**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide treatment and care in accordance with professional standards of practice, for six of twelve residents sampled. Two residents (Residents #5 and #8) did not have orders for wound care, three residents (Residents #6, #7, #9) wound care orders were not followed, and five residents (Residents #4, #6, #7, #8, #9) wound dressings were not dated or initialed per facility policy. The facility census was 62. Review of the facility's policy and procedure for Physician Order, revised 4/2025, showed:-Purpose: To establish guidelines for properly obtaining physician orders and processing these orders;-Policy: Telephone and verbal orders should be documented in the resident's electronic medical record then read back to the ordering physician or independent practitioner for verification;-It is the responsibility of the licensed nurse and Certified Medical Technician (CMT) to understand and comply with this procedure;-It is the responsibility of the Nurse Manager to maintain, enforce and monitor the procedure. Review of the facility's policy and procedure for Wound Care, revised 6/25/2025, showed:-To provide guidelines for use in wound assessment, treatment, and documentation;-Policy: A physician's order is required for all wound treatment;-Responsibility: It is the responsibility of the Director of Nursing (DON) to oversee this policy and procedure;-Practice: All dressings will be dated and initialed by the nurse applying the dressing. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/27/25, showed:-Cognitively intact;-Medical diagnoses and treatments: Right knee fracture, history of hip and knee fractures, obesity, heart failure, surgical wound, intravenous (IV) antibiotics. Review of resident's care plan, in use at the time of the investigation, showed:-Surgical incision at risk for skin impairment due to immobility. Reposition resident frequently. Keep resident clean and dry. Check resident skin daily with care and inform the nurse of any skin issues. Please let the nurse know if resident dressing is not intact or any new areas of redness/skin breakdown. Treatments as ordered by physician;-Goal is to reduce the risks factors that could contribute to skin impairment and/or optimize wound healing through this next review period;-No care plan for skin tears or fragile skin. Review of resident's physician orders, reviewed on 7/7/25, showed no order for left lower leg/calf dressing. Review of the resident's physician and nursing progress notes, showed no documentation of orders received for a skin tear to the left calf. Observation and interview with the resident on 7/7/2025 at 8:23 A.M., showed the resident had a wound dressing to the left lateral (outer side) of his/her calf, dated 7/4/25 and staff initials labeled on it. The resident said he/she thinks it gets changed every couple of days. 2. Review of Resident #8's admission MDS, dated [DATE], showed:-Intact cognition;-Medical diagnoses and treatments: surgical wound, skin tears, anemia, heart failure, and history of falls. Review of resident's care plan, in use at the time of the investigation, showed:-Surgical incision on right hip/thigh and right elbow skin tear;-Reposition frequently, check skin daily with care and inform the nurse of any skin issues. Let the nurse know if dressing is not intact or any new areas of redness or skin breakdown. Review of the resident's physician's orders, showed the following:-Wound care order dated 7/2/25: Skin tear on the left arm, leave Tegaderm (transparent dressing) in place for 21 days and change as needed, monitor daily for signs and symptoms of infection;-No order for Tegaderm dressing to right elbow. Observation and interview with the resident on 7/7/25 at 10:15 A.M., showed the resident had Tegaderm dressings to the right elbow and left wrist, both dated 7/2/25, no staff initials. The resident said he/she thinks they get changed every few days but is not sure. 3. Review of Resident #6's admission MDS, dated [DATE], showed:-Moderate cognitive impairment;-Medical diagnoses and treatments: heart disease, history of falls, kidney disease, and diabetes. Review of resident's care plan, in use at the time of the investigation, showed:-Surgical incision to right ankle. Risk for skin impairment due to immobility. Reposition frequently. Keep resident clean and dry. Check skin daily with care and inform the nurse of any skin issues. Let the nurse know if dressing is not intact or any new areas of redness or skin breakdown. Treatments as ordered by physician;-Risk for bleeding due to anticoagulant use. Monitor urine for blood and monitor body for excessive bleeding or bruising and contact nurse with changes;-No care plan for skin tears or fragile skin. Review of the resident's physician orders, showed the following:-Wound care order dated 7/6/25: Left arm skin tear, apply adherent film (a type of wound dressing that has an adhesive layer or border, allowing it to stick to the skin and stay in place for up to seven days), change every seven days and as needed if soiled. Monitor daily;-Wound care order dated 6/26/25: Right ankle surgical incision, cleanse with wound cleanser, pat dry and apply a dry gauze dressing daily. Observation and interview with the resident on 7/7/25 at 8:58 A.M., showed the resident had a left arm skin tear covered with a Tegaderm dressing, with no date or staff initials. The resident said he/she fell yesterday in the bathroom and the nurse applied the dressing. During an interview on 7/7/25 at 8:59 A.M., Registered Nurse (RN) A observed the wound and said that it is a Tegaderm dressing, and it is supposed to be dated and initialed. 4. Review of Resident #7's admission MDS, dated [DATE], showed:-Intact cognition;-Diagnoses and treatments included pressure ulcers to sacrum (top of buttocks), right thigh, and right upper back, intravenous (IV) antibiotic, surgical wound, wound dressing, and malnutrition. Review of resident's care plan, in use at the time of the investigation, showed:-Pressure ulcers at risk for skin impairment due to immobility;-Reposition frequently. Keep resident clean and dry. Check skin daily with care and inform the nurse of any skin issues. Let the nurse know if dressing is not intact or any new areas of redness or skin breakdown;-No care plan for the presence and care of the IV. Review of the resident's physician's orders, showed the following:-Wound care order dated 6/25/25, showed:-Sacrum pressure ulcer, cleanse with wound cleanser, pack with moistened gauze being sure to pack tunnelling, cover with abdominal dressing pad and secure with tape every 12 hours; -Peripherally inserted central line, change dressing using transparent dressing, measure line external length every Tuesday. Observation and interview with the resident on 7/7/25 at 9:13 A.M., showed Certified Nursing Assistant (CNA) B provided incontinence care to the resident. The Resident had a dressing on his/her sacrum with no initials and no date. He/she also has a transparent IV dressing on the right upper arm with no initials or date. The resident said the nurse last night tried something new to help keep the dressing on his/her bottom, to prevent stool from getting into it. He/she did not know exactly what the nurse tried. The IV dressing is changed every Tuesday. CNA B confirmed there was no date or initials on the sacrum and IV dressing. 5. Review of Resident #9's medical record, showed:-Moderate cognitive impairment;-Diagnoses included dementia, Parkinson's disease, fall, tremors, and urinary retention. Review of the resident's physician orders, showed:-Wound care order dated 7/2/25: Left ankle abrasion, clean with wound cleanser, pat dry apply Xerofoam (fine mesh gauze occlusive dressing for use on low draining wounds), cover with gauze daily and as needed. Observation and interview with the resident and family on 7/7/25 at 10:25 A.M., showed the resident had a Tegaderm dressing to the left ankle dated 7/4/25, with no staff initials. The family said they think the dressing is changed every three to four days but are not sure. 6. Review of Resident #4's admission MDS dated [DATE], showed:-Cognitively intact;-Diagnoses and treatments included acute pancreatitis with infected necrosis (infected pancreases), surgical wound with drainage tube, non-surgical dressings, and wound ointments/medications. Review of resident's care plan, in use at the time of the investigation, showed:-Excoriation (redness) on left flank (side of body between bottom of rib cage to the hip) at biliary drain (a tube placed to help drain bile from the liver and gallbladder), location. Please check resident skin daily with care and inform the nurse of any skin issues. Please reposition resident frequently;-Goal is to reduce the risks factors that could contribute to skin impairment and/or optimize wound healing through this next review period. Review of the resident's physician orders, showed:-Wound care order dated 6/29/25: Provide wound care for surgical incision on left flank, clean site with wound cleaner, pat dry, apply split gauze around drainage tube, cover with abdominal dressing, secure with tape every six hours, and as needed. Use Kerlix roll (gauze roll) to support tube to decrease leaking around the tube;-Wound care order dated 6/29/25: Flank excoriation, clean with soap and water, pat dry and apply Miconazole (antifungal medication) every 12 hours, and as needed;-Wound care order dated 6/29/25: Left flank surgical incision and left flank interventional radiology (IR) drain (a tube inserted into the body to drain fluid), used alcohol pad to clean the connection between the drainage catheter and bag. Flush drainage tube with 10 milliliters (ml) of normal saline (NS) twice a day. Reconnect the drainage tube to the drainage bag. Observation on 7/7/25 at 8:50 A.M., showed the resident had a wound dressing and drain to the left flank with no date or staff initials labeled on it. During an interview on 7/7/25 at 8:55 A.M., RN A observed the resident's wound and drainage cite and said the wound and drainage cite are supposed to be dated and initialed. 7. During an interview with Administrator and Director of nursing on 7/8/25 at 1:17 P.M., they said nursing staff should receive wound care orders or follow standing order sets from a physician or NP prior to providing wound care. Nursing staff are expected to know the difference between the types of wound dressings, to follow wound care orders, and document date and time on all wounds per facility policy and procedures, including IV dressings. If the nursing staff is unclear of the order, they are responsible to call and clarify the order with the ordering physician or NP. In addition, if a dressing has a date of 7/2/25 and the order says to change every three days it should have been changed on 7/5/25. MO00253503

Based on observation, interview and record review, the facility failed to provide appealing meal options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice, by failing to provide alternate meals per resident preference (Residents #10, #11, and #12). The sample size was 12. The facility census was 62. Review of the facility's menu for the week of 7/7/25 through 7/13/25, showed:-Breakfast for 7/7/25: Oatmeal, scrambled eggs, pancake with maple syrup;-Lunch for 7/7/25: Tomato Florentine soup, maple glazed ham, rice pilaf, green beans, blonde bar;-Breakfast for 7/8/25: Grits, scrambled eggs, bacon strips, biscuit;-Lunch for 7/8/25: Garden vegetable soup, beef sirloin steak, green peas, wheat roll, chocolate pudding;-Breakfast for 7/9/25: Oatmeal, scrambled eggs, orange bread;-Breakfast for 7/10/25: Grits, scrambled eggs, pancake with maple syrup, minestrone;-Breakfast for 7/11/25: Oatmeal, scrambled eggs, biscuit and gravy;-Breakfast for 7/12/25: Grits, scrambled eggs, cinnamon muffin;-Breakfast for 7/13/25: Oatmeal, scrambled eggs, bacon strips, French toast. Review of the facility's Always Available menu, showed:-Center of Plate: Classic cheeseburger, Hot dog on bun, Chicken tenders, Grilled Cheese sandwich, Deli sandwich, Grilled chicken breast;-Lighter Fare: Chef salad, fruit & cottage cheese plate, yogurt parfait;-Sides: French fries, side salad, cottage cheese, fresh fruit;-Beverages: Milk, water, coffee, iced tea, fruit juice, soda. Review of the facility's posted menu and menu substitution, showed: -When menu items are unavailable substitutions of comparable nutritional value are made;-Menus should include daily choices available for each meal;-Menu changes or substitutions for situations such as an emergency event, food unavailability or special dining events will be posted or otherwise communicated prior to meal service;-Menus for resident advanced ordering will be delivered to the resident;-Completed menus are collected and reviewed by dietary staff for diet congruency and honored. 1. Review of Resident #10's medical record, showed the following:-No cognitive impairment;-Consistent carbohydrate diet (CCHO) with Regular texture;-Diagnoses includes stroke and diabetes. Observation and interview on 7/7/25 at 10:05 A.M., showed the resident lay in bed with his/her breakfast tray that contained scrambled eggs, one pancake and a bowl of oatmeal, untouched with the lid half on that exposed half of the plate, on the resident's bedside table. Various different cereals and snacks were stored on the resident's windowsill. The resident said he/she just woke up and pushed the call light for the certified nurse aid (CNA) to reheat his/her breakfast tray. The resident said, I hate those powered eggs and oatmeal, but I do like the pancakes. The resident said although he/she continues to tell the facility that he/she dislikes oatmeal or grits he/she continues to get it every morning. At 10:10 A.M., CNA E said he/she could not reheat the breakfast tray because it would be considered cross contamination but would ask the kitchen for another breakfast tray. The CNA removed the breakfast tray and exited the room. At 10:20 A.M., CNA E returned to the room and said the kitchen could only offer a sandwich. The resident said he/she did not want a sandwich and if the CNA could please bring some milk so he/she could eat the cereal that was sitting on his/her windowsill. The resident said this was why he/she had to personally buy his/her own food to keep in his/her room. He/She has just given up on making requests because the facility never listens, so he/she just has his/her family bring food. 2. Review of Resident #11's medical record, showed the following:-No cognitive impairment;-Consistent Diet Therapy (CDT) and Low Concentrated Sweets (LCS);-Diagnosis includes Diabetes and cancer. Observation and interview on 7/7/25 at 1:10 P.M., showed the resident sat up in bed being fed by his/her spouse. The lunch tray contained two slices of ham and a large portion of green beans. A separate plate contained what appeared to be a blondie bar that was approximately two-inches by two-inches square and one mid-size cup of liquid. On the table a diet ticket showed the following:-Tomato Florentine soup, crossed out in blue ink;-Maple glazed ham;-Rice pilaf, crossed out with the wording mash potatoes in blue ink. Above the wording rice pilaf in a different handwriting and in black ink was do not have;-Seasoned green beans, crossed out in blue ink;-Blondie bar;-Saltine crackers;-Ice water;The spouse said he/she continues to voice frustration with the staff over not following the resident's requests or providing an acceptable alternative. The resident shook his/her head in acknowledgement. The spouse said all that happens when the facility does not have an alternative, they will double up on something else verses offering a comparable alternative. Filling out the diet tickets is pointless. They had filled out the diet ticket requesting the resident not have rice or green beans because these items upset the resident's stomach. However, all the facility did was write do not have above where he/she wrote mash potatoes and gave the resident a double amount of ham and green beans. He/She is very concerned for the resident nutrition needs. His/Her other concern was since the resident cannot have carbonation and is a diabetic all the facility has to offer him/her to drink at meals is tea or water. The facility does not offer any other diabetic alternative. Since the resident does not like tea this is why the resident is only served water for lunch and dinner. 3. Review of Resident #12's medical record, showed the following:-No cognitive impairment;-CDT and LCS diet, thin liquids;-Diagnoses included spinal stenosis and type 2 diabetes Observation and interview on 7/7/25 at 10:05 A.M., showed the resident sat in his/her wheelchair in his/her room and watched television. The resident said the food is horrible, it is not seasoned so it is very bland and has no flavor. On 7/6/25 he/she only got one piece of French toast with no meat and that is one meal he/she looks forward to because every day he/she is served powered eggs and either grits or oatmeal, all of which he/she does not like at all. He/She wishes the facility would offer cereal and more diabetic options. He/She was unaware the facility offered cereal as an alternative. 4. During an interview on 7/7/25 at 10:20 A.M., CNA E said that the dietary concierge meets with the residents and helps them fill out their menu ticket. If the resident wants a substitution, they can pick something off the Always Available menu and mark it on the menu ticket. The concierge gives all the completed tickets to the kitchen. However, the residents sometimes do not get what they asked for, but he/she lets the kitchen know when that happens. 5. During an interview on 7/7/25 at 1:45 P.M., the dietary manager said the dietary concierge is responsible for assisting the residents in completing three days of individualized menu tickets and returning the completed tickets to the kitchen. When the dietary concierge is off, a dietary staff member will ensure the menu tickets are completed and returned to the kitchen for processing. If a resident wants a substitution the facility has an Always Available menu that has a list of food alternatives for the resident to choose from. If a resident has a physician order for a dietary restriction the facility's software will automatically generate the restriction on the resident's menu slip. The dietary manager said the Always Available does not include breakfast or identify cereal as an alternative. If a resident wants a breakfast substitution, he/she expects the concierge or dietary staff to mark it on the menu ticket. All food on the meal ticket was verified by the kitchen staff before the tray went up to the floors. The dietary manager said he was not made aware there was an issue or concern with the beverage choices, and he would switch out one of the juices for flavored water or sugar-free fruit drink. The dietary manager said he expected the staff to inform the resident when a requested substitution was not available and to offer an alternative with equivalent nutritional value. 6. During an interview on 7/8/25 at 12:13 P.M., the dietary concierge/CNA said he/she is responsible for assisting the residents in completing the menu tickets and returning the tickets to the kitchen. If the resident and/or the resident's family member are unable to complete the ticket, he/she will assist in filling the ticket out. Each resident has a copy of the Always Available menu that lists out the options available for substitutions. However, he/she also has one in case the resident has lost their copy. If the resident wants a substitution, the concierge makes sure the substitution is marked on the ticket. However, once the ticket is returned into the kitchen, he/she is unaware of the outcome. The concierge said the menu ticket does not address alternatives for breakfast but if a resident informs him/her they want cereal, he/she will write the request on the back of the ticket. The concierge said he/she was not aware of the different types of cereal that are available. 7. During an interview on 7/8/25 at 11:14 A.M., the administrator said she expected staff to follow the preference of the resident and substitutes should be provided with an equivalent nutritional value. The administrator was not aware of any residents who were not getting their substitutions. MO00254148

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's care plan accurately reflected the residents' needs and medical conditions upon admission. This failure was noted in 5 of 17 sampled residents, including Resident #199, whose gastrostomy tube (g-tube, a surgical opening made in the stomach to feed nutrition directly into the stomach) was not included on the care plan, Resident #299 whose continuous positive airway pressure (CPAP, used to treat sleep apnea) was not included on the care plan, Resident #298 whose urinary catheter was not included and Resident #301, whose intravenous (IV) line was not included on the care plan, and for Resident #248 when a foot wound was not included on the care plan. The census was 69. Review of the facility's Care Planning policy, revised 11/22 showed: -It is the responsibility of all members of the interdisciplinary team to know and comply with this policy; -Initial/Baseline care plans must be completed within 48 hours of the resident's admission, and should include pain levels, fall risks, skin conditions, assistance with Activities of Daily Living (ADLs), and the risk for hospitalization no later than eight hours after admission; -The initial care plan is based on several areas, such as physician orders, pertinent diagnoses that would impact the resident's care, dietary orders, therapy services, social services, and utilization of the assessment tool to identify needs, risks, preferences, and services or treatment to be administered by facility staff. 1. Review of Resident #199's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/24, showed: -Cognitively intact; -Diagnoses included malignant neoplasm (a cancerous tumor) of the larynx; -Independence with ADLs including bathing, dressing, and personal hygiene; -An admission date of 5/16/24. Review of the resident's baseline care plan, entered on 5/17/24, made no mention of the resident's g-tube site or the resident's necessity to receive medications through his/her g-tube site. Observation on 5/20/24 at 11:46 A.M., showed the resident resting in bed with an enteral tube feeding (nutrition infused through a surgical opening in the intestine to meet a resident's caloric intake needs) infusing. The resident said he/she received scheduled enteral feedings and all medications through his/her g-tube and provided care for the g-tube site himself/herself. Observation on 5/21/24 at 9:46 A.M., showed the resident resting in bed with an enteral tube feeding infusing. The resident said he/she got evening meds as ordered by the physician, administered through his/her g-tube. Observation on 5/22/24 at 10:41 A.M., showed the resident resting in bed with an enteral feeding infusing. The resident said his/her g-tube was functioning properly and the dressing had been recently changed. During an interview on 5/23/24 at 10:28 A.M., Certified Medication Technician (CMT) F said the Social Services Designee is responsible for completing baseline and comprehensive care plans at the facility, and the development of care plans begins at admission. CMT F said he/she expected a resident admitted with a g-tube and administered medications through a g-tube to be included on the care plan. CMT F said care plans are important so that each resident's specific needs can be met by facility nursing staff. During an interview on 5/23/24 at 10:11 A.M. Licensed Practical Nurse (LPN) E said the Social Services Designee and floor nurses are responsible for completing baseline and comprehensive care plans at the facility, and the development of care plans begins at admission. LPN E said he/she expected a resident admitted with a g-tube and being administered medications through a g-tube to be included on the care plan. LPN E said care plans are important so that each resident's specific needs can be met by facility nursing staff. During an interview on 5/23/24 at 12:35 P.M., the Administrator and Director of Nursing (DON) said Nurse Managers in conjunction with the facility MDS Coordinator, are responsible for developing care plans, and care planning starts upon admission. The DON said baseline care plans should include fall risks, whether residents are at risk for skin breakdown, active wounds and surgical lines, and other immediate needs. The DON said the resident's g-tube status should be included on the care plan. 2. Review of Resident #299's electronic medical record (EMR) and resident information card, showed: -An entry MDS, dated [DATE], showed an admission date 5/13/24; -A baseline care plan showed general information that included a diagnosis of obstructive sleep apnea (OSA, breathing interrupted during sleep); -Diagnoses included cancer, high blood pressure, depression, high cholesterol and sleep apnea; -CPAP device was not listed on the resident's baseline care plan and information card. Observation on 5/20/24 at 11:21 A.M., showed the resident's CPAP rested on top of the headboard. During an interview on 5/23/24 at 10:16 A.M., Registered Nurse (RN) B said the CPAP should be listed on the care plan. During an interview on 5/23/24 at 12:35 A.M., the DON said she expected the CPAP to be on the resident's care plan. 3. Review of Resident #298's EMR and resident information card, showed: -An entry MDS, dated [DATE], showed an admission date 5/10/24; -A baseline care plan, dated 5/10/24, showed the resident as incontinent of bowel and bladder; -Indwelling urinary catheter (a tube inserted into the bladder through the urinary tract to drain urine) not indicated on resident information card; -Diagnoses include sleeplessness, seizure, bipolar disorder (a mood disorder characterized with manic highs and depressed lows) and neurogenic bladder (difficulty emptying the bladder due to neurological conditions). Observation on 5/21/24 at 6:54 A.M., showed the resident's indwelling urinary catheter in use and attached to the resident's bedrail. Observation and interview on 5/22/24 at 6:58 A.M., showed RN B and Certified Nursing Assistant (CNA) C performed a skin assessment while the resident lay in bed. CNA C said that he/she drains the indwelling urinary catheter gravity bag at the end of the shift. RN B said nurses should change the indwelling urinary catheter every thirty days or as needed. During an interview on 5/23/24 at 10:16 A.M., RN B said he/she expected to see the indwelling urinary catheter on the care plan and any nurse can update the care plan. During an interview on 5/23/24 at 12:35 P.M., the DON said if a resident has an indwelling urinary catheter, she expected it to be on the care plan. 4. Review of Resident #301's EMR, showed: -admit date [DATE]; -Diagnoses included stroke, infection, high blood pressure, and pacemaker (a device to help control the heart rate); -The resident's baseline care plan did not identify the use of any intravenous (IV) devices. Observation on 5/21/24 at 6:41 A.M., showed the resident had an IV pole with tubing at the bedside, and a double lumen peripherally inserted central catheter (PICC, a device which delivers fluids directly into a much larger vein) inserted into the right side of the resident's neck. During an interview on 5/23/24 at 10:16 A.M., RN B said he/she expected to see a PICC line on a care plan and any nurse can update the care plan. During an interview on 5/23/24 at 12:35 P.M., the DON said if a resident has a PICC line, she expected it to be on the care plan. 5. Review of Resident #248's EMR, showed: -admit date [DATE]; -Diagnoses included cellulitis, altered mental status, wound on coccyx, wound on right heel, right foot toes are amputated; -The resident's baseline care plan, in use at the time of the survey, did not identify wound care of the resident's right foot surgical incisions. During an interview on 5/20/24 at 11:48 A.M., the resident said he/she was at the facility for rehab and to heal the surgery incisions on his/her foot. During an interview on 5/23/24 at 11:36 A.M., LPN K said he/she was aware of the resident's wounds being treated on the resident's right foot. He/She expected for wound care to be on the care plan. During an interview on 5/23/24 at 12:38 P.M., the DON said she expected wounds and surgical incisions to be on the care plan to ensure staff know how to care for the resident properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on observation, interview and record review, the facility failed to ensure two residents' Activities of Daily Living (ADL) needs were met by failing to ensure both residents received at least two showers/bed baths weekly (Residents #248 and #249) . The sample was 17. The census was 69. Review of the facility's AM and PM Care policy, revised 10/2022, showed: -Purpose: to provide grooming and hygiene for each resident, assisting with bathing, dressing and elimination as needed; -Policy: it shall be the policy of Bethesda that each resident receives assistance with ADLs as needed throughout each day. Consideration will be given to making the experience as home-like and individual as possible; -Procedure: on the designated day, assist the resident with their bath or shower. 1. Review of Resident #248's electronic medical record (EMR), showed: -admit date [DATE]; -Cognitively intact; -Diagnoses included cellulitis, altered mental status, wound on coccyx, wound on right heel, right foot toes are amputated. Observation on 5/20/24 at 12:00 P.M., showed the resident had greasy hair. During an interview on 5/23/24 at 8:30 A.M., the resident said he/she has not had a shower or bed bath since his/her arrival to the facility. He/She felt dirty and uncomfortable and would like a shower. During an interview on 5/23/24 at 11:42 A.M., Licensed Practical Nurse (LPN) G said the resident had received a bed bath on 5/21/24 but the nursing staff who gave him/her the bath forgot to document. He/She expected for staff to document anytime they give a resident a shower or bed bath. 2. Review of Resident #249's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/20/24, showed: -admit date of 5/13/24; -Cognitively intact; -Diagnoses included below the knee amputation of the left leg. During an interview on 5/20/24 at 1:55 P.M., the resident said he/she had only received one bed bath since he/she arrived at the facility. He/She said he/she would like a shower and feels dirty. He/She said he/she had not refused any bed baths or showers since arriving to the facility. Review of the facility's shower documentation on 5/23/24 at 9:59 A.M., showed the only shower the resident received was on 5/17/24. During an interview on 5/23/24 at 12:41 P.M., the Director of Nursing (DON) said the resident has a history of refusing ADL care. 3. During an interview on 5/23/24 at 12:08 P.M., Certified Nursing Assistant (CNA) M said staff should document showers and refusal of showers in the resident's chart. 4. During an interview on 5/23/24 at 12:41 P.M., the DON said she expected all residents to receive at least two showers or bed baths weekly. She expected nursing staff to document when showers are given and when a resident refused a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one resident (Resident #301). The resident admitted from the hospital on 5/16/24. The facility admission nursing assessment identified an open area on the buttock and a double lumen peripherally inserted central catheter (PICC, a device which delivers fluids directly into a much larger vein) inserted into the right side of the resident's neck. There was no order for the PICC line dressing change, flushing, or care. In addition, facility staff failed to complete treatment orders and apply dressing changes as ordered to the buttocks. The sample was 17. The census was 69. Review of the facility's Central Vascular Access Device (CVAD) Flushing and Locking policy, dated 1/15/2004 and last revision 6/1/21, showed: -Licensed nurses providing infusion therapy in the post-acute setting; -To be performed by licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy with his/her scope of practice; -A prescriber's order is required to access/flush/lock a catheter. Review of the facility's Prescribing and Ordering of Medication/Products policy, dated effective date 4/2002 and last revision 1/24, showed: -To establish guideline for properly obtaining physician orders and processing these orders; -To obtain admission orders from the physician, check the transfer sheet from the discharging facility as a reference; -Enter orders into the resident's medical record. Review of Resident #301's electronic medical record (EMR), reviewed on 5/21/24 at 11:45 A.M., showed: -admit date [DATE]; -Diagnoses included stroke, infection, high blood pressure, and pacemaker (a device to help control the heart rate); -An admission wound assessment, dated 5/16/24, showed a wound to the buttocks; unstageable (the actual base and condition of the ulcer cannot be determined), clear drainage, peri wound (the skin surrounding the wound bed) excoriated (reddened), measured 3.7 x 4.6 x 0.0 centimeter (cm). Review of the resident's electronic physician order sheet (ePOS), showed: -A order dated 5/16/24, for intravenous (IV) medication, Cefazolin (antibiotic) 2 gram (G) every 8 hours; -An order dated 5/17/24, for Calvida (barrier cream). Cleanse wound on buttocks with cleanser and apply Calvida; -An order dated 5/20/24, for Medi honey (ointment to assist in wound healing and prevent infection). Cleanse wound on buttocks with cleanser, protect peri wound with skin prep (barrier wipe), apply to wound bed Medi honey gel, cover wound with bordered foam, change as needed for soiling and/or saturation; -An order dated 5/22/24 at 5:23 P.M., to add foam to the buttocks pressure ulcer (wound caused by pressure or friction) and change every three days; -No order for the PICC line, dressing change, care, or flushing. Observation on 5/21/24 at 6:41 A.M., showed the resident had an IV pole with tubing at the bedside, and a double lumen PICC line inserted into the right side of the resident's neck. The dressing over the PICC line was dated 5/14/24 8:00 P.M. Observation on 5/22/24 at 7:08 A.M., showed Registered Nurse (RN) B and Certified Nursing Assist (CNA) C performed care on the resident. Upon turning the resident over, no dressing was present on the resident's buttocks wound. The wound had an oval shape, approximately the size of a half dollar, with no drainage. The wound bed appeared beefy read with approximately a nickel size area of yellow stringy tissue. RN B applied Calvida cream to the resident buttocks. The ordered treatment to cleanse wound on buttocks with cleanser, protect peri wound with skin prep, apply to wound bed Medi honey gel, and cover wound with bordered foam dressing was not completed as ordered. Dressing to the PICC line was dated as changed on 5/21/24 at 9:00 P.M. Observation on 5/23/24 at 7:38 A.M., showed CNA L provided a bed bath to the resident. The resident's buttocks wound was open to air with no treatment in place. RN B instructed CNA L to apply Calvida to the resident buttocks. CNA L applied the Calvida cream. The ordered foam dressing was not applied. During an interview on 5/23/24 at 10:16 A.M., RN B said that a resident should have an order for a PICC line, included with the order is the type of access, dressing change, and flush. Nurses should follow physician's orders for wound treatments. During an interview with the Director of Nursing (DON) on 5/23/24 at 12:35 P.M., she said that a resident with a PICC line should have orders and the orders should include flushing, dressing change, and monitoring. On 5/24/24 at 11:04 A.M., she said that nurses should perform wound treatments per physician's orders.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #298) who was admitted with a indwelling urinary catheter (thin tube inserted into the bladder to drain urine) had a physicians order to provide care for the catheter. The sample size was 17. The census was 69. Review of the facility's Prescribing and Ordering of Medication/Products policy, dated effective date 4/2002 and last revision 1/24, showed: -To establish guideline for properly obtaining physician orders and processing these orders; -To obtain admission orders from the physician, check the transfer sheet from the discharging facility as a reference; -Enter orders into the resident's medical record. Review of Resident #298's electronic medical record (EMR) and resident information card, reviewed on 5/21/24 at 10:40 A.M., showed: -An entry Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff, dated 5/10/24, showed an admission date 5/10/24; -A baseline care plan showed the resident as incontinent of bowel and bladder; -Indwelling urinary catheter not indicated on resident information card; -No order for an indwelling urinary catheter; -Diagnoses include sleeplessness, seizure, bipolar disorder (a mood disorder characterized with manic highs and depressed lows), and neurogenic bladder (difficulty emptying the bladder due to neurological conditions). Observation on 5/21/24 at 6:54 A.M., showed the resident's indwelling urinary catheter in use and attached to the resident's bedrail. During an interview on 5/23/24 at 10:16 A.M., Registered Nurse (RN) B said that he/she would expect to see a physician order for the indwelling urinary catheter, included with the order would be the size of the catheter, diagnosis for the catheter, balloon size, routine for changing, and monitoring output. During an interview with the Director of Nursing (DON) on 5/23/24 at 12:35 P.M., she said would expect to see a physician order for the indwelling catheter, included with order would be the size, monitoring, and cleaning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident maintained acceptable parameters of nutritional status to the extent possible, for one resident (Resident #34) who experienced a significant weight loss (weight loss of 5% or more in the last month, loss of 7.5% or more in the last three months, or loss of 10% or more in the last six months) of -10.35% from July 2023 to January 2024. During this timeframe, the facility's Registered Dietician (RD) completed two nutritional assessments, noted a decline in the resident's meal intake, and did not recommend additional nutritional interventions. The resident was not served fortified cheesy eggs as recommended by the RD, and the RD's recommendation for fortified pudding did not get added to the resident's meal ticket. Nursing staff failed to consistently chart the resident's meal intake, which is reviewed during the RD's nutrition assessments, and the resident was not served preferred foods at meals. The sample was 17. The census was 69. Review of the facility's Nutritional Intervention Program policy, revised November 2023, showed: -Purpose: To provide guidelines for assessing the need for medical nutritional products and administering nutritional supplements to residents. To ensure that residents are receiving medical nutritional products per physician's orders and consumption is monitored and documented; -Responsibility: It is the responsibility of the nursing and clinical nutrition staff to initiate the program in collaboration with physicians when a resident exhibits the need for a nutritional supplement. The Nurse Manager or Charge Nurse is responsible for the oversight of all nutritional supplements; -Policy: There will be a program to provide a palatable nutritional supplement pass program to enhance the nutritional status of residents as recommended by clinical staff. It will be the policy of the company to administer nutritional supplements to residents in agreement with physician's orders; -Nursing and clinical staff will assess residents for the following indicators of the need for Nutritional Interventions: --An un-planned weight loss; --Resident exhibits a decline in usual meal consumption; -RD/doctor will make recommendations for interventions based on resident preferences and nutritional needs; -All efforts to use regular food and beverage will be made. Use of medical nutritional products/ formulas will be used as a last resort and only when other attempted interventions are unsuccessful; -Offer high calorie/fortified foods/beverage options. A variety of items can be offered to prevent taste fatigue and better acceptance by residents. No physician order is required for fortified foods; -The RD/doctor will document the assessment/progress note the number of fortified/enhanced foods needed per day for the resident. This information is included on the care plan and noted on the resident's meal ticket. Review of the Resident #34's medical record, showed: -Diagnoses included Multiple Sclerosis (MS, disease of the central nervous system), autoimmune hepatitis (when the body's immune system attacks the liver), hypothyroidism (underactive thyroid), high blood pressure, gastroesophageal reflux disease (GERD, stomach contents leak backwards into the esophagus) and depression; -A physician order, dated 3/3/22, for fortified foods: fortified cheesy eggs and fortified oatmeal; -A physician order, dated 4/19/22, for Boost Plus (nutritional shake) once daily; -A physician order, dated 12/13/22, for Boost Breeze (nutritional shake) 237 milliliters (mL) twice daily; -On 7/24/23, weighed 163.3 pounds (lb.). Review of the resident's quarterly nutrition assessment, completed by the facility's previous RD, dated 8/17/23, showed: -Current weight: 161 lb.; -Diet: Regular with average meal intake reported approximately (~) 70 percent (%) in the past 30 days; -Nutrition interventions: Boost Plus once daily (360 kilocalories (kcal, a unit of energy), 14 grams (g.) protein), fortified eggs (435 kcal, 20 g. protein), fortified oatmeal (430 kcal, 14 g. protein) with breakfast; -Resident is historically alert and oriented to person and place. Able to feed self after set-up assistance with supervision; -Estimated energy needs based on current body weight: 1772 to 2127 kcal per day, 70 g. protein per day. Resident needs to consume approximately 75% of meals to meet calculated needs without in place interventions, suggesting continued need for in place interventions; -No change to nutrition plan at this time. Review of the resident's weights, showed: -On 9/5/23: 163.3 lb.; -On 10/19/23: 154 lb.; -On 10/23/23: 152.6 lb. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/1/23, showed: -Resident unable to complete Brief Interview for Mental Status (BIMS); -Substantial/maximal assistance required for eating; -Weight: 153 lb. Review of the resident's annual nutrition assessment, completed by the facility's previous RD, dated 11/14/23, showed: -Current weight: 153 lb. -5% weight loss in three months. 0.65% weight loss in 6 six months. No significant weight changes noted; -Diet: Regular with average meal intake reported ~55% in the past 30 days; -Nutrition interventions: Boost Plus once daily (360 kcal, 14 g. protein), fortified eggs (435 kcal, 20 g. protein), fortified oatmeal (430 kcal, 14 g. protein) with breakfast; -Resident is historically alert and oriented to person and place. Able to feed self after set-up assistance with supervision; -Estimated energy needs based on current body weight: 1772 to 2127 kcal per day, 70 g. protein per day. Resident needs to consume approximately 75% of meals to meet calculated needs without in place interventions, suggesting continued need for in place interventions; -No change to nutrition plan at this time. Review of the resident's weights, showed: -On 11/16/23: 149.2 lb.; -On 11/20/23 and 11/29/23: 150.3 lb.; -On 12/7/23: 149.9 lb.; -On 12/18/23: 149.4 lb.; -On 1/24/24: 146.4 lb.; -Significant weight loss of -10.35% in six months, from 7/24/23 to 1/24/24. Review of the resident's quarterly MDS, dated [DATE], showed: -Resident rarely/never understood; -Substantial/maximal assistance required for eating; -Weight: 146 lb.; -No weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of the resident's quarterly nutrition assessment, completed by the facility's current RD, dated 2/6/24, showed: -Diet: Regular; -Nutrition interventions: Boost Plus once daily (360 kcal, 14 g. protein), fortified eggs (435 kcal, 20 g protein), fortified oatmeal (430 kcal, 14 g. protein) with breakfast; -Weight: 146.4 lb. No significant weight changes noted. -Estimated energy needs based on current body weight: -Energy needs: 1848 to 1980 kcal; -Protein needs: ~66 g. per day; -Resident needs to consume ~80 to 85% of meals to meet their daily energy needs. Current intake per nursing staff documentation is ~58% of meals; -Resident appears to not be meeting their nutritional needs as evidenced by reported intake less than estimated needs. Will continue current nutrition interventions. Will add fortified pudding daily (340 kcal, 15 g protein) to promote kcal intake. Review of the resident's electronic Physician Order Sheet (ePOS), showed no order for fortified pudding. Review of the resident's weights, showed: -On 2/22/24: 148.2 lb.; -On 2/28/24: 143.3 lb.; -On 3/4/24: 144 lb.; -On 3/11/24: 145.6 lb.; -On 3/19/24: 142.7 lb.; -On 3/26/24: 142.4 lb. Review of the resident's March 2024 meal intake, showed: -93 meals total; -30 meals missing documentation of meal intake; -Six meals documented with 0% of meal consumed; -Average of total average meal consumption: 44%. Review of the resident's weights, showed: -On 4/17/24: 140 lb.; -On 4/22/24: 139.9 lb. Review of the resident's quarterly MDS, dated [DATE], showed: -Substantial/maximal assistance required for eating; -Weight: 140 lb.; -Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, not on physician-prescribed weight-loss regimen. Review of the resident's quarterly nutrition assessment, completed by the facility's current RD, dated 4/29/24, showed: -Diet: Regular diet with regular texture; -Nutrition interventions: Boost Plus once daily (360 kcal, 14 g. protein), fortified oatmeal (430 kcal, 14 g. protein) with breakfast, fortified pudding daily (340 kcal, 15 g. protein); -Weight: 139.9 lb. Patient with 11% weight loss in six months (significant for timeframe); -Estimated energy needs based on current body weight: -Energy needs: 1848 to 1980 kcal; -Protein needs: ~66 g. per day; -Resident needs to consume ~80 to 85% of meals to meet their daily energy needs. Current intake per nursing staff documentation is ~61% of meals; -Resident appears to not be meeting their nutritional needs as evidenced by reported intake less than estimated needs. Will continue current nutrition interventions. Review of the resident's April 2024 meal intake, showed: -90 meals total; -46 meals missing documentation of meal intake; -Five meals documented with 0% of meal consumed; -Average of total average meal consumption: 60%. Review of the resident's RD note, dated 5/3/24, showed the nurse reported to the RD that the resident is having difficulty chewing regular texture food and that resident would benefit from mechanical soft diet for chewing. Downgraded diet to regular diet with mechanical soft texture. Diet order modified to promote by mouth (PO) intake, reduce risk of weight loss, and preserve quality of life. Review of the resident's ePOS, showed an order, dated 5/13/24, for mechanical soft diet. Review of the resident's care plan, in use at the time of survey, showed: -Resident is alert and oriented to self and not able to express his/her needs; -Usual body weight is ~155 lb.; -Meals/snacks/fluids: -Resident is offered a regular diet with mechanical soft texture; -Resident is able to feed self after set-up assistance with supervision; -Resident is at nutrition/hydration risk because of advanced age and diagnosis of depression; -Please offer fortified oatmeal and cheesy eggs, which provide an additional 430 kcal each and 13 g./21 g. protein, respectively; -Resident will maintain his/her weight +/-6% through next 90 day review; -No documentation regarding the resident's significant weight loss, average meal intake, substantial/maximal assistance from staff required for eating, preferred foods, or RD's recommendation on 2/6/24 for addition of fortified pudding. Review of the resident's meal intake from 5/1/24 through 5/21/24, reviewed 5/22/24, showed: -63 meals total; -22 meals missing documentation of meal intake; -Five meals documented with 0% of meal consumed; -Average of total average meal consumption: 35%. Review of the resident's meal tickets, showed: -Breakfast: fortified eggs, fortified oatmeal; -No documentation of fortified pudding. Observation on 5/20/24 at 1:04 P.M., showed the resident sat upright in a reclining chair with Certified Nurse Aide (CNA) A seated next to the resident, attempting to provide feeding assistance. Lunch was served on a divided plate and included raw baby carrots. No fortified pudding was observed. Review of the dietary slip, showed the mechanical soft diet. CNA A held bites of food to the resident's mouth and the resident did not eat. CNA A held a container of Boost Breeze to the resident's mouth and the resident drank the shake. During an attempted interview, the resident did not respond. During an interview, CNA A said the resident used to eat independently, but now requires feeding assistance from staff. The resident does not eat much, but will drink nutritional shakes. It is unknown why the resident is no longer eating much and he/she does not have a new health condition. He/She should receive a mechanical soft diet but today was served raw carrots. Observation on 5/21/24 at 8:08 A.M., showed the resident sat upright in bed with a plate of breakfast on his/her bedside table. Breakfast consisted of scrambled eggs with no cheese, a biscuit, and a bowl of oatmeal. No fortified cheesy eggs were served. No banana or frosted flake cereal was served. CNA A attempted to feed the resident and the resident did not eat. Observation on 5/21/24 at 1:27 P.M., showed the resident's lunch tray on a cart of trays on the hall. CNA M removed the resident's lunch tray and showed the plate consisted of full portions of spaghetti and large steamed broccoli florets. A small plate contained a piece of cake with one bite missing. A carton of Boost Breeze was empty. No fortified pudding was observed. Observation of breakfast preparation on 5/22/24 at 7:01 A.M., showed [NAME] O made regular texture scrambled eggs and pureed eggs. He/She did not make fortified cheesy eggs. Observation on 5/22/24 at 8:24 A.M., showed the resident sat upright in bed with CNA A seated next to the bed, attempting to provide feeding assistance. Breakfast served consisted of scrambled eggs, a muffin, mechanical soft sausage with gravy, a cup of yogurt and a bowl of oatmeal. No fortified cheesy eggs were served. No banana or frosted flake cereal were served. CNA A held bites of food to the resident's mouth and the resident did not eat. CNA A held a carton of Boost Breeze to the resident's mouth and the resident drank the shake. During an interview, CNA A said the resident used to eat independently and consumed 100% of his/her meals. Then the resident declined a little and staff had to start feeding him/her, but the resident still ate 100% of his/her meals. A couple months ago, the resident moved to his/her current room and completely declined. He/She no longer feeds him/herself at all and consumes less than 25% of each meal served. He/She likes the nutritional shakes and loves bananas and pancakes at breakfast, but doesn't really eat anything else. CNA A told the RD about the resident's food preferences and the RD said the kitchen seldom has bananas. Observations on 5/23/24, showed: -At 8:20 A.M., the resident seated at a table in the dining room while CNA N provided feeding assistance. Breakfast served consisted of scrambled eggs, pancakes, and a bowl of oatmeal. No fortified cheesy eggs were served. No banana or frosted flake cereal were served; -At 8:30 A.M., 75% of the resident's pancakes and eggs consumed. During an interview, CNA N said the resident is still eating his/her breakfast. He/She likes pancakes. It is hit and miss how much food the resident will eat because it depends on if the resident likes the food served. During an interview on 5/23/24 at 10:06 A.M., [NAME] O said he/she did not make fortified cheesy eggs on 5/22/24. He/She expected nursing staff to communicate a resident's dietary preferences with dietary staff. Dietary slips that go out with resident trays are generated by the RD. During an interview on 5/23/24 at 10:09 A.M., the Dining Services Director said the RD generates the dietary slips that show what residents are served at each meal. If a resident with weight loss is only willing to eat certain foods, like bananas, it should be communicated to dietary so they can add it to the food order. During an interview on 5/23/24 at 10:14 A.M., CNA H said the resident receives a regular diet, not mechanical soft or puree. He/She has no issues with chewing or swallowing. He/She requires total assistance from staff, including while eating. His/her appetite is alright. He/She closes his/her mouth and shakes his/her head no when he/she doesn't want to eat. He/She really likes drinking Boost shakes and will drink 100% of them. If he/she is not eating the meal served, staff should offer him/her a Boost or a different supplement. CNAs are responsible for charting a resident's intake of each meal served during the shift. During an interview on 5/23/24 at 10:32 A.M., Licensed Practical Nurse (LPN) I said the resident is alert and oriented to self. He/She requires feeding assistance from staff. He/She has not been eating well, generally consuming 25% of each meal. He/She loves to drink Boost shakes. If the resident doesn't eat his/her meal, it should be reported to the nurse and the resident should be given an extra Boost shake. This should also be documented in the resident's record. It is expected that CNAs chart a resident's meal intake during each shift, especially if a resident has had weight loss. During an interview on 5/23/24 at 10:50 A.M., LPN E said it is expected that CNAs chart meal intake at each shift. If a resident is not eating, it should be reported to the nurse. During an interview on 5/23/24 at 11:00 A.M., the facility's current RD said she completes admission, quarterly, and annual nutrition assessments on all long-term care residents. Some residents may be seen more frequently based on clinical judgement. He/She just identified the resident's weight loss during the resident's quarterly assessment in April 2024, and now the resident is on the high-risk caseload. Prior to this, the resident was having weight loss, but it was not significant. Before the RD started working at the facility in November 2023, the resident was feeding him/herself and now requires feeding assistance. His/Her decline in health has been a natural progression, and there has not been any new disease process. During her nutrition assessments, the RD reviews the resident's chart, including labs, weights, and meal intake. She expected nursing staff to chart routinely so she can assess the resident. Recently, it was reported the resident had difficulty chewing so the RD changed his/her diet to mechanical soft. Raw carrots and large steamed broccoli would not be considered mechanical. The resident's meal intake has remained the same since being changed to mechanical. When meal intake decreases, the RD will ask residents if there is anything in particular they will eat. Resident #34 is not interviewable. The RD knows the resident like bananas, frosted flake cereal, potatoes, peas, corn, and no cheese on his/her sandwiches. The facility does not have frosted flake cereal and bananas were on order, but did not arrive with the food order. The RD enters the resident's diet orders, including fortified foods, and preferences into a computer system shared with dietary. Dietary can adjust their food orders to add the foods preferred by residents. The RD can also add a resident's dislikes, which would prompt dietary staff to provide a substitution. The facility stopped doing fortified cheesy eggs a while ago. Residents didn't seem to like them, so the facility started using fortified milk (regular whole milk with added dry milk flavoring) instead. Residents didn't seem to like that, either. The facility is in the process of trying to identify other options. The order for fortified cheesy eggs should be removed from the resident's ePOS. The order for fortified pudding should be added to the ePOS. While the resident likes pancakes, the kitchen may not be able to make pancakes every morning for one particular resident. The resident's food preferences should be provided. Review of the resident's dietary profile, provided 5/23/24, showed at breakfast, the resident likes bananas and frosted flakes. During an interview on 5/23/24 at 12:25 P.M., the Dining Services Director said it was not a problem for dietary staff to make pancakes daily for one resident who is not eating other foods. Dietary can provide substitutions for items based on what the resident's preferences are, which should be communicated to dietary by the RD via the shared computer system. The facility does not have bananas or frosted flakes right now. During an interview on 5/23/24 at 12:35 P.M., the Director of Nurses and Administrator said the resident has had significant weight loss. When he/she does not eat, it is expected that staff offer the resident a shake. If fortified cheesy eggs are not made anymore, it is expected the RD and dietary staff come together to identify an alternate fortified food or nutritional supplement. Any nutritional intervention identified and recommended by the RD should be added to the resident's ePOS, meal ticket, or care plan, and should served to the resident. It is expected that nursing staff communicate a resident's food preferences to dietary and the RD. It is expected that CNAs chart meal intake during every shift to assist the RD during her nutritional assessments. It is expected that residents receive diets per orders, and raw carrots should not be served to a resident with difficulty chewing who should receive a mechanical soft diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician orders were obtained for the use of a continuous positive airway pressure (CPAP, machine that keeps the airways open during sleep for persons with sleep apnea) for one resident (Resident #299) and to ensure CPAP masks were properly stored while not in use for infection control purposes for two residents (Residents #299 and #146). The sample was 17. The census was 69. Review of the facility's CPAP/Bilateral Positive Airway Pressure (BIPAP, mechanical breathing device)/Average Volume Assured Pressure Support (AVAPS, mode of non-invasive ventilation)/Trilogy Ventilator (device used to provide pressure support, pressure control, or volume control during breathing support) policy, revised November 2021, showed: -Purpose: To provide guidelines for staff to assist the resident in using a CPAP/BIPAP/AVAPS/Trilogy Ventilator device; -Responsibility: It will be the responsibility of all licensed nursing staff to know and follow these guidelines; -Policy: A physician's order is required for CPAP/BIPAP/AVAPS/Trilogy Ventilator. Pressure settings are to be set by the durable medical equipment (DME) company per physician order/direction. If the resident brings equipment from home, the settings used at home can be used if approved by the physician; -Obtain physician's order for device use; -If device is from home, the order should specify home settings; -Add device use and care to resident's care plan/resident profile; -Equipment cleaning: -Wipe mask daily using a damp cloth; -The policy failed to provide guidance for mask storage while not in use. 1. Review of Resident #299's electronic medical record (EMR) and resident information card, reviewed on 5/21/24 at 8:46 A.M., showed: -An entry Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 5/13/24, showed an admission date 5/13/24; -A baseline care plan showed a diagnosis of obstructive sleep apnea (OSA, breathing interrupted during sleep); -Diagnoses included cancer, high blood pressure, depression, high cholesterol, and sleep apnea; -CPAP device was not listed on the resident's baseline care plan and information card; -No physicians order for the CPAP on admission. New order obtained 5/23/24 8:00 A.M. Observations on 5/20/24 at 11:21 A.M., showed the resident's CPAP tubing rested over the top of the headboard, mask faced down and rested against the headboard. During an interview on 5/21/24 at 6:46 A.M., the resident said he/she receives supplies every six weeks to his/her home and that he/she takes care of the CPAP machine while at the facility. During an interview on 5/22/24 at 10:32 A.M., Registered Nurse (RN) B said that the resident takes care of the CPAP, the mask should be stored when not being used, and he/she only monitors the machine to see if it is clean. On 5/23/24 at 10:16 A.M., RN B said that there should be on order for the CPAP. During an interview on 5/23/24 at 10:27 A.M., Certified Nursing Assistant (CNA) C said he/she is aware that the resident has a CPAP, the mask should be stored when not being used, and that the resident takes care of it. During an interview with the Director of Nursing (DON) on 5/23/24 at 12:35 A.M., she said she would expect there to be an order for the CPAP. 2. Review of Resident #146's admission MDS, dated [DATE], showed: -Cognitively intact; -Supervision/touch assistance required for sit to stand; -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), obstructive sleep apnea, and acute and chronic respiratory failure. Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 5/13/24, for CPAP application, apply CPAP at bedtime. Check every two hours for mask placement and complications; -An order dated 5/14/24, for CPAP removal every 24 hours, clean mask and rinse humidifier with soap and water. Rinse and let air dry. Review of the resident's care plan, in use at the time of survey, showed: -General: Resident is at facility for physical therapy/occupational therapy for COPD exacerbation. Resident uses a rented CPAP to assist him/her at night with home settings. Please ensure to rinse and fill humidifier each night and monitor him/her throughout the shift for mask placement and/or complications; -Vitals/pain: Resident wears CPAP at night. Observations on 5/20/24 at 11:28 A.M. and 1:06 P.M., showed the resident sat upright in a recliner chair next to his/her bed with oxygen on via nasal cannula (device used to deliver oxygen with two small tubes that fit into the nostrils). A CPAP machine sat on a nightstand next to his/her bed, not in use. The CPAP mask was uncovered and with no barrier, face down on top of miscellaneous items in the open top drawer of the nightstand. Observations on 5/21/24, showed: -At 7:59 A.M., the resident sat upright in bed. His/Her CPAP machine was not in use. The CPAP mask was uncovered and had no barrier on top of the nightstand, behind the CPAP machine, with the base of the mask face down directly on the table and partially touching the base of a table lamp; -At 9:40 A.M., the resident sat upright in bed. His/Her CPAP machine was not in use. The CPAP mask was uncovered with no barrier on top of the nightstand, behind the CPAP machine, with base of the mask face down directly on the table and partially touching the base of a table lamp. Licensed Practical Nurse (LPN) G entered the resident's room and spoke with the resident; -At 11:13 A.M., LPN G and CNA A entered the resident's room; -At 11:31 A.M. and 1:16 P.M., the resident sat upright in his/her recliner. His/Her CPAP machine was not in use. The CPAP mask was uncovered with no barrier on top of the nightstand, behind the CPAP machine, with base of mask face down directly on the table and partially touching the base of a table lamp. During an interview on 5/21/24 at 1:16 P.M., the resident said he/she uses his/her CPAP machine at night. He/She does not clean the CPAP mask. He/She thinks the staff might clean it, but isn't sure. He/She does not have a protective covering to store the CPAP mask while not in use and was not sure if he/she was supposed to cover the mask when not in use. Observations on 5/22/24, showed: -At 8:27 A.M., the resident sat in bed. His/Her CPAP machine was not in use. The CPAP mask was uncovered with no barrier, at the bottom of the open top drawer in his/her nightstand, face down with base of mask touching the bottom of the drawer. During an interview, the resident said he/she used his/her CPAP last night and removed it him/herself at 7:30 A.M.; -At 12:44 P.M., the resident sat in his/her recliner chair. His/Her CPAP machine not in use. The CPAP mask uncovered and with no barrier, at the bottom of the open top drawer in his/her nightstand, face down with base of mask touching the bottom of the drawer. During an interview on 5/22/24 at 1:43 P.M., CNA A said the resident wears a CPAP at night. The resident was wearing his/her CPAP mask when CNA saw the resident earlier that morning. Nurses handle the CPAP machines, not the aides. During an interview on 5/23/24 at 10:32 A.M., LPN I said the resident can use his/her CPAP on his/her own. Nursing staff puts the resident's CPAP mask on him/her at night. 3. During an interview on 5/23/24 at 10:32 A.M., LPN I said nursing staff is responsible for cleaning CPAP masks. CPAP masks should be stored in a plastic bag while not in use. 4. During an interview on 5/23/24 at 10:50 A.M., LPN E said some residents can remove their CPAP masks themselves and some require assistance from the nurse. Nurses are responsible for ensuring CPAP masks are stored in plastic bags while not in use. 5. During an interview on 5/23/24 at 12:35 P.M., the DON and Administrator said residents, nursing and respiratory therapy staff are responsible for ensuring CPAP masks are stored properly. After CPAP mask use, either the resident or nursing staff should rinse off the mask and store it in a bag. Since Resident #146 does not stand or walk, it is expected that nursing staff assist him/her with CPAP mask cleaning and storage. It is expected that CPAP use be indicated on a resident's care plan. Department heads complete their respective portions of a resident's care plan upon admission and comprehensive care plans are overseen by MDS staff.

Based on observation, interview and record review, the facility failed to provide necessary behavioral health services to maintain the highest practicable psychosocial well-being for one resident (Resident #6) who expressed feelings of being better off dead and thoughts of unplugging his/her left ventricular assist device (LVAD, a device implanted in the chest to help the heart pump blood). The sample was 17. The census was 69. Review of Resident #6's medical record, showed: -admission date 5/11/23; -Diagnoses included history of stroke with residual hemiparesis (weakness on one side of the body), heart disease, heart failure, atrioventricular block (interrupted or delayed heart rate), ischemic cardiomyopathy (heart's decreased ability to pump blood properly), and presence of heart assist device. Review of the resident's physical therapy evaluation, dated 11/9/23, showed: -Discharge environmental factors/social support: Resident has been staying at this facility. Previously, resident lived with family. Resident reported independence with activities of daily living (ADLs); -Prior residence and living arrangement: Resident was living in a two-level home. Resident was using front-wheeled walker (FWW) and wheelchair; -Physical mobility scale = 13/45 which indicates resident is dependent for functional mobility. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 11/28/23, for ventricular assist device; -An order, dated 1/3/24, for duloxetine (antidepressant medication) 30 milligrams (mg.) delayed release capsule, 20 mg. daily for depression. Review of the resident's Social Services (SS) note, dated 2/28/24, showed the Social Services Coordinator (SSC) documented completion of a quarterly assessment with the resident. Brief interview of mental status (BIMS) placed resident in cognitively intact range. Score of 9 on the Patient Health Questionnaire (PHQ, an assessment tool used to screen for depression), which placed resident in the mild depression range. Resident expressed having little interest in doing things. He/She expressed feeling depressed every day. He/She states he/she feels depressed because he/she can't walk and can't take care of his/her business. He/She expressed having thoughts about self being better off dead. He/She stated he/she has thought about unplugging his/her heart machine. SSC informed floor nurse of the above information. SSC asked if they have a psychologist or psychiatrist that comes in to visit with the long-term care patients. Nurse said no, and he/she will inform the doctor of the above information. Review of the resident's nurse's note, dated 2/28/24, showed the nurse documented the Social Worker (SW) reported to the nurse that resident desired to end his/her life by disconnecting his/her LVAD. Notified Nurse Practitioner (NP) of resident's statements and received orders to send resident to hospital for psych evaluation. Notified resident of transfer, resident states he/she does not want to go but continues to confirm to nurse and Certified Nurse Aide (CNA) of desire to unplug his/her LVAD machine. Upon emergency medical service (EMS) arrival, resident stated he/she often feels this way and cries and prays. Review of the resident's hospital record, dated 2/28/24, showed: -Chief complaint: Patient presents with suicidal ideation; -History of present illness (HPI): Resident reports he/she was brought into the emergency department (ED) because he/she did not deny occasional passive thoughts of suicide when SW asked him/her about it. He/She reports he/she chronically has transient thoughts of pulling out his/her LVAD because he/she is sick of going in and out of hospitals; -ED provider notes: Resident denies any active suicidality. He/She states the SW asked if he/she ever had suicidal thoughts and he/she reported that over the past three years he/she has had these intermittent thoughts but does not currently have any suicidal ideation. He/She says his/her biggest complaint is that he/she has not been allowed to walk as much as he/she would like to and as such has been inadequately rehabbed; -Clinical impressions: Depression, unspecified depressive type. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/2/24, showed: -Cognitively intact; -Little interest or pleasure in doing things, 7-11 days (half or more of the days); -Feeling down, depressed, or hopeless, 12-14 days (nearly every day); -Feeling tired or having little energy, 12-14 days (nearly every day); -Thoughts that you would be better off dead, or of hurting yourself in some way, 2-6 days (several days); -Social isolation: Sometimes; -Substantial/maximal assistance required for lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer. Review of the resident's care plan, in use at the time of survey, showed: -Resident has an LVAD that controls the functions of his/her heart; -Requires assistance of one to two persons for transfers and assistance of one person for ambulation; -Prefers to get up and dressed each day by 1:00 P.M. for at least one hour and lay resident down upon request; -The care plan failed to identify the resident's reported feelings of depression, expression of suicidal ideation, and activities of interest. Review of the resident's physician progress note, dated 4/1/24, showed: -General: Alert and oriented, mild distress; -Resident asking about wheelchair. Discussed with nurse, not sure if going to use. Review of the resident's medical record, showed: -No therapy assessments completed after 11/9/23; -No documentation of social services follow-up between 2/28/24 and 5/20/24. Observation on 5/20/24 at 11:02 A.M., showed the resident on his/her back in bed, watching TV. No wheelchair in his/her room. During an interview, the resident said staff does not want him/her to stand or walk on his/her own because they are afraid he/she will have a stroke. He/She relies on staff to get him/her up out of bed and he/she cannot walk. He/She does not have a wheelchair to be able to leave his/her room. He/She keeps asking for a wheelchair and therapy to get stronger. Last week, he/she asked the doctor again about a wheelchair and therapy but it still has not happened. He/She purchased a pedal exercise machine to get stronger, but staff will not help him/her use it. He/She just stays in bed all day. Observation on 5/21/24 at 1:21 P.M., showed the resident sat in a wheeled reclining chair in his/her room. No wheelchair in his/her room. During an interview, the resident said he/she is happy to be up out of bed today. He/She would like to have a wheelchair so he/she could leave his/her room for a while. He/She cannot move the reclining chair without staff assistance. During an interview on 5/22/24 at 12:30 P.M., the resident said he/she is not happy and feels sad. There is nothing interesting to do. He/She lays in bed all day. People act surprised when he/she says he/she isn't happy, but he/she asked what does he/she have to be happy about. He/She used to have a job where he/she stayed active. After he/she retired, he/she still kept busy by going out shopping and seeing family and friends. Now, he/she does nothing. He/She can't get out of bed on his/her own and cannot leave his/her room. The nurses get mad when he/she tries to put his/her legs over the side of the bed. He/She is tired all the time from being in bed all the time and would like to get out of bed. He/She does not have a wheelchair and is stuck in his/her room. He/She has wheelchairs at home that could be brought to the facility. He/She does not have a current plan to hurt him/herself and told the SW this yesterday. He/She does not see the SW regularly and does not receive counseling. During an interview on 5/22/24 at 1:12 P.M., the SSC said she has been working with the facility since January 2024. She met with the resident on 2/28/24 to complete the resident's quarterly BIMS and PHQ-9 assessments. During the assessment, the resident said he/she felt he/she would be better off dead. The SSC reported this to the resident's nurse, whose name the SSC could not recall. When asked who is responsible for following up with a resident after they express feelings of being better off dead, the SSC said that is a good question. She is not sure what follow-up was made with the resident after the SSC reported to the nurse on 2/28/24. She is not sure if the facility has a psychiatrist or psychologist they work with. She is not sure if the facility works with a particular counseling agency to whom they can refer residents. She met with the resident yesterday, 5/21/24, to complete the resident's quarterly BIMS and PHQ-9 assessments and the resident did not indicate he/she felt he/she would be better off dead. The resident is young for being a long-term care resident, so that could place him/her on the depression scale. The resident said he/she is tired and has little energy, and the resident sleeps all day. The resident likes to watch TV and spend time with family, but they don't visit as often as he/she would like. SSC does not know if the resident has any other preferred activities or interests. Review of the resident's SS note, dated 5/22/24, showed the SSC completed quarterly assessments with the resident on 5/21/24. BIMS placed resident in the cognitively intact range. Scored 2 on the PHQ-9 which placed resident in the minimal depression range. He/She expressed feeling down for a few days. He/She stated he/she feels down because he/she can't do for self. He/She expressed feeling tired. He/She stated he/she likes to sleep and sleeps all day and that's why he/she feels tired. He/She enjoys sleeping, talking on the phone with family, eating his/her snacks in his/her room and watching TV. During an interview on 5/22/24 at 1:43 P.M., CNA A said the resident seems sad. He/She wants staff to unplug his/her LVAD. He/She told the SW this a while ago, and the resident went out to the hospital, and came right back. He/She has not made suicidal statements since then. He/She does not seem happy. He/She cannot stand up on his/her own and says no when staff ask him/her if he/she wants to get out of bed. He/She can't do therapy at the facility because he/she is a long-term resident. He/She does not have a wheelchair, but has a reclining chair with wheels on it that staff can push. The resident loves shopping, eating food from outside of the facility, and visiting with people, especially family. During an interview on 5/23/24 at 10:15 A.M., CNA H said the resident requires two staff to assist him/her with transfers. Sometimes he/she likes to get out of bed, and sometimes he/she doesn't. His/Her LVAD limits what activities he/she can do. He/She likes to watch TV, talk on his/her phone and with people, and to eat. During an interview on 5/23/24 at 10:32 A.M., LPN I said the resident requires two staff to assist with transfers and he/she cannot walk on his/her own. He/She gets out of bed occasionally. He/She does not have a wheelchair and has a recliner with wheels that staff can push. He/She is sad and wants to live at home and with family. He/She is lonely. He/She likes to shop and to talk to staff when they go into his/her room. During an interview on 5/23/24 at 12:35 P.M., the Director of Nurses (DON) and Administrator said the resident is a long-term care resident of the facility. He/She goes out to the hospital frequently. When he/she returns to the facility, he/she is motivated, but then when therapy assesses him/her, he/she is not interested. Facility staff beg him/her to get up out of bed and to go to activities, but he/she is not interested in any of it. He/She does not attempt to stand at the facility, but hospital staff reported the resident stood during his/her her most recent hospitalization. The DON and Administrator are not sure if the resident has a wheelchair. Physically, the resident would be able to use a wheelchair, but whether he/she would use it may not be the case. If the resident spoke about a wheelchair in his/her meeting with the physician and the physician wanted the resident to have a wheelchair, the physician would communicate this to nursing staff. The DON said it was her understanding that when the resident expressed suicidal ideation on 2/28/24, it was because the resident's favorite aide had been off for a couple days. When the aide returned, the resident was angry and said he/she would pull out his/her LVAD wires. The resident was sent out to the hospital, where he/she said he/she had no intension of pulling out his/her LVAD. The DON and Administrator said when the resident returned to the facility, it expected that nursing staff and SS should have followed up with the resident regarding his/her suicidal statements. It is expected that the facility's department heads come together to discuss ideas and identify interventions that may help improve the resident's mood. The resident's feelings of sadness and identified interventions should be documented on the resident's care plan.

Based on observation, interview and record review, the facility failed to store medication and medical equipment in accordance with professional principles, including abiding by the expiration date on stock medications in facility medication rooms and medication carts. Concerns were found in one of two medication rooms and in two of six treatment carts in the facility. The sample size was 17. The census was 69. Review of the facility's LTC Facility's Pharmacy Services and Procedures Manual, revised 12/01/22, showed: -Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to pharmacy supplier; -Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. 1. Observation of the third floor medication room on 5/21/24 at 1:21 P.M., showed: -One bottle of SunMark gentle laxative expired February, 2024; -One bottle of HealthStart 3 milligram (mg) melatonin supplement, expired October, 2023; -Five bottles of Rugby meclizine (a medication used to control nausea, vomiting, and dizziness), expired March, 2024; -One bottle of SunMark 12-hour mucus relief guafenesin (a medication used to control coughing and to clear phlegm from the chest and nose) 600 mg tablets, expired January, 2024; -Two bottles of Amneal Folic Acid (Vitamin B) 1mg tablets expired January, 2024; -Three bottles of GeriCare Oyster Shell Calcium 500 mg supplement tablets, expired April, 2024; -Two bottles of GeriCare Ferric X-150 150 mg iron supplement tablets, expired March, 2024. 2. Observation of a third floor nursing staff medication cart on 5/22/24 at 10:46 A.M. showed: -One bottle of GeriCare Magnesium Oxide (an antacid and mild laxative medication) 400 mg supplement tablets, expired October, 2023; -One bottle of NorthStarX Omeprazole (an antacid used to reduce stomach upset) Extended Release 200 mg capsules, expired March, 2024. 3. Observation of a second floor nursing staff medication cart on 5/22/24 at 10:53 A.M., showed: -One 16 ounce (oz) bottle of GeriCare Milk of Magnesium (a medication to treat stomach upset, constipation, and heart burn), expired April 2024. The bottle was opened and marked by staff as opened on 5/13/24. 4. During an interview on 5/23/24 at 10:11 A.M., Licensed Practical Nurse (LPN) E said a facility pharmacy representative goes through the facility medication rooms a few times per year but was unsure if the medication rooms or medication carts were audited regularly. LPN E said the facility expected nursing staff to remove expired medications from medication carts and destroy or dispose of them per facility policy. 4. During an interview on 5/23/24 at 10:23 A.M., Certified Medication Technician (CMT) F said a facility pharmacy representative goes through the facility's medication rooms and medication carts a couple times a month to look for expired medications and to pick up medications and biologicals that need to be destroyed. CMT F said the facility expected CMTs and nurses to remove expired medications from medication carts if discovered in order to be destroyed or wasted per facility policy. 5. During an interview on 5/23/24 at 12:35 P.M., the Director of Nursing (DON) and Administrator said they expected all expired medications in the facility to be removed from medication carts and destroyed per facility policy. The DON and Administrator said they expected staff to discard expired medications when found on a treatment cart or medication room, and not to administer expired medications to residents at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities with residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) (Residents #295, #301, #6, #200, #249, and #9). The sample was 17. The census was 69. Review of the facility's Enhanced Barrier Precautions (EBP) policy, revised February 2024, showed: -Purpose: To provide direction for the implementation of precautions to prevent transmission of novel or targeted multidrug-resistant organisms (MDRO) utilizing guidelines from Centers for Disease Control (CDC); -Responsibility: It is the responsibility of each administrator to enforce this procedure for his/her respective residence. It is the responsibility of all employees to understand and comply with the specific procedures in each residence as related to this policy; -Policy: It is the policy of the company to implement EBP to prevent transmission of novel or targeted MDRO as defined by CDC to residents, staff, volunteers, visitors or any other individuals providing services under a contractual agreement; -Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices); -EBP shall be implemented for resident with any of the following: -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -Infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions (precautions that reduce the risk of transmission of infectious materials by direct contact) do not apply; -Implementation of EBP: -Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray; -Disposable or dedicated medical equipment is not required; but any reusable medical equipment should be cleaned and disinfected with an appropriate agent between residents; -High-contact resident care activities are: -Dressing; -Bathing; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; -Wound care: any skin opening requiring a dressing; -EBP should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, or any high-contact activity; -EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical devices is removed. Review of the facility's EBP signage, undated, showed: -Enhanced Barrier Precautions; -Everyone must clean their hands, including before entering and when leaving the room; -Providers and staff must also: -Wear gloves and a gown for the following high-contact resident care activities; -Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), wound care. 1. Review of Resident #295's electronic medical record (EMR), showed: -An entry Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/14/24 showed: -Diagnoses included wound infection, fusion (joining two or more bones) of the cervical spine, and generalized muscle weakness; -An order, dated 5/7/24, for patient isolation, EBP; -An order, dated 5/8/24, for Unasyn (antibiotic) 3 gram (gm), intravenous (IV) every six hours for wound infection. Observation on 5/21/24 at 9:08 A.M., showed an EBP sign on the resident room door. Licensed Practical Nurse (LPN) J entered the resident room without gown or gloves and proceeded to administer the resident IV medication, through double lumen peripherally inserted central catheter (PICC, a device which delivers fluids directly into a much larger vein) inserted into the right arm. 2. Review of Resident #301's EMR, showed: -admit date [DATE]; -Diagnoses included stroke, infection, high blood pressure, and pacemaker (a device to help control the heart rate); -An order, dated 5/16/24, for patient isolation, EBP. Observation on 5/21/24 at 6:44 A.M., showed a laminated placard titled EBP on the resident room door. Registered Nurse (RN) B entered the resident's room without a gown and proceeded to check the residents blood sugar. Observation on 5/22/24 at 7:08 A.M., showed a laminated placard titled EBP on the resident room door. RN B and Certified Nurses Assistant (CNA) C entered the resident room without gowns on, and exposed the resident's heels and buttocks for skin observation. Observation on 5/23/24 at 7:38 A.M., showed a laminated placard titled EBP on the resident room door. CNA L did not wear a gown while he/she provided a bed bath to the resident. 3. Review of Resident #6's medical record, showed: -Diagnoses included heart failure and presence of heart assist device; -An order, dated 2/26/24, for patient isolation, EBP, for left ventricular assist device (LVAD, device implanted in the chest to help the heart pump blood from one of the main pumping chambers to the rest of the body or to the other side of the heart). Observation on 5/20/24 at 11:02 A.M., showed no EBP sign outside the resident's room. Observation on 5/20/24 at 1:00 P.M., showed an EBP sign posted on the front of the door to the resident's room. During an interview, the resident said staff just told him/her that he/she is being quarantined and he/she does not know why. Staff told him/her it had something to do with having an LVAD, but the LVAD is not new and he/she has had it the whole time he/she has been at the facility. Observation on 5/21/24 at 1:29 P.M., showed the resident sat in a recliner chair. CNA A was in the resident's room with no gown or gloves on, moving items throughout the room. He/She lifted and smoothed the blanket on the resident's bed with ungloved hands. As he/she walked through a small space in between the resident's bed and bedside table, his/her clothing caught and moved the blanket on the resident's bed. He/She picked up a blanket from the table at the foot of the resident's bed and placed it over the resident, using ungloved hands, to cover the resident's feet and smooth the blanket on top of the resident's shoulders. During an interview on 5/22/24 at 1:43 P.M., CNA A said the resident has an LVAD. A gown and gloves are required when changing the resident, but not when transferring or touching them. 4. Review of Resident #200's medical record, showed: -Diagnoses included subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it) left posterior cerebral artery aneurysm (bulge in the wall of an artery); -An order, dated 5/13/24, for patient isolation, EBP, for gastrostomy tube (g-tube, a tube surgically inserted into the stomach to provide hydration, nutrition, and medications). Observation on 5/22/24 at 1:28 P.M., showed an EBP sign posted on the front of the door to the resident's room. The resident sat in a recliner chair in front of a bedside table. CNA A was in the resident's room with no gown or gloves on, adjusting items on the bedside table. CNA A asked if the resident was wet and the resident said no. CNA A said, Let me check, and with ungloved hands, he/she lifted the resident's shirt and pulled the waistband of the resident's pants forward and downward to expose the resident's brief. CNA A moved his/her hands along the waistband of the resident's pants and told the resident he/she was wet and CNA A would come back in a few minutes to change him/her. CNA A picked up a plastic bag filled with soiled linens, exited the room, and brought the bag of soiled linens down the hall to the soiled utility room. Upon exiting the soiled utility room, CNA A attempted to sanitize his/her hands using a dispenser on the wall, but the dispenser did not work. CNA A walked down the hall and entered another resident's room. 5. Review of Resident #249's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included below the knee amputation of left leg and moderate calorie malnutrition. Review of the resident's EMR, showed the resident was on EBP for an infected wound on the resident's right upper leg. Observation on 5/22/24 at approximately 10:00 A.M., showed LPN D in the resident's room to transfer him/her to his/her wheelchair. LPN D touched the resident's arm while guiding him/her into the wheelchair for transport. LPN D was not wearing a gown or gloves. 6. Review of Resident #9's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses including atrial fibrillation (a-fib, a heart condition that causes the upper chambers to beat faster than the lower chambers of the heart, reducing oxygenation of the organs), coronary artery disease (a blockage in one of the arteries to the heart), and heart failure. Review of the resident's EMR, showed the resident on EBP for his/her indwelling urinary catheter. Observation on 5/22/24 at 8:19 A.M., showed a member of the physical therapy staff providing care to the resident, including transferring the resident from his/her bed to the chair, and moving the resident's urinary catheter bag from the bed frame to the chair frame. The physical therapy staff member then wheeled the resident out into the hallway to conduct the resident's scheduled therapy session. For the duration of the observation, the physical therapy staff member wore gloves, but no gown or mask was donned or doffed by the staff member. 7. Observation on 5/21/24 at 7:32 A.M., showed CNA M walked down the 300 hall with a blood pressure monitor on a rolling stand. He/She entered room [ROOM NUMBER], which had an EBP sign posted on the front of the door. CNA M did not sanitize his/her hands upon entry and placed the blood pressure cuff around the resident's right arm. He/She removed the blood pressure cuff, placed the cuff on the rolling stand, and exited the room. CNA M did not sanitize his/her hands upon exiting the room. He/She rolled the stand down the hall and entered room [ROOM NUMBER]. 8. During an interview on 5/22/24 at 1:43 P.M., CNA A said EBP signs are posted outside of the room of residents who have wounds, catheters, colostomies or tube feedings. Those residents require extra precautions to make sure urine or colostomy (fecal matter) doesn't get on staff. Gloves and yellow gowns are required when providing personal care to these residents. Gowns and gloves are not required when transferring or touching the residents. Staff should sanitize their hands when they enter the resident's room and when they exit. 9. During an interview on 5/23/24 at 10:15 A.M., CNA H said if a resident is on EBP, staff should wash their hands every time they go in and out of the room. Staff should wear whatever PPE the sign says. Staff should always wear gloves in the room of a resident who is on EBP. CNA H also prefers to wear a gown because he/she never knows if the resident might have something contagious. Gowns are usually in a container outside of the resident's room, but if not, gowns can be found in the supply closet on the hall. 10. During an interview on 5/23/24 at 10:32 A.M., LPN I said if a resident has a medical device, such as an LVAD, a particular infection, or anything that makes them more susceptible, they are placed on EBP. Nurse Managers are responsible for placing the EBP signs outside of the resident rooms. EBP requires staff to wear gloves and gown while providing any type of direct care. Gowns can be located in the closet of the resident's room or in the supply closet on the hall. It would not be appropriate for staff to touch a resident on EBP with ungloved hands. When taking vitals with the machine on the rolling stand, staff should sanitize the equipment after each use. 11. During an interview on 5/23/24 at 10:50 A.M., LPN E said if a resident is on EBP, it means extra precautions must be taken because the resident has wounds or a medical device, such as a g-tube, LVAD, or catheter. Staff should wear a gown and gloves every time they provide any type of direct care to a resident on EBP. Staff should try and make sure gowns are available right outside of the resident's room, but they are also found in the closets on each hall. When taking vitals with the machine on the rolling stand, staff should sanitize the equipment after each use. 12. During an interview on 5/23/24 at 10:16 A.M., RN B said that if he/she had to perform any care related to wounds, he/she should wear gown and gloves. He/She said the yellow gowns are located in storage and also in the residents' rooms. 13. During an interview on 5/20/24 at 12:26 P.M., the Director of Nurses (DON) said rooms with an EBP sign posted on them require staff to wear gloves and gowns in the room if they are providing direct care. On 5/23/24 at 12:35 P.M., the DON said she is currently the facility's Infection Preventionist. The DON and Administrator said residents are placed on EBP if they have a wound, indwelling medical device, or MDRO. Staff should have a heightened sense of awareness when working with these residents. For residents on EBP, staff should wear gowns and gloves in any high-touch situations, including when checking a resident's brief, handling linens, performing transfers, and using a blood pressure cuff. Therapy staff should also wear gowns and gloves while working with the residents on EBP. All staff have been educated on using gowns and gloves during all high touch activities with residents on EBP. Gowns can be located in the closets of each resident's room and in the supply closets on the halls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of adverse events when the facility failed to follow the Food and Drug Administration's (FDA) Emergency Use Authorization (EUA) guidelines for the Moderna Covid-19 vaccine for one resident (Resident #503) who received a third dose of the Covid-19 vaccine. The census was 55. The administrator was notified on 1/5/23, of the past non-compliance. The facility has changed their process on how they are obtaining consent for the Covid-19 vaccine and the pharmacy nurse consultant is reviewing the consents and checking the residents vaccine history using Show Me Vax (a web-based database that maintains complete, accurate, and secure immunizations records for Missouri residents) prior to administering the vaccine. The deficiency was corrected on 6/30/21. Review of the FDA news release, dated 12/18/20, The FDA Takes Additional Actions in the Fight Against Covid-19 by Issuing an EUA for the Second Covid-19 Vaccine, showed: -Moderna Covid-19 vaccine is administered as a series of two doses, one month apart. -It is mandatory for vaccination providers to report the following to the Vaccine Adverse Event Reporting System (VAERS) for Moderna COVID-19 vaccine: All vaccine administration errors. Review of the FDA's Coronavirus (Covid-19) update news release, dated 4/1/21, showed: -The FDA makes two revisions to Moderna Covid-19 vaccine EUA to help increase the number of vaccine doses available; -The dosing regimen remains unchanged, the vaccine is administered as a two dose series, one month apart. Review of the facility's Resident Immunizations Policy, dated 7/2007, revised 4/2011 and reviewed 9/2022, showed: -Prior to administration of any vaccine, an assessment for contraindications will be completed and documented and a consent form signed; -Practice: as part of the admission process, the resident's immunization history will be assessed; -Assessment and monitoring of residents receiving immunizations: if a resident is admitted with documentation of having had previous immunizations a copy of the documentation should be placed in the medical record and documented on the immunization record; -Documentation: should include either that the resident received the immunization, has already been immunized, the vaccine is medically contraindicated or the resident or resident representative refused. Review of Resident #503's electronic medical record (EMR), showed: -admitted on [DATE] and discharged on 3/5/21; -readmitted on [DATE] and discharged on 7/21/21; -Diagnoses included: leukoencephalopathy (any disorder that affect the white matter of the central nervous system), altered mental status and history of stroke; -Moderately impaired cognition. Review of the care plan, dated: admission 6/16/21 through 7/21/21, showed, I have confusion at times but am typically able to make my needs known. My goal is to have my needs met by staff during my temporary stay on rehab. Please re-orient me as needed, use simple and direct communications, keep my days as routine as possible to decrease my confusion. During an interview on 12/12/22, Resident Representative A said the resident received his/her first Covid-19 vaccination at the beginning of March, at the facility. The facility did not contact Resident Representative A to ask for consent prior to administering the vaccine. A few days later, the resident was discharged from the facility. A resident representative brought the resident back to the facility on 3/30/21 to receive his/her second dose of the Covid-19 vaccine. The resident was re-admitted to the facility on [DATE]. On 6/22/22 the resident received a third Covid-19 vaccine. The facility did not contact the resident representative for consent prior to administrating the vaccine. Resident Representative A was made aware the resident received a third Covid-19 vaccine when he/she was speaking to a staff member about the facility's visitation policy. The staff member told the resident representative he/she could not visit the resident because the resident was not fully vaccinated, but, the staff member stated the resident did received his/her first dose of the Covid-19 vaccine. Review of the progress note dated 6/30/21 at 11:00 A.M., showed, family verbalized concern that the patient received three Covid vaccinations since his/her previous stay at the facility. Upon further investigation and discussion with pharmacy nurse consultant, confirmation received that patient received three separate Covid vaccinations. Patient received first dose on 3/2/21, second dose on 3/30/21 and third dose on 6/22/21. The facility's house Medical Doctor (MD) and the patient's primary care physician (PCP) were notified. PCP states no concerns, patient will not require a Covid booster vaccination. The director of nursing (DON), social worker (SW), Nurse Manager and Administrator met the family to discuss. Family made aware of the patients Covid vaccination status. Family made aware of the MD and PCP response. Family reports concerns that patient appeared short of breathe during his/her visit. Reviewed nurse's assessment of patient and patient vital signs with family. Family requested a chest x-ray due to patient's recent hospitalization. MD in facility and made aware. Nurse Manager requested MD assess patient. Chest x-ray ordered and MD in to see patient. Family updated. Review of the Covid Vaccine Intake Consent From, showed: under the consent for services, the line for signature of patient to receive vaccine (or parent, guardian, or authorized representative) was hand written in, verbal consent from (name of the resident), dated 3/1/21; Vaccine administration information for immunizer/pharmacist use only, showed on 3/2/21, the Moderna Covid-19 vaccine was administered. Review of the pharmacy consent form, dated 3/30/21, showed the resident received the Moderna Covid-19 vaccine. Review of the pharmacy form, dated 6/21/21, showed: -In the past year, have you received a dose of the Covid-19 vaccine? Marked no; -Consent for services signature line: Verbal consent was hand written with a nurse signature and the resident's name hand written with another nurse signature on a line below. Review of the residents Covid card, showed the resident had received the Moderna Covid-19 vaccine on 6/22/21. Review of the facility's Covid-19 certificate, with a report run date of 11/15/22, showed: -Date given 3/1/21. Product: Moderna Covid-19 vaccine; -Date given 3/29/21. Product: Moderna Covid-19 vaccine; -Date given, 6/21/21. Product: Moderna Covid-19 vaccine. During an interview on 1/5/23, at 11:00 A.M., Nurse Manager B, said when a resident is admitted to the facility, the nurse checks the hospital paperwork for the resident's vaccination status. If no information is provided by the hospital, the nurse will ask the resident and/or the resident's family about the resident's vaccination status. If the nurse does not know the vaccination status they would leave that information blank. When the nurse manager does their admission audit, they check to see if immunizations were documented. If a resident was discharged from the facility and was readmitted back to the facility later, the residents past history including the resident's immunization records could transfer to the resident's new chart depending on how the nurse enters the information. The help desk can also merge the two charts together. The facility utilizes an outside company to provide the Covid-19 vaccinations. Therefore, the Covid vaccination would only be documented under immunizations in the EMR. If a resident was their own responsible party, their family would not be notified, if the resident received or refused the Covid-19 vaccination. Nurse Manager B did not recall if the resident gave his/her own consent for the vaccine or not. During an interview on 1/5/23 at 12:49 P.M. and 1/13/23 at 12:30 P.M., the Administrator said, during a family meeting on 6/30/21, the family notified the facility the resident had received three Covid-19 vaccines at the facility. Once the facility discovered the resident did receive three vaccines, staff notified the MD and the PCP who had no concerns. The nurse consultant started using show me vac on 6/7/21. The Administrator said she does not believe the resident was in the Show Me Vax system, because the nurse consultant would not have given the resident the vaccine if he/she was in the data base. Once the facility was made aware of the adverse event, the nurse consultant was notified and he/she made the necessary notifications on their end. The administrator said resident #503 was probably not due to receive a third dose of the Covid vaccine. Since then, the facility has changed their process. Upon admission, the admission nurse prints out whatever information is available regarding the resident's Covid history and vaccination status. Nurse management is now obtaining consent for the vaccine. If a staff member questions the resident's cognitive status, the staff should reach out to the resident's responsible party. If a resident gives verbal consent, two nurses are assessing the resident. The nurse consult also reviews the consent forms and checks Show Me Vax to verify the vaccine history. MO00211153

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure staff followed the complaint/grievance policy, when staff failed to make prompt efforts to resolve the resident's grievances affecting one resident (Resident #20). The facility also failed to follow the grievance policy by not providing a written method for the residents to file grievances. The facility census was 60. Review of the resident and family concern policy, revised 2/2019, showed: -Purpose: To establish written guidelines for the filing of resident concerns and to assure that appropriate investigation and action is promptly taken. Customer feedback is an important source of information about an organization's performance. The verbal or written resident concerns received by staff, physicians and administrators provide vital information about improvement opportunities; -Responsibility: It is the responsibility of all management staff to understand and enforce this policy and the responsibility of all employees to abide by the policy; -Policy: -Resident rights: Residents have certain rights and protections under federal and state law. Notices of resident rights regarding grievances/concerns will be posted in prominent locations throughout the community. Appropriate arrangements to see that individuals with disabilities are provided auxiliary aides and services or language assistance services. Residents have the right to express concerns or grievance to the community or any other entity that hears grievances. A resident or family member may voice grievances/concerns with respect to care and treatment which has been furnished, as well as that which has not been furnished, the behavior of staff and other residents, resident abuse, neglect, exploitation, misappropriation of resident property in the community, non-compliance with advance directives, request for information regarding returning to the community and other concerns regarding their long term care stay. Information on how to file a grievance or complaint will be available to the resident, including a copy of this policy, if requested by the resident; -A concern may be filed anonymously, in written form, verbal form or by calling the facility hotline. Concerns/grievances are encouraged to be communicated as soon a possible to any staff member, an outside party or Grievance official. The Administrator has been designated as the grievance official at each community. The grievance official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the community, maintaining the confidentiality of all information associated with the grievance, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations. Residents/families should feel free to speak with the Administrator or the Director of Nursing (DON) if they should encounter problems, especially those requiring immediate action; -The community will make prompt efforts to resolve such concerns/grievances; -Concern Policy: -It is the policy of the facility to create an atmosphere in which the residents or family members feel free to voice concerns related to their care of living conditions without discrimination or reprisal. All employees who receive concerns are responsible for completing the Resident Concerns Report upon receiving a report of a resident's or a family's concern and notifying shift supervisors and/or managers. The completed form must be forwarded to the Administrator or DON by the end of the shift during which the concern is reported or discovered; -All notification of dissatisfaction with resident care of service will be investigated promptly, corrective action will be taken where appropriate and the results of the entire process, including the details of the concerns and actions taken, will be documented thoroughly and reported through the Quality Assessment and Performance Improvement (QAPI) Committee; -Follow up conversations with the residents or family members will be scheduled to assure that the problem or concerns has been resolved. This notification will be documented on the resident concern form. The follow-up may be with the Administrator, the DON or any affected department manager, but the Administrator as the Grievance Official, is responsible to see that this is completed; -Procedure: -In each facility, there is a form available to all staff called the resident concern report. Each department is responsible for keeping an electronic version or a supply of these forms on hand; -All concerns will be entered on a resident concern report form, signed and dated by the person receiving the report. The resident/family will be informed that they will receive a response to their concern. The form must be sent to the Administrator and to the DON immediately, or in an event, prior to the end of the shift during which the concern was reported/discovered; -A staff member will also take immediate and direct action by either making referrals to the appropriate department manager, nursing supervisor and/or by personally assisting with any immediate problem or need; -Upon review of the concern, the Administrator/DON should route to the appropriate department manager for follow up; -The supervisor or manager, upon receiving the resident concern will gather pertinent documents and details for review. This may include contacting the resident of family to confirm previously provided information; -A written response to the concern will be requested from all staff members or physicians who were named in the concern, staff members who witnessed the situation or staff members who can provide additional information; -A response to the department's investigation, corrective action taken (if any) and the final determination will be communicated timely to the person who initiated the concern. The response will originate from the manager. The written response to the concern/grievance will include the date the grievance was received, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the community as a result of the grievance, the date the written decision was issued; -Evidence demonstrating the results of all concerns/grievances will be maintained for a period of no less than three years for the issuance of the grievance decision or concern resolution. 1. Review of Resident #20's admission minimum data set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/22, showed: -admitted to the facility on : 9/19/22; -Cognitively intact; -Extensive staff assistance with daily care; -Diagnoses included: heart disease, high blood pressure, leg and arm fractures and lung disease. Review of the physician order sheet (POS), showed: -An order, dated 9/19/22, for Clonidine (Catapres-TTS-2, used to treat high blood pressure ) 0.2 milligram (mg) per 24 hour transdermal film, extended release. Apply one patch every Thursday. Documented as ordered through the facility pharmacy. Review of the medication administration record (MAR), dated September 2022 through November 2022, showed: -September 2022 MAR: An order for Clonidine (Catapres-TTS-2). Apply one patch every Thursday at 9:00 A.M. Documented as administered on 9/22/22 and 9/29/22; -October 2022 MAR: An order for Clonidine (Catapres-TTS-2). Apply one patch every Thursday at 9:00 A.M. Documented as administered on 10/6/22, 10/13/22 and 10/20/22. No further administration was documented for the month of October. Review of the progress notes, showed: -On 10/20/22 at 3:21 P.M., while administering the resident's morning medication, staff asked the resident if he/she had the Cataprese patches, as the patches were not located on the medication cart. The resident stated, he/she did not have the patches and the facility had the patches. Writer located a box with one remaining Cataprese patch. The resident was notified a patch was located. The resident stated he/she gave the admitting nurse a full box of patches and paid out of pocket expense of $550.00 for the patches. Writer escalated concerns to the nursing manager; -On 10/28/22 at 10:53 A.M., writer contacted facility pharmacy regarding the Cataprese 0.2 mg patch. The patches were ordered on 10/26/22 as brand name only. Writer contacted the pharmacy on 10/27/22 and was advised the medication would be delivered to the facility that day in the evening. The resident noted upset due to the patches not delivered on 10/27/22. Writer contacted the pharmacy again and told the brand name medication will take one or two more days to deliver. The resident left with family; -On 10/28/22 at 3:52 P.M., addendum: the resident returned with a paid receipt from an outside pharmacy. The resident refused to give the medication to the nursing staff and requested to keep medication with himself/herself. Advised the resident a patch will be administered today and he/she may keep the medication. He/she is alert and able to make sound judgement. Receipt given to the administrator. Review of the October 2022 MAR, showed no documented administration of the Cataprese 2.0 mg patch after 10/20/22. Review of the November 2022 MAR, showed an order for Clonidine (Catapres-TTS-2). Apply one patch every Thursday at 9:00 A.M. No documented administration of the patch noted. Review of the POS, showed an order, dated 11/2/22, to discharge home. During an interview on 11/17/22 at 2:53 P.M., the resident said he/she admitted to the facility for therapy following a fractured foot and ankle for therapy. Due to medication allergies, he/she only used brand name medications. The resident provided his/her own Cataprese patches when he/she admitted . The facility used the patches he/she admitted with and changed the patches until 10/13/22. The nurse notified him/her the facility had no more patches on 10/26/22. The resident spoke to the nurse manager who said the pharmacy would supply the name brand patches for the dose that was due on 10/27/22. None of the staff followed up and the medication was not administered as scheduled. On 10/28/22, the resident informed the nurse manager, he/she would purchase a new box of the patches. The resident returned from an appointment and he/she used his/her own funds to purchase a new box of the patches. Upon return to the facility, the nurse assisted him/her to apply a new patch. The resident provided the facility with the pharmacy receipt for out of pocket expense. On 11/1/22, the day before discharge, the resident spoke to the DON regarding reimbursement, and the DON stated, he was not notified of the resident's concern. On 11/2/22, prior to his/her discharge, the resident again spoke with the DON, who stated the administrator would speak to corporate regarding reimbursement. On 11/15/22 the resident called and spoke to the DON who told the resident that state was in the building and told the resident he needed more time to settle the issue and he would call the resident on 11/16/22. The DON did not call the resident back. The resident said the facility is not following up on his/her grievances. During an interview on 11/17/22 at 3:10 P.M., Licensed Practical Nurse (LPN) E said when the resident was admitted into the facility, he/she brought a box of patches from home. The facility could account for five patches. The admitting nurse sent the medication orders to the pharmacy. When the resident's medication was delivered, it was noted the Cataprese patches were under the generic name and not the needed brand name. The generic named patches were returned to the pharmacy and were not re-ordered under the brand name. The staff used the box the resident brought in upon admission. On 10/26/22, the resident informed LPN E that no more patches were located for administration. He/she called the pharmacy and ordered the patches and was told the patches would be delivered on 10/27/22. The morning of 10/27/22, the patches were not delivered. LPN E called the pharmacy and was informed the brand name patches had to be ordered and would not be delivered for a few days. He/she informed the resident the patch would not be delivered on time for the next administration and on 10/28/22, after an outside appointment, the resident returned to the facility with a box of the patches. The resident paid for the patches out of pocket. LPN E assisted the resident to apply the new patch and informed the DON of the incident and provided the DON a copy of the out of pocket expense receipt. LPN E had not been informed if any resolution occurred. The resident discharged home on [DATE] with the remaining patches. During an interview on 11/18/22 at 12:52 P.M., the DON said he was notified the resident had purchased medication from the pharmacy and paid for the medication out of pocket. The resident refused to use generic brand medications. The resident notified the facility at the time of admission that he/she would not use generic brand medications. Staff received the new order for one week and the resident missed one dose of the patch, and the physician was notified. The resident was notified on 11/18/22 the conclusion of the grievance would be reimbursement for the purchased patches. 2. Review of Resident #7's quarterly MDS, dated [DATE], showed: -An admission date of 2/21/18; -No cognitive impairment. During an interview on 11/16/22 at 10:30 A.M., the resident said he/she had not filed a written grievance in the past. The normal process was to notify the nurse or any staff. He/she said the unit manager was usually the person the residents notified if they had issues. The resident added that there were no types of paper or form to fill out for any grievances. 3. During an interview on 11/16/22 at 10:35 A.M., the DON said the administrator and himself take care of the residents' grievances. He said the residents verbally notify the staff for any concerns and the staff will fill out the grievance form, which were printed out from the facility's electronic records. No physical forms were available for residents' access. During an interview on 11/16/22 at 2:41 P.M., the administrator said the residents can file grievances anonymously by calling the facility's Compliance Hotline. There were no physical forms available in the facility for residents to fill out anonymously. She added the residents can fill out the grievance form but will need to request a copy or print out from the staff. During an interview on 11/18/22 at 12:18 P.M., the Corporate Director of Clinical Services said aside from notifying staff for any concerns, the residents can report grievances by calling the Compliance Hotline. The contact number was available in the Resident's Rights Policy, which was posted in the facility. The residents may also request grievance forms from the staff. She added no grievance forms were currently in place for residents if they choose to file in writing anonymously. MO00210036 MO00180826

Based on interview and record review, the facility's admission packet failed to include transportation as a billable, non-covered service not provided by the facility for one sampled resident (Resident #376). This deficiency had the potential to affect all residents who required transportation. The census was 60. Review of the facility's admission policy, date last reviewed 5/20, and showed: -Transportation was not addressed. Review of the facility's admission Packet, undated, showed: -Transportation was not addressed. Review of the List of Covered/Non-Covered Charges, undated, showed: -The list of ancillary services billable by supplying provider, transportation was not addressed. Review of Resident #376's medical record, showed: -admission date of 10/25/22; -The resident was alert and able to make needs and wants known. During interviews on 11/14/22 at approximately 11:30 A.M. and on 11/18/22 at 10:37 A.M., the resident said when he/she was at the facility in the past, the facility had transportation to take him/her to his/her doctor's appointments. Now the facility says they don't do that anymore and we have to find our own transportation and/or hire someone our self to get us to our appointments. The hospital did not tell him/her the facility no longer provided transportation to doctors' appointments before he/she was discharged . He/she found out the facility no longer provided transportation by the charge nurse, approximately one to two days after he/she was admitted to the facility. During an interview on 11/16/22 at 8:25 A.M., the Social Services Coordinator said in January 2022, the facility's policy changed and the facility no longer provided transportation to doctor's appointments. When a resident is admitted to the facility, the nurse or the unit secretary will look at the admission paperwork for scheduled appointments. If the appointment can be rescheduled, the appointments is rescheduled. If the resident needs to go out for the appointment, either the resident's family will provide transportation or the facility can assist with setting up transportation for the appointment. If transportation is set up, the resident may be responsible for paying for the transportation if the insurance does not cover it. If the resident had Medicaid, the facility would set up transportation with a Medicaid transport company. During an interview on 11/16/22 at 10:30 A.M., Registered Nurse (RN) D said the facility does not transport residents to appointments. For residents who have a doctor's appointment, the family may transport the resident to the appointment or the facility will provide the resident/family with a list of transportation companies who come to the facility. During an interview on 11/17/22 at 3:10 P.M., the Transportation Coordinator, said residents are made aware the facility no longer provides transportation. When she is made aware a resident needs transportation to a doctor's appointment, she will look at the resident's chart to see what type of insurance the resident has. If the resident had Medicaid, she can set up the transportation. If the resident does not have Medicaid, she will tell the residents to call the number on the back of their insurance card to see if their insurance will cover the transportation cost. Some insurance companies will assist with setting up transportation and cover the costs. If a resident is unable to make the calls or does not have family to help them with this process, the facility will assist the resident. The transportation coordinator has escorted and provided transportation for residents who needed it. During an interview on 11/17/22 at 3:15 P.M. and 11/18/22 at 11:14 A.M., the administrator said the facility has notified the hospital social workers they are no longer providing transportation. The hospital social worker should tell the residents this information before they leave the hospital. The facility cannot ensure the hospital relays this information to the resident before they are discharged . The facility usually doesn't communicate with the resident until the resident arrives at the facility. Most residents come to the facility with scheduled appointments. When the resident arrives at the facility, transportation for doctor's appointments is not covered during the admission paperwork. Transportation is discussed when an appointment comes up. Nursing or the unit secretary will review the admission paperwork sent from the hospital for any appointments. The facility will check to see if the appointment can be rescheduled. If the appointment cannot be rescheduled, the facility will assist the resident/family with setting up transportation. If the resident does not have the means to pay for transportation, the facility will cover the expense. If a resident refused to pay for transportation, the facility would get the resident to the appointment and worry about the money later.

Based on interview and record review, the facility failed to ensure a resident admitted to the facility with a deep tissue injury (DTI, an injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body, usually a dark purple color) received an accurate admission skin assessment, physician notification of the wound and orders for wound care. The nursing staff also failed to ensure treatment orders once obtained four days after admission, were accurately entered onto the treatment administration record (TAR). This affected one of three residents reviewed for pressure injury care (Resident #420). The census was 60. The administrator was notified on 11/17/22, of the past non-compliance. The facility provided training and in-services for all staff regarding the facility's skin integrity, assessment and prevention of wounds and documentation policies. Review of the Skin Integrity, Assessment and Prevention of Wounds policy, revised 9/2022, showed: -Purpose: to prevent avoidable skin breakdown and pressure injuries, provide guidelines for the treatment of impaired skin and guidelines for documentation; -Responsibility: it is the responsibility of the nurse manager to oversee the policy. It is the responsibility of all involved caregivers to know and assist in the implementation of the policy and applicable procedures; -Policy: all residents will be assessed for the risk of skin breakdown. Risk factors identified will be evaluated. Interventions will be developed and implemented to minimize or stabilize the risk. Interventions will be care planned; -Practice: -Assessment: -The admitting nurse will complete a head to toe skin assessment (body check) and risk assessment (Braden Score, standardized, evidence-based assessment tool used to assess and document the risk for developing pressure injury/ulcer) to determine the absence, presence, and existing skin impairment or risk for skin impairment and document accordingly. If there are existing impairments, implement appropriate interventions including notification of the physician and obtaining treatment orders. If there are no existing impairments, document there are none; -For residents who do not already have skin impairment, utilize the Braden score and the pressure injury prevention points to assist in identification of preventative measures: -Severe risk: Braden less than 9; -High risk: Braden of 10-12; -Moderate risk: Braden of 13-14; -Mild risk: Braden of 15-18; -The Braden is to be completed: -On admission; -Weekly for the first four weeks after admission; -Quarterly; -Significant change in condition; -In addition, the admission evaluation may identify pre-existing signs suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable Stage III (a pressure injury/ulcer that has gone through all layers of skin into the fat layer) or a Stage IV (a deep wound reaching the muscles, ligaments, or bones) pressure injury of progression of a Stage I (the skin is not broken but is red or discolored) pressure injury to an injury with eschar (dry, dead tissue) or exudates (fluid that leaks out of blood vessels into nearby tissues) within days after admission; -Some signs and symptoms that might indicate deep tissue injury that occurred prior to admission are intact skin with one or more of the following: -A purple area; -Very dark area surrounded by redness; -Edema (swelling); -Induration (area of hardness in the skin); -Accurately describe and document any of these conditions if observed. Document as unstageable at this time, suspect deep tissue injury; -In addition to the Braden scale score examples of other risk factors, which should be considered are: -Previous history of pressure ulcer/injuries; -Co-morbidities such as end-stage renal disease, diabetes, thyroid disease, heart failure, vascular disease, tissue and skin disorders; -Obesity; -Poor protein intake; -Cognitive impairment; -Refusal of treatment; -Prevention: The following guidelines should be implemented based on medical history and physical assessment. On admission, the skin prevention protocol will be implemented if ordered by the physician; -Residents at risk should be monitored, paying attention to bony prominences and pressure caused by ill-fitting shoes or medical devices. Certified nurse aides (CNAs) will report abnormal findings to a nurse, such as: -Reddened skin; -Blanching; -Bluish or purple skin mark; -Black or red heels; -Rashes; -Swelling or change in skin temperature; -Raw skin; -Pain; -Other unusual conditions; -Abnormal findings will be assessed by the nurse and appropriate interventions and documentation completed by the nurse. Review of Resident #420's hospital wound consult, dated 5/12/21, showed: -Active wound: pressure ulcer right buttock; -Present on admission: yes; -Wound bed: deep pink, deep purple; -Length: 9 centimeters (cm); -Width: 5 cm; -Depth: 0 cm; -Staging: suspected deep tissue injury; -Peri-wound (skin around wound): intact; -Dressing: cleaned, foam dressing applied; -Dressing status: clean, dry, intact and reinforced; -Braden score: 13; -Recommendation: -Cleanse right buttock would with saline and gauze and pat dry. Apply ClearAid (helps seal out wetness and relieve chapped or cracked skin) ointment to wound base daily and as needed (PRN). Cover with a foam dressing. The foam dressing is good for three days if not soiled. Peel back the dressing to cleanse the wound, apply the ClearAid and then reattach the dressing. Date the dressing; -Maintain the patient on low air loss mattress with one single layer draw sheet and one air absorbent permeable pad; -The patient is at higher risk for skin breakdown. Implement preventative measures such as pressure redistribution, reduce friction/sheer and reduce/relieve excessive moisture; -Reduce friction/shear: -Keep the head of bed below 30 degrees when possible; -Lift in bed with sheet or pad, do not pull or drag; -Pressure redistribution: -Initiate a turn schedule; -Use pillows or positioning wedge; -Keep pressure off the heels, use pillows or heel protectors; -Inspect the skin folds every shift; -Reduce excess moisture: -Contain incontinence; -Utilize skin protectant. Review of the hospital discharge transfer orders, dated 5/14/21, showed: -Reason for hospitalization: failure to thrive; -No wound care orders included. Review of the admission physician order sheet (POS), dated 5/14/21, showed skin care protocol. Review of the admission nurse's note skin assessment on 5/15/21 at 1:24 A.M. showed the resident arrived to the facility via ambulance. He/She had a bruise to his/her left hand and scabbed area to the left knee. He/She noted to have open sores on the peri area (groin) noted to the right and left side, and pink in color. Six areas noted to the back, the first layer of skin is gone with some bleeding. Areas cleaned. All medications verified by the physician; -The note did not address physician notification regarding open wounds. Review of the skin care flow sheets, showed: -On 5/17/21 at 3:18 P.M.: -Skin color: usual for ethnicity; -Skin temperature: warm; -Skin moisture: dry; -Skin turgor: elastic; -Skin integrity: localized abnormality; -Mucous membrane color: pink; -Skin abnormalities: none; -Skin abnormalities comment: open area to buttocks; -Preventative skin care: barrier cream, protectant ointment; -Sensory perception Braden: very limited; -Moisture Braden: very moist; -Activity Braden: chair fast; -Mobility Braden: very limited; -Nutrition Braden: adequate; -Friction and shear Braden: problem; -Braden score total: 12. Review of the nurse wound assessment report, dated 5/18/21 at 8:25 A.M., showed: -Present on admission. The resident is alert to self, skin warm and dry. He/She noted a Stage III pressure ulcer observed to the right buttock. Noted are a proximal (close) and distal (far) wound. The proximal wound measured 2.5 cm x 2.2 cm, with pink granulating wound bed. The medial wound measured 9.0 cm x 5.0 cm. and noted with 50% eschar and adherent brown slough (dead tissue separating from living tissue) observed. Moderate serosanguineous (thin and watery fluid pink wound drainage secreted by an open wound in response to tissue damage) drainage noted in the brief. The peri-wound no noted abnormalities, no redness, warmth or odor. The distal wound is intact with pink pigmentation observed. Cavilon (concentrated, therapeutic cream that provides durable, long-lasting protection from body fluid) applied to the distal, proximal and medial wounds. Areas cleaned with wound cleanser. Medihoney (wound and burn gel) applied and covered with a foam dressing. The resident will be placed on a low air loss mattress to assist with weight distribution. Review of the POS, showed: -An order, dated 5/18/21: Cleanse right buttock pressure ulcer with wound cleanser. Apply Medihoney and foam to the proximal and medial wound daily and as needed. Ordered to start on 5/18/21 and stopped on 5/18/21. Documented as completed on 5/18/21. No further documented treatments noted. Review of the skin care flow sheets, showed: -On 5/20/21 at 3:59 P.M.: -Skin color: usual for ethnicity; -Skin temperature: warm; -Skin moisture: dry; -Skin turgor: elastic; -Skin integrity: intact; -Mucous membrane color: pink; -Mucous membrane description: dry; -Skin abnormalities: none; -Preventative skin care: barrier cream, protectant ointment; -Sensory perception Braden: very limited; -Moisture Braden: very moist; -Activity Braden: chair fast; -Mobility Braden: very limited; -Nutrition Braden: adequate; -Friction and shear Braden: problem; -Braden score total: 12; -Flow sheet did not reflect pressure ulcer to buttock. Review of the skin care flow sheets, showed: -On 5/21/21 at 1:35 P.M.: -Skin color: usual for ethnicity; -Skin temperature: warm; -Skin moisture: dry; -Skin turgor: elastic; -Skin integrity: intact; -Mucous membrane color: pink; -Mucous membrane description: moist; -Skin abnormalities: none; -Sensory perception Braden: very limited; -Moisture Braden: very moist; -Activity Braden: chair fast; -Mobility Braden: very limited; -Nutrition Braden: adequate; -Friction and shear Braden: potential problem; -Braden score total: 13; -Flow sheet did not reflect pressure ulcer to buttock Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/21/21, showed: -Severe cognitive impairment; -Required extensive staff assistance with daily care; -At risk to develop pressure ulcer; -admitted with one Stage III pressure ulcer; -Received pressure reducing device for bed and chair; -Received hydration, nutrition to treat pressure ulcer. Review of the wound physician progress note, dated 5/24/21, showed: -Weeks in treatment: 0; -Chief complaint: new patient sacral (tailbone) and right buttock pressure ulcer; -History of present illness: admitted with 2 pressure injuries to the right buttock and sacral. Both areas noted with slough. Staff started Medihoney and improving based on measurements; -Wound #1: Right lateral (outer edge) gluteus (buttock). Original cause is pressure injury. Classified as a Stage III. Wound measured 1.9 cm length x 1.5 cm width x 0.1 cm depth. There is a fat layer exposed. There is a medium amount of serous drainage noted. The wound margin is distinct with the outline attached to the wound base. There is a large (67-100%) pink granulation within the wound bed. There is a small (1-33%) amount of necrotic (dead, black) tissue within the wound bed including adherent slough. The periwound appearance had no abnormalities; -Wound #2: Unstageable pressure injury to the sacrum. The wound measured 6.5 cm length x 5.3 cm width. There is fat layer exposed and medium amount of serous drainage. The wound margin is distinct with the outline attached to the wound base. There is a small (1-33%) pink granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough. The periwound skin appearance had no abnormalities noted for texture, moisture, color or temperature. The periwound has tenderness to palpation; -Plan: -Follow up in 1-2 weeks; -Wound cleansing: cleanse both areas with wound cleanser; -Primary wound dressing: Apply honey dressing to both sites; -Secondary dressing: Apply ABD padding; -Change frequency: Change both sites daily and as needed; -Off-loading: float heels anytime while in bed, do not sit for long periods and turn and reposition according to current plan of care. Review of the electronic POS and treatment administration record (TAR), dated 5/14/21 through 5/28/21, showed no wound care orders. Review of the nurse wound assessment report, dated 5/26/21 at 12:56 P.M., showed: -Where is skin problem: Right gluteus; -Origin: present on admission; -Pressure injury staging: Stage III; -Length: 1.9 cm; -Width: 1.5 cm; -Depth: 0.1 cm; -Describe drainage: moderate serous drainage; -Describe wound: granulation; -Describe wound: eschar; -Describe wound: slough; -Describe wound: periwound; -Comprehensive wound note: resident followed by wound care company. The wound bed noted beefy red, pink with large amount of granulation and small amount of necrotic tissue, including adherent slough. Treatment remains appropriate for healing. Cleanse wound with wound cleanser, apply Medihoney and ABD pad daily and PRN. Resident continues on low air loss mattress for off-loading; -Where is skin problem: Right gluteus/sacrum; -Origin: present on admission; -Pressure injury staging: unstageable; -Length: 6.5 cm; -Width: 5.2 cm; -Describe drainage: moderate serous drainage; -Describe wound: granulation; -Describe wound: eschar; -Describe wound: slough; -Describe wound: periwound; -Comprehensive wound note: the resident is seen by wound care company. The previous wound documented as the right buttock now observed as the right gluteal/sacral region. The wound bed is covered with a large amount of necrotic tissue including adherent slough. The exposed wound bed is pink with a small amount of granulation. The resident remains on the correct mattress for off-loading of pressure and treatment remains appropriate for healing. Continue cleaning wound with wound cleanser, apply Medihoney and cover with ABD pad. Change daily and PRN. Review of the electronic POS and TAR, dated 5/14/21 through 5/28/21, showed no wound treatment orders. Review of the discharge documentation, dated 5/28/22 at 10:57 A.M., showed: -discharged : home with home health; -Orders: did not include wound care; -Medication: supply sent with resident and family. Review of the in-service programs, showed nursing staff were trained on skin/wound documentation, treatment, task, orders for new admissions on 6/1/21, 6/2/21 and 9/7/21. During an interview on 11/15/22 at 10:15 A.M., the corporate nurse said the facility did not have any TAR records available for the resident. Around the time the resident was inpatient, the facility was changing electronic medical records. During an interview on 11/16/22 at 11:40 A.M., the wound nurse said he/she helped take care of the resident during his/her stay. The admission nurse did not accurately document the resident's skin condition. The admitting nurse should have called the physician for wound care orders. The wound nurse said she completed the initial skin assessment on the resident on 5/18/21 and documented the accurate skin conditions. At that time, the wound nurse added the resident to be seen by the wound care physician. The orders obtained on 5/18/21 were not accurately entered onto the TAR. The wound orders did not reflect on the TAR and would not have triggered for the nurse to complete. She conducted in-servicing with all nursing staff when the error was recognized. MO00193048 MO00171082 MO00186263 MO00167129 MO00170831 MO00191140

Based on observation, interview and record review, the facility failed to ensure residents could safely administer their own medications for three sampled residents (Residents #374, #376 and #186), who had medications left at their bedside. The census was 60. Review of the facility's Self Administering Medication Policy, reviewed 8/2022, showed: -Medications may be self-administered only after the resident has been evaluated by an interdisciplinary team to determine that the resident can safely self-administer medications with administrator/Executive Director Approval; -An evaluation will be completed and documented prior to allowing self-administration of medications; -If the evaluation indicates the resident may self-administer medications, the resident's/community member's physician must also give an order allowing self-administration. 1. Review of Resident #374's medical record, showed: -Alert and orientated times four (person, place, time and situation); -Required no assistance with eating; -No self-administration assessment completed; -No physician's order to self-administer medications. Observation on 11/16/22 at 10:15 A.M., showed the resident was in his/her room, with a clear plastic cup of medication in his/her hand. The resident put a pill in his/her mouth, took a sip of water and wrote something down in a notebook. He/She then took another pill and again wrote something down in the notebook. There was an inhaler on the resident's over the bed table. The resident said breakfast was late today, it did not come up until 8:45 A.M. Then, he/she had to do therapy and the nurse just brought down his/her pills and inhaler. The nurse leaves all his/her medications and he/she writes down each pill and the dosage as he/she takes it, to be sure he/she has taken all 11 pills. The resident said he/she double checked the medications when the nurse brought them in because most of the pills were white and yellow. Registered Nurse (RN) H then entered the room and picked up the inhaler. Review of the Medication Administration Record (MAR), dated 11/16/22, showed: -An order for cholecalciferol 50 milligram (mg), one tablet daily, indication: osteoporosis (weak, brittle bones); -Documentation showed the medication was administered at 9:00 A.M.; -An order for cranberry capsule 200 mg, one capsule daily, indication: urinary health; -Documentation showed the medication was administered at 9:00 A.M.; -An order for fluticasone 220 microgram (mcg)/inhalation, two puffs twice daily, indication: asthma; -Documentation showed the medication was administered at 9:00 A.M.; -An order for folic acid 1 mg, two tablets daily, indication; anemia (low red blood cells); -Documentation showed the medication was administered at 9:00 A.M.; -An order for furosemide 20 mg, take half tablet daily, indication: lymphedema (swelling due to a buildup of lymph fluid); -Documentation showed the medication was administered at 9:00 A.M.; -An order for metoprolol 25 mg, one tablet daily, indication: high blood pressure; -Documentation showed the medication was administered at 9:00 A.M.; -An order for wheat dextrin powder for reconstitution 5 gm/7.4 gm, daily, indication: supplement; -Documentation showed the medication was administered at 9:00 A.M.; -An order for prednisone 10 mg tablet, three tablets daily, indication: inflammation; -Documentation showed the medication was administered at 9:00 A.M. Review of the progress notes, dated 11/16/22 at 11:33 A.M., showed the resident at 10:00 A.M. self-administered inhaler with effectiveness. During an interview on 11/16/22 at 10:30 A.M., RN D said if a resident wanted to self-administer their medications, they would need a doctor's order. He/she would try to discourage the resident from self-administering their own medications because of safety concerns. Someone could go into the resident's room and take their medications. During an interview on 11/16/22 at 10:57 A.M., RN H, said if a resident wanted to self-administer his/her medications, an evaluation should be done and documented in the progress notes. Medications should be kept in the medication cart when not administered. Residents should be watched while taking their medications. RN H said he/she administered the resident's medications this morning but he/she did not watch the resident taken them. RN H did not know if an evaluation had been completed for the resident to self-administer his/her own medications. 2. Review of Resident #376's medical record, showed: -Alert and able to make needs and wants known; -Required set up assistance for eating; -No evaluation was completed for self-administration of medications; -No physician's order for self-administration of medications. Observation on 11/18/22 at 10:37 A.M., showed the resident lay in his/her bed. A clear plastic medication cup with approximately 6-8 pills in it sat on the over the bed table next to the bed. The resident said some of the nurses leave his/her medications at the bedside because they know he/she will take them and other nurses will stay in the room and watch him/her take them. The resident picked up the medication cup and started taking his/her medications. Review of the MAR, dated 11/18/22 showed: -An order for finasteride 5 mg tablet, one tablet daily indication: urinary health; -Documentation showed the medication was administered at 9:00 A.M.; -An order for hydroxychloroquine 200 mg tablet, one tablet twice daily, indication: arthritis; --Documentation showed the medication was administered at 9:00 A.M.; -An order for multivitamin with minerals tablet, one tablet daily, indication: vitamin deficiency; -Documentation showed the medication was administered at 9:00 A.M.; -An order for tamsulosin 0.4 mg capsule, one capsule daily, indication: prostate health; -Documentation showed the medication was administered at 9:00 A.M.; -An order for apixaban 5 mg tablet, one tablet twice daily, indication: blood thinner; -Documentation showed the medication was administered at 9:00 A.M.; -An order for famotidine 20 mg tablet, one tablet twice daily, indication: stomach acid; -Documentation showed the medication was administered at 9:00 A.M.; -An order for ascorbic acid 1000 mg tablet, one tablet daily, indication: supplement; -Documentation showed the medication was administered at 9:00 A.M.; -An order duloxetine 60 mg capsule, one capsule twice daily, indication: mental health; -Documentation showed the medication was administered at 9:00 A.M.; -An order for prednisone 10 mg tablet, one tablet daily, indication: inflammation; -Documentation showed the medication was administered at 9:00 A.M.; -An order for arginaid packet, one packet twice daily, indication: supplement; -Documentation showed the medication was administered at 9:00 A.M. 3. Review of Resident #186's medical record, showed the following: -An admission date of 11/4/22; -An order for Calcium Carbonate (dietary supplement), one tab to be taken once a day; -No assessment for self-administration of medication; -No physician's order to self-administer medications. Observation and interview on 11/16/22 at 8:57 A.M., showed the resident lay in bed on his/her back with the head of bed raised. An over the bed table was positioned over his/her lap. A pill cup sat on the table and contained a large blue pill. The resident said it was a calcium tablet. The nurse gave him/her medications earlier and he/she asked what the pill was. The resident said he/she had never seen it before. He/she said the nurse administered the other medications and left the room. The resident hadn't taken the calcium tablet yet because he/she was afraid of choking on it. Once in the hospital, the resident got a large pill stuck in his/her throat. The resident thought the pill was too big to swallow. During an interview on 11/16/22 at 1:11 P.M., Nurse A said he/she administered the resident's morning medications. The resident does not have an order to self-administer medications. In order to self-administer, the admission nurse would need to assess the resident for safety. A physician's order would also be required. Medications should not be left at bedside. 4. During an interview on 11/16/22 at 10:30 A.M., RN D, said no medications should be left at the resident's bedside, if the resident did not want to take their medications at that time, the nurse should take the medications back and try again at a later time. 5. During interviews on 11/16/22 at 3:05 P.M. and 11/18/22 at 12:15 P.M., the Director of Nursing (DON) said self-administration of medication was not allowed per the facility's policy and procedure. Currently, he was not aware of any residents who are self-administering their medications. He would expect for staff to follow the facility's policies and procedures. MO00180826

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure residents who were unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good personal hygiene and grooming by not providing baths or showers at least twice a week, for three sampled residents (Residents #180, #183 and #187). In addition, two sampled residents were observed to have long nails, who preferred to have their nails short and clipped (Residents #7 and #12). The census was 60. Review of the facility's A.M. and P.M. Care Policy, revised on 10/2022, showed: -Purpose: To provide grooming and hygiene for each resident, assisting with bathing, dressing and elimination as needed; -Responsibility: All nursing staff shall be responsible for assisting with ADLs; -Policy: It shall be the policy that each resident receives assistance with ADLs as needed throughout each day; -Procedures included, give nail care as needed. -No specific policy and procedure for baths and showers provided. 1. Review of Resident #180's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 11/4/22, showed: -An admission date of 10/29/22; -No cognitive impairment; -Required one person to assist with personal hygiene and bathing. Review of the resident's care plan, in use during the survey, showed the resident preferred to receive a shower twice a week. Observation and interview on 11/14/22 at 11:43 A.M., showed the resident wore a hospital gown and his/her hair appeared greasy. His/her fingernails were long with visible dirt underneath. The resident said he/she hadn't had a shower since he/she had been at the facility. He/She would like one because his/her skin feels itchy. The resident felt like a dirty old person. No one had offered him/her a shower. He/She has asked and they said he/she will get one, but no one has given one. The staff do help the resident wash up, but it is not the same as a shower. Observations of the resident on 11/15/22 at 12:06 P.M. and 5:00 P.M., and on 11/16/22 at 8:57 A.M., showed the resident's hair appeared greasy and his/her fingernails were long with visible dirt underneath. The resident wore a hospital gown. During an interview on 11/16/22 at 4:16 P.M., the resident said he/she received a shower on this day. It was the first one he/she had received since admission. The resident's nails remained long with visible dirt underneath. Review of the resident's Bath Type Detail Report, showed the resident had received one shower since admission. 2. Review of Resident #183's admission MDS, dated [DATE], showed: -An admission date of 10/19/22; -No cognitive impairment; -Required extensive assistance from staff for personal hygiene and bathing. Review of the resident's care plan, in use during the survey, showed the resident preferred to receive a shower twice a week. Observation and interview on 11/14/22 at 1:12 P.M., showed the resident lay in bed on his/her back and wore a hospital gown. He/She said he/she had not had a shower since he/she had been there. He/she was ok with this because he/she had a cast on his/her leg and did not want to get it wet. Staff gave the resident bed baths, but did not wash his/her hair. The resident said he/she had been at the facility for 30 days before he/she got his/her hair washed. An occupational therapist gave him/her a shampoo shower cap that washed his/her hair and now he/she felt so much better. Until then, the resident was waiting for his/her family member to visit and figure out a way to wash his/her hair. During an interview on 11/18/22 at 12:5 P.M., Certified Occupational Therapy assistant (COTA) B said he/she helped the resident use a shower cap one time. The resident said it had been a long time since his/her hair had been washed. COTA B thought the resident said it had been at least a few weeks since the last time he/she had his/her hair washed. 3. Review of Resident #187's medical record, showed an admission date of 11/7/22. Review of the resident's care plan, in use during the survey, showed: -The resident preferred to receive a shower twice a week; -The resident preferred to get up and dressed each day by 10:00 A.M. Observation and interview on 11/14/22 at 12:54 P.M., showed the resident lay in bed on his/her back and wore a hospital gown. The resident's hair appeared greasy and there was visible dirt under his/her nails. He/She said he/she had not received a shower since he/she had been at the facility. He/She had only received bed baths. Observation and an interview on 11/15/22 at 4:15 P.M., showed the resident lay in bed on his/her back and wore a hospital gown. The resident's hair appeared greasy and there was visible dirt under his/her nails. The resident said staff told him/her he/she would get a shower tomorrow morning. He/she is also supposed to have group therapy tomorrow morning, so he/she hopes it all works out. Observation and interview on 11/16/22 at 4:25 P.M., showed the resident lay in bed on his/her back and wore a hospital gown. The resident's hair appeared greasy and there was visible dirt under his/her nails. The resident said he/she had to choose between going to group therapy this morning and getting a shower. He/She chose to go to therapy. This afternoon, he/she asked for a bed bath, but so far, no one had come to help him/her. He/she would prefer a shower. Review of the resident's Bath Type Detail Report, showed the resident received one shower since admission. 4. During an interview on 11/18/22 at 11:59 A.M., Certified Nurse Aide (CNA) C said they have shower sheets they looked at and assignments. Sometimes, if a resident asks for a shower on another day, they will squeeze them in. He/She knew the residents' preferences because he/she asked them. Showers were documented in the electronic medical record (EMR) and a shower sheet is completed for each shower. The shower sheet then went to the nurse. If he/she noticed a resident had long toe or finger nails, he/she would ask if the resident would like them cut. If a resident refused a shower, the resident would sign the shower sheet, it would be documented in the EMR and the nurse would be made aware. He/She did not know Resident #180's preferences. Resident #183 received bed baths because he/she was afraid his/her cast would get wet. The resident does not refuse bed baths. Resident #187 received bed baths and never refused. 5. Review of Resident #7's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Required one physical assistance from staff for personal hygiene and bathing. Review of the resident's EMR, showed diagnoses, included: -Hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (weakness of one side of the body) related to stroke, affecting left side; -Rheumatoid arthritis (RA, an autoimmune disease, a chronic inflammatory disorder affecting many joints, including those in the hands and feet). Observation and interview on 11/14/22 at 8:55 A.M., showed the resident had long fingernails. The resident said he/she wanted his/her nails cut, and had asked staff to get them cut but nobody had followed up on his/her request. Observation and interview on 11/15/22 at 1:13 P.M., showed the resident's fingernails remained long. The resident said he/she used to clip his/her own nails until recently when he/she was unable. The resident said his/her RA condition had weakened his/her hands, which prevented him/her from clipping his/her own nails. He/She had notified the nurse again but had not received the care at that time. He/She preferred to have short nails and wanted to have them clipped sooner. During an interview on 11/15/22 at 1:26 P.M., Registered Nurse (RN) D said nursing staff are responsible for the residents' nail care. He/She was not aware of Resident #7's request and said he/she will clip the resident's nails right away. Observation and interview on 11/17/22 at 9:07 A.M., showed the resident was in bed, with long fingernails. The resident said nobody had clipped his/her fingernails yet. He/She said again the nurse was aware but not sure when they would take care of the issue. 6. Review of Resident #12's annual MDS, dated [DATE], showed: -An admission date of 9/23/17; -Cognitively impaired; -Required one physical assistance from staff for personal hygiene and bathing. Review of the resident's EMR, showed his/her diagnoses included fracture of coracoid process or scapula (broken shoulder blade), muscle weakness, osteoarthritis (degenerative joint disease) and Alzheimer's disease. Observation and interview on 11/17/22 at 9:02 A.M., showed the resident's fingernails were long, with some visible dirt underneath. The resident said he/she preferred to have short nails but nobody wanted to clip his/her nails. He/she said he/she tried to clean them him/herself, and no staff provided assistance. 7. During an interview on 11/18/22 at 12:18 P.M., the Director of Nursing (DON) said staff should follow their policy and try to honor residents' shower preferences. He expected residents to receive showers at least twice a week. He was not aware of any issues with residents not receiving showers as preferred. Residents' hair should be kept clean. If he were caring for a resident, he would attempt to honor the resident's wishes and typically work around the therapy schedule. The DON said CNAs and nurses are responsible for providing nail care to residents, including clipping or cutting. If residents are diabetic, a licensed nurse should provide nail care. He expected staff to ensure nails are clean and short per residents' preference. MO00178263 MO00185948 MO00180826

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate amounts of all the necessary items were available for the dinner meal on 11/16/22 and for breakfast on 11/17/22 for two residents (Residents #186 and #370). This practice potentially affected all residents who ate food from the facility kitchen. The facility census was 60 residents. Review of the facility's menu for the week of 11/14/22 through 11/20/22, showed: -The dinner menu for 11/16/22: Chicken and dumplings, baby carrots, roll and peaches; -The breakfast menu for 11/17/22: Oatmeal, scrambled eggs, bacon, pancake with maple syrup. 1. Review of Resident #186's medical record, showed the following: -admission: [DATE]; -No cognitive impairment; -Regular diet; -Diagnoses included malnutrition. During observation and interview on 11/17/22 at 8:40 A.M., the resident said he/she ordered chicken and dumplings the previous night, but instead received a grilled cheese sandwich. The resident called the kitchen to find out why he/she received a grilled cheese sandwich. The resident said he/she was told the kitchen had ran out of chicken and dumplings, so a grilled cheese was sent instead. The resident provided a photo on his/her cell phone of a picture of plate pellet (used to keep food warm while in transport), a plate and what appeared to be a grilled cheese sandwich. The plate contained no other food. The resident also showed a picture of his/her meal ticket and showed the following: -Dated 11/16/22; -Chicken and dumplings, circled; -Peaches, circled. 2. Review of Resident #370's medical record, showed: -No cognitive impairment; -Was on a Consistent Carbohydrate Diet (CCHO, helps people with diabetes keep their carbohydrate consumption at a steady level) with regular texture and thin liquids; -Required no assistance with eating; -Diagnoses included diabetes. During an interview on 11/17/22 at 9:50 A.M., the resident said, he/she requested bacon or sausage for breakfast and he/she was told the kitchen was out of meat. 3. During an interview on 11/17/22 at 10:40 A.M., [NAME] M said they ran out of chicken and dumplings last night. They substituted chicken tenders for the chicken and dumplings, but also ran out of that. This does not happen often. If they have to make a substitution, they alert the kitchen supervisor and ask what to serve. The resident floors are then made aware of the alternate meal. 4. During an interview on 11/17/22 at 4:20 P.M., the dietary manger (DM) said he was not aware residents were not served chicken and dumplings due to running out of it. The facility only serves breakfast meat 5 days a week and 11/17/22 was a day breakfast meat was not served. All food is made fresh and they only buy what they need for each meal. The current kitchen budget is for 45 residents, but the last three weeks the census has been in the 60's. 5. During an interview on 11/18/22 at 11:15 A.M., the administrator said she expected the items listed on the menu to be served. The kitchen should plan to be able to have enough food for all residents. If an item is not available, she would expect staff would find something suitable as an alternative. 6. During an interview on 11/18/22 at 2:00 P.M., the district manager for the company contracted to provide food services at the facility said she expected the food on the menu to be served to residents. The dietary manager and chef are responsible to make sure there is enough food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice, by failing to provide alternate meals (Resident #186). The facility also failed to consistently provide menu tickets for residents to select their meal preferences or serve the items residents selected on their menu ticket (Resident #370). The facility census was 60. 1. Review of the facility's menu for the week of 11/14/22 through 11/20/22, showed: -Breakfast for 11/14/22: Oatmeal, scrambled eggs, pancake with maple syrup; -Breakfast for 11/15/22: Oatmeal, egg scramble, ham, hash brown potatoes; -Breakfast for 11/16/22: Oatmeal, banana, sausage links, chocolate chip muffins; -Breakfast for 11/17/22: Oatmeal, scrambled eggs, bacon, pancake with maple syrup; -Breakfast for 11/18/22: Oatmeal, scrambled eggs, biscuit and gravy; -Breakfast for 11/19/22: Oatmeal, scrambled eggs, sausage patty, orange cranberry muffin; -Breakfast for 11/20/22: Oatmeal, scrambled eggs, bacon, cinnamon French toast. 2. Review of Resident #186's medical record, showed the following: -admission: [DATE]; -No cognitive impairment; -Regular diet; -Diagnoses included malnutrition. During an interview on 11/15/22 at 12:18 P.M., the resident said he/she did not eat pork. He/she liked hot tea with brown sugar. The facility does not provide an alternative for him/her. He/she would like to eat meat at breakfast and needed to put on weight. He/she did not like oatmeal either, but ate it today because he/she was very hungry. The resident reviews the menu and selects what he/she wants for the next day. Staff had not come back with his/her menu so he/she had not yet ordered tomorrow's meals. Observation and interview on 11/16/22 at 9:03 A.M., showed the resident in bed with his/her breakfast tray on the over the bed table. Observation, showed the resident was served cheesy eggs and a pork sausage patty. The resident said he/she did not get toast or milk, but did receive tea and orange juice. Review of the resident's breakfast ticket for 11/16/22 showed: -Condiment: 1 ounce (oz) non-dairy creamer, 1 packet sugar; -Beverage: 6 oz coffee, crossed out; -Handwritten oatmeal, crossed out; -Handwritten egg scramble, with cheese; -Handwritten bacon strips, crossed out and turkey bacon written above; -Handwritten chocolate chip bread crossed out; -Handwritten 2% milk; -Handwritten regular toast with grape jelly; -Handwritten tea with brown sugar; -Typed at the bottom of the ticket for pretences: No pork. Cheesy Eggs, hot tea with brown sugar. During an interview on 11/16/22 at 11:22 A.M., the chef manager said resident meal tickets are completed the day before at 2:30 P.M. The next morning, dietary staff retrieve the tickets and set up the trays. During meal service, the supervisor and servers call out what is on the ticket and are responsible to ensure tray contents are correct. The dietician fills out the resident's likes, dislikes and allergies and documents it on the diet slip. There was also a communication board that faced the steam table that listed residents' preferences and special diets by room number. Observation of the communication board in the kitchen on 11/16/22 at 11:28 A.M., showed, No Pork with the resident's room number listed underneath. Observation and interview with the resident on 11/17/22 at 8:40 A.M., showed the resident in bed with his/her breakfast tray on the over the bed table. The resident received cheesy eggs and hot tea. The resident did not receive turkey bacon, orange juice or toast and jelly. The resident said he/she never receives turkey bacon. Review of the resident's 11/17/22 breakfast ticket, showed: -No pork handwritten at the top; -Juice: 4 oz orange juice; -Cereal: 6 oz oatmeal, crossed out; -Entree: Egg scrambled, circled with cheese written above the typed words; -Breakfast sides: -Substitute needed: -Bread: 1 each pancake, crossed out with turkey bacon written over the typed words; -Condiment: 1 each syrup, crossed out; -Dietary beverage: 8 oz 2% milk crossed out with tea, brown sugar written below; -Typed at the bottom of the ticket for pretences: No pork. Cheesy Eggs, hot tea with brown sugar. During an interview on 11/17/22 4:20 P.M., the dietary manager said resident food preferences being honored was an ongoing issue. He was aware of the resident's request for turkey bacon and said the resident would write it on the menu ticket. They did not provide turkey bacon. They cannot provide everything. If a resident does not eat a certain kind of meat, they are not offered an alternate choice. A substitute was not available. There was not a policy for resident food preferences. He expected staff to verify what was on the meal tray compared to what was requested on the menu ticket. 3. Review of Resident #370's medical record, showed: -Alert and oriented times four (person, place, time and situation); -Was on a Consistent Carbohydrate Diet (CCHO, helps people with diabetes keep their carbohydrate consumption at a steady level) diet with regular texture and thin liquids; -Required no assistance with eating; -Diagnoses included: diabetes. During an interview on 11/15/22 at 1:00 P.M., the resident said the dietician gave him/her a weekly menu and told him/her if he/she did not want the item on the menu to mark it out and write in what he/she would like and someone would come by in the evening and pick up the menu for the next day. Last night he/she did not get a meal ticket, so today he/she was just getting whatever was served. He/she did not like orange juice, grapefruit juice or cookies because that was too much sugar. During an interview on 11/17/22 at 9:50 A.M., the resident said he/she requested bacon or sausage for breakfast and he/she was told the kitchen was out of meat. During an interview on 11/17/22 at 4:19 P.M., the dietary manager said, breakfast meat was only offered five times a week. 11/17/22 was a day when there was no breakfast meat available. 4. Review of the facility's Resident Council minutes, showed: -6/8/22: Residents state they are not always offered to fill out their meal menu; -7/7/22: Residents are still not being offered choices for meals. Tickets not getting filled out by the residents; -8/11/22: When a dessert is posted, they would like what is on the menu. Sometimes the dessert is not what the menu states; -10/4/22: Residents are still not always being offered a meal ticket to fill out; -11/1/22: Rehab residents stated food is poor quality and does not have flavor. Menus do not match up with what they are getting on their trays. Meal tickets still not being passed out or certified nurse aides (CNAs) are filling them out themselves. During an interview on 10/17/22 at 10:17 A.M., Licensed Practical Nurse (LPN) F said both the CNAs and the nurses pass out the residents' meal trays. They check the tray to be sure all items are there, if an item was missing, they would ask the resident if they ordered the item, if the resident said yes, they would notify the kitchen and they would bring the item up. During an interview on 11/17/22 at 10:20 A.M., CNA G said both CNAs and nurses passed out the trays. They checked the tickets, if an item was missing, he/she would notify the nurse and dietary. The kitchen staff would bring the item up to the floor for the resident. If the resident wanted the alternate meal, they would need to mark it on their menu ticket the day before. Once the meal is served, if a resident did not like what was on the menu, they may be able to get an alternate the same day, he/she would tell the nurse and dietary. During an interview on 11/17/22 at 4:19 P.M., the dietary manager said in the evening, a menu ticket is taken up to the floor for nursing to help the residents to complete for the next day. Then, the next morning, dietary picked up the menu tickets. The problem was sometimes nursing did not give the tickets to the residents to complete. All food on the meal ticket was verified by the kitchen staff before the tray went up to the floors. During an interview on 11/18/22 at 11:14 A.M., the administrator said she expected staff to follow the preference of the resident and substitutes should be provided. The residents received a menu ticket every day to review or make changes for the next day. The menu tickets should be picked up every evening. The menu ticket should match the meal being served to the resident. The administrator was not aware of any residents who were not getting a meal ticket to review on a regular basis. -

Based on observation and interview , facility staff failed to store food in a manner to prevent contamination and out-dated use by not covering and dating food items stored in the refrigerator and storing scoops and cups inside bulk bins. These deficient practices had the potential to effect all residents who at the facility. The census was 60. Review of the facility's Storage of Food and Supplies policy, revised 12/7/20, showed; -All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesome of the food for human consumption; -Refrigerated Foods: Use food grade plastic bags for food storage. Cover foods stored on ladder/seed racks to prevent contamination from airborne contaminants as well as from dripping condensation. Either use a bag that covers the entire cart or cover each tray individually; -Dry Storage: Opened foods must be stored in approved containers that have tight-fitting lids. Label both the bin and the lid. Hang scoop. Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop. Observation on 11/14/22 at 9:18 A.M., showed: -Two chocolate pudding cups in the reach in refrigerator by the toaster with no date; - A baking sheet with cake and a tray of cookies in the reach in refrigerator by the sink were not covered and were undated; -A storage bin labeled corn meal contained a scoop inside, submerged in the corn meal. Observation on 11/15/22 at 11:13 A.M., showed: -A tray with six fruit cups and a tray of two ounce disposable cups that contained what appeared to be condiments in the reach in refrigerator by the sink, all undated; -Three trays of cookies in the reach in refrigerator by the sink uncovered and undated; -At 11:20 A.M. [NAME] N put two trays of raw cookies in the reach in refrigerator by the sink without covering or dating either. Observations on 11/15/22 at 11:37 A.M. and 3:02 P.M., showed: -Three trays of muffins and one tray of cookies on plates in the reach in refrigerator by the sink with no cover or date; -The scoop remained in the same position in the corn meal container; -A rectangular bin under the work table by the food processor was unlabeled and had a Styrofoam cup partially submerged in the contents. During an interview on 11/15/22 at 11:37 A.M., [NAME] M said the rectangular bin contained polenta. Observation on 11/16/22 at 11:18 A.M. and 11:43 A.M., showed: -The scoop remained in the corn meal bin and the cup remained in the polenta bin; -Cook N placed a tray of sliced cake on plates in the reach in refrigerator across from the plate warmer. During an interview on 11/17/22 at 10:37 A.M., [NAME] M said items stored in the reach in refrigerators should be wrapped in plastic wrap and dated for three days. Things should be wrapped to keep the food fresh and free from germs. It was important to date food to avoid serving spoiled food. Everyone was responsible to make sure things are covered and dated. Cups and scoops should not be stored inside the bins to avoid cross contamination. During an interview on 11/17/22 15 10:40 A.M., [NAME] L said everything in the refrigerators should have a cover or a lid so that nothing falls on the food and there's no cross contamination. All food should have a date so staff know when food was expired. Cups and scoops should be kept separated from items in storage bins because of cross contamination. During an interview on 11/17/22 at 4:20 P.M. the dietary manager said everything in the reach in refrigerators are for daily use and at the end of the day everything should be used. The items in the reach in refrigerators are made that day. Baked items must be brought to room temperature. They are then placed in the reach in refrigerators to be brought to 41 degrees. Food cannot be covered while it is cooling. If it is covered it will trap heat and bacteria could form. If something is leftover, it would be dated and moved to the walk in refrigerator. If something was in the refrigerator to be cooled, it does not need to be covered or dated. Items in the reach in refrigerators in the morning will be used for lunch and dinner. Scoops or cups should be stored outside the storage bins because you don't know who last touched the scoop. This is to prevent cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the interdisciplinary team has determined if self-administration of medication was clinically appropriate for one resident who was observed to self-administer medication. In addition, the facility failed to ensure one resident had the right to self-administer medications when the interdisciplinary team has determined that this practice is clinically appropriate (Residents #282 and #47). The sample was 17. The census was 82 with 69 residents in certified beds. Review of the facility's Self-Administering Medications policy, dated August 2018, showed: -Policy: Medications may be self-administered only after the resident has been evaluated by an interdisciplinary team to determine that the resident can safely self-administer medications and with administrator/Executive Director approval; -An evaluation with be completed and documented prior to allowing self-administration of medications, quarterly, with any change of condition or for any route not previously evaluated to be given (example: evaluated self-administer oral medications only and later has inhaler ordered); -The evaluation will be documented in the resident's medical record; -If the evaluation indicates the resident may self-administer medications, the resident's physician must also give an order allowing the self-administration. 1. Review of Resident #282's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/19, showed: -Brief Interview for Mental Status (BIMS, a screen for cognitive impairment) score of 15 out of a possible score of 15; -A BIMS score of 15 showed the resident cognitively intact; -Diagnoses included septicemia (a serious bloodstream infection, also known as blood poisoning), atrial fibrillation (A-fib, an irregular, often rapid heart rate), coronary artery disease (CAD, narrowing or blockage of the coronary arteries), high blood pressure, paraplegic (paralysis that affects all or part of the trunk, legs and body) and anemia (a condition in which the blood does not have enough healthy red blood cells). Review of the resident's treatment administration record (TAR), showed: -An order for Eucerin topical cream (used to treat dry skin) two times a day, dated 7/2/19, and marked as administered on 7/3/19 through 7/10/19, as ordered; -An order for Hydrocortisone (steroid) 1% topical cream, apply three times a day, dated 6/28/19, and marked as administered 6/28/19 through 7/8/19, as ordered. Review of the resident's current physician order sheet (POS), showed no order to self-administer his/her medications. Observation and interview on 7/12/19 at 8:59 A.M., showed the resident sat, propped up by pillows, in his/her bed and applied lotion to his/her chest, neck and arms. He/she said the itching was just terrible and staff gave him/her this cream to put on for the itching. He/she said the container read to apply three times a day, but he/she was itching so much, he/she had to apply more often. He/she continued to dip his/her finger into the container and apply to his/her skin from the half empty container. The container showed a label which read, hydrocortisone cream, apply three times a day. During an interview on 7/12/19 at 10:30 A.M., the Director of Nursing (DON) said she was not aware the resident was self-administering topical cream. The resident had not been evaluated for self-administration of medication and she would expect a resident to be evaluated prior to self-administering. 2. Review of Resident #47's admission MDS, dated [DATE], showed: -A BIMS score of 15 out of 15, showed the resident cognitively intact; -Diagnoses included A-fib, heart failure, diabetes, hip fracture, asthma, history of falling, muscle weakness and obstructive sleep apnea. Review of the resident's POS, dated 7/1/19 through 7/31/19, showed an order dated 6/5/19 for Refresh eye drops, one drop, both eyes, four times a day as needed (PRN). Patient may have at bedside if requested. Review of the resident's self-medication evaluation, dated 7/8/19, showed resident is able to have PRN eye drops at bedside. He/she had demonstrated the ability to self-administer without difficulty. Observation and interview on 7/8/19 at 2:15 P.M., 7/9/19 at 12:00 P.M., 7/10/19 at 12:08 P.M. and 6:11 P.M. and 7/11/19 at 1:13 P.M., showed the resident did not have his/her eye drops in the room. The resident said he/she was supposed to have them, but he/she had to continue to wait for the nurse to administer them. He/she had to wait up to an hour before he/she received the eye drops. He/she has dry eyes and it becomes more irritated the longer he/she had to wait. During an interview on 7/11/19 at 1:07 P.M., Nurse F said the resident did not have an order to have the eye drops at bedside. After shown the order to have the eye drops at bedside, Nurse F said he/she had no idea why the eye drops were never given to the resident if there was a physician order to have at bedside. During an interview on 7/12/19 at 10:19 A.M., the DON said she would expect staff to complete an evaluation to self-administer medications. Staff would discuss it with the physician and if the team felt it would be appropriate, there would be a physician's order to self-administer. She would expect staff to follow physician's orders and allow the resident to have his/her eye drops.

Based on observation, interview and record review, the facility failed to ensure staff utilize facility protocols regarding feeding tube nutrition and care for one resident with a gastrostomy tube (g-tube, a small rubber tube surgically inserted through the abdomen in to the stomach to administer nutrition, fluids and medications) feedings by not obtaining a physician's order for formula. The facility identified five residents who received g-tube feeding. Of those five, three were chosen for the sample of 17 and problems were found with one (Resident #9). The census was 82 with 69 residents in certified beds. Review of the facility's tube feeding and pump operation policy, dated March 2019, showed: -Responsibility: It is the responsibility of the Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) to know and follow this policy; -Policy: Licensed nursing personnel will administer tube feedings with a proper physician's order; -Practice: Obtain physician's order, per dietician's recommendation, which includes tube feeding formula and the total volume needed to assure caloric needs are met. Order should also include the rate and flush volume/frequency. If tube feeding is to be off for certain activities, the order must specify as such. Review of Resident #9's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/19, showed: -A Brief Interview of Mental Status (BIMS, a brief screening tool used to assess cognitive impairment) score of 0 out of a possible 15; -A BIMS score of 0-7, showed severe cognitive impairment; -Diagnoses included anemia, heart failure, high blood pressure and non-Alzheimer's dementia; -Received tube feeding. Review of the resident's care plan, in use during the survey, showed resident received nothing by mouth (NPO) except for pleasure foods if daughter gives it to him/her. Resident is on a tube feeding, please administer this as indicated. He/she is at risk for dehydration, aspiration and malnutrition related to g-tube status. Review of the resident's physician's orders sheet (POS), dated 7/1/19 through 7/12/19, showed: -An order dated 6/5/19, for Fibersource HN (liquid nutrition), 60 milliliter (ml)/hour. First dose 6/5/19 and stop date 6/5/19 for nutritional support; -An order dated 7/2/19, for tube feeding water bolus 175 ml every six hours; -An order dated 7/5/19, for medication administration note to dissolve each medication in a separate cup with 10-30 ml of water. Flush g-tube initially with 30 ml water, then give medications with 5 ml of water between each med cup. Flush finally with 30 ml water; -Further review of the POS, showed no orders for tube feeding formula from 6/6/19 to 7/11/19. Review of the resident's Medication Administration Record (MAR), dated 6/5/19 through 6/30/19, showed: -Fibersource documented as administered on 6/5/19. Staff documented the tube feeding infused at 60 ml at 6:23 P.M.; -No documentation of the administration of Fibersource formula from 6/6/19 to 6/30/19. Review of the resident's MAR, dated 7/1/19 through 7/11/19, showed no documentation of the administration of Fibersource formula. Observation on 7/8/19 at 9:34 A.M. and 12:22 P.M., 7/10/19 at 12:29 P.M. and 6:29 P.M., and 7/11/19 at 1:11 P.M., showed the resident in bed. A tube feeding formula bag labeled Fibersource infused at 60 ml/hr. During interviews on 7/11/19 at 1:14 P.M. and 2:33 P.M., the Director of Nursing (DON) said she could not locate a physician's order for the tube feeding formula. A new order was never entered in the electronic medical record. The DON confirmed that the previous order for the formula was ordered and stopped on 6/5/19. She would expect tube feeding orders to include the type of formula, rate, and frequency. She would expect the nurse to know that there was not an active order if they were not able to document the administration in the MAR. The DON confirmed that the resident did receive the tube feeding, but did not have a physician's order for the formula. He/she did not experience any weight loss.

Based on observation, interview and record review, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice by not following physician orders for oxygen therapy and failing to provide ongoing assessment and documentation of the resident's respiratory status and response to oxygen therapy, for one of two sampled residents on oxygen therapy (Resident #55). The census was 82 with 69 residents in certified beds. Review of the facility's oxygen administration policy, dated 2/2019, showed the following: -Purpose: To provide guidelines for oxygen administration; -A physician's order is required to administer oxygen. The order should include the administrative device, liter flow and the parameters for use, i.e., indications for and frequency of use; -Continue to assess and monitor the resident by checking vital signs and respiratory status, including apparent work of breathing and cardiac (heart) and pulmonary (lung) status; -Document oxygen initiated or continued, flow rate, method of delivery and resident's response/tolerance of treatment; -Residents who have chronic obstructive pulmonary disease (COPD, lung disease) must be observed carefully during any supplemental oxygen therapy. These residents are breathing from a hypoxic drive (elevated carbon dioxide levels) and over-oxygenation (oxygen concentration in blood and other tissues of the body is greater than normal) may cause respiratory arrest (stop breathing); -Oxygen safety - Ensure that the liter flow the resident is receiving is as prescribed by the physician. Review of Resident #55's medical record, showed: -admission date of 6/26/19; -Medical diagnoses included COPD, high blood pressure and heart failure. Review of the resident's physician order sheet, dated 7/1/19 through 7/31/19, showed an order, dated 6/27/19, for oxygen at 2 liters (L) per nasal cannula (NC), every 12 hours. Review of the resident's nurse's notes, dated 6/27/19 at 1:43 A.M., showed the resident admitted to the facility and was on oxygen at 3 L/NC. Lung sounds diminished. Review of the resident's care plan, dated 7/3/19, showed he/she was on oxygen per order. Staff would monitor him/her for shortness of breath. Review of the resident's July 2019 medication administration record (MAR) and treatment administration record (TAR), reviewed on 7/11/19 at 2:00 P.M., showed -On 7/8/19 at 9:00 A.M., 2 L oxygen administered. At 9:00 P.M., 2 L. oxygen administered; -On 7/9/10 at 9:00 A.M., 2 L oxygen administered. At 9:00 P.M., 2 L oxygen administered; -On 7/10/19 at 9:00 A.M., 2 L oxygen administered. At 9:00 P.M., 2 L oxygen administered; -On 7/11/19 at 9:00 A.M., 2 L oxygen administered. At 9:00 P.M., 2 L oxygen administered. Observation on 7/8/19 at 3:40 P.M., showed the resident lay in his/her bed and wore oxygen per nasal cannula. An oxygen concentrator unit located alongside the resident's bed set at 3 L. On 7/9/19 at 6:35 A.M., 12:10 P.M. and 2:25 P.M., on 7/10/19 at 7:15 A.M. and 10:35 A.M., and on 7/11/19 at 7:50 A.M. and 1:15 P.M., showed the resident wore oxygen at 3 L per nasal cannula. During an observation and interview on 7/11/19 at 9:05 A.M., the resident pulled at his/her oxygen cannula and said it needed to be replaced because it did not stay in well. Staff had not checked on it since he/she was admitted to facility. During an interview on 7/11/19 at 1:16 P.M., Certified Nurse's Aide (CNA) D verified the resident's oxygen level was at 3 L and said staff checked it every shift and let the nurse know the rate to record in the resident's MARs. Observation of the resident on 7/12/19 at 7:15 A.M., showed the resident wore oxygen at 3 L per nasal cannula. During an interview on 7/12/19 at 7:41 A.M., Registered Nurse (RN) C verified the resident's oxygen level was at 3 L. and said staff were supposed to check it every shift and document it on the MAR. During an interview on 7/12/19 at 8:41 A.M., Licensed Practical Nurse (LPN) G said the on duty nurse is responsible to check the resident's oxygen rate and record it on the MAR. During an interview on 7/12/19 at 10:03 A.M., the Director of Nursing (DON) said the resident's oxygen should not have been on 3 L, if the physician's order was for 2 L. Staff should have followed the physician's orders. Sometimes staff would change a resident's oxygen level if there is a breathing emergency but it would only be for a short period of time and should be documented.

Based on interview and record review, the facility failed to ensure resident requests for less than $100.00 ($50.00 for Medicaid residents) are honored within the same day by not assuring residents had access to their trust account on the weekends. This deficient practice affected all the residents who had a resident trust account. The census was 82 with 69 residents in certified beds. During an interview on 7/9/19 at 10:30 A.M., nine residents at a group meeting said they did not have access to resident funds on the weekend. During an interview on 7/11/19 at 11:26 A.M., the Business Office Manager (BOM) confirmed that the residents do not have access to their funds on the weekends. Since there were only a few residents in the facility with a resident trust, they usually get their money during the business hours on Monday through Friday. The facility does not have a system in place to allow residents to have access to their money on the Saturday or Sunday. During an interview on 7/12/19 at 1:36 P.M., the Revenue Cycle Manager said he/she would expect a system be in place to allow residents to have access to their funds on the weekends. There should be a cash bag of $50 left at the reception desk. During an interview on 7/12/19 at 11:15 A.M., the administrator said he believed the residents already had access to their money on the weekends. He would expect the residents to have access to funds during normal business hours, and it would also include Saturdays.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to label and date food and failing to ensure food items were closed and sealed. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 82 with 69 residents in certified beds. 1. Observations on 7/8/19 at 8:30 A.M., 7/9/19 at 11:19 A.M., 7/10/19 at 7:17 A.M., and 7/12/19 at 10:43 A.M. of the kitchen, showed the following: -An open package that contained breaded chicken patties located on the third shelf in the walk in freezer, tied in a knot at the end of the package, and not labeled or dated; -An open package of waffles located on the third shelf in the walk in freezer, not labeled or dated and exposed to air. 2. Observations on 7/10/19 at 7:17 A.M. and 7/12/19 at 10:43 A.M. of the kitchen, showed green peppers inside a plastic bin that sat on the second shelf in the walk in cooler, with a shelf date of 7/4/19 and a use by date of 7/8/19 sticker attached. 3. During interviews on 7/9/19 and 7/12/19, the food services manager said state requirements states the maximum amount of time food could remain in the refrigerator is seven days. Food is supposed to be dated for seven days but they do less than seven days. They use the food by the use by date or it is discarded. She would expect for food to properly sealed, labeled, and dated once it is opened.