinse soap from genital area, moving from front to back, using a clean area of the cloth for each stroke; -Do not touch any clean linen with soiled gloves; -Remove gloves and wash hands. Review of the facility's Pericare policy, dated January 2017, showed: -Wipe the genital area from front to back, rotating disposable wipe between each wipe; -Remove gloves and wash hands; -Wipe the rectal area from front to back, rotating disposable wipe between each wipe; -Remove gloves, wash hands, reapply gloves; -Apply barrier cream and assist to comfortable position; -Remove gloves and wash hands. Review of the facility's Prevention of wounds and wound care policy, dated November 2019, showed it did not contain direction for wound care or wound care protocol. Observation on 3/6/23 at 8:11 A.M., showed CNA O and CMT F entered Resident #23's room to provide care. CNA O did not perform hand hygiene or change his/her gloves after he/she transferred the resident to bed with a mechanical lift or before he/she provided perineal care. He/She did not change the position of the wipe with each swipe when he/she cleaned around the resident's buttock dressing. With the same gloves, CNA O rolled the resident to his/her back, grabbed a foam wedge cushion, and handed it to CMT F who placed it behind the resident's back, placed a pillow on the opposite side of the resident, cleaned the resident's inner thighs and genitals and did not use a clean area of the wipe for each stroke. CNA O hooked the catheter to the bed and lowered the bed to the floor. CNA O and CMT F removed their gloves. CMT F gathered the soiled linens and trash and left the room and did not wash his/her hands. During an interview on 3/6/23 at 8:22 A.M., CNA O said he/she should have washed his/her hands after putting the resident to bed, when taking his/her gloves off, and after perineal care. He/She said he/she did not think about it and was taught when providing perineal care to rub the same area multiple times with a wipe. Observation on 3/6/23 at 8:53 A.M., showed LPN M and CNA O entered the room to provide wound care on Resident #23. LPN M did not wash his/her hands before he/she applied gloves. He/She removed the dressing from the resident's left toe, left inner ankle, and right shin, discarded the old dressings, removed his/her gloves and applied new gloves and did not perform hand hygiene between glove changes. He/She cleansed the right shin with wound cleanser and gauze pad, discarded the gauze pad. The LPN cleansed the left toe and left inner ankle with the same gauze pad. The LPN did not change his/her gloves after he/she provided wound care or before he/she applied the new dressings to the left toe, left inner ankle and right shin. He/She removed his/her gloves gathered the trash and left the room for more supplies and did not perform hand hygiene. The MDS nurse and LPN entered the room and did not wash their hands before they applied gloves. LPN M placed the supplies at the foot of the bed while CNA O and the MDS nurse positioned the resident exposing the right hip. LPN M removed the right hip dressing, removed his/her gloves and applied new gloves and did not perform hand hygiene between glove changes. He/She cleansed the wound with the same area on and inside the wound. He/She did not change his/her gloves or perform hand hygiene before he/she applied a new hip dressing. LPN M sprayed wound cleanser directly into the coccyx (tailbone) wound and patted dry with a gauze pad multiple times with the same area of the gauze pad, removed his/her gloves and applied new gloves and did not perform hand hygiene. He/She applied the dressing to the wound, removed his/her gloves, and took leftover supplies to the treatment cart outside the resident room and did not perform hand hygiene. CNA O positioned the resident and lowered the bed to the floor. During an interview on 3/6/23 at 8:51 A.M., LPN M said staff are directed to change gloves and wash hands from dirty to clean areas, between glove changes and before and after care is given. He/She said they were trying to hurry due to the resident has history of restlessness and agitation when he/she is messed with much. During an interview on 3/9/23 at 11:03 A.M., the DON said staff are directed to wash their hand between glove changes, before and after care of the resident, between clean and dirty tasks. 3. Review of the facility's policy Purified Protein Derivative (PPD-used in a skin test to help diagnose tuberculosis infection in persons at increased risk of developing active disease) Administration-Employees, dated December 18, 2015, showed the following: - When an employee accepts a position with the facility they must be brought to a licensed Clinical Manager or the Clinical Manager Coordinator to have a tuberculosis (TB) test administered. This is step 1 of Tuberculin Skin Test (TST). The employee must have the results read within 48-72 hours of receiving the TB test. The employee may not work until 1st step has been completed. Within 1-3 weeks of employee receiving the 1st step TST, a 2nd step TST must be completed and read within 48-72 hours. Current employees who have a step 2 on file will receive the annual TST in January. Review of DA G's employee file showed the following: - Hire date of 1/13/20; - Staff did not document they administered any PPD. Review of CNA H's employee file showed the following: - Hire date of 7/21/22; - Staff did not document they administered any PPD. Review of CNA I's employee file showed the following: - Hire date of 9/16/21; - Staff did not document they administered any PPD. Review of the Activity Director's employee file showed the following: - Hire date of 5/20/21; - Staff did not document they administered any PPD. Review of CNA J's employee file showed the following: - Hire date of 5/5/22; -Staff did not document they administered any PPD. Review of AA K's employee file showed the following: - Hire date of 8/17/22; -Staff did not document they administered any PPD. Review of DA L's employee file showed the following: - Hire date of 12/2/22; -Staff did not document they administered any PPD. Review of the Maintenance Director employee file showed the following: - Hire date of 9/27/22; -Staff did not document they administered any PPD. Review of LPN M's employee file showed the following: - Hire date of 12/31/22; -Staff did not document they administered any PPD. Review of DA N's employee file showed the following: - Hire date of 3/24/22; -Staff did not document they administered any PPD. During an interview on 3/9/22 at 10:00 A.M., the Medical Records Director said he/she was aware of the requirement for employee testing, but did not know where the results were for testing prior to their employment. During an interview on 3/9/22 at 10:15 A.M., the administrator said a past employee that was responsible for the documentation of employee testing misplaced the records. The administrator added that he/she was aware of the requirement to test new employees in a timely manner. 4. Record review of the CDC website, updated 09/23/2022, showed the following: -When SARS-CoV-2 Community Transmission levels are high, source control (use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing) is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. Review of the facility's Infection Prevention and Control Program, dated August 2021, showed when not experiencing an outbreak, it's recommended for all staff and visitors to wear surgical masks or equivalent when in areas of the facility when in resident contact. Further review showed the policy did not direct staff on how to wear the facemask. Review of the facility's community transmission level showed the level was high. Observation on 3/5/23 at 9:30 A.M., showed Nurse Aide (NA) D answered the front door, walked past residents in the hall, resident rooms that had the door open, and to the dining area with his/her mask off. Observation on 3/5/23 at 9:36 A.M., showed the Assistant Director of Nursing (ADON)'s face mask did not cover his/her nose during medication administration to an unknown resident. Observation on 3/5/23 at 11:17 A.M., showed CNA A entered Resident #45's room to provide care to the resident with his/her mask under his/her nose. Observation on 3/5/23 at 11:49 A.M., showed NA D wheeled an unidentified resident to the dining room and his/her mask did not cover their nose. Observation on 3/5/23 at 12:07 A.M., showed CNA A entered the dining room and sat down with two residents with his/her mask under his/her nose. Observation showed the CNA A pull the mask below his/her the chin to talk to Resident #23 within a 6 foot distance, then put the mask up below the nose. Observation on 3/5/23 at 12:16 P.M., showed CNA A pull his/her mask down below his/her chin to talk to another staff member while he/she fed a resident. He/She returned the mask over the his/her mouth, but under the nose. Observation on 3/5/23 at 1:49 P.M., showed Housekeeper P enter resident room [ROOM NUMBER] with his/her mask under his/her nose. Observation on 3/6/23 at 12:14 P.M., showed the DON sat with Resident #56 at the dining room table. The DON pulled down the facemask under his/her chin to talk to resident. Observation on 3/9/23 at 8:18 A.M., showed CNA A sat at the dining room table with his/her mask under his/her nose and chin while he/she fed an unidentified resident. Observation on 3/9/23 at 10:22 A.M., showed CNA A in Resident #45's room with his/her mask under his/her chin to provide care. During an interview on 3/9/23 at 8:30 A.M., CNA A said staff should always wear a mask. He/She said occasionally they need to pull the mask down because they have difficulty breathing. CNA A said it is policy, so we need to wear them to decrease spread of bacteria and germs. During an interview on 3/9/23 at 9:14 A.M., CMT B said staff should always keep a mask on so disease is not spread from one person to another and should cover the nose and mouth. During an interview on 3/9/23 at 10:24 A.M., LPN C said all staff should be wearing a surgical mask unless the facility is in outbreak for COVID-19, then an N95 mask or respirator is required. He/She said the mask should cover the nose and mouth to decrease risk of spreading germs and bacteria to other residents, staff and/or visitors. During an interview on 3/9/23 at 11:03 A.M., the DON said staff are to wear surgical masks at all times except when on break. He/She said the masks should cover the nose and mouth to decrease spread of bacteria. 5. Review of the facility's Infection Prevention and Control Program, revised 8/18/21, showed: -The facility will maintain an infection prevention and control program in order to maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -The infection prevention and control program follows national standards and guidelines and contains a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff and visitors; -Data analysis, documentation, and reporting: The facility will gather and analyze data to properly identify communicable diseases or infections to reduce/eliminate the spread of communicable diseases/infections; -The facility will conduct an annual review of its IPCP and update their program, as necessary, in order to ensure effectiveness and that they are in accordance with current standards of practice for preventing and controlling infections; -The facility did not document they updated the IPCP on an annual basis. During an interview on 3/08/23 at 10:28 A.M., the Infection Preventionist (IP) said he/she started as the IP in January and kept track of infection types, but did not track bacterial sources of infections. The IP said infection related lab reports were faxed to the doctor and placed in the residents' records and he/she did not always see them. The IP also said he/she did not receive monthly lab reports summarizing bacteria types in the facility. The IP did not know how many residents in the facility had active infections. During an interview on 3/08/23 at 9:55 A.M., the DON said the IP is responsible for ensuring the Infection Prevention and Control Program meets standards and is reviewed when required. During an interview on 3/09/23 at 8:55 A.M., the Administrator said the IP should be tracking bacteria types and sources within the facility. He/She also said the IP is responsible for tracking antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility staff failed to prevent the misappropriation of one resident's (Resident # 143) narcotic medication, which was taken without authorization of the resident or the resident's responsible party. On 8/2/19, Certified Medication Technician(CMT) P took narcotic medication belonging to Resident #143, and administered a non-narcotic medication(Tylenol). The facility census was 61. 1. Review of the facility's Abuse Prohibition Policy, dated 12/14/2018, showed the policy defined misappropriation of resident's property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 2. Review of Resident #143's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/10/2019, showed staff assessed the resident with no cognitive or memory concerns(score of 15 out of 15). 3. Review of the facility investigation report dated 9/3/19 showed; -The Director of Nursing(DON) was notified at 7:52 PM on 9/2/19 by a charge nurse that Resident # 1 reported CMT A had administered her Tylenol 650 milligrams(mg) instead of a resident requested and physician ordered Norco(Hydrocodone/Tylenol) 5/325 mg. The CMT did not ensure the resident took the medication and the resident brought the medication to the charge nurse who verified the medication to be Tylenol 650 mg and not Norco. -The administrator and physician were notified and the physician provided orders to replace and administer the stolen Narco from the facility emergency kit. -On 9/3/2019 the CMT consented to a drug screen which was performed and read by the DON and verified by the former administrator. The results showed the CMT tested positive for opiods. -The CMT was asked if she had taken the Norco intended for the resident and admitted to did take the medication. Both the DON and the former administrator witnessed the CMT's acknowledgement of taking the resident's medication. -The administrator notified the [NAME] Police Department and officer #883 generated report # 19024915. 4. Review of the resident's POS dated 9/2019 showed staff are directed to provide Norco 5/325 mg tablet by mouth three times a day as needed for pain. 5. Review of the resident's Medication Administration Record(MAR) dated 9/2/19 at 6:48 PM showed CMT A documented he/she administered Narco 5/325 mg. 6. In a statement dated 9/3/19 Charge Nurse B confirmed that the CMT did sign out in the computer that the Norco was given at 6:48 PM and signed out in the narcotic count book that the narcotic medication administered for the scheduled 8:00 PM time. 7. During a interview on 9/16/2020 Officer #883 reported that charges had been filed for the theft of the narcotic medication and referred to the [NAME] County Prosecutor. 8. During an interview on 9/16/2020 at 4:00 PM the administrator/former DON said the CMT A admitted to taking the resident's Narco and substituting Tylenol to the resident, that the CMT tested positive for opiates when specimen obtained, and was terminated on 9/3/2019. MO001175300

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #55) received care, consistent with professional standards of practice, and received services to promote healing of a pressure injury that was identified on admission, and progressed to a stage IV pressure ulcer. Furthermore, the facility failed to notify the resident's physician of the pressure injury upon admission, failed to provide treatments as ordered by the physician, and failed to transcribe treatments in a timely manner. Furthermore, staff failed to follow infection control practices during a wound treatment to prevent possible infection. The facility census was 88. 1. Review of Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, defined the following: -Pressure ulcer/injury: localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear (friction plus the force of gravity on a person's body causing skin damage). The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful; -Stage 1 pressure injury: an observable, pressure-related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching) and/or a defined area of persistent redness; -Stage 2 pressure ulcer: partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or bruising. May also present as an intact or open/ruptured blister; -Stage 3 pressure ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss; -Stage 4 pressure ulcer: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be present on some parts of the wound bed; -Unstageable pressure ulcer: Known but not stageable due to coverage of the wound bed by slough and/or eschar. 2. Review of the facility's Pressure Ulcer, Care and Prevention policy from Nursing Guidelines and Protocol Manual, dated April 2006, showed staff are directed as follows: -Treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Follow skin care protocol; -Observe skin. A persistent reddened area that remains after pressure is a high risk area for a pressure ulcer to begin; -Apply skin lotion gently to dry skin; -Change bed linen promptly whenever wet or soiled; -Keep sheets dry, free of wrinkles and free of debris; -Use pressure-reducing devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominences; -Active and passive range of motion may be ordered by the physician to improve circulation (gentle movement of the joints); -Whenever possible, teach the resident to change his/her own position at regular intervals and shift his/her weight in the wheelchair; -Assist resident at mealtime to assure adequate nutrition; -And offer fluids frequently for adequate hydration. 3. Review of Resident #55's entry tracking record showed the resident was admitted on [DATE] from an acute care hospital. Review of the resident's nurse's notes, dated 12/24/19, showed facility staff documented the resident arrived to the facility via facility transport from the hospital at approximately 1:10 P.M. The resident's bottom was red and had some shearing. A Calmoseptine treatment (a cream moisture barrier used to keep feces, urine, and wound drainage from intact and injured skin) was in place. Further review showed the nurse's note did not contain measurements of the redness or shearing, if the redness was blanchable or non-blanchable, or if the wound nurse or physician were notified of the area. Review of the resident's, December 2019, Medication Administration Record (MAR) showed an order, dated 12/24/19, for Calmoseptine 0.44%-20.625% ointment to be Applied topically two times per day to bottom for diagnosis of bilateral (pertaining to both sides) primary osteoarthritis (protective cartilage between bones has worn down) of hip. Review of the resident's care plan, dated 12/24/19, showed staff were directed as follows: -Skin breakdown: at risk for/actual as evidenced by occasional incontinent, decreased movement of right and left lower extremity, rash, wound (pressure, diabetic, or stasis) yes, bruise/discolored, heel discoloration; -Goals: will maintain clean and intact skin & measures will be taken to prevent skin breakdown; -Interventions: -Apply protective or barrier after incontinence; -Assist to turn and reposition frequently; -Condition of each area of skin breakdown to be documented with every treatment and/or dressing change; -Dietician referral as needed; -Inspect skin head to toe every week and document results; -Keep skin clean, dry, and free of irritants; -Notify the physician of any worsening of skin breakdown; -Position with pads and pillows to prevent pressure; -And treatments and dressings as ordered. Review of resident's History and Physical (H&P) completed by his/her Family Nurse Practitioner (FNP), dated 12/27/19, showed the resident was assessed as follows: -Diagnoses included osteomyelitis (infection of the bone) of left heel, history of colon cancer, ulcer of the left foot, and chronic nonmalignant pain (pain persisting beyond the expected normal healing time for an injury); -Current Medications included Calmoseptine 0.44-20.625% ointment as directed. Review showed the H&P did not identify an area of skin breakdown to the resident's buttocks. Review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required supervision with bed mobility; -Required limited assistance of one staff for transfers, ambulation, and toilet use; -Was Always continent of urine; -Was occasionally incontinent of bowel; -Had no unhealed pressure ulcers; -Did not require pressure reducing devices on the bed or in the chair; -Had no applications of ointments/medications; -And did not reject evaluation or care. Review of the resident's skin data sheet, dated 12/26/19, showed staff documented the following: rash/redness was marked yes and the location was on the resident's buttock/coccyx (tailbone area). Further review showed it did not include any measurements or a description/assessment of the area. Review of the nurses's notes for 12/26/19, showed they did not contain an assessment or description of the rash/redness that was identified on the resident's buttock/coccyx. Review of the resident's nurse's note, dated 1/7/20 showed facility staff documented the following: -The resident was not feeling well that shift. [NAME] was applied to the resident's buttocks. The resident complained of pain to buttocks. Further review showed the nurse's note did not contain an assessment of the resident's buttocks/coccyx. Review of the resident's nurse's note, dated 1/8/20 showed the resident's physician made rounds. New orders were received to discontinue Flexeril (muscle relaxant) and for podiatry to evaluate the resident's left foot wound. Further review showed the nurse's note did not contain documentation in regards to the resident's skin breakdown to his/her coccyx, or that the physician was notified of the area of breakdown. Review of the resident's skin data sheet, dated 1/10/20, 15 days after the last skin data sheet was completed, showed staff documented the following: rash/redness was marked yes and the location was on the resident's buttock/coccyx. Further review showed it did not contain any measurements or description of the area. Review of the resident's nurse's notes, dated 1/16/20, showed staff documented the resident had an open area on his/her coccyx. Further review showed the wound nurse assessed the area and documented a treatment was in place to apply [NAME] to the open area. Review of the resident's wound report, dated 1/16/20, showed staff documented the following: -Stage II pressure injury (partial thickness loss of skin presenting as a shallow open ulcer with a red-pink wound bed, without slough, bruising, granulation, or eschar) on his/her coccyx measuring 3 centimeters (cm) x 2.5 cm. Zero depth, pain, or drainage. Wound base was covered with epithelial tissue (new skin that is light pink and shiny). Further review showed the assessment did not contain an assessment of the periwound (the skin around the wound). Additional review showed the report with measurements was completed 23 days after the resident was admitted with an area to his/her buttocks/coccyx and did not contain directed documentation in regards to whether the resident utilized an air bed, or if the family and physician had been notified. Review of the resident's January 2020 treatment administration record (TAR)/MAR showed the following: -On 1/16/20, a new, second order for [NAME]: apply to open area on coccyx every shift until healed. Review of the resident's Nutrition Therapy Assessment, dated 1/16/20, completed the Registered Dietician (RD) showed the resident was assessed as follows: -Regular diet; -Pressure ulcer; -Weight loss since admission with consideration to dependent edema (swelling in the extremities); -Diagnosis, medication, and diet intolerance considerations; -Would provide 60 milliliters (mls) Med Pass supplement twice a day for 30 days. During an interview on 10/2/20 at 2:50 P.M., the RD said he/she did not have the coccyx wound in his/her notes for 1/16/20, and did not add it to his/her assessment until 2/17/20 when she was aware of the wound. Review of the resident's, January 2020, MAR showed on 1/22/20, a new order was added for Adult Nutritional Supplement oral liquid 60mls by mouth twice a day before meals for 30 days. Further review showed the order was transcribed six days after the supplement had been recommended by the RD. Review of the resident's wound report dated 1/22/20 showed staff documented the following: -Stage II pressure injury on his/her coccyx measured 0.9 cm x 0.9 cm. Zero depth, pain, or drainage. Wound base was covered with epithelial tissue. Further, review showed the wound assessment did not contain an assessment of the periwound (the skin around the wound). Review of the resident's wound report dated 1/28/20 showed staff documented the following: -Stage II pressure injury on his/her coccyx measuring 2.5 cm x 2 cm, improved. Zero depth, pain, or drainage. Wound base was covered with epithelial tissue. Further review showed the wound had increased in size by length and width since previous assessment on 1/22/20, and did not contain an assessment of the peri-wound. Additional review, showed the medical record did not contain documentation that the physician was notified the wound had gotten larger. Review of the resident's nurse's note, dated 2/5/20, showed the FNP provided an order for duoderm (a dressing with gel-like properties that absorb drainage, protect the wound, and assists in breaking down dead tissue in the wound) to the open area on coccyx and it was to be changed every other day and as needed (PRN). Review of the resident's February 2020 TAR/MAR showed: -On 2/5/20, a new order for Duoderm to open area on coccyx every other day and PRN, and was scheduled for odd days; -And weekly skin assessment by RN/LPN every Wednesday on the day shift. Further review showed it did not contain documentation that staff changed the Duoderm to the resident's coccyx per the physician's order on 2/5/20, 2/7/20, 2/11/20, and 2/17/20. Review of the resident's wound report, dated 2/6/20, showed staff documented the following: Stage II pressure injury on his/her coccyx measuring 1.5 cm x 2 cm, deteriorated. Zero depth or pain. Light amount of yellow drainage. The wound base was covered by granulating tissue (red tissue with bumpy appearance (tissue that is present in Stage III and Stage IV pressure injuries)). Review of the resident's medical record showed a fax received from the resident's FNP, dated 2/10/20 at 4:52 P.M., with an order for Santyl (a gel used as enzymatic debridement (removal of dead tissue)) and calcium alginate (wound dressing used to absorb drainage) to his/her sacrum (coccyx area) daily and cover with a dry dressing. Further review showed this order was obtained four days after staff documented the wound to the resident's coccyx had deteriorated. Review of the resident's wound report, dated 2/12/20, showed a Stage II pressure injury on his/her coccyx measuring 3.5 cm x 3.9 cm x 0.1 cm, deteriorated. Zero pain. Light amount of yellow drainage. The wound bed was covered by eschar (dead tissue that is hard or soft in texture and is usually black, brown, or tan in color, and may appear scab-like in Stage III, Stage IV, and unstageable pressure injuries). Further review of the wound report did not contain documentation that the physician was updated in regards to the change in the resident's wound and did not contain an assessment of the peri-wound. Review of the resident's nurse's notes, dated 2/17/20 at 4:07 P.M., showed new orders were received from the resident's FNP to apply Santyl and calcium alginate to the sacrum and cover with a dressing daily. The resident's spouse was made aware and wanted the resident to be seen by the wound physician. Review of the resident's MAR/TAR dated, February 2020 showed the following: -2/17/20 Duoderm was discontinued; -2/17/20, Every morning cleanse sacral wound, apply Santyl 250 unit/g ointment, calcium alginate to fit wound bed and cover with dry dressing; -2/17/20, Continuous upon rising, make sure cushion in recliner in room for pressure ulcer of sacral region, Stage 2. Review showed the MAR/TAR did not contain the Santyl and Calcium Alginate order from the FNP for seven days after the order was received. Review of the resident's Specialty Physician Initial Wound Evaluation and Management Summary, dated 2/19/20, showed: -An unstageable pressure wound (pressure ulcer tissues are obscured such that the depth of soft tissue damage cannot be observed) on the sacrum due to necrosis (dead tissue); -Wound size was 5.2 x 3.9 x 0.1 cm; -Periwound (area around the wound) radius had erythema, odor, and mild green drainage; -The wound bed was 60 percent slough, 30 percent granulation tissue, and 10 percent skin; -Treatment was changed to Santyl, apply once daily for 30 days and alginate calcium apply once daily for 30 days; -He/she develops pain during bed mobilization and seating. He/she ambulates with the walker but the wound is affecting his/her activities of daily living. Review of the resident's nurse's notes by the DON, dated 2/26/20 at 2:23 P.M., showed the resident was admitted with osteomyelitis of the left foot and now had a pressure ulcer on his/her coccyx. The resident was slightly confused and was independently ambulatory. He/she had a recliner in his/her room with a cushion in place. The resident had been educated to off load pressure to his/her sacrum, as to which he/she was compliant. The resident and spouse agreed to a low airloss mattress. Due to the size and worsening of the wound, the resident began seeing the wound care physician who recommended a pelvis X-ray AP and lateral to rule out any secondary causes of the wound as the resident had multiple surgeries in that area including hip, pelvis and non-working pain device. Review of the resident's care plan, dated 9/14/20 showed: -Onset 2/27/20, wound related to pressure as evidenced by wound on sacrum; -Goal: I have a wound. Please assist me to promote healing; -Interventions: Educate the resident on how to offload pressure to the site. Inform the physician of worsening condition. Low air loss mattress. Measure wound weekly. Medications and treatments as ordered. Wound consult as necessary; -The care plan did not indicate the resident refused care or direct staff on what to do if the resident did refuse care. Review of the resident's sacrum/coccyx x-ray, dated 2/28/20, showed questionable subtle bone loss of the dorsal (rear) aspect of the sacrum/coccyx. Soft tissues appear swollen with ulceration dorsally. Conclusion: cannot exclude osteomyelitis, recommend Magnetic Resonance Imaging (MRI) (further imaging to show structures in a clearer view) workup. Review of the resident's bone scintigraphy (three phase) with spect (images obtained detect changes in hard to see bones, tumors or blood flow tumors), dated 3/11/20, showed: -Diffuse increased uptake in the inferior sacrum/coccyx on the delayed SPECT could reflect underlying osteomyelitis in the correct clinical setting. Observation on 9/17/20 at 9:25 A.M. showed the resident standing in his/her room with the use of a walker. Licensed Practical Nurse (LPN) J assisted the resident to pull his/her pants down past his/her hips. LPN J removed the resident's sacral dressing. The dressing had a moderate amount of yellow drainage that had seeped through to the outside. LPN J cleansed the sacral pressure ulcer with gauze pads and wound cleanser. With the same gloves on, LPN J applied Iodosorb (a gel used to promote wound healing), Calicium Alginate (absorbent dressing derived from seaweed), 4 x 4 gauze pads and a boarder gauze. During an interview on 9/21/20 at 3:30 P.M. the DON said the facility used A & D ointment for preventative wound care and used Calazime if an area was red or had open areas. The charge nurse gets an order for the Calazime. She did not have a policy that showed when to use the A&D vs the Calazime. The resident initially would refuse to sleep in the bed and slept in a recliner. The resident had an air mattress at different times but he/she did not know the dates the resident was on the air mattress. During an interview on 9/21/20 at 5:15 P.M., Nurse's Aide (NA) S said if a resident is starting to get a wound the staff use [NAME], and if a resident is known to have skin breakdown the staff use A & D ointment. He/She said the charge nurse completes skin assessments. During an interview on 9/21/at 5:20 P.M., Certified Nursing Assistant (CNA)/Certified Medication Technician (CMT) L said shower aides will have the nurse come in and look if they discover a skin issue during showers. He/she said residents must have an order for [NAME] and the licensed nurse is responsible to apply it. Further, he/she said A & D ointment is used as a barrier, but the facility did not carry it anymore. During an interview on 9/21/20 at 5:30 A.M., LPN T said the facility used to use A & D ointment as a house barrier. He/She said [NAME] was currently used for open areas and non-blanchable areas. Further, he/she said residents have to have an order for [NAME] because it has zinc in it. He/She said staff would get a physician's order for [NAME], licensed nurses' are to apply the [NAME], and reassess to make sure the wound was not getting worse. He/She said skin issues should be immediately reported to the physician, DON, and the wound nurse. Skin assessments are completed weekly by licensed nurses. During an interview on 9/22/20 at 4:00 P.M. the DON said the regular staff would not complete wound measurements if redness or shearing was noted on a resident. He/She said the wound nurse should measure the area and get treatments in place. He/she said the floor nurse should get orders or do treatments in the evenings or on weekends and then pass it on to the wound nurse. He/she said the resident had not had an order for Med Pass 2.0 that he/she was aware of because the resident had not been a weight loss. Furthermore, he/she said the resident had snacks in her room, things he/she liked from home. During an interview on 10/2/20 at 12:11 P.M., the resident's FNP said he/she was first notified of the pressure injury on the resident's coccyx on 1/24/20. He/she said the resident did not have the wound on admission. He/She said the injury looked like a pretty basic Stage II when he/she first saw it. Furthermore, he/she said the wound got bad quickly. He/she said it had slough and was unstageable. He/she said on 2/17/20, the facility reported to him/her staff had not transcribed the order change for seven days after it had been faxed. He/she said, at the time, he/she would have said staff not transcribing the order timely would have contributed to the wound deterioration but, he/she did not know how much it would have made a difference. He/She said the wound was difficult to treat and was unavoidable. Furthermore, he/she said the resident was very non-compliant, persistently sleeping in a chair. Additionally, he/she said they thought there might have been infection in the wound but could not confirm that, because the resident's white blood cells were never been elevated.

Based on observation, interview and record review, facility staff failed to serve food items in accordance with the nutritionally calculated recipes and menus to 10 residents (Residents #7, #16, #22, #23, #39, #60, #74, #78, #85 and #91) who received mechanical soft diets. The facility census was 88. 1. Review of the facility's Menus policy dated 01/2018, showed Menus shall be followed which have been written and approved by a Registered, Licensed Dietitian in compliance with Federal and State Regulations and consistent with Standards of Practice on nutritional care. Do not change the menu unless it is approved by the dietitian. Review of the facility's menus dated 09/15/20 (Week 4, Tuesday), showed the menus directed staff to provide the residents on mechanical soft diets with one half cup (four ounces) of ground roast sirloin. Review of the dining tray tickets for Residents #7, #16, #22, #23, #39, #60, #74, #78, #85 and #91, showed the tickets directed staff to provide the residents with a mechanical soft diet. Observation of the noon meal service on 09/15/20 beginning at 11:47 A.M., showed [NAME] A served the residents on mechanical soft diets a #16 (two ounces) scoop of ground roast sirloin (two ounces less than directed by the menus). During an interview on 09/15/20 at 12:00 P.M., [NAME] A said he/she had been trained to follow the planned menus upon hire, but the head cook who trained him/her said to always use the blue two ounce scoop to serve the ground meat for mechanical soft diets instead of the portion directed by the menus. During an interview on 09/15/20 at 1:50 P.M., the Certified Dietary Manager said staff are trained to follow the menus which would include serving the portion sizes directed by the menus. During an interview on 09/18/20 at 11:00 A.M., the administrator said staff should follow the planned menus including the portion sizes directed by the menus unless a resident request otherwise.

Based on observation, interview and record review, facility staff failed to wash their hands as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed to allow sanitized kitchenware to air dry prior to storage and use to prevent the growth of food-borne pathogens and cross-contamination. Facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff also failed to sanitize food-contact surfaces, including manually washed kitchenware, in accordance with manufacturer's instructions to prevent cross-contamination. The facility census was 88. 1. Review of the facility's Handwashing policy dated 01/2018, showed the following: -Staff shall clean their hands and wrist area for at least 20 seconds in a handwashing sink that is equipped with warm water, a handwashing soap, paper towels and a trash can with a foot operated lid. -The procedure shall include: (1) rinsing under clean running water; (2) applying soap; (3) rubbing vigorously for 10-15 seconds to ensure removal of soil from surface of hands and wrists and underneath nails; (4) rinsing under running warm water; and, (5) drying with a single use towel. -Employees shall wash their hands: (1) after touching bare human body parts (face, nose, etc.): (2) after using the restroom; (3) after coughing, sneezing, using a handkerchief or tissue; (4) after eating or drinking; (5) after handling soiled equipment; (6) as much as possible during food preparation to remove soil and contamination and to prevent cross contamination; (6) when changing task; (7) when changing from handling raw to ready-to-eat food; (8) before donning gloves; and, (8) after engaging in any activity or task which contaminates hands. Observation on 09/15/20 at 11:07 A.M., showed [NAME] A washed soiled kitchenware in the mechanical dishwashing station with gloved hands. Observation showed the cook then removed his/her gloves, lifted the trash can lid with his/her bare hand to dispose of the gloves, and, without washing his/her hands, obtained pans of prepared food from the oven and placed them on the steamtable for service at the noon meal. Observation on 09/15/20 at 11:10 A.M., showed [NAME] A washed soiled kitchenware in the mechanical dishwashing station. Further observation showed the cook left the station and, without washing his/her hands, filled a large pan with water from the sink in the cook's station and placed the pan on the stove. Observation showed the cook then returned to the mechanical dishwashing station, loaded soiled kitchenware into the dishwasher, and, without washing his/her hands, obtained a another pan of prepared food from the oven and placed it on the steamtable for service at the noon meal. Observation on 09/15/20 at 1:25 P.M., showed Dietary Aide (DA) C washed soiled kitchenware in the mechanical dishwashing station. Further observation showed, without washing his/her hands, the DA then handled sanitized kitchenware from the clean side of the station. Observation on 09/15/20 at 1:35 P.M., showed DA D washed soiled kitchenware in the mechanical dishwashing station. Further observation showed, without washing his/her hands, the DA then put away dishes from the clean side of the station. During an interview on 09/15/20 at 1:35 P.M., the DA D said staff should wash their hands between washing dirty dishes and putting away clean dishes. The DA said he/she did not know why he/she did not wash his/her hands. Observation on 09/15/20 at 1:37 P.M., showed DA D rinsed his/her hands under running water at the handwashing sink, turned the faucet off with his/her bare hand, dried his/her hands and then put away sanitized dishes from the clean side of the mechanical dishwashing station. During an interview on 09/15/20 at 1:50 P.M., the Certified Dietary Manager (CDM) said staff should wash their hands with soap and water for at least 20 seconds and turn the faucet off with a paper towel. The CDM said staff should wash their hands between tasks and after touching anything dirty which would include between washing dirty dishes and putting away clean dishes. The CDM said all dietary staff have been trained on proper handwashing procedures. During an interview on 09/18/20 at 10:54 A.M., the administrator said kitchen staff should wash their hands between the dirty and clean sides of dishwashing station and as needed. Staff should wash their hands with soap and water for 20 to 30 seconds and use a paper towel to turn off the faucet. The administrator said the CDM trains staff on proper handwashing upon hire and as needed. 2. Review of the facility's Warewashing and Storage policy dated 01/2019, showed All dinnerware, utensils, preparation and service supplies shall be washed and sanitized in the pot sink and/or through use of a commercially approved dishmachine and shall be air dried prior to storage. Observation on 09/15/20 at 11:10 A.M., showed [NAME] A removed sanitized kitchenware while wet from the clean side of the mechanical dishwashing station and put it on the storage shelf. Observation on 09/15/20 at 11:13 A.M., showed DA E removed sanitized metal food preparation pans from the clean side of the mechanical dishwashing station and stacked them on the storage rack by the beverage station. Observation also showed nine metal food preparation pans of various sizes, two large metal bowls and a metal strainer stacked together wet on the rack. Observation on 09/15/20 at 1:15 P.M., showed [NAME] B removed the sanitized food processor from the clean side of the mechanical dishwashing station while wet and then used the food processor to chop onions and peppers. Observation on 09/15/20 at 1:30 P.M., showed DA D removed the sanitized food processor from the clean side of the mechanical dishwashing station while wet and returned it to its base in the cook's station. During an interview on 09/15/20 at 1:30 P.M., the DA said dishes should be dry before they are put away. The DA said he/she thought the food processor had dried. Observation on 09/15/20 at 1:37 P.M., showed DA D removed sanitized kitchenware from the clean side of the mechanical dishwashing station while wet and stacked the kitchenware on the storage rack near the beverage station. During an interview on 09/15/20 at 1:50 P.M., the CDM said all dishes should be air dried before they are put away and all dietary staff are trained on this requirement. During an interview on 09/18/20 at 11:03 A.M., the administrator said dishes should be air dried before they are put away. The administrator said the cook is responsible to ensure dishes are dry before they are put away after every meal and staff are trained that all dishes are required to be air dried. 3. Review of the facility's Food Storage policy dated 01/2016, showed the policy directed the following: -all leftovers shall be labeled and dated with expiration dates; -the manager and/or his/her designee should monitor the food storage daily to ensure leftovers are discarded and all food is properly stored; -food and food products should not be stored on the floor. Observation on 09/15/20 at 11:16 A.M., showed the following on the food storage racks near the beverage station: -a large undated bag of tea bags opened to the air; -an opened and undated 42 ounce (oz.) container of quick oats; -an opened and undated 35 oz. bag of fruit whirls cereal; -an undated one gallon resealable plastic bag of crisped rice cereal open to the air; -an undated one gallon resealable plastic bag of crisped rice cereal; -an undated one gallon resealable plastic bag of raisin bran cereal open to the air; -an undated one gallon resealable plastic bag of raisin bran cereal; -an opened and undated five pound bag of buttermilk pancake mix; -an opened and undated five pound bag of instant non-fat dry milk. Observation on 09/15/20 at 11:38 A.M., showed cases of vegetables and meat stored on the floor in the walk-in freezer. During an interview on 09/15/20 at 11:38 A.M., [NAME] B said the food truck delivered food on 09/14/20. The cook said food should not be stored on the floor, but there was no more room inside the freezer. Observation on 09/15/20 at 11:40 A.M., showed the following in the dry goods pantry: -an opened and undated bag of egg noodles; -an opened and undated bag of cheese puffs; -an opened and undated eight oz. can of powdered food thickener; -two opened and undated bags of potato chips. Observation on 09/15/20 at 11:45 A.M., showed an opened and undated plastic bag of beef patties in the reach-in freezer. During an interview on 09/15/20 at 1:50 P.M., the CDM said opened food items should be covered/sealed, labeled and dated. The CDM said all staff are trained on proper food storage and all staff are responsible to monitor the food storage. The CDM said food items should not be stored on the floor. During an interview on 09/18/20 at 11:08 A.M., the administrator said opened food items should be covered, dated, labeled, rotated, and not stored on the floor. The administrator said staff are trained on this requirement and the dietary manager is responsible to monitor the food storage whenever he/she is in the kitchen. 4. Review of the facility's Sanitation Solution policy dated 01/2019, showed Staff shall prepare a container with sanitizing solution to hold cleaning cloths and to use for sanitizing equipment and work areas. The sanitizing solution shall be a quaternary compound and shall be prepared at 200 ppms. The solution shall be checked using manufacturer approved test strips. Observation on 09/15/20 at 1:30 P.M., showed [NAME] B sprayed the top of the food preparation table in the cook's station with an all-purpose disinfecting spray and glass cleaner and then immediately wiped the table with a dry cloth. Further observation showed the cook continued to use the table to prepare food items for service at the evening meal. Review of the product's labeling for instructions on the use of the product as a sanitizer, showed the label directed staff to spray the surface and let stand for five minutes. Further review showed a rinse is required for surfaces in direct contact with food. During an interview on 09/15/20 at 1:31 P.M., the cook said the spray is what he/she had been directed to use to sanitize kitchen surfaces. The cook said he/she had not read the instructions for use on the product for use as a sanitizer and did not know how long it should remain on surfaces to sanitize properly. During an interview on 09/15/20 at 1:50 P.M., the CDM said the staff are directed to use the all-purpose disinfecting spray and glass cleaner to sanitize kitchen surfaces. The CDM said staff should allow the product to sit on the surface for five minutes before wiping and staff had been trained how to use the product. During an interview on 09/18/20 at 11:18 A.M., the administrator said staff should use an approved product to sanitize kitchen surfaces. Should follow the manufacturer's instructions for use. 5. Review of the facility's Warewashing and Storage policy dated 01/2019, showed All dinnerware, utensils, preparation and service supplies shall be washed and sanitized in the pot sink and/or through use of a commercially approved dishmachine and shall be air dried prior to storage. The pot sink shall be a three (3) sink unit with detergent in the first sink, clear rinse water in the second, and sanitizer in the third and final sink. Pots and pans washed in the pot sink may be sanitized in the dishmachine. Observation on 09/15/20 at 1:33 P.M., showed [NAME] A washed soiled kitchenware in the three-compartment sink. Observation on multiple occasions, showed after rinsing, the cook placed the kitchenware in a quaternary ammonium sanitizing solution and then immediately removed the items to drain. Review of the product label for the quaternary ammonium sanitizer, showed direction to immerse kitchenware for one minute in the solution to sanitize food contact surfaces. During an interview on 09/15/20 at 1:50 P.M., the CDM said staff should wash, rinse and sanitize dishes manually washed at the three-compartment sink. The CDM said staff should allow dishes to remain in the sanitizing solution for at least three minutes before they are removed to dry. During an interview on 09/18/20 at 11:23 A.M., the administrator said staff should wash, rinse and then sanitize dishes that are manually washed. The administrator said he/she did not know don't know how long dishes should remain in the sanitizing solution.

Based on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all resident funds the facility holds. The facility census was 88. Review of the resident trust fund account for September 2019 through August 2020, showed an average monthly balance of $30,322.57, which requires a surety bond of $45,000.00. Further review showed the current ledger amount was $27,420.22 Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $28,500.00. Review of the Increase Certificate from Travelers showed an increase request in the facility's surety bond, from $20,000 to $40,000. During an interview on 9/18/20 at 3:30 P.M., the Business Office Manager said corporate office and the administrator is responsible to ensure the bond amount is sufficient. During an interview on 9/22/20 at 4:30 P.M., the administrator said he/she takes responsibility for the bond amount not being sufficient. He/she said they usually review the bond a least every six months, however with everything going on, it has honestly been hectic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to update the plan of care with changes in the residents' care needs and did not provide clear direction for staff for three residents (Resident #29, #55, and #16). The facility census was 88. 1. Review of the facility's Care Plan Section Responsibility policy, undated, showed: -The objective was to ensure individualized completion of the care plan, and family/resident participation in the resident's plan of care with admission, quarterly, annual update, and if there was a significant change of condition; -A care plan would be developed upon admission per Center for Medicare and Medicaid Services (CMS) guidelines. It would be updated quarterly and annually per CMS guidelines to ensure there was a continuity of care and was in accordance with the individual's needs; -The care plan would also be updated with a significant change of condition. 2. Review of Resident #29's quarterly Minimum Data Set (MDS) (federally mandated assessment completed by facility staff), dated 6/28/20, showed staff assessed the resident as follows: -Moderately impaired cognitive status; -Required extensive assist of one staff for bed mobility, transfers, and bathing; -Resident did not ambulate; -Independent with set-up assist for locomotion; -Required limited assist on one for dressing, toilet use, and personal hygiene; -Independent with eating; Review of the residents nurse's notes showed: -On 3/16/20, the resident was noted on the floor in front of the toilet. The resident said he/she was dizzy and when he/she stood his/her right knee gave out. The resident was encouraged to use the call light before self-transferring; -On 3/17/20 the resident complained of increased pain and an x-ray was completed showing acute right distal tibia/fibula (bones in the lower leg) fractures. The resident was sent to the emergency room. Entry tracking showed the resident returned from the hospital on 3/31/20. Review of the resident's physician order sheet, dated 9/24/20, showed an order on 4/30/20 for weight bearing as tolerated. Review of the resident's physical therapy Discharge summary, dated [DATE], showed the resident was educated regarding transfer training skills and proper upright standing posture to achieve center of mass over base of support. The resident was discharged to care of facility staff with contact guard assistance (have one or two hands on the body but no further assistance to perform the task). Review of the resident's fall care plan, dated 9/14/20, showed the resident was a fall risk evidenced by: -10 falls dated 8/24/17 - 9/15/19; -Fall within the last month, dated 3/20/20; -Transfer limited assist, onset 5/28/20; -Weight bearing status partial, onset 4/1/20. Review of the resident's fall care plan, dated 9/14/20, showed interventions included: -Appropriate footwear while out of bed; -Encourage to use call light for transfer assistance, onset 3/16/20; -Fall without injury-encourage to ask for assistance, onset 3/16/20. -Went to the hospital with fracture after fall, onset 3/17/20; -Assist with activities of daily living (ADLs) as needed, onset 3/20/20; -Assist with toileting as needed, onset 3/20/20; Review of the resident's Impaired Physical Mobility care plan, dated 9/14/20, showed evidenced by: -Hoyer (manual lift) transfer, onset 4/10/20; -Extensive assist to transfer, onset 4/10/20; -Partial weight bearing, onset 3/20/20; -Supervision to turn and reposition, onset 3/7/16; -Supervision to ambulate, onset 3/7/16. Review of the resident's Impaired Physical Mobility care plan, dated 9/14/20, showed interventions: -Assist as needed with wheel chair mobility, onset 3/20/20; -Assess balance before transferring, onset 6/24/19; -Hoyer lift for transfers, onset 4/21/20; -Praise safe use of motorized wheelchair (w/c), confront inappropriate use, dated 3/7/16; -Provide me with appropriate level of assistance to help me promote safety, dated 9/1/15; -Provide appropriate level of assistance to promote safety of resident, dated 3/20/20. Review of the resident's Self Care Deficit care plan, dated 9/14/20, showed evidenced by: -Non-weight bearing, onset 3/20/20; -Used w/c; -Bed mobility: Extensive, onset 3/20/20: -Transfers: Total, onset 3/20/20; -Ambulation: Total/does not ambulate, onset 3/20/20. Review of the resident's Self Care Deficit care plan, dated 9/14/20, interventions included: -Assist with oral hygiene after meals and PRN; -Provide assistance with self-care as needed; -Required supervision. Review of the resident's care plan, dated 9/14/20, showed the resident had a recent fracture related to a fall in the last six months, onset 4/30/20, 30 days after the resident returned from the hospital. The resident's fall, impaired physical mobility, and self-care deficit care plans showed different levels of care required for transfers, bed mobility, and ambulation and different levels of the resident's weight bearing status. The interventions were not individualized to the care needs of the resident and did not provide information regarding the appropriate level of care. The care plan included, on 3/16/20, the resident had a fall without injury when the fall resulted in a right fibula and tibia fracture with hospitalization. Several interventions were added during the resident's hospitalization and not updated after his/her return. The care plan did not include any information regarding coronavirus (COVID-19), the effects or potential effects it had on the resident, or any interventions related to COVID-19. Observation 9/17/20 at 2:17 P.M., showed the resident up in a manual w/c in his/her room using a hand held nebulizer machine. Staff were not present in the room. The resident did not have a cast on his/her right leg. During an interview on 9/17/20 at 3:35 P.M., the resident said he/she gets in and out of bed by him/herself. The staff helped me after I broke my ankle but stopped after it got well enough I could do things on my own. I get myself on and off the toilet. It is difficult to hang on to a bar with one hand and try to pull my pants up. If staff weren't doing a whole lot of other stuff, I feel like they would help. There were times when the staff couldn't get to the light because they did not have enough help. He/she had been dressing him/herself. He/she just had trouble pulling his/her pants up. Sometimes his/her roommate helped. His/her falls were caused by vertigo and sometimes it scared him/her to get out of bed. Observation on 9/18/20 at 9:45 A.M., showed the resident in his/her room in a manual wheelchair. During an interview on 9/22/20 at 3:20 P.M., certified nursing assistant (CNA) O said he/she provides the resident with one person assist for everything. The resident does a lot on his/her own. The resident can hold on to the bar and pull up in the bathroom on his/her own. 3. Review of resident #55's MDS, dated [DATE], showed staff assessed the resident as: -Required supervision and set-up assist for bed mobility, transfers, ambulation, locomotion in and out of room, dressing, eating, toilet use, personal hygiene and bathing; -Occasionally incontinent of bowel and bladder; -Unstageabe pressure ulcer (pressure ulcer tissues are obscured such that the depth of soft tissue damage cannot be observed); -Moisture associated skin damage (MASD) (superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration). Review of the resident's history and physical, dated 12/27/19, showed diagnoses included osteomyelitis (infection of the bone) and ulcer of left foot. Review of the resident's January 2020 medication administration record (MAR) showed the resident received his/her last intravenous (IV) antibiotic for osteomyelitis of the left foot on 1/28/20 and the peripherally inserted central catheter (PICC) (a long catheter inserted through a peripheral vein, into a larger vein, when intravenous treatment is required for a long time) line was discontinued on 1/29/20. Review of the resident's Wound Report showed: -On 1/16/20, the resident had a Stage II pressure injury (partial thickness loss of skin presenting as a shallow open ulcer with a red-pink wound bed, without granulation, slough or bruising) on his/her coccyx (tailbone) measuring 3 (centimeters) cm x 2.5cm. Observation on 9/17/20 at 9:25 A.M., showed the resident independently rising from a recliner in his/her room, taking a few steps and turning with the use of a rollator walker without difficulty. Review of the resident's care plan, dated 9/14/20 showed: -The resident had impaired mobility related to IV antibiotic therapy for osteomyelitis, abnormalities of gait and mobility, and bilateral osteoarthritis of hip; -The resident took medication for dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) with a goal that measures would be taken to assist the resident with memory/medication administration. Interventions directed staff to contact the physician with pertinent lab results and monitor for side effects of the medication; -Staff were to encourage family/friend involvement and socialization; -A problem with skin breakdown evidenced by rash, wound (pressure, diabetic or stasis) (yes), bruises/discolored, heel discoloration, onset 12/24/20; -On 2/27/20, a new care plan for pressure wound to sacrum (lower portion of the spine) was added; -Frequently incontinent of urine due to stress or urgency; -Frequently incontinent of bowel. The resident's IV antibiotics had been discontinued since 1/28/20. The dementia care plan did not direct staff on how to assist the resident with memory. The care plan had not been updated to include changes related to coronavirus (COVID-19), how that could potentially effect the resident, or interventions on how to continue family/friend involvement and socialization during COVID-19 restrictions. The skin breakdown problem did not include the location of the rash, wound, and bruising, extent of the wound, or what type of wound the resident had since 12/24/20. The sacral pressure wound care plan was added six weeks after the pressure wound was identified. The resident had been assessed as occasional incontinence of bowel and bladder but the care plan showed the resident was frequently incontinent of bowel and bladder. During an interview on 9/22/20 at 3:20 P.M., CNA O said the resident walked on his/her own. The resident positioned him/herself in bed and can get in and out of bed independently. 4. Review of Resident #16's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene; -Always incontinent of bowel and bladder; -Stage II pressure ulcer. Review of the resident's nurse's notes, dated 9/11/20, staff documented the resident was found lying on the floor beside the left side of the bed. The resident had bolsters on the bed, per staff, it seemed the bolsters were not correctly secured to the bed, allowing the resident to roll out of the bed. The resident was assisted to bed. The bed was in low position and bolsters (a long, thick pillow used for support) securely in place. Fall mats at bedside. Observation on 9/16/20 at 9:45 A.M., showed the resident lying on an alternating air mattress in a hi-low (electric hospital bed that can be lowered to a few inches off the ground) bed with bolsters and fall mats on both sides. Review of the resident's care plan, dated 9/16/20, showed: -The resident was a fall risk; -The resident had a fall on 9/11/20; -The resident was always incontinent of bowel and bladder; -The resident was never aware of toileting needs; -A new goal, dated 7/2/20, the resident will be continent at all times; -A new goal, dated 7/2/20, the resident will have decreased episodes of bowel incontinence; -Wound (pressure, diabetic or stasis) ( Yes). New interventions were not added following the fall on 9/11/20. The care plan did not include bolsters, hi-low bed, or fall mats. Interventions were not added directing staff how to assist the resident to meet the new bowel and bladder elimination goals. The care plan did not include the type of wound, staging, or location. During an interview on 9/21/20 at 6:10 P.M., the care plan coordinator said care plans should be reviewed and continued quarterly and annually. Other times interventions would be added included with falls, medication changes, and if the resident was exit seeking. Baseline care plans are completed by the nursing staff when they enter their assessments and the information is transferred to a care plan. During an interview on 9/22/20 at 3:20 P.M., CNA O said care plans are available at the nurse's station for review by the staff. He/she said the nurses make the CNAs aware of changes to the care plan, including new interventions. During an interview on 9/22/20 at 5:00 P.M., the director of nursing (DON) said any resident specific information for caring for a resident would be on the care plan. Falls, interventions, wounds, treatments and hospice are all things that should be on a residents care plan. During an interview on 9/23/20 at 12:00 P.M., the assistant care plan coordinator said care plans should reflect the current needs and status of the resident. He/She was made aware of a change in the resident's level of care by reviewing documentation on a quarterly basis, in report, word of mouth, and there was a form the charge nurse and DON would complete and give to him/her. Therapy also let him/her know of any changes. Changes were made immediately or they may wait to see if the resident bounced back. Pressure sore information is added to a care plan as soon as they received the information. Care plans should say where a wound was located. Old transfer and weight bearing instructions should be removed from a care plan if they have changed. He/she liked to keep them on the care plan to show a history of what happened. He/she was not sure if that was appropriate. Other staff would go by the latest date to know what the resident should be doing. Interventions should be specific to the number of staff needed for a transfer. Use of a walker, Hoyer lift, w/c, and motorized w/c was not reflective of Resident #29's current status but of past status. He/she believed the resident used a manual lift. Someday's the resident might need a manual lift and someday's only one for transfers. Fluctuations in care needs should be clear on the care plan. New interventions were always added after falls. If a resident currently had a pressure ulcer, preventing further skin breakdown should be the goal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, staff failed to maintain professional standards of practice by not completing neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) following a fall for four residents (Resident #85, Resident #42, Resident #75, and Resident #43) failed to notify the resident's family, the resident's physician, and administration of a fall for one resident (Resident #16), and failed to complete neurological assessments and fall investigations for one resident (Resident #14). Additionally, staff failed to follow physician orders for oxygen administration for two residents (Resident #21 and Resident #22). The facility census was 88. 1. Review of the facility's Fall policy, dated 8/24/20, showed following a fall staff are directed as follows: -Ascertain if there were injuries and provide treatment as necessary; -Fill out a fall event report for any fall sustained by a resident; -Determine what may have caused or contributed to the fall, including ascertaining what the resident was trying to do before he/she fell; -Neurological checks will be initiated with unwitnessed falls or if a head injury is apparent at the time of the fall; -Notify the physician, the resident's family, and supervisor; -Review with the physician if there is a necessity for a physical therapy/occupational therapy evaluation; -Complete documentation in the resident's chart; -The nursing office will follow-up with the review and assessment. The care plan office will follow-up with the interventions; -The care plan team will address the risk factors for the fall such as the resident's medical conditions, facility environment issues, or staffing issues; -And revise the resident's plan of care and/or facility practices, as needed, to reduce the likelihood of another fall. 2. Review of the facility's Neurological Assessment Policy, undated, showed staff are directed as follows: -When a resident has an incident with a head injury/trauma, or an unwitnessed fall, the nurse is to immediately perform a neurological assessment, notify the physician, and document the results on the Neurological Assessment Flow sheet in the resident's chart. Residents with head injury/trauma are to have assessments and documentation for 72 hours; -Unless directed differently by the physician, the following schedule is to be used for the completion of neurological checks: Every 15 minutes for the first hour (8 times), every 30 minutes for the next two hours (4 times), and every shift until the 72 hours are completed; -And neurological checks consist of level of consciousness, pupil size, hand grasps, extremity strength, pain response, and vital signs. All items must be completed on each neurological check. Checks must be performed by a licensed nurse, and any changes throughout the assessment must be reported to the physician immediately. 3. Review of Resident #16's quarterly Minimum Data Set (MDS) (a federally mandated assessment completed by facility staff), dated 6/25/20, showed the following: -Had severe cognitive impairment; -Was dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene; -Diagnoses included congestive heart failure (progressive disease that affects the pumping action of the heart), high blood pressure, and diabetes mellitus (high blood sugar levels due to the bodies inability to produce or respond to insulin). Review of the resident's care plan, dated 9/11/20, showed the resident was at high risk for falls related to weakness, history of falls, reduced mobility, and dependence on wheelchair. Review of the resident's nurse's notes, dated 9/11/20 at 3:37 P.M., showed facility staff documented the resident was found lying on the floor on the left side of his/her bed. The resident had bolsters on the side of the bed and, per staff, it seemed the bolsters were not correctly secured to the bed, allowing the resident to roll out of the bed. The resident had a small, red abrasion on the right side of his/her forehead where the resident had been lying on the floor. Review of the resident's neurological (neuro) checks showed checks were completed: -9/12/20 on the day shift, 24 hours after the fall; -9/12/20 on the night shift; -9/13/20 on the night shift. Review showed staff did not complete all the required neurological checks for the resident's fall with a head injury/trauma per their facility policy. Observation on 9/16/20 at 9:45 A.M., showed the resident had a fading yellow bruise in the center of his/her forehead. Observation on 9/17/20 at 4:00 P.M. showed the resident was up in a w/c between his/her bed and the roommate. The door to room was shut and staff were not in the room. During an interview on 9/21/20 at 2:30 P.M. the assistant administrator said he/she did not have any fall investigations. Administrative staff looked at incident reports and if they had concerns, then they would ask questions. During an interview on 9/21/20 at 3:30 P.M. the Director of Nursing (DON) said he/she was not aware of the resident's fall on 9/11/20. The nurse did not complete an incident report. He/she did not know if the resident's responsible party and/or physician had been notified of the fall. He/she did not educate staff after the fall. 4. Review of Resident #14's MDS, dated [DATE], showed: -Had diagnoses of Stroke with right sided hemiplegia (partial or total paralysis on one side of the body), repeated falls, high blood pressure, diabetes mellitus, thrombosis (blood clot) of intracranial (within the skull) venous system, unspecified head injury; -Presence of cerebrospinal fluid drainage device; -Received coumadin (used to prevent blood clots) 7mg daily at bedtime; -Received insulin (injections to lower blood sugar levels) four times a day; -And wore a self-release belt to wheelchair as resident continues to lean forward and forgets he/she needs assist. Review of the resident's nurse's notes, dated 7/24/20 at 10:24 P.M., showed the resident was on the floor on his/her left side in front of his/her wheelchair (w/c). An abrasion was noted on his/her left knee. Vital signs were within normal limits and neurological checks were started. The nurse's notes did not address the root cause of the fall, what the resident was trying to do before the fall, risk factors for the fall, if current interventions were being followed, or new interventions put in place. Review of the resident's neuro checks showed checks were completed: -7/24/20 at 7:20 P.M.; -7/24/20 at 7:35 P.M.; -7/24/20 at 8:50 P.M.; -7/24/20 at 10:20 P.M.; -7/24/20 at 11:20 P.M.; -7/26/20 on the day shift; -7/26/20 on the night shift. Review of the resident's nurse's notes, dated 8/3/20 at 10:55 P.M., showed the resident was found on the floor beside his/her bed. The resident was unable to verbalize pain due to a previous stroke. The resident was able to move all extremities and was alert with no facial drooping. Neurological checks were initiated. The nurse's notes did not address the root cause of the fall, what the resident was trying to do before the fall, risk factors for the fall, if current interventions were being followed, or new interventions put in place. Review of the resident's neuro checks showed checks were completed: -8/3/20 at 10:36 P.M.; -8/3/20 at 10:51 P.M.; -8/3/20 at 11:06 P.M.; -8/3/20 at 11:21 P.M.; -8/3/20 at 11:36 P.M.; -8/4/20 at 12:06 A.M.; -8/4/20 at 12:36 A.M.; -8/5/20 on the night shift; -8/6/20 on the night shift. Review showed staff did not complete all the required neurological checks for the resident's fall on 7/24/20 or 8/3/20 per their facility policy, and failed to determine the root cause of the resident's fall to prevent further falls and injuries. Review of the resident's care plan showed it was reviewed, 9/9/20. Further review, showed the resident's plan of care did not contain new or different interventions in regards to his/her falls on 7/24/20 and 8/3/20. Observation on 9/16/20 at 10:20 A.M. showed the resident up in his/her room in a wheelchair wearing a helmet. Fall mats were on the floor on both sides of the bed. The resident wheeled across the mats several times. During an interview on 9/21/20 at 2:30 P.M. the assistant administrator said he/she did not have any fall investigations. Administrative staff looked at incident reports and if they had concerns, then they would ask questions. 5. Review of Resident #85's Quarterly MDS, dated [DATE], showed the following: - Severe Cognitive Impairment; -Required extensive assistance of one person physical assist for toilet use; -Used a wheelchair for mobility; -Always incontinent of bladder and bowel; -Diagnoses of cerebrovascular accident (CVA) (damage to the brain due to decreased blood flow), transient ischemic attack (TIA) (mini-stroke often resolving within 24 hours), or stroke (damage to the brain due to decreased blood flow); -And received anticoagulants (blood thinners) and opioids (pain medication). Review of the nurse's notes, dated 6/2/20 at 5:24 A.M., showed the resident fell while self-transferring from his/her wheelchair to the toilet. Further review of the nurse's notes, dated 6/2/20, showed the resident was on fall charting and would remain on fall charting until 6/5/20. Additionally, this resident was transferred to the hospital at 9:50 P.M. the day of the fall for evaluation, after imaging determined the resident had fractured his/her left femoral neck. Review of the neurological assessment charting shows no evaluations were made by the staff to assess the resident's neurological status after the fall on 6/2/20. Review of the resident's care plan, dated 8/26/20, showed staff documented the resident as a fall risk. The plan directed staff to anticipate the resident's needs frequently and assist him/her with activities of daily living (ADLs) as needed. Additionally, staff were directed to assist the resident with toileting as needed. Furthermore, staff were expected to encourage the resident to use the call light and staff to assist with transfers. 6. Review of Resident #42's Quarterly MDS, dated [DATE], showed the following: -Moderately Impaired Cognition; -Totally dependent for bed mobility, dressing, toilet use, and personal hygiene; -Always incontinent of bladder and bowel; -Diagnoses of cancer, hypertension (high blood pressure), anxiety, and depression; -Frequently experiences pain; -Receives anticoagulants and opioids. Review of the nurse's notes, dated 8/21/20 at 7:18 P.M., showed the resident was found face down on the floor with a hematoma (collection of blood outside the blood vessel) to his/her right forehead. Additional review of the nurse's notes showed the resident stated he/she woke up and felt himself/herself falling out of bed and was unable to grab anything to stop the fall. Furthermore, the note showed that neurological assessments were initiated at this time. Review of the resident's neurological charting shows assessments were completed on the following dates and times: -8/21/20 at 6:28 P.M.; -8/21/20 at 7:13 P.M., 45 minutes after initial assessment; -8/21/20 at 8:28 P.M., 1 hour and 15 minutes later; -8/21/20 at 9:28 P.M., 1 hour later; -8/21/20 at 10:28 P.M., 1 hour later; -8/22/20 at 7:52 A.M., -8/23/20 at 2:57 A.M., -8/24/20 at 3:03 P.M. Review showed staff did not complete all the required neurological checks for the resident's fall with a head injury/trauma per their facility policy. 7. Review of Resident #75's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Limited one person physical assist for toileting; -Not steady when moving on and off toilet and requires stabilization of human assistance; -Uses a walker and wheelchair for mobility; -Occasionally incontinent of bladder; -Active diagnosis of hypertension; -Receives diuretics (medications used to treat swelling and high blood pressure). Observation on 9/17/20 at 9:58 A.M. showed the resident lying naked on the floor near the door to the bathroom with his/her wheelchair behind him/her. Further observation showed LPN J and CMT H assisted the resident to a standing position and walk him/her to the toilet. LPN then assisted the resident to put on pants and walked him/her to the bed. Additionally, the LPN called for another nurse to assess the resident. Observation on 9/17/20 at 10:15 A.M. showed LPN I arrived to the resident's room to assess him/her. Review of the resident's neurological charting shows assessments were completed on the following dates and times: -9/17/20 at 10:52 A.M.; -9/18/20 at 12:56 A.M.; -9/18/20 at 3:25 P.M.; -9/19/20 at 1:51 A.M.; -9/19/20 at 11:09 A.M.; -9/20/20 at 1:46 P.M. Review of the nurse's notes, dated 9/17/20, showed the resident had normal vital signs after the fall and the resident denied any complaints of pain. Additionally, the note showed LPN I assessed the resident's bottom. Further review showed the LPN directed the resident to use his/her call light to ask for assistance before attempting to ambulate to the bathroom again to prevent further falls. The nurse's note shows neurological assessments were initiated. During an interview on 9/17/20 at 10:00 A.M., the resident said he/she wanted to use the restroom. During an interview on 9/17/20 at 10:03 A.M., CMT H said the resident is a standby assist when going to the restroom, but he/she sometimes forgets he/she is not supposed to walk. During an interview on 9/17/20 at 5:53 P.M. LPN I said he/she was informed the resident was lying on the floor and the resident said he/she had landed on his/her bottom. The LPN said he/she assessed the resident's bottom, back, and head as well as assess the resident's ability to move his/her extremities and checked his/her vital signs. He/she said the resident's son was notified of the fall. Furthermore, the LPN said he/she did not notify the physician immediately after the fall because he/she did not find an injury to the resident. He/she said the staff fax a form called the SBAR (situation, background, assessment, recommendation) to the physician and the physician has up to 48 hours to sign and return the form with any orders. The LPN said for unwitnessed falls, licensed staff perform neurological assessments every shift for three days following the fall. Facility staff failed to complete neurological checks per their facility policy for an unwitnessed fall. 8. Review of Resident #43's Quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Requires extensive assistance of one person physical assist for transfers between surfaces; -Uses a wheelchair for mobility; -Occasionally incontinent of bladder and bowel; -Active diagnoses of coronary artery disease (narrowing of the arteries leading to decreased blood flow to the heart), heart failure (condition in which the heart does not pump blood well), hypertension (high blood pressure), diabetes (disease that results in too much glucose (sugar) in the blood), dementia (group of conditions characterized by the impairment of at least two brain functions), depression, asthma (respiratory condition leading to spasms in the lungs causing difficulty breathing), and respiratory failure (blood doesn't have enough oxygen or has too much carbon dioxide, making it difficult to breathe); -Is on a schedule pain regimen; -Experiences shortness of breath or trouble breathing with exertion; -Has two unstageable pressure ulcers (injuries to the skin caused by prolonged pressure on the skin); -Receives insulin (medication used to decrease glucose levels), anticoagulants, diuretics, and oxygen. Review of the nurse's notes, dated 7/26/20, show the resident fell out of his/her bed and was found by an aide at 5:08 A.M. The resident was short of breath because he/she did not have his/her oxygen on. Additionally, the note shows the staff completed a neurological assessment and said they would complete the assessments every 15 minutes along with checking the resident's vital signs. The note said the resident hit the left side of his/her head above his/her left brow and along his/her nose. Review of the resident's neurological charting shows assessments were completed on the following dates and times: -7/26/20 at 5:08 A.M.; -7/26/20 at 5:23 A.M., -7/26/20 at 5:38 A.M.; -7/26/20 at 5:53 A.M.; -7/26/20 at 3:37 P.M.; -7/27/20 at 6:06 A.M.; -7/28/20 at 2:10 A.M.; -7/28/20 at 6:40 P.M.; -7/28/20 at 8:46 P.M. Review of nurse's notes, dated 9/3/20, showed staff found the resident sitting on the bathroom floor after attempting to use the bathroom by himself/herself. The staff said no injuries were noted to the resident. Additional review showed staff did not initiate neurological checks for the resident's unwitnessed fall. Staff did not complete all the required neurological checks for the resident's fall with a head injury/trauma per their facility policy for the resident's fall with head injury/trauma on 7/26/20 or the resident's unwitnessed fall on 9/3/20. 9. Review of Resident #21's Annual MDS, dated [DATE], showed the following: -Cognitively impaired; -Short term and long term memory problems; -Moderately impaired decision making ability; -Experiences inattention and disorganized thinking; -Totally dependent on staff requiring one person physical assist for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing; -Uses a wheelchair for mobility; -Always incontinent of bladder and bowel; -Active diagnoses of heart failure, hypertension, pneumonia (infection that causes inflammation in the lungs); cerebrovascular accident, transient ischemic attack, or stroke; dementia; hemiplegia or hemiparesis (one-sided muscle weakness); seizure disorder or epilepsy (disorder that causes abnormal brain activity); and asthma; -Experiences shortness of breath or trouble breathing when lying flat; -Receives a diuretic; -Receives oxygen. Review of the resident's physician orders, dated 7/14/20, shows the resident is ordered to have 2 liters continuous oxygen due to a diagnosis of heart failure. Review of the resident's care plan, dated 9/11/20, shows staff are directed as follows: -Administer medications, respiratory treatments, and oxygen as ordered; -Ensure nasal cannula placement is correct; -Oxygen is on correct ordered liter setting. Observation on 9/16/20 showed the following: -At 2:18 P.M. the resident was in the 400 hallway working with the activity staff and his/her nasal cannula (device used to deliver supplemental oxygen) was not in his/her nose and the oxygen tank on the back of his/her wheelchair was in the red zone, indicating it was empty; -At 3:27 P.M., the resident was in the hallway near his/her room and his/her oxygen tubing was not in his/her nose and the oxygen tank was in the red zone. Observation on 9/17/20 showed the following: -At 8:43 A.M. the resident was sitting in the dining room and his/her oxygen tubing was not in his/her nose and the tank was not turned on; -At 8:56 A.M., the nasal cannula was in the resident's nose and the tank was set to 2 liters with the oxygen tank in the red zone; -At 2:22 P.M., the resident was sitting in a common area by the dining room and nurse's station with the oxygen tank turned on and in the red zone with no flow of oxygen and CMT H was notified about the tank being in the red zone and he/she changed the resident's oxygen tank. 10. Review of Resident #22's Quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Used a wheelchair for mobility; -Had active diagnoses of heart failure; asthma, chronic obstructive pulmonary disease (chronic obstruction of airflow that interferes with normal breathing), or chronic lung disease; -Experienced shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat; -Received a diuretic; -And received oxygen. Review of the resident's physician orders, dated 9/8/19, shows the resident is ordered to have 4 liters continuous oxygen due to a diagnosis of chronic obstructive pulmonary disease. Review of the resident's care plan, dated 9/9/20, shows staff are directed as follows: -Ensure the oxygen is on the correct setting; -Ensure portable oxygen tank is full and replace when it is empty; -Oxygen is on the correct ordered liter setting of 4 liters; -Administer medications, respiratory treatments, and oxygen as ordered; -Ensure oxygen via nasal cannula is at ordered amount. Observation on 9/16/20 at 10:25 A.M. showed the resident lying in bed with his/he nasal cannula in place. Further observation showed his/her oxygen concentrator was set at 2 liters. Observation on 9/17/20 at 2:00 P.M. showed the resident's nasal cannula was in his/her nose with the oxygen tank off and the tank showing empty. During an interview on 9/17/20 at 2:15 P.M., LPN J said there is not just one person who is responsible for checking the resident's oxygen tanks. He/she said all the staff check the tanks as they go into the resident's rooms and provide care. During an interview on 9/17/20 at 6:45 P.M., the DON said when a resident requires neurological assessments after a fall, the electronic health record creates a task for the staff to complete at the correct intervals. The DON said he/she is not sure what the exact times are to complete the tasks because the computer tells him/her when he/she needs to complete the assessment. Furthermore, the DON expects staff to complete neurological assessments per the facility policy. During an interview on 9/22/20 at 3:02 P.M., LPN F said oxygen tanks should be checked every time a resident is put into his/her wheelchair and periodically after depending on the liter flow and how long the resident is in the wheelchair. Additionally, he/she said oxygen tanks need to be changed when the tank shows it is in the red on the gauge. The LPN said only licensed staff are allowed to make changes to the oxygen flow and CNAs are allowed to place nasal cannulas on the residents. Furthermore, the LPN said nursing staff are able to use their judgment to change the oxygen flow, but it would need physician approval. He/she said the oxygen tanks attached to the resident's wheelchairs generally match the concentrators in the resident's room and the CNAs can use walkie-talkies to ask licensed staff what the rate for a resident should be. The LPN said oxygen orders for the resident's rate can be found in the computer. During an interview on 9/22/20 at 3:02 P.M., LPN F, said when licensed staff observe a resident fall, they check the resident's vital signs and perform a neurological assessment and assist the resident to their bed or wheelchair. He/she said staff fill out an incident report which includes the resident's diagnoses, medications, a description of the incident, what footwear the resident was wearing, whether there was an injury, and who was notified following the fall. LPN F said the incident report is completed on the computer and the DON and management are notified so they can complete the form and review. Additionally, LPN F said if there was an unwitnessed resident fall, staff automatically perform neurological assessments because there is no way to know if the resident hit his/her head. He/she said the n neurological assessments include checking vital signs, range of motion, pupil checks, and assessing resident's grip strength. LPN F said neurological assessments are to be completed every 15 minutes for the first hour, every 30 minutes for the next hour, and then every shift for the rest of the three days or 72 hours. He/she said when a resident falls, the first contact in the resident's record is contacted, along with management and the physician. LPN F said neurological assessments are completed in the computer charting and when an assessment is due, a reminder pops up. During an interview on 9/22/20 at 3:20 P.M., CNA O said he/she checks the oxygen tanks when the resident gets into his/her wheelchair. He/she said when the tanks are in the red zone on the gauge, they are getting low and he/she will get a new tank if he/she notices a resident's tank getting low. He/she said if he/she was unsure what the correct rate of oxygen is for a resident, he/she would verify with the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to properly dispose of medications for three resident's (Resident #194, #195, #193), after they had been discharged from the facility, failed to verify reconciliation of controlled medication (a medication whose manufacturing, possession, or use is regulated by the government) counts for three residents (Resident #20, #11, and #42), and failed to destroy a controlled medication in a timely manner for one resident (Resident #42). Resident census was 88. 1. Review of the facility's Medication Storage and Labeling Policy, undated, showed pharmaceutical medication will be labeled and stored in accordance with all state of Missouri and federal guidelines as well as all standards of clinical practice. 2. Review of the facility's Destroying Medications policy, undated, showed: -Immediately upon discharge of a resident, all the resident's medications remaining are documented according to our return policy and sent directly to the nursing office; -Medications that are returnable to the pharmacy according to regulation guidelines will be refunded for credit; -All medications that are non-returnable will be discarded through the office of the director of nursing (DON). -And the policy did not direct staff on what to do with medications if a resident returns home or is sent to another facility. 3. Review of the facility's Counting Schedule II Narcotics (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) and Other Controlled Substance procedure, undated, showed: -All schedule II narcotics are kept behind two locks and counted each shift; -Medications are counted at the beginning and end of each shift by nurses from the off-going and on-coming shift. They must be counted together; -The medications are compared to the control sheet to review if the count is correct; -The nurses then sign on the front cover sheet that they have counted; -And the procedure did not direct staff on what to do if the count was incorrect or a medication was missing. 4. Observation on 9/17/20 at 11:00 A.M. of the 300 hall medication room showed a plastic bag in the cabinet that contained prescription pharmacy bottles. Further review showed: -Resident #194 had a bottle of Carvedilol (used to treat high blood pressure and heart failure)12.5 milligrams (mg) and Junumet XR (helps control blood sugar levels) 100 mg, both containing multiple pills. Record review showed Resident #194 was discharged to the community on 8/27/20. The facility failed to dispose of the medication per their policy. 5. Observation on 9/17/20 at 11:00 A.M. of the stock/overflow cart in the 300 hall medication room showed: -Bicalutamide (used to treat cancer) 50 mg belonging to Resident #195; -Alendronate (used to treat bone loss) 70 mg and a Salonpas pain patch belonging to Resident #193. Record review showed Resident #195 was discharged to the community on 6/3/20 and Resident #193 had been discharged to another facility on 7/10/20. The facility failed to dispose of the medication per their policy. During an interview on 9/17/20 at 11:00 A.M., Certified Medication Technician (CMT) H said when a resident is discharged with doctor's orders for medications, the facility sends a seven to ten day supply home with the resident. He/she said if the resident goes to a different facility they send a seven day supply and send the rest back to pharmacy. Additionally, he/she said the medications were probably overlooked. During an interview on 9/17/20 at 11:00 A.M., CMT G said the residents' medication was probably overflow and had not been sent back to pharmacy. He/she said the pharmacy had not given them a certain amount of time to return medications by. 6. Observation on 9/17/20 at 12:25 P.M. of the medication cart for 300/400 hall showed: -Resident #20 had a card of Oxycodone (narcotic pain medication) 5 mg with 2 left in the card. The narcotic reconciliation sheet showed the resident had 3 left in the card and Oxycodone had not been signed out on 9/17/20; -And resident #11 had a card of Hydrocodone-Acetaminophen (narcotic pain medication) 5/325 mg with 5 left in the card. The narcotic reconciliation sheet showed the resident had 4 remaining. During an interview on 9/17/20 at 12:25 P.M., CMT G said he/she had given Resident #20 an Oxycodone that morning and had not signed it out yet. He/she did not know why Resident #11's Hydrocodone-Acetaminophen count was incorrect. Resident #11 had gone to the hospital the night before and he/she gave the resident the medication before leaving. 7. Observation on 9/17/20 at 10:00 A.M. in medication room [ROOM NUMBER] showed -An unopened, 30 ml bottle of Lorazepam (antianxiety medication, controlled substance) 2 mg/ml, belonging to resident #42, was under insulin pens in a plastic tub in the refrigerator. During an interview on 9/17/20 at 10:00 A.M., Licensed Practical Nurse (LPN) F said the licensed nurse for the 300/400 hall was responsible for counting the medication. Observation on 9/17/20 at 12:45 P.M. showed during a narcotic reconciliation count for the licensed medication cart for 300/400 hall, LPN I held a narcotic reconciliation sheet and asked for the count of Morphine (a narcotic pain medication). The surveyor pointed out the sheet was for Resident #42's Lorazepam concentrate 2 mg/ml [NAME] instead of Morphine. During an interview on 9/17/20 at 12:45 P.M., LPN I said he/she was not sure where the Lorazepam was and the label on the narcotic reconciliation sheet showed Lorazepam was received on 6/18/20. He/she went on to say it was probably destroyed but the sheet should have gone with it. He/she did not see or count the Lorazepam that morning, but did sign the count was correct that morning. He/she was not aware the Lorazepam was in the medication room on the 200 hall. Record review showed resident #42's Lorazepam had been discontinued on 6/30/20. During an interview on 9/22/20 at 4:15 P.M. the Director of Nursing (DON) said nurses and CMT's count together at the start of their shift. Staff should look at the binder and the medication during count to make sure they match. Narcotic medications should be signed out immediately upon administration. If the narcotic count is incorrect, staff should recount and then notify the supervisor. Staff do not leave the building until the missing medication is accounted for. If a medication is discontinued it should be destroyed as soon as possible. He/she was not aware of a time frame discontinued medications should be destroyed by. Prior to COVID, when a resident was discharged , pharmacy would pick up their medications. It is not getting done as quickly now. When the pharmacy comes by and staff remember it, staff will give the medication to the pharmacy through the door. During an interview on 9/23/20 at 8:30 A.M. the DON said staff did not make her aware of the incorrect count on the 300/400 hall cart for Resident #11 on 9/17/20 and they had still not made him/her aware of the discrepancy. He/she would expect staff to immediately report any discrepancies to him/her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to maintain a medication error rate of less than 5%. ([NAME], if you look below at the regulation it says error rates are not 5% or greater. Out of 29 opportunities observed, ten errors occurred, resulting in a 34.48% error rate. Facility staff failed to administer medications within the ordered timeframe for five residents (Resident #30, Resident #69, Resident #70, Resident #84, and Resident #86), failed to prime (remove the air from the needle and the cartridge) insulin pens and hold the needle of the pen in place for the recommended amount of time for two residents (Resident #38 and Resident #44), and failed to administer the correct dosage of medication to one resident (Resident #72). The facility census was 88. 1. Review of the facility's policy, Medication Administration General Guidelines, revised May 2020, shows staff are directed as follows: -Medications are administered in accordance with written orders of the prescriber; -Medication administration timing: See policy on Liberalized Medication Pass; -Verify medication is correct three (3) times before administering the medication: -When pulling medication package from med cart; -When dose is prepared; -Before dose is administered; -Hands are washed with soap and water before and after administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy; -Medications are administered in accordance with Liberalized Medication Administration policy unless otherwise stated or ordered; -And if a dose of regularly scheduled medication is withheld, refused or given at another time than the scheduled time, please document in space provided in the eMAR (electronic medication administration record to allow staff to show medication was administered to a resident). 2. Review of the facility's policy, Liberal Medication Policy, dated February 21, 2020, shows staff are directed as follows: -Non-time specific medications should follow the liberalized time frames listed below, and have the administration time indicated using the appropriate abbreviations; -Upon Rising: 6:00 A.M. - 10:00 A.M.; -Mid-day Meal: 11:00 A.M. - 2:00 P.M.; -Bedtime: 8:00 P.M. - 12:00 A.M.; -And Twice per Day: Upon Rising and Bedtime. 3. Review of the facility's policy, Utilization of an Insulin Flex Pen, revised January 22, 2019, shows staff are directed as follows: -Small amounts of air may collect in the cartridge during normal use. To avoid injecting air and ensure proper dosing: -Turn the dose selector to 2 units; -Hold your flexpen with the needle point up, and tap the cartridge gently a few times, which moves the air bubbles to the top; -Press the push-button all the way in until the dose selector is back to 0. A drop of insulin should appear at the tip of the needle; -If no drop appears, change the needle and repeat. A small air bubble may remain at the needle tip with using an insulin flex pen; -The dose selector should be at 0; -Insert the needle into the skin; -Press the push-button all the way in until the dose selector is back to 0. Turning the dose selector will not inject the insulin; -Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed until the needle has been pulled out from the skin. 4. Review of Resident #44's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by staff, dated 7/17/2020, showed the resident had a diagnosis of diabetes mellitus and receives insulin. Review of the physician's order, dated 8/8/19, showed the physician ordered Novolog insulin 10 units to be given three times per day. Observation on 9/15/20 at 11:51 A.M. showed Licensed Practical Nurse (LPN) I administer the Novolog insulin to the resident. He/she did not prime the insulin pen with 2 units prior to administering the ordered dose. Further observation showed the LPN immediately removed the pen from the resident's kin, and did not leave it in place for the directed six seconds. Observation on 9/17/20 at 8:35 A.M. showed LPN I administer the Novolog insulin to the resident. He/she did not prime the insulin pen with 2 units prior administering the ordered dose. Further observation showed the LPN immediately remove the pen from the resident's skin, and did not leave it in place for the directed six seconds. 5. Review of Resident #38's Quarterly MDS, dated [DATE], showed the resident had a diagnosis of diabetes mellitus and receives insulin (medication used to decrease glucose levels). Review of the physician's order, dated 9/29/19, showed the physician ordered Novolog insulin on a sliding scale dose to be given before meals and at bedtime. Review of the physician's order, dated 5/6/20, showed the physician ordered Basaglar insulin 29 units to be given before breakfast and at bedtime. Observation on 9/17/20 at 8:48 A.M., showed LPN I administer the Basaglar insulin to the resident. He/she did not prime the insulin pen with 2 units prior to administering the ordered dose. Further observation showed the LPN immediately removed the pen from the resident's skin, and did not leave it in place for the directed six seconds. Additional observation showed LPN I administer the Novolog insulin pen to the resident. He/she did not prime the insulin pen with 2 units prior to administration and immediately removed the pen from the resident's skin, not leaving it in place for the directed six seconds. 6. Review of Resident #70's Quarterly MDS, dated [DATE], showed the resident had diagnoses of heart failure (condition in which the heart does not pump blood well) and hypertension (high blood pressure). Review of the resident's physician order, dated 11/25/19, showed the physician ordered Lasix 40 mg to be given twice per day; upon rising, between the hours of 6:00 A.M. and 10:00 A.M., and at bedtime, between the hours of 8:00 P.M. and 12:00 A.M. Observation on 9/18/20 at 11:00 A.M., showed Certified Medication Technician (CMT) G administered Lasix 40 mg to the resident. Staff did not administer the medication to the resident in the ordered time frame. 7. Review of Resident #69's admission MDS, dated [DATE], showed the resident had a diagnosis of coronary artery disease (narrowing of the arteries leading to decreased blood flow to the heart). Review of the resident's physician order, dated 7/16/20, showed the physician ordered Lasix (medication used to treat swelling), for primary pulmonary hypertension (high blood pressure that affects the arteries in the lungs and heart), 40 mg to be given twice per day; upon rising, between the hours of 6:00 A.M. and 10:00 A.M., and at bedtime, between the hours of 8:00 P.M. and 12:00 A.M. Observation on 9/18/20 at 11:02 A.M., showed CMT G, administered Lasix 40 mg to the resident. Staff did not administer the medication to the resident in the ordered time frame. 8. Review of Resident #86's Quarterly MDS, dated [DATE], showed the resident had a diagnosis of hyperlipidemia (condition that results in high levels of fat in the blood). Review of the resident's physician order, dated 5/15/20, showed the physician ordered Lasix 40 mg to be given twice per day; upon rising, between the hours of 6:00 A.M. and 10:00 A.M., and at bedtime, between the hours of 8:00 P.M. and 12:00 A.M. Observation on 9/18/20 at 11:11 A.M., showed CMT H administered Lasix 40 mg to the resident. Staff did not administer the medication to the resident in the ordered time frame. 9. Review of Resident #84's Quarterly MDS, dated [DATE], showed the resident had diagnosis of diabetes mellitus (disease that results in too much glucose (sugar) in the blood) and is on a scheduled pain regimen. Review of the resident's physician order, dated 9/17/20, showed the physician ordered Gabapentin 600 mg to be given twice per day; upon rising, between the hours of 6:00 A.M. and 10:00 A.M., and at bedtime, between the hours of 8:00 P.M. and 12:00 A.M. Observation on 9:18 A.M. at 11:18 A.M., showed CMT H administered 600 mg to the resident. Staff did not administer the medication to the resident in the ordered time frame. 10. Review of Resident #30's Quarterly MDS, dated [DATE], showed the resident had a diagnoses of Diabetes Mellitus and is on a scheduled pain regimen. Review of the resident's physician order, dated 9/17/20, showed the physician ordered Gabapentin (medication used to treat chronic pain) 600 milligrams (mg) to be given twice per day; upon rising, between the hours of 6:00 A.M. and 10:00 A.M., and at bedtime, between the hours of 8:00 P.M. and 12:00 A.M. Observation on 9/18/20 at 12:01 P.M., showed CMT H, administered gabapentin 600 mg to the resident. Staff did not administer the medication to the resident in the ordered time frame. 11. Review of Resident #72's Quarterly MDS, dated [DATE], showed the resident had a diagnosis heart failure, hypertension, diabetes mellitus, and hyperlipidemia. Review of physician's order, dated 7/4/20, showed the physician ordered Aldactone (medication to treat high blood pressure and swelling) 50 mg to be given one time with the mid-day meal. Observation on 9/18/20 at 12:04 P.M. showed CMT H gave Aldactone 25 mg. The CMT did not administer the ordered dose of medication. During an interview on 9/21/20 at 6:10 P.M., Certified Nursing Assistant (CNA)/CMT L said when a medication order says it is due upon rising staff are to administer it by 10:00 A.M. He/she said when a medication is overdue, it turns red in the eMAR. Additionally, he/she said if a medication is due at 8:00 A.M., staff have a window of an hour before and an hour after to administer it. CNA/CMT L said he/she wouldn't give a medication outside of the scheduled administration time because it would not be following the orders. He/she said he/she would inform the nurse on duty of the missed dose and the nurse would direct the CMT what to do. During an interview on 9/21/20 at 6:21 P.M., LPN V said he/she mainly administers insulin and opioids. LPN V said insulin can be given an hour before and an hour after it is due. He/she said prior to giving insulin, he/she checks the resident's glucose level and if it is high, he/she will notify the resident's physician. Additionally, LPN V said when he/she prepares insulin, he/she attaches a syringe to the insulin pen and turns the dose selector to the correct dose. He/she said he/she asks the resident where they want they would like their insulin given, administers the insulin, and then disposes of the syringe. He/she said insulin pens do not get primed prior administration of insulin. LPN V said every six to 12 months, staff attend an in-service training to review insulin administration and how to use glucometers. Furthermore, he/she said the pen automatically ejects once the insulin has been administered to the resident and he/she does not hold the insulin pen in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility staff failed to ensure expired medications were destroyed in a timely manner and failed to ensure medications were properly labeled. Additionally, staff failed to store a controlled substance for one resident (Resident #42) in a safe manner. The facility census was 88. 1. Review of the facility's Medication Storage and Labeling Policy, undated, showed staff are directed as follows: -Pharmaceutical medication will be labeled and stored in accordance with all state of Missouri and federal guidelines, as well as all standards of clinical practice; -Controlled substances (any of a category of behavior-altering or addictive drugs whose possession and use are restricted by law) must be stored separately from non-controlled medication and locked behind a double lock system in which only authorized personnel may have access; -Pharmaceutical medications will be labeled with the resident's name, date of birth , ordering physician, prescription number, date of packaging, name of medication, strength, and clear dispensing instructions as ordered by the physician; -In the case that a medication is delivered that is not labeled correctly, staff will return the unused package to the pharmacy for correction; -Expired medications are removed from the area of care immediately and disposed of according to facility medication disposal policy, per state and federal guidelines. 2. Review of the Facility's Destroying Medication policy, undated, showed staff are directed as follows: -All medications that are non-returnable, such as scheduled drugs and opened products, will be discarded through the office of the director of nursing; -The policy did not provide direction for staff in regards to expired medication. 3. Observation on 9/17/20 at 10:00 A.M. of medication room [ROOM NUMBER] showed the following: -An unopened container of Restasis (prescription eye drops for dry eyes), 30 single use vials with no name or label on a shelf with stock medications; -An unopened box of artificial tears on a shelf with stock medications with an expiration date of June 2020; -A 1000 milliliter (ml) bag of 0.9% Sodium Chloride under the sink with an expiration date of 4/1/20; -And an unopened, 30 ml bottle of Lorazepam (controlled antianxiety medication) 2 milligram (mg)/ml under insulin pens, in a plastic tub in the refrigerator belonging to Resident #42. The Lorazepam was not under a double lock. During an interview on 9/17/20 at 10:00 A.M., Licensed Practical Nurse (LPN) F said the Lorazepam should be in a lock box in the refrigerator. He/she said when medication is expired staff should dispose of it in the drug buster (a medication disposal system that breaks down medications into a chemically inactive slurry). Furthermore, he/she said if a narcotic needs to be destroyed, the assistant director of nursing is responsible for ensuring it is done. Observation on 9/17/20 at 11:00 A.M. of the stock/overflow medication cart located in the 300 hall medication room showed: -Two unopened packages of Budesonide (a steroid that reduces inflammation in the body) 0.25 mg/2 ml single use vials. Neither package had a resident's name or pharmacy label; -Two open packages of Albuterol Sulfate (relaxes muscles in the airway) 2.5 mg/3 ml. Neither package had a resident's name or pharmacy label; -And a bottle of Oyster Calcium (calcium supplement) 500 mg,opened on 12/2 and a best by date of 1/2020. Observation on 9/17/20 at 12:25 P.M. of the 300/400 hall medication cart showed: -One Proair HFA (inhaler used to relax muscles in the airway) with no identifying label or name; -And one Ventolin HFA (inhaler used to relax muscles in the airway) with no identifying label or name. During an interview on 9/17/20 at 12:25 P.M., Certified Medication Technician (CMT) G said he/she had pulled the reordering sticker off the bag that contained the inhalers the night before and threw the bag away. During an interview on 9/22/20 at 4:15 P.M. the DON said prescription medications should not be in the medication rooms without names on them, and if staff find medications without names, they should take them to the charge nurse or DON. Furthermore, he/she said expired medications should not be in the medication rooms. He/She said the pharmacy used to come in and check the medication rooms for expired medications but since Coronavirus (COVID), the nurses and CMT's are supposed to check for them. He/She said there is no set time or person to do this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility staff failed to appropriately sanitize a multi-use glucometer (a device for monitoring blood sugars) before and after use for four residents (Resident #44, Resident #49, Resident #81, and Resident #43), staff did not prevent the spread of infection causing contaminants and failed to wash hands between glove change during resident care for five residents (Resident #44, Resident #39, Resident #42, Resident #80, and Resident #82) didn't see an observation for 82 for washing hands between glove changes did i miss that or do we need to delete this person from based on?, and staff failed to position the catheter drainage bag off the floor and in a way to prevent the spread of bacteria for one resident (Resident #82). Additionally, staff failed to disinfect areas of the floor after being contaminated by soiled linens or bodily fluids for three residents (Resident #48, Resident #87, and Resident #71). The facility census was 88. 1. Review of the facility's Infection Control and Prevention policy, undated, showed: -Observe standard precautions; -Wash your hands before and after procedures; -Wash your hands before and after resident contact; -Follow the manufacturer's instructions for cleaning all special equipment; -Clean all equipment and return to appropriate storage area; -Dispose of soiled linen appropriately (bagged and put in soiled utility room); -Contain and dispose of bodily fluids appropriately; -Gloves should be used as an addition to, not as a substitute for hand hygiene; -Contamination is still possible with glove use; -It is essential that gloves be used in combination with hand hygiene; -Wear gloves when contact with blood or other potential infectious materials are possible; -Do not wear the same pair of gloves for the care of more than one resident; -Remove gloves after caring for a resident; -Wash hands or perform hand hygiene after gloves are removed. Review of the facility's policy, Cleaning of Equipment Used Between Residents, undated, shows the following: -Multi-use equipment includes glucometers; -Equipment will be cleaned and disinfected by the nurse when it becomes visibly dirty, between each residents' use, as directed by the manufacturer, or as directed by the manufacturer or by facility policy for particular equipment. Review of the germicidal bleach wipes packaging used to clean the glucometers shows the following: -A 30 second contact time is required to kill all of the bacteria and viruses; -Reapply as necessary to ensure that the surface remains wet for the entire contact time; -Allow the surface to air dry. 2. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/17/2020, showed the resident has a diagnosis of diabetes mellitus (disease that results in too much glucose (sugar) in the blood) and receives insulin (medication used to decrease glucose levels). Review of the physician's order, dated 8/8/19, showed the physician ordered Novolog insulin (short acting insulin) 10 units to be given three times per day. Observation on 9/15/20 at 11:39 A.M., showed licensure practical nurse (LPN) I exited a resident's room after using the glucometer to check the resident's glucose level and entered Resident #44's room without performing hand hygiene or cleaning the glucometer. Observation on 9/15/20 at 11:45 A.M., showed LPN I apply clean gloves, and used the soiled glucometer to check the resident's glucose level. Additionally, the LPN administered insulin to the resident, removed his/her gloves and did not wash his/her hands. Observation on 9/17/20 at 8:35 A.M., showed LPN I checked the resident's glucose and administered insulin. Additionally, the LPN wiped the glucometer for 17 seconds, keeping the glucometer wet for only 30 seconds. 3. Review of Resident #49's annual MDS, dated [DATE], showed the resident has a diagnosis of diabetes and receives insulin. Review of the physician's order, dated 4/30/20, showed the physician ordered Novolog on a sliding scale (dosing is dependent on the glucose level) to be given three times per day. Observation on 9/16/20 at 11:13 A.M., showed LPN U checked the resident's glucose level and then cleaned the glucometer with a germicidal bleach wipe, for a wet time of 10 seconds. 4. Review of Resident #81's annual MDS, dated [DATE], showed the resident has a diagnosis of diabetes and receives insulin. Review of the physician's order, dated 9/28/20, showed the physician ordered Novolog insulin 10 units to be given before meals and at bedtime for blood sugars greater than 300. Observation on 9/16/20 at 11:18 A.M., showed LPN U checked the resident's glucose level and then wiped the glucometer with a germicidal bleach wipe for 3 seconds. 5. Review of Resident #43's quarterly MDS, dated [DATE], showed the resident has a diagnosis of diabetes and receives insulin. Review of the physician's order, dated 4/30/20, showed the physician ordered Novolog insulin on a sliding scale to be given four times per day. Observation on 9/16/20 at 11:24 A.M., showed LPN U checked the resident's glucose level and cleaned the glucometer with the germicidal bleach wipe six seconds. 6. Review of Resident #48's quarterly MDS, dated [DATE], showed: -Moderately impaired cognitive status; -Dependent for activities of daily living (ADLs); -Always incontinent of bowel and bladder. Observation on 9/16/2020 at 10:03 A.M., showed certified nursing assistant/certified medication technician (CNA/CMT) L and CNA R provided incontinent care for the resident. The observation showed the resident was visibly soiled. The observation showed CNA R discarded soiled depends, wipes, and gloves from providing care directly onto the resident's floor without bagging items. The soiled material lay on the floor until care was completed and resident was taken from the room. The CNA returned to the room and picked up and bagged the soiled items off the floor and exited room. The CNA did not disinfect the contaminated area of floor. 7. Review of Resident #78's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for toilet use and personal hygiene; -Always incontinent of bowel and bladder. Observation on 9/16/20 at 11:37 A.M., showed the resident in bed. The resident had been incontinent of semi-liquid stool that covered the resident's perineum (genital and anal area). CNA/CMT K and CNA/CMT L turned the resident on his/her right side. CNA/CMT L used incontinence wipes to remove the stool from the resident's buttocks and perineum, wiping from back to front several times and rolled the resident to his/her back. CNA/CMT L moved the package of incontinence wipes to the bedside table and covered the resident without removing his/her gloves while CNA/CMT K left the room to get washcloths. After CNA/CMT K returned, CNA/CMT L used wet washcloths to remove stool from the front of the resident's perineum, washing from back to front several times. i don't see wiping from back to front in the based on - if this is a failure please add to based on if not please delete. During an interview on 9/16/20 at 11:45 A.M., CNA/CMT L said when staff perform perineal care they should go from clean to dirty. CNA L said, The resident was a mess. He/She said the resident had stool in the pubic hair, and a clump of stool in there that he/she tried to get it out at every angle. 8. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Was severely impaired cognitive skills for decision making; -Dependent on staff for toileting and personal hygiene; -Was always incontinent of bowel and bladder. Observation on 9/17/20 at 8:42 A.M., showed CNA M and CNA/CMT L assisted the resident to bed. The back of the resident's pants were soiled with urine and a small amount of stool. CNA M used incontinence wipes to clean the stool from the resident's buttocks. CNA M washed the front of the resident's perineum and did not change gloves or perform hand hygiene. CNA M removed his/her gloves and, without performing hand hygiene, took the trash out of room to the soiled utility room. i don't see not changing gloves in the based on - if this is a failure please add to based on if not please delete. During an interview on 9/17/20 at 8:50 A.M., CNA M said he/she did not change gloves or wash hands. He/She said staff should change gloves and wash hands before and after wiping the perineal area. Staff should change gloves and perform hand hygiene after cleaning stool and before moving to the front perineal area. 9. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Occasionally incontinent of bowel and bladder; -Unstageable pressure injury (pressure ulcer tissues are obscured such that the depth of soft tissue damage cannot be observed); -Required supervision and set-up assist with ADLs. Observation on 9/17/20 at 9:25 A.M., showed the resident standing in his/her room with the use of a walker. LPN J removed the resident's sacral (lower part of spine) dressing. The dressing had a moderate amount of yellow drainage that had seeped through to the outside. LPN J cleansed the sacral Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) with clean gauze pads and wound cleanser. LPN J applied Iodosorb (a gel used to promote wound healing), Calcium Alginate (absorbent dressing derived from seaweed), clean 4x4 gauze pads and a boarder gauze without changing gloves or performing hand hygiene. LPN J removed his/her gloves, opened and closed the door to the room, and then used alcohol based hand rub (ABHR). i don't see not changing gloves in the based on - if this is a failure please add to based on if not please delete. 10. Review of Resident #16's quarterly MDS, dated [DATE], showed: -Severely impaired cognitive status; -Dependent on staff for bed mobility, toilet use and personal hygiene; -Always incontinent of bowel and bladder; -Stage II pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red-pink wound bed, without granulation, slough or bruising). Observation on 9/17/20 at 9:35 A.M., showed the resident in bed. LPN J gloved and removed wound care supplies from the treatment cart. LPN J cleansed the pressure ulcers on the resident's sacral region with gauze and wound cleanser without changing gloves or performing hand hygiene. LPN J removed his/her gloves and applied new gloves without performing hand hygiene. LPN J applied a clean dressing to the resident's sacral region. i don't see not changing gloves in the based on - if this is a failure please add to based on if not please delete. 11. Review of Resident #60's quarterly MDS, dated [DATE], showed: -Had severely impaired cognitive status; -Was dependent on staff for ADLs; -Was always incontinent of bowel and bladder; -Had a Stage II pressure ulcer. Observation on 9/17/20 at 9:45 A.M., showed the resident #60 in bed. LPN J gloved and removed wound care supplies from the treatment cart. LPN J began to cleanse the resident's pressure ulcers on the ischium (lower, back portion of the hip bone) and coccyx (the bone at the base of the spine) with gauze and wound cleanser without changing gloves or performing hand hygiene. The resident began to have a bowel movement. LPN J used incontinence wipes to clean the resident, removed his/her gloves, left the room to get a clean incontinence pad, and returned to the room without performing hand hygiene. LPN J applied new gloves and placed a clean dressing on the resident's ulcers. i don't see not changing gloves in the based on - if this is a failure please add to based on if not please delete. 12. Review of Resident #71's Quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of dementia define; -Frequent incontinence of bowel and bladder. Observation on 9/17/2020 at 1:52 P.M., showed the resident in the day area across from the activity room area. Additional observation showed a large puddle of urine outside the entry doors to the activity area and the 400 hall with numerous small puddles and droplets leading from the large puddle to the resident and under his/her wheelchair. CNA Q passed by and another resident told CNA Q, that someone spilled water on the floor. CNA Q started to wipe up urine with a cloth towel and non-gloved hands. CNA Q did not address the smaller areas of liquid leading to the resident or address the resident in any manner. CNA Q took the soiled towel to the dirty utility room, touching the door handle with soiled hands. CNA Q exited the soiled utility room and walked across the area where he/she wiped up the liquid, did not address the other puddles or the resident. CNA Q proceeded down the 400 hall, passed a housekeeper and did not notify him/her of the issue and entered another resident room. i don't see anything about not washing soiled hands or cleaning urine off floor without gloves in based on statement - please add. Observation on 9/17/20 at 2:15 P.M., showed the urine remained on floor and the resident sat in the wheelchair in the day area. The resident wheeled himself/herself half way up the 400 hall and a staff member assisted the resident back to the day room. The staff did not address the resident's wet clothes or the puddles on the floor. During an interview on 9/17/2020 at 2:28 P.M., CNA Q said he/she was aware the liquid on the floor was urine and did notice small puddles of urine leading to the resident in the day area. CNA Q said, I haven't seen a housekeeper, so I have not informed anyone. CNA Q said he/she did not notify the staff assigned to the resident of the incontinence, because I was trying to take care of my residents. 13. Review of Resident #39's quarterly MDS, dated [DATE], showed the following: -Totally dependent for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing; -Uses a wheelchair for mobility; -Always incontinent of bladder and bowel; -Active diagnoses of coronary artery disease (narrowing of the arteries leading to decreased blood flow to the heart), heart failure (condition in which the heart does not pump blood well), hypertension (high blood pressure), diabetes, dementia define, anxiety, and depression; -Frequently experiences pain; -One stage III pressure ulcer and one unstageable pressure ulcer (injuries to the skin caused by prolonged pressure on the skin); -Received insulin, diuretics (medications used to treat swelling and high blood pressure), and opioids (pain medication); -Received oxygen therapy. Observation on 9/17/20 showed the following: -At 10:27 A.M., LPN J applied skin prep to the resident's wound, removed his/her gloves and applied clean gloves without performing hand hygiene; -At 10:31 A.M., LPN J applied clean dressings to the resident's wounds on the heel and toe, removed his/her gloves, disposed of supplies, and applied clean gloves without performing hand hygiene. 14. Review of Resident #42's quarterly MDS, dated [DATE], showed the following: -Totally dependent for bed mobility, dressing, toilet use, and personal hygiene; -Always incontinent of bladder and bowel; -Diagnoses of cancer define, anemia (condition in which the blood doesn't have enough red blood cells), hypertension define, anxiety, and depression; -Frequently experiences pain; -One unstageable pressure ulcer; -Receives anticoagulants define and opioids. Observation on 9/17/20 showed the following: -At 12:27 P.M., LPN J removed his/her gloves after providing perineal care and applied new gloves without performing hand hygiene; -At 12:31 P.M., LPN J applied cream the resident's perineal area and removed his/her soiled gloves and applied clean gloves without performing hand hygiene; -At 12:32 P.M., CNA Q removed soiled gloves after providing care to the resident and applied new gloves without performing hand hygiene; -At 12:35 P.M., LPN J and CNA Q removed gloves after performing a wound dressing change, and applied new gloves without performing hand hygiene; -At 12:41 P.M., LPN J removed his/her gloves after positioning the resident and placing towels between the resident's legs and applied clean gloves without performing hand hygiene. During an interview on 9/17/20 at 12:49 P.M., LPN J said hand hygiene is performed before and after providing resident care and gloves should be changed when going from dirty to clean. He/She said he/she does not perform hand hygiene between glove changes and he/she is unsure what the facility policy says about hand hygiene between glove changes. 15. Review of Resident #87's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Required extensive assist with transfers and toileting; -Frequently incontinent of bladder. Observation on 9/18/20 at 8:24 A.M., showed two soiled, washable incontinence pads and bed sheets on the floor just inside the door of the resident's room. During an interview on 9/18/20 at 8:20 A.M., the resident said the linens were from his/her bed last night. He/She said staff leave linens on the floor all the time and sometimes they sit there all day. During an interview on 9/18/20 at 8:24 A.M., CMT H said he/she did not know why the linens were on the floor. He/She said he/she assumed they were soiled since they were on the floor. 16. Review of Resident #80's quarterly MDS, dated [DATE], showed the following: -Brief Interview for Mental Status (BIMS) score of 14 out of 15; -Uses a wheelchair for mobility; -Uses an indwelling catheter; -Active diagnoses of cancer, coronary artery disease, hypertension (high blood pressure), diabetes (disease that results in too much glucose (sugar) in the blood); -Received chemotherapy (cancer treatment medications). Observation on 9/18/20 at 8:55 A.M., showed CNA N removed his/her gloves after providing catheter care, left the resident's room with trash, disposed of the trash in the soiled utility room, and entered another resident's room to provide care without performing hand hygiene. 17. Review of Resident #82's significant change Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/24/2020, showed the following: -Cognitively impaired; -Short term and long term memory problems; -Severely impaired decision making ability; -Totally dependent on staff requiring one person physical assist for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing; -Uses a wheelchair for mobility; -Indwelling catheter; -Always incontinent of bowel; -Active diagnosis of seizure disorder or epilepsy (disorder that causes abnormal brain activity); -One unstageable pressure ulcer. Observation on 9/18/20 at 9:14 A.M., showed the catheter drainage bag attached to the resident's bed and on the floor. Further observation showed CNA N did not adjust the drainage bag after providing perineal care to the resident. During an interview on 9/22/20 at 3:02 P.M., LPN F said catheter drainage bags should be attached to a metal part of the bed that does not move and the drainage bag should never touch the floor. do we have a policy for this? 18. During an interview on 9/21/20 at 5:15 P.M., nurse aide (NA) S said staff should always wash their hands before providing resident care. Staff should change gloves before doing something different and sanitize hands between glove changes. Soiled linens should be put in a bag and taken to the barrels in the dirty linen closet. If a resident urinates on the floor, nursing staff cleans it up as much as we can and asks housekeeping to sanitize the floor. During an interview on 9/21/20 at 5:20 P.M., CNA/CMT L said hand hygiene should be performed when entering a resident's room and when going from dirty to clean, change gloves and sanitize between. Soiled linens should be bagged and taken to the dirty utility room. If a resident urinates on the floor, nursing gloves and immediately cleans it and then lets housekeeping know to mop it. During an interview on 9/21/20 at 5:30 P.M., LPN T said if a resident urinates on the floor, staff change the resident immediately. He/She gets a wet floor sign and gets someone to clean the floor. He/She said sometimes housekeeping is right there or nursing is responsible for cleaning the urine and then housekeeping will sanitize the floor. During an interview on 9/22/20 at 3:02 P.M., LPN F said catheter drainage bags should be attached to a metal part of the bed that does not move and the drainage bag should never touch the floor. During an interview on 9/22/20 at 3:20 P.M., CNA O said the catheter drainage bags should be placed in a dignity bag and be off the floor. Additionally, he/she said hand hygiene should occur before and after care and between glove changes. He/She said staff should wash hands with soap and water instead of hand sanitizer if hands are visibly soiled. During an interview on 9/22/20 at 5:00 P.M., the assistant administrator and director of nursing (DON) said they expect staff to wash hands when entering and exiting a room, and between glove changes or sanitize hands. did we ask them about catheter bags, or sanitizing glucometers, or disinfecting floors?