**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide catheter care consistent with physician orders when staff flushed the suprapubic catheter (a flexible tube inserted into the bladder used to drain urine continuously) of one of six sampled residents. The sample was 6. The census was 127. Review of facility's admission Checklist for new/readmits in Point Click Care (PCC, an electronic healthcare software program that maintains resident assessments, care planning, scheduling, medication and treatment administration, medical records), no date, showed: -If Foley catheter or suprapubic catheter is present, all orders must include: -Size of catheter; -Flush order with sterile water, 60 cubic centimeters (cc), as needed (PRN); -Diagnosis for Foley; -Catheter care every shift, to include daily dressing changes if a suprapubic catheter; -Change catheter monthly and as needed; -Skin assessment at Foley insertion site daily. Review of facility's Suprapubic Catheter Care Policy, revised 6/26/24, showed: -The care and maintenance of suprapubic catheters shall be in accordance with physician orders. The orders shall specify the type and size of catheter, and frequency of catheter changes. -Urinary catheters may be irrigated to provide for and maintain constant urinary drainage or to administer medication. -Urinary catheters shall be irrigated by licensed nurse using sterile technique, under the orders of the physician. Routine irrigation is not recommended. Orders shall include the type and amount of irrigating solution or medication. Review of facility's policy and procedure for Transcription of Orders/Following Physician's Orders, revised 5/18/24: -Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in the resident's electronic medical records in orders section. Review of Resident #6's medical record, showed: -Diagnoses included quadriplegia, segmental and somatic dysfunction of lumber region (altered function of lower back bone), dysphagia (difficulty swallowing), cystostomy (a surgical procedure that creates an opening in the bladder forming a stoma (an artificial opening created on the body's surface) to drain urine directly into a collection bag), neuromuscular dysfunction of bladder, urinary tract infection, hematuria (blood in urine), major depressive disorder with severe psychotic symptoms; -Resident's orders showed no physician order to flush resident's suprapubic catheter; -Resident's Treatment Administration Record (TAR) for November and December 2024, showed no scheduled treatment to flush suprapubic catheter; -Resident's progress notes showed no nursing notes for November and December 2024, documenting flushing of resident's suprapubic catheter; -Resident's care plan, last updated 9/22/24, showed; -Problem: Resident is at risk for infection and pain related to use of 20 French (Fr), suprapubic catheter. He/She has a diagnosis of painless hematuria; -Desired Outcome: Resident will be/remain free from catheter-related trauma. Resident will show no signs or symptoms of infection; -Interventions: -Monitor and document intake/output as per facility policy, by nursing; -Monitor for signs and symptoms of discomfort on urination and frequency, by nursing; -Monitor, record, and report to physician for signs and symptoms of urinary tract infection, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increase temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, by nursing. Review of the resident's hospital record, from admission [DATE] through discharge 12/9/24, showed: -Resident presented to emergency room (ER) 12/3/24 for pain with suprapubic catheter flush at skilled nursing facility; -Patient reported pain immediately began following suprapubic catheter manipulation at SNF (skilled nursing facility); -Based on presenting history, pain localized to suprapubic insertion site that worsens with palpitation near site and movement, lack of improvement with antibiotic treatment, and timing of pain immediately after manipulation suspect pain may actually be 2/2 (due to or caused by) trauma/mechanical pain, rather than true UTI (urinary tract infection). During an interview on 2/20/25 at 11:05 A.M., Registered Nurse (RN) C said the resident reported Licensed Practical Nurse (LPN) B flushed his/her catheter and did it incorrectly by pushing dirty urine back in. He/She did not know what day it happened for sure. It is not part of the standing orders for Foley and suprapubic catheters to flush or irrigate them. This order comes from the physician. During an interview on 2/20/25 at 12:33 P.M., LPN B said he/she flushed the resident's suprapubic catheter when it had clotting issues. He/She also said the resident must have an order from the physician to flush a Foley catheter or suprapubic catheter. During an interview on 2/20/25 at 12:40 P.M., Director of Nursing (DON), said there are standing orders for residents with Foley catheters and suprapubic catheters. The DON provided a check off list for new residents and resident readmits. She said flushing a Foley catheter with 60 cc of sterile water is part of the standing orders and should be entered into PCC with every Foley and suprapubic catheter resident. She also said nurses should not flush a Foley catheter without a physician order and expected them to document Foley catheter care in the progress notes. Staff should never complete a treatment on a resident without a physician order. It should also be documented under the TAR. In addition, if a resident is having issues with clotting and needs flushing, this should also be documented in the resident's plan of care. MO00246509

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when they did not obtain Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) line orders and nephrostomy tube (a tube that is directly inserted into the kidney to drain urine) orders on admission, failed to ensure that suprapubic catheter (a tube that is inserted in the lower abdomen to drain urine) care orders were in place on the Treatment Administration Record (TAR), and failed to ensure a yearly electrocardiogram (EKG, a test to diagnosis heart irregularities) was completed for one resident (Resident #64). The sample size was 26. The census was 133. Review of the facility's Intravenous (IV) Catheter Care and Maintenance and Access Procedures policy, revised on 6/29/23, showed: -PICCs: -Frequency of dressing change: -Change the dressing 24 hours after insertion; -Transparent dressing: Change every 5-7 days unless soiled or loose; -Gauze dressing: change every two days or as needed if wet or soiled, or non-occlusive; -Flushing: use of heparin (a medication that prevents clots to be formed in the catheter line) flushes and the recommended concentration and frequency of flushing are determined in accordance with the manufacturer's instructions and per the treating clinician orders. Review of the facility's Urinary Catheter Care policy, revised on 6/29/23, showed: -The facility will ensure any resident with a urinary catheter will be maintained to prevent infection; -Residents who have a urinary catheter will have a physician order for the catheter, care and diagnosis; -Residents with indwelling catheters will receive catheter care every shift or as ordered by the physician. Review of the facility's Transcription of Orders and Following Physician Orders policy, revised 9/20/23, showed: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician orders and to ensure that all physician orders are followed; That a process is in place to monitor nurses in accurately transcribing and following physician's orders; -Procedure: -Upon receiving a physician's order via telephone fax, written order, verbal order, transcribed order or other, it will be documented in the resident's electronic medical record; -Clarification of physician orders will be obtained in the event that the order is either unclear or the nurse is uncomfortable in implementation of the physician orders; -The Resident Care Coordinator (RCC)/Unit Director/designated nurse will review electronic Medication Administration Record (MAR) and electronic TARs daily to monitor medications that were not administered to the resident due to unavailability, refusal, or omission; -The Nurse or Certified Medication Technician (CMT) in charge of medicine administration must review all of their designated MARs and TARs prior to the end of their shift to ensure that all medications/treatments scheduled to be given on their shift were administered according to the physician's orders and that all necessary interventions were taken in the event of an omission; -The RCC, Unit Manager, or designated nurse will review all electronic MARs and TARs and compare all medications available for each resident in the facility weekly to ensure availability. Review of Resident #64's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/24, showed: -Severe cognitive impairment; -Has an indwelling urinary catheter; -High risk drug class: antipsychotics (mood stabilizer), antidepressants and antibiotic; -Diagnoses include multiple sclerosis (MS, a neurological condition that causes muscle weakness), seizures, high blood pressure, multi-drug resistant organism (MDRO), anxiety, diabetes, urinary tract infection (UTI) in the last 30 days, manic depression and schizophrenia (severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking and behavior). Review of the resident's progress notes showed: -On 3/6/24 at 3:43 P.M., the resident was readmitted from the hospital with an admitting diagnosis of UTI and bacteremia (infection that has spread to the blood stream); Current medication orders along with Ertapenem (antibiotic), intravenously (IV) for 3 days ending on 3/10/24, along with resuming previous meds were verified with the Nurse Practitioner (NP); Skin assessment noted skin intact with suprapubic catheter draining clear yellow urine; IV site in left inner upper arm with minimal redness noted around insertion site, nephrostomy in left lower back draining clear yellow urine; The resident has a follow up appointment for a cystoscopy retrograde pyelogram (a procedure to remove kidney stones) on 3/26/24; -On 3/26/24 at 2:06 P.M., the resident just returned from same day surgery; -On 3/26/24 at 6:56 P.M., the resident returned alert and up in wheelchair; Midline IV port in left arm was removed and nephrostomy tube was also removed; A stent was placed in the penis, blood noted in catheter bag; The resident's suprapubic catheter was changed today. Review of the resident's Physician Order Sheets (POS), dated March, 2024, showed no orders for PICC line care or nephrostomy tube care. Review of the residents POS, dated March through April, 2024, showed an order: -Suprapubic catheter care every shift, cover with dry dressing and report any signs or symptom of infection; -Order status: active; -Start date: blank; -End date: blank; -Revision date: 2/2/23. Review of the resident's MAR and TAR, dated March, 2024 and April, 2024, showed no order for suprapubic catheter site care or documentation to show the treatment was completed. Observation on 4/14/24 at 10:17 A.M. and on 4/17/24 at 10 :37 A.M., showed the resident did not have a dressing located around his/her suprapubic catheter site. During an interview on 4/17/24 at 2:15 P.M., Licensed Practical Nurse (LPN) D said when the resident arrives from the hospital, there should be orders on how to care for the PICC, such as dressing changes and flushes from the hospital and if there are no orders, the nurse should ask the facility doctor for orders. If the resident returns from the hospital with a nephrostomy tube, there should also be orders obtained for care of the nephrostomy tube, such as cleaning and dressing changes. During an interview on 4/18/24 at 10:30 A.M., LPN O said he/she admitted the resident back into the facility on 3/6/24 and verified the resident had a PICC line, nephrostomy tube and suprapubic on admission. He/She said the orders for the suprapubic were probably placed in the computer incorrectly due to the tab for the order to be sent to the TAR was not selected. The orders did not show on the TAR to be completed by nursing staff. He/She was not sure what orders specifically needed to be obtained regarding the PICC line and nephrostomy tube. The resident had the PICC line and nephrostomy tube removed at the hospital when he/she went there for outpatient surgery on 3/26/24. Review of the residents POS, dated April, 2024, showed an order: -EKG yearly; -Status: active; -Start date: 4/5/22; -Revision date: 6/15/21. Review of the resident's diagnostic administration report, dated April, 2024, showed an order for a yearly EKG and on 4/5/24 the documentation box was blank. During an interview on 4/18/24 at 10:30 A.M., LPN O said the EKG company was currently backed up in their workload, therefore the resident's EKG was not completed. During an interview on 4/18/24 at 1:41 P.M., the Director of Nursing said she expected staff to place the orders in the computer correctly so the order would show on the TAR to be completed. She also expected staff to obtain orders related to the care for the resident's PICC line and nephrostomy tube. The EKG was not completed. The provider is backed up on orders. The resident is required to have the yearly EKG due to being on anti-psychotic medications. MO00233864

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs-bathing, dressing, toileting) received necessary services to maintain adequate personal hygiene when staff left one resident soiled for an extended period (Resident #44), and when staff did not shave and provide nail care for three residents (Residents #102, #64 and #18). The sample was 26. The census was 133. Review of the facility's ADL and Documentation Policy, last reviewed 10/18/23, showed: -All nurses, aides and other employees must follow nursing standard of practice of completing ADLs; -For independent residents, ADLs must be documented two times per week; -For all other residents who are not independent, ADLs must be documented daily; -All documentation is completed in the electronic medical charting system. 1. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/23/24, showed: -Mild cognitive impairment; -Uses manual wheelchair; -No behaviors; -Occasionally incontinent of urine and continent of bowel; -Diagnoses included viral hepatitis (a liver disease), anxiety, manic depression (a mental disorder) and schizophrenia (a mental disorder that is characterized by severely impaired thinking, emotions and behaviors). Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is incontinent of urine; -Interventions: -Clean peri-area (genital area) after each incontinent episode; -Ensure the resident has an unobstructed path to the bathroom; -Monitor and document signs and symptoms of a urinary tract infection (UTI): pain, burning, blood-tinged urine, urine cloudiness, deepening in color of urine, no output from the catheter, increased pulse, increased temperature, foul smelling urine, chills, altered mental status changes, change in behavior, and change in eating habits. Review of the resident's behavior monitoring and intervention sheet, dated 3/19/24 through 4/16/24, showed no behaviors noted. Observation and interview on 4/16/24 at 11:04 A.M., showed upon entering the resident's room, a strong odor of urine present. The resident lay in bed with his/her eyes closed. The resident's maroon bedspread and thick blue blanket were saturated with urine. The resident said he/she was tired and didn't know when the last time was that he/she was assisted with getting his/her brief changed. The resident said he/she welcomed the assistance of staff and had some of his/her favorite staff members who help him/her get cleaned up. Certified Nursing Assistant (CNA) K entered the resident's room and removed the resident's bedspread and blanket. The resident's pants and lower part of his/her shirt was saturated with urine. CNA K assisted the resident in removing his/her brief. The resident's brief was completely saturated, and the brief lining had white balls formed and appeared to be disintegrating. CNA K raised the resident's pannus (abdominal fold) and the resident had a bright red and inflamed rash under his/her pannus. The resident's white sheet on his/her bed had a yellow ring on it. The CNA assisted to remove the resident's soiled brief and pulled up his/her soiled pants. The resident then walked to the shower room on 100 hall with his/her walker. During an interview on 4/16/24 at 11:10 A.M., CNA K said it was terrible and disgusting to leave someone wet like this for so long and it was obvious the resident was left wet the entire night and morning. CNA K said the resident required some reminders to get out of bed but normally never gave him/her any issues about getting up. CNA K did not know the last time the resident was changed. Staff are to check on and change incontinent residents at least every two hours. During an interview on 4/16/24 at approximately 1:00 P.M., Certified Medication Technician (CMT) J said he/she was familiar with the resident and said the resident can go to the bathroom him/herself and can clean him/herself when he/she is incontinent. The resident is encouraged to use the restroom during the shift but often has behaviors and refuses care from the staff. The nurse is notified of the resident's refusal of care and it is documented in the electronic chart. During an interview on 4/17/24 at 2:15 P.M., Licensed Practical Nurse (LPN) D said he/she was not aware of any refusals of care by the resident but expected staff to encourage the resident to be cleaned up and to document refusals. During an interview on 4/18/24 at 1:41 P.M., the Director of Nursing (DON) said staff is expected to change soiled residents in a timely manner and document any behaviors related to refusals of incontinence care. 2. Review of Resident #102's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for bed to chair transfers; -Dependent on staff for bathing and showers and personal hygiene; -Diagnoses included diabetes, kidney disease, stroke and dementia. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has a history of stoke and requires dependent to maximum assistance with ADLs; -Plan: Activity as tolerated and out of bed as tolerated; Monitor and document mobility status. Observation on 4/14/24 at 10:17 A.M., on 4/15/24 at 8:39 A.M. and on 4/16/24 at 12:02 P.M., showed the resident sat in his/her wheelchair with an unshaven face and an approximately half-inch beard that had food particles in it. Both of the resident's hands had long jagged nails with brown matter underneath. 3. Review of #64's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Uses manual wheelchair; -Requires substantial to maximum assist from the sitting to standing position and with chair to bed transfers; -Requires substantial to maximum assist for bathing and showering; -Requires partial to moderate assist for personal hygiene; -Diagnoses included multiple sclerosis (MS, a neurological condition that causes muscle weakness) seizures, anxiety, manic depression and schizophrenia. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's ADL needs. Observation on 4/14/24 at 10:17 A.M., on 4/16/24 at 1:35 P.M., and on 4/17/24 at 10:37 A.M., showed the resident sat in his/her wheelchair with a greasy, shiny, unshaven face with an approximately one-half inch beard. Both of the resident's hands had long nails with dark matter underneath. 4. Review of Resident #18's quarterly MDS, dated [DATE], showed: -The resident is rarely or never understood; -Uses a manual wheelchair; -Diagnoses included pneumonia, dementia, Alzheimer's disease, Parkinson's disease (a neurological condition that is characterized by tremors) and anxiety. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident requires ADL assistance with bathing, dressing and hygiene; -Interventions: -Allow the resident time to complete the task and intervene as needed; -Monitor for a decline in function; -Provide assistance, set up, supervision, and cueing as needed. Observation on 4/14/24 at 9:55 A.M. and on 4/15/24 at 9:40 A.M., showed the resident unshaven with an approximately one-half inch beard. Both of his/her hands had long nails. 5. During an interview on 4/17/24 at 8:46 A.M., CNA K said staff are to shave residents on their shower days. The residents' nails have not been clipped on 100 hall because none of the staff could find any nail clippers. Staff are to inspect and trim residents' nails on their shower days and to clean and trim them when needed. 6. During an interview on 4/17/24 at 2:15 PM., LPN D staff are to complete residents' shaving and nail care with the residents' showers. 7. During an interview on 4/18/24 at 1:41 P.M., the DON said she expected staff to shave and provide nail care on the residents' shower days and as needed. MO00233864

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standard when staff failed to identify newly acquired skin issues and obtain treatment orders for two residents (Residents #64 and #44). The sample was 26. The census was 133. Review of the facility's Skin Integrity Assessment policy, revised on 6/30/23, showed: -The purpose of this policy is to ensure that all residents are being assessed for skin integrity issues or concerns weekly and changes being reported to the physician, legal guardian, family, interdisciplinary care plan team and the wound nurse consultant. Procedure: -All residents will be assessed for skin integrity concerns weekly by the Resident Care Coordinator (RCC), wound nurse, or licensed designee; -Any skin integrity concerns will be reported to the RCC, DON and physician for treatment orders as needed; -All pressure ulcers or skin integrity concerns will be marked on the assessment. 1. Review of #64's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 3/10/24, showed: -Severe cognitive impairment; -Uses manual wheelchair; -Requires substantial to maximum assist from the sitting to standing position and with chair to bed transfers; -Requires substantial to maximum assist for bathing and showering; -Requires partial to moderate assist for personal hygiene; -At risk for developing pressure ulcers (injury to underlying skin resulting from prolonged pressure of the skin); -Diagnoses include: multiple sclerosis (MS, a neurological condition that causes muscle weakness) seizures, anxiety, manic depression and schizophrenia. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's skin condition. Review of the resident's skin assessment, dated 4/5/24, showed the resident had no skin issues. No further skin assessments were noted. During observation and interview on 4/14/24 at 10:17 A.M., the resident sat in his/her wheelchair in his/her room. Certified Nursing Assistant (CNA) G assisted the resident to bed to check his/her incontinence brief. CNA G removed the resident's incontinence brief. The resident had a round open area that was approximately one inch in diameter on the resident's right anterior (front) abdominal area. The open area was red with no drainage and had a pale white ring around it. CNA G observed the open area and said, I'm not sure what that is. During observation on 4/17/24 at 10:37 A.M., the resident sat in his/her wheelchair in his/her room. CNA I and CNA K pivoted the resident to his/her bed. At 10:47 A.M., Licensed Practical Nurse (LPN) O entered the resident's room to apply a dressing to the resident's suprapubic catheter (a tube that drains urine from the abdomen) site. CNA I and CNA K removed the resident's brief. The open area on the resident's right abdominal area remained present. The open area did not have a dressing. After completing the treatment to the resident's suprapubic catheter site, LPN O closed the resident's brief without addressing the resident's open area. Review of the resident's Physician Order Sheets (POS), dated April 2024, showed no treatment orders for the open area on the resident's abdomen. Review of the resident's progress notes, dated April 2024, showed no documentation of the open area on the resident's abdomen and no documentation that the physician was notified . During an interview on 4/18/24 at 10:30 A.M., LPN O said he/she was not aware of the open area on the resident's right abdomen. He/She did not observe it when he/she completed the suprapubic catheter treatment. 2. Review of Resident #44's, quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -No behaviors; -Occasionally incontinent of urine and continent of bowel; -Diagnoses included viral hepatitis (a liver disease), anxiety, manic depression (a mental disorder) and schizophrenia (a mental disorder that is characterized by severely impaired thinking, emotions and behaviors). Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is incontinent of urine; -Interventions: -Clean peri-area (genital area) after each incontinent episode; -Ensure the resident has an unobstructed path to the bathroom; -Monitor and document signs and symptoms of a urinary tract infection (UTI): pain, burning, blood-tinged urine, urine cloudiness, deepening in color of urine, no output from the catheter, increased pulse, increased temperature, foul smelling urine, chills, altered mental status changes, change in behavior, and change in eating habits. Review of the resident's skin assessment, dated 4/7/24, showed no skin issues. No further skin assessments were noted. Observation and interview on 4/16/24 at 11:04 A.M., showed upon entering the resident's room, a strong odor of urine present. The resident lay in bed with his/her eyes closed. The resident's maroon bedspread and thick blue blanket was saturated with urine. The resident said he/she was tired and didn't know when the last time he/she was assisted with getting his/her brief changed. The resident said he/she welcomed the assistance of staff and had some of his/her favorite staff members who help him/her get cleaned up. CNA K entered the resident's room and removed the resident's bedspread and blanket. The resident's pants and lower part of his/her shirt were saturated with urine. CNA K assisted the resident in removing his/her brief. The resident's brief was completely saturated, and the brief lining had white balls forming and appeared to be disintegrating. CNA K raised the resident's pannus (abdominal fold) and the resident had a bright red and inflamed rash under his/her pannus. The resident denied pain and was unaware the rash was present. Review of the resident's POS, dated April, 2024, showed no treatment order for the resident's pannus rash. Review of the resident's progress note, dated April, 2024, showed no documentation of the resident's rash or that the physician was notified. During an interview on 4/17/24 at 8:46 A.M., CNA K said the aides should inform the nurse of any new skin issues when they occur, including rashes. During an interview on 4/18/24 at 10:30 A.M., LPN O said the resident frequently gets rashes in his/her abdominal fold, but the resident usually will tell staff that he/she has a rash. 3. During an interview on 4/17/24 at 2:15 P.M., LPN D said skin checks are to be completed weekly by the nurses. The aides are to report any new skin issues to the nurse. Once the skin issue is assessed, the nurse should call the physician for new orders immediately. 4. During an interview on 4/18/24 at 1:41 P.M., the DON said the nurses are responsible for weekly skin assessments that are complete and accurate. She expected staff who observed the new skin issues to report it to the nurse immediately so new orders could be obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure catheter bags (used to collect urine) remained positioned below the bladder of two residents with indwelling urinary catheters (thin tubes inserted into the bladder to drain urine), and to ensure catheter bags and catheter tubing remained off the floor. The facility's failure caused the potential for contamination and urinary tract infection. The facility identified six residents with catheters, all of whom were sampled, and problems were identified with two (Residents #64 and #36). The sample was 26. The census was 133. Review of the facility's Catheter Care policy, revised 6/29/23, showed: -Purpose: The facility will ensure any resident with a urinary catheter will be maintained to prevent infection; -Procedure included: -Keep the urinary drainage bag below the level of the bladder to prevent backflow of the urine; -Make sure the urinary drainage bag does not touch the floor. 1. Review of Resident #64's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/24, showed: -Moderate cognitive impairment; -Indwelling catheter; -Diagnoses included urinary tract infection (UTI) in the last 30 days, multiple sclerosis (MS, a neurological disease that causes muscle weakness), seizure disorder, anxiety, manic depression (a mood disorder), and schizophrenia (a mental condition that exhibits severely impaired thinking, emotions and behaviors). Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is at risk for infection related to the resident having a supra-pubic catheter (a tube to drain urine that is inserted in the lower abdomen); -Interventions: -Monitor and document intake and output per facility policy; -Monitor signs of pain or discomfort related to the catheter; -Monitor and record to the medical doctor (MD) signs and symptoms of a UTI: pain, burning, blood-tinged urine, urine cloudiness, deepening in color of urine, no output from the catheter, increased pulse, increased temperature, foul smelling urine, chills, altered mental status changes, change in behavior, and change in eating habits. Observation on 4/14/24 at 10:17 A.M., showed Certified Nurse Aide (CNA) G assisted the resident in the resident's room, to change the resident's clothing. While the resident lay in bed, CNA G adjusted the resident's urinary catheter tubing and bag through his/her pant leg. Once the catheter bag and tubing were freed from the resident's pant leg, CNA G raised the urinary catheter bag and catheter tubing that contained cloudy yellow urine, approximately 18 inches (in.) directly above the resident's waist. Cloudy urine in the catheter tubing flowed back towards the resident's abdomen. Observation on 4/17/24 at 10:37 A.M., showed the resident sitting in his/her wheelchair. CNA K freed the resident's catheter from the privacy bag that was located under the resident's wheelchair and emptied the resident's catheter while raising the catheter bag and tubing above the resident's waist. Cloudy yellow urine in the catheter tubing flowed back towards the resident's abdomen. 2. Review of Resident #36's admission MDS, dated [DATE], showed: -Resident rarely/never understood; -Lower extremity impairment on both sides; -Use of wheelchair; -Self-care admission performance: Dependent for toileting hygiene, upper and lower body dressing, and personal hygiene; -Indwelling catheter; -Diagnoses included seizure disorder, schizophrenia and anxiety disorder. Review of the resident's care plan, in use at the time of survey, showed: -Problem, initiated 3/22/24: Resident is at risk of infection and discomfort related to presence of urinary catheter; -Desired outcome: Resident will be/remain free from catheter-related trauma through review date. Resident will show no signs/symptoms of urinary infection through review date; -Interventions: Monitor and document intake and output as per facility policy. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to physician signs/symptoms of UTI. Observation on 4/15/24 at 7:18 A.M., showed the resident positioned in a Hoyer (mechanical lift) sling, two feet above a wheelchair, with a catheter bag on his/her stomach. CNA N operated the Hoyer lift and lowered the resident into the wheelchair. Once the resident was lowered into the wheelchair, his/her catheter bag fell onto the floor. The top several inches of the catheter bag and approximately two feet (ft.) of catheter tubing lay directly on the floor. CNA N picked up the catheter bag, readjusted the protective covering, and placed it onto the resident's lap. Approximately sixteen inches of catheter tubing dragged on the floor while CNA B secured the catheter bag underneath the seat of the wheelchair. CNA B brought the resident in his/her wheelchair down the hall to the 300/400 hall dining room, with the resident's catheter tubing dragging along the floor for approximately 50 ft. CNA B positioned the resident in front of a table and left the room. Approximately 14 inches of catheter tubing was coiled on the dining room floor underneath the resident's feet. The dining room floor was covered with a light grey film and debris. Observations on 4/16/24, showed: -At approximately 10:10 A.M., the resident sat in a wheelchair in his/her room. Approximately eight inches of catheter tubing lay on the floor, around the front left wheel of his/her wheelchair; -At approximately 11:00 A.M., the resident sat in a wheelchair in his/her room. Approximately eight inches of catheter tubing lay on the floor, around the front left wheel of his/her wheelchair; -At 11:00 A.M., the resident sat in a wheelchair in the 300/400 hall dining room. Approximately eight inches of catheter tubing lay on the floor, behind the front left wheel of his/her wheelchair; -At 12:10 P.M., the resident sat in a wheelchair in the 300/400 hall dining room. Approximately eight inches of catheter tubing lay on the floor, behind the front left wheel of his/her wheelchair; -At 2:33 P.M., the resident lay on his/her back in bed. A fall mat was positioned on the floor to the right of the resident's bed. The fall mat had dark grey streaks of dirt. Approximately four inches of catheter tubing was coiled on top of the dark streaks on the fall mat; -At 4:43 P.M., the resident sat in a wheelchair in his/her room. Approximately eight inches of catheter tubing lay coiled on the floor beneath the resident's feet; -At 5:49 P.M., the resident sat in a wheelchair in the 300/400 hall dining room. The dining room floor was sticky and covered in debris and a grey film. Approximately eight inches of the resident's catheter tubing lay on the floor underneath his/her feet. During an interview on 4/17/24 at 1:43 P.M., CNA B said a resident's catheter bag should be positioned below their bladder. He/She was not sure why a catheter bag should be positioned below the bladder. During the resident's Hoyer transfer, CNA B should have tried to hang the catheter bag on the Hoyer pad strap and once the resident was in the wheelchair, CNA B should have moved the catheter bag so it was underneath the resident's wheelchair. Catheter bags should be in a protective covering and catheter tubing should be off the floor. Catheter tubing should be off the floor to reduce the risk of tripping and because the floors are dirty. If CNAs observe a resident's catheter tubing dragging on the floor, they should tell the nurse. 3. During an interview on 4/17/24 at 2:21 P.M., CNA C said catheter bags should be positioned below the resident's bladder to prevent urine from flowing from the tubing and back into the resident's bladder. Nursing staff is responsible for ensuring catheter tubing is floating above the floor due to contamination. If CNAs observe a resident's catheter tubing has come in contact with a contaminated surface, they should readjust the tubing so it is no longer in contact with the surface and then wipe it down to clean it. 4. During an interview on 4/17/24 at 2:40 P.M., CNA F and CNA H said when staff is providing care to any resident who has a catheter, the catheter should remain below the resident's knees to prevent the urine flowing back into the resident, causing an infection. 5. During an interview on 4/17/24 at 2:45 P.M., Licensed Practical Nurse (LPN) D said a resident's catheter bag should be positioned below the bladder to ensure urine does not reflux back into the bladder. During a Hoyer transfer, nursing staff should ensure a resident's catheter bag is maintained below the bladder. Nursing staff is responsible for ensuring catheter bags and catheter tubing is off the floor to avoid contamination. 6. During an interview on 4/18/24 at 8:44 A.M., Registered Nurse (RN) E said a resident's catheter bag should be positioned below their waist, including during a Hoyer transfer. Maintaining a catheter bag below the waist prevents urine from returning to the bladder. Nursing staff should ensure catheter tubing is off the floor for infection control. 7. During an interview on 4/18/24 at 12:21 P.M., the Director of Nurses (DON) and Administrator said they expected nursing staff to ensure a resident's catheter bag is positioned below the bladder so urine does not flow back into the bladder. During a Hoyer transfer, it is not appropriate for staff to place a resident's catheter bag on the resident's lap, and the catheter bag should be maintained below the bladder during the transfer. Nursing staff is responsible for ensuring catheter bags and catheter tubing are off the floor for infection control. If CNAs observe catheter tubing has come into contact with a contaminated surface, they should clean the catheter tubing or report it to the nurse.

Based on interview and record review, the facility failed to ensure residents had appropriate physician orders for assessment/monitoring of dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) access sites and to failed to maintain ongoing communication with dialysis centers for residents receiving dialysis treatment. Two residents were sampled for dialysis and problems were found for one resident (Resident #3). The sample was 26. The census was 133. Review of the facility's Dialysis policy, revised 3/18/22, showed: -Purpose: Ensure that residents who require dialysis receive such services as ordered by physician. The facility will ensure that residents who require dialysis receive such services, consistent with professional standards for practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility will ensure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including the: -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified facility; -Ongoing assessment and oversight of the resident before and after dialysis treatments; -Ongoing communication and collaboration with the dialysis clinic, regarding dialysis care and services; -The nurse will monitor bruit (audible vascular sound) and thrill (vibration felt on the skin) every shift and document in treatment administration record (TAR); -Assess the vascular access for signs and symptoms of infection such as redness, warmth, tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney disease are at increased risk of infection; -Assess for blebs (ballooning or bulging) of the vascular access that may indicate an aneurysm that can rupture and cause hemorrhage; -Document assessment findings, any interventions and patient response, patient teaching, and the patient's level of understanding. Review of the facility's Dialysis and Nursing Home Handoff Communication Tool, undated, showed: -Section to be completed by nursing home and sent with resident each treatment included code status, mental status, vital signs, allergies, current diet/fluid restrictions, type of access, signs and symptoms of infection, and medical problems, hospitalizations, medications, vaccinations, labs, and blood transfusions since last dialysis; -Section to be completed by dialysis and returned with resident each treatment included pre and post-dialysis weight, problems during dialysis, amount of fluid removed, post-dialysis vitals, labs drawn, updated physician orders, Dietician and Social Worker recommendations, food/fluid consumed during dialysis, medications given during dialysis, and vascular access condition. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/4/24, showed: -Moderate cognitive impairment; -Diagnoses included end stage renal disease (ESRD); -Dialysis received. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident receives dialysis on Monday, Wednesday, Friday related to diagnosis of ESRD; -Desired outcome: Resident will have immediate intervention should any signs/symptoms of complications from dialysis occur through the review date; -Interventions included: --Check and change dressing daily at access site; --Monitor/document/report as needed (PRN) any signs/symptoms of infection to access site (redness, swelling, warmth, or drainage); --Monitor/document/report PRN for signs/symptoms of renal insufficiency; --Monitory/document/report PRN for signs/symptoms of the following: bleeding, hemorrhage, bacteremia (presence of bacteria and infectious organisms in the blood stream), septic shock. Review of the resident's electronic Physician Order Sheet (ePOS) and TAR, showed: -An order, dated 8/23/23, for hemodialysis three times a week, Monday, Wednesday, and Friday; -No physician orders for pre and post-dialysis assessments. Review of the resident's electronic medical record (EMR), showed: -Blood pressure and pulse documented once on 2/23/24 and 4/15/24; -Temperature documented twice on 2/7/24, and once on 2/12/24, 2/14/24, 2/23/24 and 4/15/24; -No additional documentation of weights, blood pressure, pulse, or temperature obtained pre and post-dialysis in February, March and April 2024; -No documentation of pre and post-dialysis assessments of vascular access site in February, March and April 2024; -No documentation of communication with the dialysis center in February, March and April 2024. During an interview on 4/15/24 at 7:08 A.M., the resident said he/she goes to a dialysis center for treatment every Monday, Wednesday, and Friday. When he/she returns to the facility, he/she is not assessed by the nurse. During an interview on 4/16/24 at 10:48 A.M., the resident said he/she went to dialysis yesterday. When he/she returned to the facility, no one assessed his/her dialysis site or checked his/her vital signs. During an interview on 4/16/24 at 4:45 P.M., the resident said the facility does not send paperwork with him/her to give to the dialysis center. The dialysis center does not give him/her any paperwork to return to the facility staff. During an interview on 4/17/24 at 2:45 P.M., Licensed Practical Nurse (LPN) D said before a resident goes to dialysis, a weight should be obtained. The nurse is responsible for obtaining a full set of vital signs and assessing the resident's dialysis access site. Upon a resident's return to the facility, the nurse obtains another full set of vital signs and assesses the dialysis access site. Each resident on dialysis should have physician orders for pre and post-dialysis assessments, which populate on the TAR. Prior to last week, nurses documented their pre and post-dialysis assessments on the TAR. Now, nurses document their pre-dialysis assessments on a communication form that goes with the resident to dialysis. The dialysis center is supposed to fill out their portion of the form and send it back to the facility with the resident. There should be communication between the facility and the dialysis center documented in the resident's EMR. During an interview on 4/18/24 at 8:44 A.M., Registered Nurse (RN) E said nurses obtain a complete set of vital signs and assess the resident's dialysis access site before and after the resident goes to dialysis. Pre and post-dialysis assessments are documented on the resident's TAR. Residents receiving dialysis should have physician orders for pre and post-dialysis assessments. The facility does not use communication forms with the dialysis centers. The dialysis centers will call the facility if they have any updates or they will fax over labs completed during dialysis. During an interview on 4/17/24 at 2:13 P.M., the Director of Nurses (DON) said nurses should assess residents before and after dialysis. Until last week, pre and post-dialysis assessments were documented as a progress note in the EMR. There was no other place to document dialysis assessments. Last week, the facility started using forms to communicate with the dialysis center. The nurse is expected to obtain a full set of vital signs and to assess the dialysis access site. The nurse documents the assessment on the form, which also includes documentation of the resident's code status, allergies, medications, diet and fluid restrictions, and any changes since the last time the resident received dialysis, such as blood transfusions and new conditions, vaccinations, and labs. The nurse signs the form and gives it to the resident to bring to the dialysis center for them to fill out. The form has the facility's fax number at the bottom for them to send the form back to the facility. Once a form is received by the facility, it should be uploaded into the resident's medical record. When a resident returns to the facility from dialysis, the nurse should re-assess the resident. The nurse should also review the resident's pre and post-dialysis weights, amount of fluid removed, amount of food and fluid consumed, medications administered, and labs completed during dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable infection control standards when providing peri-care (cleansing of the genitals and anal area) for one resident (Resident #102) and when providing treatment for a supra-pubic catheter (a tube to drain urine that is inserted in the lower abdomen) for one resident (Resident #64) The sample size was 26. The census was 133. Review of the facility's Using Gloves policy, revised 6/29/23, showed: -When gloves are indicated, disposable single-use gloves should be worn; -When to use gloves: -When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin; -Gloves need to be used during removal of wound dressings; -Gloves are changed and hands are washed, new gloves donned before a clean dressing is applied; -When the employee's hands have any cuts, scrapes, wound, chapped skin, or dermatitis; -When cleaning up spills or splashes of blood or body fluids; -When cleaning potentially contaminated items; -Whenever in doubt. Review of the facility's Peri-care policy, revised 6/29/23, showed: -Procedure: Gather necessary equipment; Wash hands; Explain what you are going to do; Provide privacy; Fill basin with warm water; Cover the resident with a towel or sheet; Cleanse peri-area; Pat area dry; Remove towel or sheet; Remove and dispose of gloves; Remove, clean and store equipment; Wash hands; Make the resident comfortable; and record observations and report anything unusual to the nurse. 1. Review of Resident #102's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/24, showed: -Severe cognitive impairment; -Always incontinent of bowel and bladder; -Dependent on staff for toileting and personal hygiene; -Diagnoses included diabetes, kidney disease, stroke and dementia. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: The resident has a history of a stroke and is dependent to maximum assist with all Activities of Daily Living (ADL); -Interventions: -Activity as tolerated and out of bed if tolerated; -Monitor and document mobility status; -Monitor and document resident's abilities for ADLs and assist as needed. Observation on 4/15/24 at 8:39 A.M., showed Certified Nursing Assistant (CNA) T provided peri-care with gloved hands to the resident while the resident lay in bed. After providing peri-care, CNA T removed a clean brief off the resident's dresser and applied the clean brief with the same gloved hands. CNA T then went into the resident's closet while wearing the same gloves, touched the clothing in the closet and retrieved clean clothing for the resident. CNA T dressed the resident, still while wearing the same gloves. Once the resident was dressed, CNA T observed the bottoms of the resident's feet were crusted with dark matter. CNA T washed the resident's feet, while he/she still wore the same gloves. CNA T applied socks to the resident and then opened the resident's door, touching the door handle, and stepped into the hallway to find another staff member to assist him/her get the resident out of bed. CNA T and CNA U assisted the resident into his/her wheelchair. CNA T continued to wear the same gloves during the transfer. CNA T removed his/her gloves after getting the resident into the wheelchair. During an interview on 4/17/24 at 8:47 A.M., CNA K said staff should change gloves and perform hand hygiene after providing peri-care. Soiled gloves should not be used to touch the residents' clean clothing or items in their room. Gloves should be changed when going from dirty to clean. During an interview on 4/18/24 at 10:30 A.M., Licensed Practical Nurse (LPN) O said staff should remove gloves and perform hand hygiene after providing peri-care, and not touch other things in the room with soiled gloves on. During an interview on 4/18/24 at 1:41 P.M., the Director of Nurses (DON) said she expected staff to remove their soiled gloves and perform hand hygiene after providing peri-care, then reapply new gloves before touching anything that is clean in the resident's room. 2. Review of #64's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Has indwelling urinary catheter; -High risk drug class: antipsychotics (mood stabilizer), antidepressants, and antibiotic; -Diagnoses included multiple sclerosis (MS, a neurological condition that causes muscle weakness) seizures, high blood pressure, multi drug resistant organism (MDRO), anxiety, diabetes, urinary tract infection (UTI) in the last 30 days, manic depression, and schizophrenia (a severe mental disorder that can result in hallucinations, delusions and extremely distorted thinking and behaviors). Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is at risk for infection related to the resident having a supra-pubic catheter; -Interventions: monitor and document intake and output per facility policy; -Monitor signs of pain or discomfort related to the catheter; -Monitor and record to the medical doctor (MD) signs and symptoms of a UTI: pain burning, blood-tinged urine, urine cloudiness, deepening in color of urine, no output from the catheter, increased pulse, increased temperature, foul smelling urine, chills, altered mental status changes, change in behavior, and change in eating habits. Review of the resident's Physician Order Sheets (POS), dated April, 2024, showed an order for suprapubic catheter care every shift, cover with dry dressing and report any signs or symptoms of infection. Observation on 4/17/24 at 10:47 A.M., showed LPN O entered the resident's room with wound care supplies. He/She laid a pair of scissors on the resident's bathroom sink located in the resident's room. LPN O prepared an area on the resident's bedside table with a drape and laid the supplies on the drape. LPN O cleansed the resident's suprapubic with normal saline and opened a wound dressing package labeled border gauze (a specialized dressing). LPN O then removed the scissors that were located on the resident's bathroom sink and cut a slit in the border dressing and then applied the dressing to the resident's suprapubic catheter site. LPN O did not clean the scissors prior to cutting the border gauze dressing. During an interview on 4/18/24 at 10:30 A.M., LPN O said he/she should have cleaned the scissors with a bleach wipe or antibacterial wipe prior to cutting the dressing and applying it to the resident. During an interview with on 4/18/24 at 1:41 P.M., the DON said she expected staff to practice good infection control practices during catheter care and the nurse should have cleaned the contaminated scissors with a cleansing antibacterial wipe prior to cutting the dressing and applying it to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all call lights in the facility were in working order, including a visual notification above the door and audible notification at the nurse's station. Concerns were noted in one of 17 resident rooms surveyed, affecting one of 26 sampled residents (Resident #65). The census was 133. Review of Resident #65's medical record, showed diagnoses included hemiplegia (paralysis affecting one side of the body), pseudobulbar affect (episodes of sudden or uncontrolled emotion), multiple sclerosis (MS, a chronic disease of the central nervous system causing pain and loss of fine motor function) and hypertension. Review of the resident's quarterly Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 1/11/24, showed: -No cognitive impairment; -Required moderate assistance from staff with dressing and bathing tasks; -Wheelchair for locomotion. Review of the resident's care plan, in use at the time of survey, showed: -The resident is a fall risk related to his/her diagnosis of MS. Interventions included following facility protocol and ensuring the resident's call light is within reach while encouraging the resident to use the call light when assistance is required; -The resident is at risk for alteration in musculoskeletal status related to his/her diagnosis of MS. Interventions included monitoring for falls, monitoring for fatigue, ensuring administration of prescribed analgesics, and ensuring the call light is within reach for the resident to use. Observation on 4/14/24 at 9:04 A.M., showed the resident resting in his/her bed. The resident pressed the call button hooked to his/her bed, and said the light had been off for about three weeks and had not been working. The notification light above the door to the room did not illuminate and a small light on the wall that would indicate normal functioning when lit also did not illuminate. The resident said staff were aware of this but were ignoring it. Observation on 4/16/24 at 5:39 P.M., showed the resident resting in his/her bed. The resident pressed the call light, and the notification light above the door did not illuminate. A small light on the wall that would indicate normal functioning when lit was also did not illuminate. Observation on 4/17/24 at 2:09 P.M., showed the resident resting in his/her bed. The resident pressed the call light, and the notification light above the door did not illuminate. A small light on the wall that would indicate normal functioning when lit also did not illuminate. During interview on 4/18/24 at 11:03 A.M., CNA H said a call light was reported to be non-functioning on the 200 hall that morning, and staff had reported it to maintenance. CNA H was not aware the call light in room [ROOM NUMBER] was not functioning properly, and said nursing staff are expected to report non-functioning call lights to maintenance when observed. During an interview on 4/18/24 at 11:07 A.M., Registered Nurse (RN) E said a call light was reported as non-functioning today on the 200 hall, but he/she was not aware of the call light in room [ROOM NUMBER] not working. RN E said nursing staff were expected to contact Maintenance when a call light was noticed as non-functioning so that it could be fixed. During an interview on 4/18/24 at 12:21 P.M., the Maintenance Director said he/she was made aware of a non-functioning call light on the 200 hall today, but had not been made aware of any call light not working prior to today. All call lights should function normally in resident rooms. The Maintenance Director expected nursing staff to notify the Maintenance staff of non-functioning call lights as soon as possible, as nursing staff have the most interaction with resident call systems. During an interview on 4/18/24 at 1:37 P.M., the Director of Nursing (DON) and Administrator said they expected all resident call lights in the facility to function normally, and all lights should provide an audible alarm at the nurse's station as well as a visual notification above the resident's door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personal funds withdrawn from the resident trust account were appropriately accounted for and used exclusively for three residents (Residents #36, #48 and #26). The facility failed to ensure withdrawals for personal spending were authorized by the resident and/or the resident's legal guardian, and signed off and approved by the appropriate facility staff, in accordance with the facility's policy. The facility identified 105 residents with funds handled by the facility. The census was 133. Review of the facility's Resident Trust policy, revised 11/8/23, showed: -Purpose: Complete procedures on resident trust responsibilities; -General Information Regarding Responsibilities of Holding Resident Funds: --The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility, using complete and separate accounting principles; --Personal funds of the resident shall be exclusively for the resident, which must be authorized in writing. The individuals who can authorize such transactions may be the resident, his/her legal guardian, or legal representative (who may not be an employee at the facility); --The resident trust bank account should have at least two (2) facility personnel as check signers. One such person is the Administrator and the other(s) should be chosen at the discretion of the Administrator. However, no one who handles the petty cash box, the checkbook, the posting of transactions, or assists residents in shopping for personal items should be a signer on the account; --All receipts and records shall be retained for at least seven (7) years from the end of the fiscal year during which the receipts and records were originally made; -Making Withdrawals from the Resident Trust Account: -All checks written out of the trust account should be prepared by the Resident Trust Clerk and signed by the Administrator or other designated signer and should always be accompanied by a check request or other supporting documentation. All checks written out of the resident trust account should be copied prior to deposit or disbursement and attached to the appropriate documentation; -Family members or friends who do not have legal access to a resident's account but wish to purchase clothing or personal items for a resident can do one of the following: --1. Purchase the items needed and bring in the receipts to the Resident Trust Clerk. The clerk will then verify that a) the resident requested the items by signing the check request form and b) the resident has sufficient funds to reimburse the purchases; --2. Have the resident sign a check request form to make the check payable to the individual wanting to purchase the items. The Resident Trust Clerk must verify the funds are available before writing the check. 1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/24, showed: -Severe cognitive impairment; -Diagnoses included unspecified intellectual disabilities (limits to a person's ability to learn at an expected level and function in daily life), mild mental retardation and schizophrenia (serious mental illness that affects how a person things, feels, and behaves). Review of the resident's medical record, showed the resident listed as his/her own financial responsible party. The resident has a legal guardian. Review of the resident's trust account records, showed: -On 3/7/24, a withdrawal for personal spending, in the amount of $2,000.00; -Check request, dated 3/7/24; -Make payable to: Life Enrichment Director; -Request/comment: $2000.00; -Signed by Financial Coordinator, Social Services (SS) or designee, and Life Enrichment Director; -*Note all receipts must be submitted with request. All receipts must include the resident's name, signature (if applicable), amount, and description; -On 3/7/24, a withdrawal for personal spending, $52.16; -Check request, dated 3/13/24: -Make payable to: Life Enrichment Director; -Request/comment: $52.16; -Signed by Financial Coordinator, Social Services (SS) or designee, and Life Enrichment Director; -*Note all receipts must be submitted with request. All receipts must include the resident's name, signature (if applicable), amount, and description; -Receipt from Sam's Club, dated 3/9/24: -Gift card, ending 9256, $206.48; -Gift card, ending 1891, $206.48; -Gift card, ending 3094, $206.48; -Gift card, ending 7750, $206.48; -Gift card, ending 6440, $206.48; -Total or receipt: $1032.40; -Receipt not signed by resident; -Receipt from Sam's Club, dated 3/10/24: -Gift card, ending 1142, $500.00; -Gift card, ending 7237, $500.00; -Two gift card fees, totaling $9.76; -Total on receipt: $1009.76; -Receipt not signed by resident. Review of the withdrawals made on 3/7/24, showed a total of $2,052.16. Review of the receipts dated 3/9/24 and 3/10/24, showed a total of $2,042.16. A difference of $10.00 between withdrawals and receipt totals. During an attempted interview on 4/18/24 at 10:24 A.M., the resident was unable to answer questions regarding his/her funds. During an interview on 4/17/24 at 11:17 A.M., the Financial Coordinator said the resident had limited cognition. He/She was nearing his/her spenddown limit of around $5,500.00, so the Life Enrichment Director withdrew $2,000.00 from his/her account to get the money off the books. The money was used to purchase gift cards to be used at a later time. After the Life Enrichment Director purchased the gift cards, he gave them to the Financial Coordinator in a sealed envelope, along with the receipts of purchase. 2. Review of Resident #48's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included Alzheimer's disease, dementia, schizophrenia and depression. Review of the resident's medical record, showed the resident listed as his/her own financial responsible party. Review of the resident's trust account records, showed: -On 3/7/24, a withdrawal for personal spending, in the amount of $2,000.00; -Receipt from Sam's Club, dated 3/21/24: -Gift card ending 9417, $500.00; -Receipt not signed by resident; -Receipt from Schnucks, dated 3/25/24: -Gift card, ending 7068, $500.00; -Receipt not signed by resident; -Receipt from Sam's Club, dated 3/26/24: -Gift card, ending 5565, $500.00; -Gift card, ending 7998, $500.00; -Receipt not signed by resident. During an attempted interview on 4/18/24 at 10:24 A.M., the resident unable to answer questions regarding his/her funds. 3. Observation on 4/18/24 at 7:33 A.M., showed the Financial Coordinator opened a safe in her office and withdrew two sealed envelopes. During an interview, the Financial Coordinator said the two envelopes contained gift cards purchased for Residents #36 and #48. There are no other gift cards or envelopes of money in the safe belonging to other residents in the facility. Review of the sealed envelope for Resident #36 and his/her receipts of purchase, showed: -Gift card ending 7237, on the resident's receipt from 3/10/24; -Gift card ending 1142, on the resident's receipt from 3/10/24; -Gift card ending 8717, not on the resident's receipts; -Gift card ending 7998, not on the resident's receipts; -The gift card is on a receipt of purchase for Resident #48, dated 3/26/24. Review of the sealed envelope for Resident #48 and his/her receipts of purchase, showed: -Gift card ending 9417, on the resident's receipt from 3/21/24; -Gift card ending 5565, on the resident's receipt from 3/26/24; -Gift card ending 9256, not on the resident's receipts; -The gift card is on a receipt of purchase for Resident #36, dated 3/9/24; -Gift card ending 3094, not on the resident's receipts; -The gift card is on a receipt of purchase for Resident #36, dated 3/9/24; -Gift card ending 1891, not on the resident's receipts; -The gift card is on a receipt of purchase for Resident #36, dated 3/9/24. Review of gift cards and receipts for Residents #36 and #48, showed; -Resident #48 missing gift card ending 7068 for $500.00; -Resident #36 missing gift cards ending 7750 and 6440, totaling $412.96. During an interview on 4/18/24 at 7:33 A.M., the Financial Coordinator said gift cards were purchased for Residents #36 and #48 to spend down their accounts. The gift cards for the residents must have gotten mixed up. She is not sure to whom the gift card ending 8717 belongs. She is not sure where the missing gift cards are. Neither Resident #48 nor Resident #36 have made purchases, or have had purchases made for them, using their gift cards. Gift cards were purchased for the residents to spend down their accounts. When money is withdrawn for spenddown and cannot be signed off by the resident, it should be signed off by her, Social Services, and the shopper. After all three parties sign, a check is issued for the shopper, which is the Life Enrichment Director. After the Life Enrichment Director purchased the gift cards, he brought them back to the facility with the receipts and gave them to the Financial Coordinator in sealed envelopes, which she put in the safe. She made sure the receipts matched the withdrawal amounts authorized for both residents, but did not count the gift cards or check them against the receipts. 4. Review of Resident #36's trust account records, showed: -On 2/20/24, a withdrawal for personal spending, in the amount of $1,000.00; -Check request, dated 2/20/24: -Make payable to: Life Enrichment Director; -Request/comment: $1,000.00; -Signed by Financial Coordinator on 2/20/24; -No signature from Social Services or designee; -No signature from shopper; -*Note all receipts must be submitted with request. All receipts must include the resident's name, signature (if applicable), amount, and description; -For accounting use section with party authorizing approval: blank; -Receipt from WalMart, dated 3/28/24, total $879.72, included; -32 ONN television; -Six Dove beauty products; -Approximately eight toiletries from Head and Shoulders, Crest and Suave; -Receipt not signed by resident; -Receipt from Marshalls, dated 3/28/24, total $167.10, included: -Two items coded as beauty accessories; -One item coded as jewelry/watches; -Three items coded as accessories/luggage; -Receipt not signed by resident. Review of the resident's inventory sheets, showed the last personal inventory sheet updated on 12/14/22. No documentation on the resident's inventory sheets of items purchased using the money withdrawn from the resident's account on 2/20/24. During an interview on 4/18/24 at 7:33 A.M., the resident shook his/her head no when asked if he/she recently received a new television, accessories, or toiletries. The resident was unable to respond regarding specific questions pertaining to funds. Observation on 4/18/24 at 7:50 A.M., showed the resident's room did not have a television, jewelry, accessories, luggage, bags or Dove beauty products. 5. Review of Resident #48's trust account records, showed: -On 2/20/24, a withdrawal for personal spending, in the amount of $1,000.00; -Check request, dated 2/20/24: -Make payable to: Life Enrichment Director; -Request/comment: $1,000.00; -Signed by Financial Coordinator on 2/20/24; -No signature from Social Services or designee; -No signature from shopper; -*Note all receipts must be submitted with request. All receipts must include the resident's name, signature (if applicable), amount, and description; -For accounting use section with party authorizing approval: blank; -Receipt from WalMart, dated 9/9/23, total $149.30, included: -Six 18 gallon totes; -Two watches; -Three units of filler paper; -Two baskets; -One iron; -Receipt not signed by resident; -Receipt from Schnucks, undated, total $37.13, included four [NAME] Crocker gels. The receipt not signed by resident; -Receipt from Princess Beauty Supply, dated 2/28/24, total $31.53, included: -5 pack of shaper blades; -[NAME] leave-in conditioner; -Neutralizing shampoo; -Hawaiian Silky relaxer; -Receipt not signed by resident; -Receipt from WalMart, dated 3/28/24, total $52.97, included: -Antenna; -Emersen clock radio; -Receipt not signed by resident. Review of the resident's inventory sheets, showed the last personal inventory sheet updated on 10/25/22. No documentation on the resident's inventory sheets of items purchased using the money withdrawn from the resident's account on 2/20/24. Observation on 4/18/24 at 10:24 A.M., showed no totes, watches, paper, baskets, iron, hair beauty supplies, antenna, or clock radio. During an interview, the resident was unable to answer questions regarding the items. 6. Review of Resident #26's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included blindness to right eye and low vision to left eye, schizophrenia, and bipolar disorder (mood disorder). Review of the resident's medical record, showed the resident listed as his/her own financial responsible party. The resident has a legal guardian. Review of the resident's trust account records, showed: -On 2/20/24, a withdrawal for personal spending, in the amount of $2,000.00; -Check request, dated 2/20/24: -Make payable to: Life Enrichment Director; -Request/comment: $1,000.00; -Signed by Financial Coordinator on 2/20/24; -No signature from Social Services or designee; -No signature from shopper; -*Note all receipts must be submitted with request. All receipts must include the resident's name, signature (if applicable), amount, and description; -For accounting use section with party authorizing approval: blank; -Receipt from Bath and Body Works, undated, total $169.99, included: -18 body care items purchased; -Receipt not signed by resident; -Receipt from WalMart, dated 2/25/24, total $44.00, included: -Two watches; -Receipt not signed by resident; -Receipt from WalMart, dated 2/25/24, total $247.19, included: -Two watches; -Two units of ladies socks; -Four smock dresses; -Receipt not signed by resident; -Receipt from Sam's Club, dated 2/25/24, total $488.87, included: -Three 2-packs of bras; -One package of feminine hygiene pads; -Two bottles of Dove body wash; -Five units of Fructis, [NAME], and Dove toiletries; -Receipt not signed by resident. Review of the resident's inventory sheets, showed the last personal inventory sheet updated on 8/10/23. No documentation on the resident's inventory sheets of items purchased using the money withdrawn from the resident's account on 2/20/24. Observation on 4/18/24 at 10:28 A.M., showed the resident seated in a wheelchair in his/her room, not wearing a watch. No watches, ladies socks, feminine hygiene products, smock dresses, Bath and Body Works products, or toiletries from Dove, Fructis, or [NAME] observed. During an interview, the resident exhibited confusion. During an interview on 4/18/24 at 10:29 A.M., Certified Nurse Aide (CNA) B said the resident is blind. He/She did not wear smock dresses and did not use Bath and Body Works products, unless the products were provided by staff. 7. During an interview on 4/18/24 at 11:18 A.M., the Financial Coordinator said the facility's management company notifies Social Services when a resident is near their spenddown limit. Social Services notifies the Financial Coordinator and she notifies the Life Enrichment Director. The Life Enrichment Director makes the purchases and gives her the receipts. She checks the purchase amount against the check, and then files the documents. She does not review the items purchased on the receipts. During an interview on 4/18/24 at 11:18 A.M., the Life Enrichment Director said when he is notified that a resident is near their spenddown limit, he goes and talks to the resident about what they need. He obtains a check from the Financial Coordinator and goes shopping for the resident. He is the only facility employee to go shopping for residents. He goes shopping for multiple residents at the same time. When he is finished shopping, he gives the Financial Coordinator the receipts of purchase and then he inventories all of the resident's purchased items by labeling the items with the resident's name and adding the item to the resident's personal inventory sheet. He maintains the inventory sheets for all residents and keeps them in a binder in his office. Once the items are inventoried, he gives the resident their items. The resident does not sign off on having received the items. He purchased gift cards for Residents #36 and #48, but must have gotten them mixed up with each other and other residents. He purchased multiple gift cards for multiple people on those days. He does not recall the names of the other residents he purchased gift cards for on the same day. He gave the gift cards and receipts to the Financial Coordinator and when the residents are ready to use them, he will get the gift cards from the Financial Coordinator, make the purchases, and provide the Financial Coordinator with the receipts. He understands that by mixing up the gift cards, it means resident money is not properly accounted for. Resident #26 is legally blind. He/She asked for a watch, so the Financial Coordinator purchased this for him/her. The resident does not use feminine hygiene pads and does not wear dresses or use Bath and Body Works products. The receipts for these items do not belong to Resident #26 and have been mixed up with another resident. The Financial Coordinator understands that by mixing up receipts, there is no way to properly account for items purchased with the resident's money. The clock radio and antenna purchased for Resident #48 should be in the resident's room. The totes purchased for Resident #48 are in the basement. The receipt showing a purchase of [NAME] Crocker items does not belong to Resident #48 and was mixed up with someone else's. The television purchased for Resident #36 is in the basement. Observation on 4/18/24 at 11:59 A.M., showed the basement's beauty shop with a cart of items, including a 32 TCL television. The box was not labeled with a resident's name. During an interview, the Life Enrichment Director said the TCL television is the television purchased for Resident #36. When asked about the television brand name as TCL, but the receipt of purchase showing a brand name of ONN, the Life Enrichment Director said he did not know why the brand names were listed differently. He knows the TCL television belongs to Resident #36 and he will write the resident's name on the television when it is removed from the box. The Life Enrichment Director opened a door to a storage room in the basement containing stacks of tubs and miscellaneous personal effects throughout the room, from floor to ceiling, along each wall. When asked about the location of the 18 gallon tubs purchased for Resident #48, the Life Enrichment Director pointed to two red tubs with no labels or resident names indicated, one of which had a layer of dust along the rim. He could not provide a location of the other tubs on the purchase receipts. He knows which personal effects in storage belong to each resident in the facility. He understands the personal effects should be labeled with a resident's name. Activities staff is responsible for updating inventory sheets. The employee primarily responsible for this left in January 2024, and the inventory sheets have not been updated since then. 8. During an interview on 4/18/24 at 12:21 P.M., the Administrator said sometimes money is withdrawn for personal spending and used to purchase gift cards for residents who want to use their gift cards on purchases for things like Door Dash or other food deliveries. She was not aware money was being withdrawn from resident accounts and used to purchase gift cards that remained in the safe in order to get money out of the resident's account when close to their spenddown limits. She expects money withdrawn from a resident's account to be used for the resident. She expects more than one person to sign off on the money being withdrawn and for receipts to be maintained accurately to reflect purchases made with resident money. She expects purchased items to be inventoried as soon as possible. During an interview on 4/19/24 at 10:26 A.M., the Administrator said when resident's spenddown money is going to be used, she expects the resident representative and/or guardian to be consulted. The 18 gallon totes on a receipt for Resident #48 were purchased for the facility's use, and should not have been purchased using the resident's funds. Resident #26 can see a little, but would not be able to read a watch. He/She can express his/her wants and needs, but cannot make his/her own decisions regarding his/her finances. It is possible that when the Financial Coordinator received receipts from the Life Enrichment Director, she checked the dollar amount, and not what specific items were purchased. Now knowing there are discrepancies with the purchase receipts, the facility will have to investigate.

Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to follow up on outstanding checks during monthly resident trust fund reconciliations. This facility identified 105 residents with funds handled by the facility. The census was 133. Review of the facility's Resident Trust policy, revised 11/8/23, showed: -Purpose: Complete procedures on resident trust responsibilities; -Resident trust bank reconciliation: --A reconciliation of the bank statement, checkbook, and resident trust funds module must be completed monthly. This will be completed by the facility's management company staff accountant responsible for the facility's financials; -The Resident Trust Clerk will review the monthly bank reconciliation for any outstanding checks listed that are over two months. If this is found, the Resident Trust Clerk will void the check listed and reissue a new check to reflect current date to be in accordance with state regulation. Review of the facility's monthly resident trust reconciliation, from April 2023 through March 2024, showed outstanding checks as follows: -Check #1394, October 2015, $30.00; -Check #2644, July 2019, $573.06; -Check #2880, March 2020, $72.89; -Check #2915, March 2020, $41.71; -Check #2953, May 2020, $10.00; -Check #3073, July 2020, $102.00; -Check #3103, August 2020, $1,238.00; -Check #3104, August 2020, $158.17; -Check #3436, April 2021, $134.00; -Check #3437, April 2021, $134.00; -Check #3438, April 2021, $134.00; -Check #3519, June 2021, $1,857.99; -Check #3726, November 2021, $149.96; -Check #4060, February 2023, $115.00; -Check #4154, March 2023, $1,121.00; -Check #4428, December 2023, $2,740.00; -Check #4434, December 2023, $224.46. During an interview on 4/17/24 at 8:37 A.M., the Financial Coordinator said the resident trust account is reconciled each month by an accountant with the facility's management company. The Financial Coordinator factors outstanding checks into the monthly reconciliation, which are carried over to the following month if they are not cashed. When trained for this position, she was never instructed to investigate outstanding checks. She does not have the authority to cancel or void checks. During an interview on 4/18/24 at 12:21 P.M., the Administrator said the resident trust account is reconciled monthly by the accountant with the facility's management company. The accountant notifies the Financial Coordinator when there are any issues that need to be addressed. The Administrator expected outstanding checks to be investigated during the resident trust reconciliation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a homelike environment when staff served meals on Styrofoam and used plastic utensils, provided a dirty wheelchair to one resident (Resident #102), and did not clean three resident rooms (Resident #130, room [ROOM NUMBER], and room [ROOM NUMBER]). The sample was 26. The census was 133. Review of the facility's housekeeping deep cleaning policy, dated 6/29/23, showed: -Purpose: to ensure all rooms are clean; -Policy: Deep cleaning is to be completed as scheduled. This includes complete pull-outs of furniture in rooms, wall cleaning, floor cleaning (scrubbing and waxing included), restrooms to be cleaned and disinfected, cobwebs removed, beds and rails to be cleaned, sprinkler heads to be cleaned, light covers to be clean and free of bugs, over-bed light covers to be cleaned and free of bugs, sinks cleaned, windows to be cleaned and ensure no spider webs, drapes and curtains to be cleaned (including privacy curtains), call lights to be clean and free from dust/dirt build-up, floors, closets and doorways are to be free from wax/dirt build up, etc. All areas should be monitored on a daily basis and all resident living areas and non-living areas should be clean and odor free; -Daily Cleaning: pick up all trash and put into trash can and empty. Dust mop or sweep floor. Submerge rag or sponge in with solution and clean surfaces beginning with touch areas on door and work clock or counterclockwise around the room. Surfaces are to be cleaned including wall smudges, light and call light and side tables, head/foot board/side rails of beds, windows. Clean the sink, around the light fixtures and dispensers. Clean inside and outside of the trash can. Let it air dry. Replace trash can liner. Clean bathroom using the same cleanser/disinfectant, wall smudges, lights, and call switches. Review of the facility's housekeeping job duties, undated, showed: -Duties: follow policy and procedures. The housekeeping process, morning walk-through, follow plan work, schedule for deep cleans, clean wash basins, mirrors, commodes, tubs, and showers daily, clean all air vents. 1. Observation of breakfast on 4/15/24 at 8:00 A.M., showed residents on the 300 hall and in the 300/400 assisted dining room were served meals on Styrofoam plates and bowls with plastic utensils. Observation of lunch on 4/16/24 at 12:40 P.M., showed residents on the 300 hall and in the 300/400 assisted dining room were served meals on Styrofoam plates and bowls with plastic utensils. Observation of dinner on 4/16/24 at 5:51 P.M., showed residents on the 300 hall and in the 300/400 assisted dining room were served meals on Styrofoam plates and bowls with plastic utensils. 2. Review of Resident #79's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/24, showed: -Cognitively intact; -Diagnoses included hemiplegia (paralysis to one side of the body) or hemiparesis (weakness to one side of the body), seizure disorder and depression. During an interview on 4/14/24 at 10:14 A.M., the resident said the facility has been serving meals on Styrofoam with plastic utensils for a long time now. He/She would not use Styrofoam and plastic utensils at home and he/she wants meals served with real dishes. Observations and interview on 4/15/24, showed: -At 8:27 A.M., the resident sat in bed in front of a divided Styrofoam plate containing a scoop of scrambled eggs, two pancakes and diced potatoes. With an unsteady left hand, he/she used a plastic fork to spear the pancakes on the Styrofoam plate. The fork was unable to fully penetrate the pancakes, which repeatedly slid across the Styrofoam plate. During an interview, the resident said the forks are cheap and break easily. He/She cannot eat his/her food with the plastic utensils and does not know why the facility is not using real utensils; -At 8:47 A.M., the resident sat in bed and was no longer eating. One pancake was untouched and one pancake had a bite mark in it and multiple stab marks from a fork. 85% of the potatoes and 80% of the scrambled eggs remained on the plate. During an interview, the resident said he/she was done eating because he/she could not get the food onto the plastic fork. 3. Review of Resident #125's quarterly MDS, dated [DATE], showed: -Totally dependent on staff for eating; -Diagnoses included stroke, dysphagia (swallowing disorder) following stroke, high blood pressure and diabetes. Observation on 4/15/24 at 9:00 A.M., showed Certified Nurse Aide (CNA) B sat next to the resident's bed and used a plastic fork to scoop food on the resident's Styrofoam plate. CNA B attempted to cut grits with the fork. The grits appeared rubbery and slid across the plate in a solid unit, unable to be separated with a fork. During an interview, CNA B said he/she was having a hard time cutting up the resident's grits. 4. Review of Resident #84's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included stroke and depression. During an interview on 4/14/24 at 11:03 A.M., the resident said meals are served on Styrofoam with plastic utensils. He/She did not know why food is served like this, but it did not feel homelike. 5. During an interview on 4/17/24 at 1:43 P.M., CNA B said he/she was not sure why meals were served on Styrofoam with plastic utensils and he/she is unsure how long it has been like this. Meals are prepared and wrapped by dietary, then brought to the floor. He/She would not consider the use of Styrofoam and plastic utensils to be homelike. 6. During an interview on 4/17/24 at 2:43 P.M., the Dietary Manager said it is not homelike for residents to use Styrofoam plates and plastic cutlery for a prolonged amount of time. She said residents have been using Styrofoam plates for at least two weeks. The dishwasher was currently fixed but residents were still using Styrofoam until she felt comfortable with the dishwasher. 7. During an interview on 4/18/24 at 2:08 P.M., the Administrator said it is absolutely not homelike for residents to be eating with Styrofoam and plastic cutlery when the dishwasher is working. 8. Review of Resident #102's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Mobility device used: manual wheelchair; -Dependent on staff for bed to chair transfers; -Diagnoses included diabetes, kidney disease, stroke and dementia. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has a history of stoke and requires dependent to maximum assistance with activities of daily living (ADLs); -Plan: Activity as tolerated and out of bed as tolerated; monitor and document mobility status. During observation and interview on 4/16/24 at 12:02 P.M., CNA I said he/she was going to change the resident's wheelchair out for a new one because the old one was leaning to one side. A new wheelchair was brought into the resident's room. The wheelchair had white crusty and reddish brown stains on the seat. The wheels on the wheelchair had dust and thick cobwebs. The resident was transferred from the broken wheelchair to the soiled chair without it being cleaned. During an interview on 4/17/24 at 2:40 P.M., CNA F said the night shift CNAs are responsible for cleaning the wheelchairs in the facility. There is a wheelchair cleaning schedule to follow. Wheelchairs are also to be cleaned as needed. During an interview on 4/18/24 at approximately 10:00 A.M., Certified Medication Technician (CMT) J said he/she observed the wheelchair that was brought into the resident's room and thought it looked pretty dirty and it should have been cleaned before giving it to the resident to use. During an interview on 4/18/24 at 1:41 P.M., the Director of Nurses (DON) said she expected staff to provide a clean wheelchair to the resident. 9. Review of Resident #130's admission MDS, dated , 3/18/24, showed: -Cognitively intact; -Diagnoses of high blood pressure and obesity. During an interview on 4/14/24 at 10:37 A.M., the resident said his/her room is not cleaned enough by staff. He/She is distressed by the state of his/her room. Observation of the resident's room, showed: -On 4/15/24 at 8:10 A.M., the room had sticky floors with a dark liquid spill next to the resident's bed, dirty blinds with dust accumulation, dirty privacy curtains with various brown stains, a dirty air conditioning unit with dust accumulation on and inside the vents, and a fly catcher which hung by the sink, stuck to the mirror; -On 4/16/24 at 11:21 A.M., the room had a dirty mirror streaked with yellow liquid coming from the fly catcher, sticky floors with trash in various areas and debris, dirty privacy curtains with brown stains, dirty blinds with dust accumulation, and a dirty air conditioning unit with dust accumulation. 10. Observation of room [ROOM NUMBER], showed: -On 4/14/24 at 8:43 A.M., the room had an overwhelming musty smell, sticky floors with various debris, and dirty privacy curtains with brown stains; -On 4/15/24 at 1:35 P.M., the room had an overwhelming musty smell, floor sticky with debris and trash, dirty air conditioning vents with visible dust buildup, and dirty privacy curtains with brown stains; -On 4/16/24 at 11:17 A.M., the room had dirty sticky floors with trash debris, an overwhelming musty smell, dirty air conditioning vents with dust accumulation, and dirty privacy curtains. 11. Observation of room [ROOM NUMBER], showed: -On 4/14/24 at 9:03 A.M., the room had sticky floors with trash debris in various locations around the room; -On 4/15/24 at 7:52 A.M., the room had sticky floors with trash debris and a dirty air conditioning unit vent with dust accumulation; -On 4/16/24 at 11:49 A.M., the room had sticky floors with trash debris in various areas, dusty blinds, and a dirty air conditioning unit vent with dust accumulation. 12. During an interview on 4/17/24 at 8:24 A.M., Floor Tech Y said he/she cleans the floors in the facility daily. He/She said he/she looks at the residents' privacy curtains to make sure they are clean twice a week. He/She expected residents' rooms to have clean floors and privacy curtains. 13. During an interview on 4/17/24 at 8:29 A.M., Housekeeper X said he/she cleans two rooms on the 400 hallway a day. The floors are to be cleaned everyday along with the sink and mirror. He/She expected the residents' rooms to be clean. 14. During an interview on 4/17/24 at 2:02 P.M., the Housekeeping Supervisor said he expected residents' rooms to be cleaned daily including floors, mirrors, sinks, blinds and air conditioning units. He expected housekeepers to let the Maintenance Department know if air conditioning units needed to be cleaned on the inside of the vent. He expected residents' rooms to be clean and orderly. 15. During an interview on 4/18/24 at 2:10 P.M., the Administrator said she expected housekeeping to follow cleaning schedules to ensure residents' rooms are clean and orderly.

**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 was updated and accurate to reflect the resident's needs. This failure affected three residents, whose care plans did not identify the residents' smoking status and one resident, whose care plan did not identify medication refusals (Residents #283, #65, #64 and #18). The sample was 26. The census was 133. Review of the facility's Comprehensive Care Plans and Baseline Care Plans policy, revised 1/19/22, showed: -A licensed nurse that has been designated by the facility administration will coordinate each assessment with the appropriate participation of health professionals among the Interdisciplinary Team (IDT); -A comprehensive care plan should be completed within 14 days of admission; -A baseline care plan should be completed within 48 hours of admission; -Information gathered to formulate care plans and assure accuracy of MDS includes but is not limited to: direct observation, communication with the resident/responsible party, direct care staff from all shifts, the resident's physician, and the resident's medical record; -Daily nursing meetings will occur Monday through Friday with a review of the resident's medical, functional, and psychological problems. From this meeting, information will be individualized to the resident's plan of care. 1. Review of Resident #283's medical record, showed diagnoses included high blood pressure, history of alcohol and substance abuse disorder, chronic obstructive pulmonary disease (COPD, a chronic narrowing of the pulmonary arteries and veins causing shortness of breath), and history of cerebral infarction (stroke, a blood clot in the brain cutting off oxygenated blood to one or several portions of the cerebrum). Review of the resident's progress notes, showed: -4/13/23, entered by the facility Nurse Practitioner during the resident's previous admission at the facility, the resident was a current, every day smoker while residing at the facility; -3/25/24, entered by the floor nurse after a smoking safety evaluation was completed on the resident, the resident currently utilizes tobacco products; -3/28/24, the Nurse Practitioner documented the resident utilized tobacco products and smoked approximately 1 pack of cigarettes per day. Review of the resident's Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 3/25/24, showed: -Moderate cognitive impairment; -Section J1300, which addresses the use of tobacco products, was not completed. Review of the resident's care plan, in use at the time of survey, showed: -No entry in the care plan was made to identify the resident's smoking status. Observation on 4/14/24 at 9:36 A.M., showed the resident entered the smoking area at the facility after the breakfast meal. The resident smoked two cigarettes in the smoking area. Observation on 4/15/24 at 11:37 A.M., showed the resident entered the smoking area at the facility prior to the lunch meal. The resident smoked two cigarettes in the smoking area. Observation on 4/16/24 at 8:06 A.M., showed the resident entered the smoking area at the facility prior to the breakfast meal. The resident smoked two cigarettes in the smoking area. During an interview on 4/14/24 at 9:28 A.M., the resident said he/she smokes his/her cigarettes outside in the smoking area with the rest of the facility's residents. During an interview on 4/18/24 at 11:03 A.M., Certified Nurse Aide (CNA) H said the resident was admitted in March of this year, but had been a resident at this facility previously for a short time. CNA H said the resident is a smoker, and does not participate in many activities outside of smoking each day. CNA H said smoking should be included on residents' care plans to ensure staff are aware of each resident's specific health conditions, and smoking could contribute to them. During an interview on 4/18/24 at 11:07 A.M., Registered Nurse (RN) E said the resident was admitted in March of this year and does not participate in many activities outside of smoking times at the facility. RN E said smoking should be included on the resident's care plan, as care plans should be specific to each resident's needs and health conditions. 2. Review of Resident #65's medical record, showed diagnoses included hemiplegia (paralysis affecting one side of the body), pseudobulbar affect (episodes of sudden or uncontrolled emotion), multiple sclerosis (MS, a chronic disease of the central nervous system causing pain and loss of fine motor function) and high blood pressure. Review of the resident's MDS, dated [DATE], showed: -No cognitive impairment; -The resident requires moderate assistance from staff with dressing and bathing tasks; -The resident uses a wheelchair for locomotion. Review of the resident's progress notes, showed: -11/27/23 at 7:28 P.M., the resident refused all medications and supplements for the duration of the day, and had been refusing all medications since 11/26/23; -1/24/24 at 3:20 P.M., the resident refused his/her scheduled Baclofen (a neurologic medication used to treat MS) as he/she was not in pain. The resident was informed this is a scheduled medication for a chronic illness and continued to refuse the medication; -2/28/24 at 6:40 P.M., following re-admission from a hospital stay as a result of a fall at the facility, the resident refused to coordinate with Social Services in relation to follow-up appointments with neurology and his/her primary care physician; -3/21/24 at 12:44 P.M., the resident refused blood draws at the facility for an upcoming physician appointment, and continued to refuse blood draws while at the facility. Review of the resident's care plan, in use at the time of survey, showed: -The resident is a fall risk related to his/her diagnosis of MS. Interventions included following facility protocol and ensuring the resident's call light is within reach while encouraging the resident to use the call light when assistance is required; -The resident is at risk for alteration in musculoskeletal status related to his/her diagnosis of MS. Interventions included monitoring for falls, monitoring for fatigue, ensuring administration of prescribed analgesics, and ensuring the call light is within reach for the resident to use; -The care plan did not address medication or treatment refusals. During an interview on 4/14/24 at 9:04 A.M., the resident said the facility administered medications to him/her as ordered each day, but that he/she is on too many medications and tells the facility which ones he/she wants to take. The resident had no concerns about the administration of medications. During an interview on 4/18/24 at 11:03 A.M., CNA H said he/she was familiar with the resident, who has been a long-term resident at the facility for some time. CNA H said the resident has a history of medication and treatment refusals while at the facility, and expected that to be included on the care plan to direct staff approaches to the resident during treatment. During an interview on 4/18/24 at 11:07 A.M., RN E said he/she was familiar with the resident, and the resident often refuses medications and treatment, so much so that the resident's medication regimen has been vastly reduced over the last year due to refusals. RN E expected refusals and other behaviors to be included on the care plan to help direct staff approaches to the resident during medication administration and treatments. 3. Review of Resident #64's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Uses manual wheelchair; -Diagnoses included MS, seizures, anxiety, manic depression (a mood disorder), and schizophrenia (a mental disorder that is characterized by severely impaired thinking, emotions and behaviors). Review of the list of residents who smoke, provided by the facility, showed the resident listed as a smoker. Observation on 4/15/24 at 9:40 A.M. and on 4/16/24 at 1:35 P.M., showed the resident in the smoking area on the 100 hall, smoking a cigarette. Review of the care plan in use at the time of survey, showed it did not address the resident's smoking status. 4. Review of Resident #18's quarterly MDS, dated [DATE], showed: -The resident is rarely or never understood; -Uses a manual wheelchair; -Diagnoses include: Pneumonia, dementia, Alzheimer's disease, Parkinson's disease (a neurological condition that is characterized by tremors) and anxiety. Review of the list of residents who smoke, provided by the facility, showed the resident listed as a smoker. Observation on 4/15/24 at 9:40 A.M. and on 4/16/24 at 1:35 P.M., showed the resident in the smoking area on the 100 hall, smoking a cigarette. Review of the care plan in use at the time of survey, showed it did not address the resident's smoking status. 5. During an interview on 4/18/24 at 1:21 P.M., the facility MDS Coordinator, who also serves as the facility's Care Plan Coordinator, said care plans are developed in collaboration with CNAs, nurses, the resident, and their families if necessary to develop a specific care plan directed to address the resident's specific care concerns. The MDS Coordinator said a resident who smokes should have that information included on the care plan, and a resident with frequent behaviors such as medication refusals should have that included on the care plan as well. 6. During an interview on 4/18/24 at 1:37 P.M., the Director of Nursing (DON) and Administrator said a resident with medication refusals should have that information included on the care plan. They also said a resident who is a current smoker at the facility should have that information included on the care plan, as all care plans should be resident-specific to address each resident's unique health concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to appropriately assess and investigate a series of falls resulting in head injuries, and to implement adequate interventions following the series of falls for one resident (Resident #36). The facility failed to ensure appropriate techniques and/or functional equipment were utilized during mechanical lift transfers for two residents (Residents #36 and #119), and to ensure staff applied and used gait belts properly during transfers or assisted ambulation for three residents (Residents #64, #102 and #39). In addition, the facility failed to ensure residents were routinely and accurately assessed for smoking safety for three residents (Residents #64, #18 and #107). The sample was 26. The census was 133. Review of the facility's Focus Risk Assessment Plan Scope/Severity of Falls (FRAPSS) policy, revised 6/29/23, showed: -Purpose: To assess all residents for potential for falls in the facility. To ensure a comprehensive interdisciplinary plan of care is established for all residents who are identified for increased risk of falls. To identify precipitating factors for fall risk and to be proactive in implementing interventions to prevent or reduce the incidence of further falls; -Procedure included: -1. Resident will be assessed using the FRAPSS form for fall risks upon admission, quarterly and in an acute situation where resident has fallen. The FRAPSS assessment guide measures areas of precipitating factors such as age, use of assistive devices, diagnoses, medical antecedents, history of previous falls, sensory deficits, medications, and resident compliance with prescribed orders. Every resident who has a fall including those without injury will be screened by the therapy department and nursing interventions will be put in place to reduce the risk of further falls; -2. The resident will be assessed by a Licensed Nurse and after the assessment is completed the resident will be scored accordingly and placed on the scope and severity level which outlines the plan of care and is denoted by different colors. The resident who is found to be at risk a score of 26 or greater or Level 3 or greater for falls will have an individualized interdisciplinary plan of care developed which will include nursing, therapy, physician, legal guardian (if applicable) and may include a pharmacist consult, dietician consult, and other outside agencies to consult; -3. The focus levels for fall risk, Scope and Severity Grid: --a. FRAPSS Level 1 score of 0-15 = Minimal risk, resident has had no falls in the last 30 days; --b. FRAPSS Level 2 score 16-25 = Potential for more than minimal harm, resident has had one fall in the last 30 days with no significant injury. Interventions will include all level 1 interventions and visual checks by nursing staff. Investigation by Registered Nurse (RN) or designee including monitoring of as needed (PRN) medications given to resident. Rule out of any medical antecedents; --c. FRAPSS Level 3 score 26-34 = Potential for actual harm, resident has had 2 or more falls without significant injury. Interventions include all Level 1 and 2 interventions and intensive monitoring. The resident will be added to the high priority RN list and assessed by the Director of Nursing (DON) or designee including a meeting to establish a plan of care addressing the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) and care plans for the resident. In-servicing to all direct care staff on plan of care for resident's individual needs related to falls; --d. FRAPSS Level 4 score 35 and up = Immediate Jeopardy, 2 or more falls with 1 or more resulting in significant injury. Interventions will include all interventions of level 1-2-3 and may include based on the interdisciplinary team (IDT), other individualized plans of care as assessed by the IDT. The Administrator, DON and Therapy Director will meet and establish interventions and plan of care that will reduce the risk of resident falling and ensure that protective oversight of the resident is priority. The DON will continue to assess the resident as a high priority resident in the facility and the plan of care will be modified to ensure the highest level of safety is in place for the resident; -4. Nursing Interventions will be individualized and addressed on the care plan for the resident. These interventions can be added to any FRAPSS Level. The resident who reaches a level 3 will be placed on the High Priority list by the DON and assessed by the DON or designee; a plan of care will be initiated with the IDT and the care plan for the resident will be in-serviced to all direct care staff under the supervision of the DON/designee. Review of the facility's Precautionary Measures for Gait Belt Application and Usage, revised 6/29/23, showed: -Purpose: The purpose of this policy is to ensure precautionary and safe measures are taken during the application and use of gait belts; -Procedure: -Safe usage of a gait belt can prevent potential risk of injury to residents that could be caused by pulling on their arms, shoulders and wrists during ambulation, transfers or repositioning; -Safety Measure: Never transfer any resident by lifting them under their arms. Avoid the axillary area on the resident as this has the potential to cause nerve damage, shoulder dislocation, bruising, pain and fractures; -Never attempt to transfer a resident independently that cannot bear weight. A mechanical device/lift must be used in the plan of care for the resident that cannot bear weight; -The gait belt is a specialized device that is utilized to assist during transfers, ambulation or repositioning of the resident; -To ensure optimum comfort and safety for the resident, the gait belt will be utilized. This will also aid in minimizing the risk of injury to the resident as well as the staff; -Staff will have better control and be able to facilitate the use of correct body mechanics to avoid injury of resident and staff; -Application of gait belt; --The gait belt is to be applied around the resident's waist below the ribs securely so that staff may grasp the belt which will prevent the belt from sliding above the resident's waist; --The gait belt buckle should be fastened securely in the front, away from the midline; -Transfer, ambulation and repositioning; --Always position fingertips pointing upward, grasping the belt from under; --Utilize proper body mechanics at all times. Review of the facility's Smoking Contraband policy, revised 4/3/24, showed: -Purpose: The purpose of this policy is to define what the facility classifies as smoking contraband and to provide safety and protective oversight to the residents and employees by monitoring the smoking contraband in the facility. It is the goal of the facility to provide a safe environment for all; -Procedure included: --Residents will be assessed for independent smoking upon admission/re-admission, quarterly and PRN. The resident must be approved per Legal Guardian and by the interdisciplinary care plan team to smoke unsupervised. This is determined by assessment of the resident's history and current plan of care. 1. Review of Resident #36's medical record, showed diagnoses included seizure disorder, unspecified intellectual disabilities (limits to a person's ability to learn at an expected level and function in daily life), schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder, drug-induced subacute (somewhat rapid change) dyskinesia (uncontrolled, involuntary muscle movement), ataxia (impaired coordination), abnormalities of gait and mobility, and generalized muscle weakness. Review of the resident's hospital after visit summary, dated 12/2/23, showed diagnoses included fall and injury of head. Review of the resident's FRAPSS fall assessment, dated 12/2/23, showed a score of 28.0 and category of Level 3. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Upper extremity impairment on one side; -Lower extremity impairment on both sides; -Use of wheelchair; -Mobility performance: Dependent (helper does all the effort) for sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer; -No falls since last assessment. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident requires total assistance with his/her activities of daily living (ADLs). Diagnoses of drug induced subacute dyskinesia and ataxia; -Problem: Resident is at risk for impaired cognitive function/dementia or impaired thought processes related to diagnoses of mental retardation and unspecified intellectual disabilities; -Problem: Resident is risk for falls related to unsteady balance and use of psychotropic medication; --Goal: Resident will not sustain serious injury through the review date; --Interventions, initiated 5/27/21, included: ---Anticipate and meet the resident's needs; ---Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; ---Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; ---Follow facility fall protocol. Review of the resident's physician order sheet, active on 1/25/24, showed: -An order, dated 1/10/23, for haloperidol decanoate (antipsychotic medication) intramuscular (IM) solution, 50 milligrams (mg)/milliliters (ml), inject one ml IM one time a day every 14 days; -An order, dated 1/10/23, for haloperidol 2 mg tablet, give 2.5 mg by mouth (PO) once daily; -An order, dated 1/10/23, for haloperidol 2 mg tablet, give 7.5 mg PO in the afternoon; -An order, dated 2/19/23, for clonazepam (anxiolytic (anti-anxiety) medication) 0.5 mg, PO once daily; -An order, dated 4/23/23, for valproic acid (anticonvulsant medication) oral solution, give 1250 mg PO two times a day; -An order, dated 7/9/23, for trazodone (antidepressant and sedative medication), give 75 mg PO in the afternoon; -An order, dated 7/9/23, for trazodone, give 75 mg PO in the morning; -An order, dated 7/9/23, for trazodone 100 mg, give one tablet PO at bedtime. Review of the resident's incident note, dated 1/25/24 at 4:55 P.M., showed staff documented the resident found lying next to his/her bed with blood coming from both the side of his/her face and the front. CNA came and notified nurse of the incident. The nurse noticed two, 2 centimeter (cm) lacerations to the resident's front forehead and right side of his/her face near his/her cheek. Resident could not inform nurse what he/she was trying to do. Patient demonstrated pain in each extremities and could not rate it or describe it due to his/her baseline. Nurse sent resident to hospital to be evaluated. Review of the resident's hospital after visit summary, dated 1/25/24, showed diagnoses of fall, facial laceration, and mental retardation. Review of the resident's FRAPSS fall assessment, dated 1/25/24, showed: -Category: Level 1, Score: 6.0; -Assistive devices checked: wheelchair; -Assistive devices not checked included: low bed and footwear; -Diagnoses/medications checked: heart failure; -Diagnoses/medications not checked included: unsteady gait, psychosis, falls, seizures, confusion, anticonvulsants, antipsychotics, sedatives/hypnotics, and anxiolytics; -Fall history: No falls in the past 30 days; -Sensory deficits checked: delirium and confusion; -Sensory deficits not checked included: agitation, anxiety, psychosis, extrapyramidal side effects (EPS, drug-induced movements); -Total score and implement the plan based on the system below for severity: --FRAPSS level implemented: Score 1-15 = Level 1. Review of the resident's physical therapy (PT) recertification, progress report, and updated therapy plan, signed by PT on 2/1/24, showed: -Precautions: Fall risk behavior - will lower him/herself to the floor; -Functional skills assessment of transfers: --Sit to stand = partial/moderate assistance; --Chair/bed-to-chair transfers = substantial/maximal assistance. Review of the resident's progress notes, dated 2/2/24, showed: -At 11:34 A.M., staff documented the resident is on incident follow up with neuro checks every 15 minutes. Resident slid out of wheelchair in dining room and hit the right side of his/her head on the arm of a chair. This was witnessed by staff. The nurse assessed the resident and sent him/her to the hospital; -At 2:44 P.M., staff documented the resident slid out of his/her wheelchair and hit his/her head on the metal handrails of the chair. No open areas, but sustained a bump on his/her right forehead. Review of the resident's hospital after visit summary, dated 2/2/24, showed diagnoses of fall and abrasion. Review of the resident's FRAPSS fall assessment, dated 2/2/24, showed: -Category: Level 3, Score: 33.0; -Assistive devices checked: wheelchair; -Assistive devices not checked included: low bed and footwear; -Diagnoses/medications checked: falls and severe mental retardation; -Diagnoses/medication not checked included: unsteady gait, psychosis, seizures, confusion, , antipsychotics, and sedatives/hypnotics; -Fall history: Two or more falls in the past 30 days without significant injury; -Sensory deficits checked: agitation; -Sensory deficits not checked included: delirium, confusion, anxiety, psychosis, and EPS; -Total score and implement the plan based on the system below for severity: --FRAPSS level implemented: Score 35 & up = Level 4. Review of the resident's incident note, dated 2/8/24 at 6:07 P.M., showed staff documented the nurse was called to assess the resident who slid on his/her wheelchair and hit his/her head on the floor. Open areas noted and bump on his/her right forehead. Resident was transported to the hospital. Review of the resident's hospital after visit summary, dated 2/8/24, showed diagnoses of fall, closed head injury, and abrasion of forehead. Review of the resident's FRAPSS fall assessment, dated 2/8/24, showed: -Category: Level 4, Score: 42.0; -Assistive devices checked: wheelchair; -Assistive devices not checked included: low bed and footwear; -Diagnoses/medications not checked included: antipsychotics and sedatives/hypnotics; -Fall history: One or more falls in the last 30 days resulting in a significant injury; -Sensory deficits checked: psychosis; -Sensory deficits not checked included: delirium, agitation, confusion, anxiety, and EPS; -Total score and implement the plan based on the system below for severity: --FRAPSS level implemented: Score 35 & up = Level 4. Review of the resident's medical record showed no documentation of investigations regarding specific circumstances of falls occurring 1/25/24, 2/2/24, and 2/8/24, including potential behaviors exhibited at the time of falls or patterns observed related to falls. Further review showed no documentation of care plan meetings held to discuss fall interventions during this timeframe. Further review of the resident's care plan, in use at the time of survey, showed: -The care plan failed to identify the resident's transfer status, including requiring the use of a Hoyer (mechanical) lift; -The care plan failed to identify the resident's behavior of lowering him/herself to the floor; -The care plan failed to identify the resident's series of falls on 1/25/24, 2/2/24, and 2/8/24, in which injuries occurred involving the resident's head; -The care plan failed to identify updated resident-specific interventions following the resident's falls on 1/25/24, 2/2/24, and 2/8/24, including use of a low bed and fall mat. Observation on 4/14/24 at 8:37 A.M., showed the resident in his/her room, seated in a wheelchair on top of a Hoyer lift pad. The resident's wheelchair did not have foot rests. The resident wore socks without shoes, and his/her feet dangled from the wheelchair, approximately one inch from the floor. A fall mat was folded and against the wall, approximately ten feet from the resident. During an attempted interview, the resident was unable to respond to questions regarding falls. Observation on 4/15/24 at 7:18 A.M., showed Certified Nurse Aide (CNA) B and CNA N in the middle of transferring the resident in his/her room, using a Hoyer lift. The resident sat in a sling attached to the Hoyer lift, approximately four feet above a wheelchair. While CNA N operated the Hoyer lift, CNA B held the resident's wheelchair by the handles, keeping the chair tipped backward so the back of the chair rested against CNA B's body. The brake was not locked. Observation on 4/15/24 at 1:37 P.M., showed the resident on his/her back in bed, with the bed positioned low to the floor. The left side of the bed was flush to the wall and a fall mat was on the floor on the right side of the bed. A call light hung on the wall at the resident's feet, approximately five feet from the resident's reach. Observations on 4/16/24 at 10:10 A.M. and approximately 11:00 A.M., showed the resident in his/her room, seated in a wheelchair. The resident's wheelchair did not have footrests. The resident wore socks without shoes, and his/her feet dangled from the wheelchair, approximately one inch from the floor. The resident's catheter tubing wrapped around the front left wheel of his/her wheelchair. A fall mat was folded and against the wall, approximately ten feet from the resident. During an interview on 4/17/24 at 1:43 P.M., CNA B said the resident is confused at times. CNA B is not sure if the resident has a history of falls or is a fall risk. The resident used to wear a helmet, but does not wear it anymore and it is unknown how long ago this was. When in bed, the resident's bed gets positioned low and he/she gets a fall mat. CNA B knows to put the bed low and put out a fall mat because the nurse told him/her. The resident also has side rails for fall prevention. CNAs are made aware of fall interventions by the nurse. The resident cannot transfer him/herself and requires a Hoyer lift. When transferring the resident on 4/15/24, CNA B had the wheelchair tilted backward so when the resident was lowered into the chair, he/she would be positioned far back in the chair. The brakes of the wheelchair were not locked while CNA B held onto the wheelchair and propped it with his/her body. The brake should have been locked and the wheelchair should have been upright because the resident could have been dropped. During an interview on 4/17/24 at 2:21 P.M., CNA C said the resident has some confusion and has a history of falling out of bed. He/She gets a low bed and fall mat when he/she is in bed. Nurses communicate fall interventions to CNAs. The resident cannot transfer him/herself and requires a Hoyer lift. During a Hoyer lift transfer, staff should keep the wheelchair positioned upright. Staff should not tilt the wheelchair because they could drop the resident. During an interview on 4/17/24 at 2:45 P.M., Licensed Practical Nurse (LPN) D said the resident has poor short-term memory. He/She has a history of falls and his/her falls were more due to behaviors, like putting him/herself on the floor. He/She used to wear a helmet. Currently, he/she requires a floor mat and low bed. The Nurse Managers determine what interventions to implement for each resident. Fall interventions are documented as a progress note and on the resident's care plan. Care plans are updated by the MDS Coordinator and nurses can update them, too. The resident requires a Hoyer lift to transfer. During a transfer, staff should ensure the resident's wheelchair is upright and the brake is locked. It would not be appropriate for staff to tilt a resident's wheelchair and support the tilted wheelchair with the employee's body weight because the wheelchair could tip over and it is not safe. During an interview on 4/18/24 at 9:06 A.M., the Residential Care Coordinator said the resident had a few falls recently. At the time, the resident had increased behaviors of climbing out of bed and flipping tables, and his/her falls were behavioral. At the time of the falls, the resident was using a low bed and he/she had fall mats. Shortly after the last fall, he/she went out to the hospital for a change in condition and was taken off all his/her psychotropic medications. Since he/she returned to the facility, he/she has not been exhibiting behaviors and has not had any falls. The Residential Care Coordinator is responsible for taking the lead on investigating the circumstances of resident falls. After a fall occurs, the nurse is responsible for completing a FRAPSS fall assessment. The assessment should be completed accurately. The score of the FRAPSS fall assessment determines the level of a resident's fall risk and the FRAPSS policy provides guidance for which interventions to implement at each level. Determining fall interventions is a team effort. At this time, there is no formal process for having IDT meetings to discuss interventions following a resident's fall. Once an intervention is identified, it goes onto the report sheet to get communicated to nursing staff. Interventions should be resident specific and should be documented on the resident's care plan. Care plans are updated by the nurse management team. During an interview on 4/18/24 at 12:21 P.M., the DON and Administrator said the resident's recent falls were due to behaviors. When he/she got angry, he/she acted out by doing things like flipping tables. The behaviors were normal for him/her and he/she fell with intention. He/She was recently hospitalized and was ultimately diagnosed with neuroleptic syndrome (life threatening reaction to antipsychotic drugs). His/Her medications were adjusted and he/she became stable. The neuroleptic syndrome might have been the cause of the resident's recent falls. The DON and Administrator expected the IDT to meet to discuss resident-specific interventions following a fall. After a fall occurs, the nurse is expected to fill out a FRAPSS fall assessment. The FRAPSS fall assessment should also be completed on admission and quarterly, and the assessment should be filled out accurately. Resident-specific fall interventions should be communicated to nursing staff in report and should be documented on the resident's care plan. Resident #36 is a Hoyer lift transfer. During a Hoyer lift transfer, it is expected that staff maintain the wheelchair in an upright position. The wheelchair should be locked and should not be tilted backward, for safety purposes. 2. Review of Resident #119's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses of multiple sclerosis (MS, neurological condition that causes muscle weakness), bipolar disorder (mood disorder) and muscle weakness. During an interview on 4/15/24 at 1:49 P.M., the resident said the sit to stand lift has been broken and staff continue to use it. He/She said the legs of the sit to stand lift do not work and there is a part visible on the bottom of the lift that is dragging. He/She said he/she does not feel safe on the lift. Observation on 4/18/24 at 10:44 A.M. showed CNA L and CNA M assisted the resident using the sit to stand lift. CNA L turned on the lift and pushed the button to spread the legs of the lift. The left leg of the lift spread while the right leg stayed in place. CNA M stood on the right side of the lift and used his/her foot to manually push the right leg of the lift open. During an interview on 4/18/24 at 11:06 A.M., CNA L said the sit to stand lift is broken. Staff have to kick the legs to open them because the remote doesn't work. He/She said he/she has used the lift at least twice on the resident and the lift was broken each time. He/She did not report the lift as broken to Maintenance or the Charge Nurse. During an interview on 4/18/24 at 11:08 A.M., CNA M said the lift has been broken for at least two weeks. He/She said the legs of the lift are broken and the lift is wobbly. He/She said CNAs are to let Maintenance and the Charge Nurse know when medical equipment is broken. He/She had not reported the lift being broken. During an interview on 4/18/24 at 11:12 A.M., LPN D said he/she was not aware the sit to stand lift was broken. He/She said he/she is to let Administration know if medical equipment is broken. He/She expected CNAs to let him/her know if equipment is broken. During an interview on 4/18/24 at 11:42 A.M., the Maintenance Director said he has taken the lift off the floor for repair. He said the legs are broken on the lift and he expected all staff to let him know if they see medical equipment that is broken. During an interview on 4/18/24 at 2:04 P.M., the Administrator said she expected medical lifts to be in working order. 3. Review of Resident #64's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Uses manual wheelchair; -Requires partial to moderate assistance from staff from sitting to lying position and lying to sitting to the side of the bed; -Requires substantial to maximum assistance from the sitting to standing position and with chair to bed transfers; -Diagnoses included MS, seizures, anxiety, manic depression (mood disorder) and schizophrenia. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident is at risk for falls related to deconditioning, gait and balance problems, incontinence, poor communication, and unaware of safety needs; -Interventions: -Anticipate and meet the resident's needs; -Be sure the resident's call light is within reach; -Physical therapy to evaluate and treat as ordered and PRN; -The resident needs to be evaluated for and supplied appropriate adaptive equipment or devices PRN. Observation on 4/14/24 at 10:17 A.M., showed the resident in his/her room, sitting in his/her wheelchair. CNA G was in the resident's room and informed the resident that he/she was going to place the resident in the bed to check his/her incontinence brief. CNA G encouraged the resident to stand up out of his/her wheelchair. The resident was unable to stand on his/her own. CNA G lifted the resident under his/her arms. The resident was not able to stand up straight and held onto CNA G's waist as the resident pivoted to the bed. Staff did not use a gait belt for the transfer. Observation on 4/17/24 at 10:37 A.M., showed the resident sat in his/her wheelchair in his/her room. CNA I and CNA K explained to the resident they were going to get him/her into the bed. The resident was encouraged to stand but was unable to stand by trying to push off the arm rests on the wheelchair. CNA I and CNA K then lifted the resident under his/her arms. The resident was unable to stand up straight and CNA I and CNA K continued to hold the resident under his/her arms then pivoted the resident to his/her bed. Staff did not use a gait belt for the transfer. 4. Review of Resident #102's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Mobility device used: manual wheelchair; -Dependent on staff for sitting to lying, lying to sitting to the side of the bed, sit to stand, and bed to chair transfers; -Diagnoses included diabetes, kidney disease, stroke and dementia. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident has a history of a stroke and is dependent to maximum assist with all ADLs; -Interventions: --Activity as tolerated and out of bed if tolerated; --Monitor and document mobility status; --Monitor and document resident's abilities for ADLs and assist as needed. Observation on 2/15/24 at 8:39 A.M., showed CNA T and CNA U informed the resident they were going to get him/her up to the chair. The resident was unable to sit in the upright position in the bed. CNA T and CNA U held the resident up by holding onto his/her arms and then shifted the resident to the edge of the bed by pulling on the bedsheet. CNA T and CNA U held the resident under the arms and rocked him/her out of the bed. The resident was unable to stand up straight or follow simple commands related to taking steps towards the wheelchair. CNA T and CNA U both held the resident by the waistband of his/her jeans and pivoted the resident into the chair. Staff did not use a gait belt for the transfer. 5. Review of Resident #39's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Upper extremity impairment on one side; -Lower extremity impairment on one side; -Use of wheelchair; -Mobility performance assessment: Supervision or touching assistance for sit to stand. Walking ten feet not attempted due to medical condition or safety concerns; -Diagnoses included stroke, seizure disorder, dementia and altered mental status. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident is at risk for falls related to decreased mobility, right sided weakness, and use of psychotropic medications; -Desired outcome: Resident will not sustain serious injury through the review date; -Interventions/tasks included PT evaluate and treat as ordered or PRN. Review of the resident's physical therapy recertification, progress report, and updated therapy plan, certification period 4/12/24 through 5/11/24, showed: -Diagnoses included unspecified sequelae (after effect of a disease, condition, or injury), unspecified abnormalities of gait and mobility, and generalized muscle weakness; -Goal: Patient will improve ability to safely transfer to a standing position from sitting in a chair, wheelchair or on the side of the bed with independence with ability to right self to achieve maintain balance and with implementation of compensatory strategies; --Current level of performance, as of 4/12/24: Supervision or touching assistance; -Goal: Patient will safely ambulate on level surfaces 30 feet using hemi-walker (walker designed for individuals with the use of only one hand) with supervision or touching assistance with adequate toe clearance, with adequate weight acceptance, with functional dynamic balance, with safety during turning and with use of righting reactions to facilitate increased participation in functional activity; --Current level of performance, as of 4/12/24: Partial/moderate assistance; -Prior equipment: Patient used a manual wheelchair prior to onset. Patient owns new right lower extremity (RLE) ankle foot orthoses (AFO) and hemi-walker; -Functional assessment: --Transfers, sit to stand = supervision or touching assistance; --Ambulation, walk 10 feet and walk 50 feet with two turns = partial/moderate assistance. Observation on 4/16/24 at 2:39 P.M., showed the resident sat in a wheelchair in the 300/400 dining room. CNA R placed a gait belt around the resident's waist and secured the belt, leaving it loose. The resident said the gait belt was tight and CNA R loosened the belt, leaving a gap of approximately 12 inches between the belt and the resident's abdomen. The resident propelled in his/her wheelchair to the hallway and CNA R stood behind the resident's wheelchair. The resident stood unsteadily and began walking unsteadily down the hall, using a hemi-walker with his/her left hand. CNA R followed behind the resident, pushing the resident's wheelchair approximately three feet behind the resident, not holding or touching the resident's gait belt. The right footrest of the wheelchair stuck straight out, not folded against the chair. The resident walked unsteadily, approximately 25 feet. CNA S walked down the hallway and stopped CNA R. CNA S said the resident's gait belt was too loose and he/she should be followed closely with the wheelchair. During an interview on 4/16/24 at 3:01 P.M., CNA S said the resident uses a wheelchair to ambulate and he/she is in therapy to work on [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents with side rails were appropriately assessed for safety in accordance with the facility's policy, for four residents (Residents #125, #36, #30 and #46). The facility identified 11 residents as utilizing side rails. The census was 133. Review of the facility's Bed Siderails Policy, revised 6/29/23, showed: -All residents using any size siderail device on their beds will have a Restraint/Entrapment Assessment completed to determine the restraining, enabling, or hazard effect of the device. The Assessment will occur upon initial use, quarterly, and as needed if there is a significant change in the resident's condition; -Each resident using a siderail device will have a detailed history documented including the symptoms or reasons for using a device; -Using any device requires a care plan. Use the Device Care Planning Process information in this policy when developing the plan. 1. Review of Resident #125's medical record, showed: -Diagnoses included stroke, abnormal posture, generalized muscle weakness, and memory deficit following stroke; -No entrapment or side rail assessments. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/13/24, showed: -Severe cognitive impairment; -Upper extremity impairment on one side; -Lower extremity impairment on one side; -Mobility performance: Dependent for rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident has limited physical mobility related to diagnosis of stroke; -Problem: Resident has impaired cognitive function/through process; -Problem: Resident is a risk for falls related to confusion, deconditioning, and psychoactive drug use; -The care plan failed to identify the resident's use of side rails. Observation on 4/14/24 at 10:42 A.M., showed the resident on his/her back in bed. A half-length rail was raised on the right side at the foot of the bed. During an interview, the resident said he/she was unsure why the rail was raised. Observation on 4/15/24 at 7:41 A.M., showed the resident on his/her back in bed. A half-length rail was raised on the right side at the foot of the bed. Observation on 4/16/24 at 10:10 A.M., 2:27 P.M., 4:45 P.M., and 6:12 P.M., showed the resident on his/her back in bed. Half-length rails were raised on both sides at the foot of the bed. During an interview on 4/17/24 at 1:43 P.M., Certified Nurse Aide (CNA) B said the resident has side rails on both sides of his/her bed that never get lowered. He/She has the rails because he/she is a fall risk. Nurses tell CNAs which residents should have rails on their bed. During an interview on 4/17/24 at 2:21 P.M., CNA C said the resident required total assistance from staff with care and does not roll in bed on his/her own. CNA C is unsure why the resident has rails on his/her bed. Nurses tell the CNAs which interventions are in place for each resident. During an interview on 4/18/24 at 12:21 P.M., the DON and Administrator said the resident uses side rails for repositioning. 2. Review of Resident #36's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Upper extremity impairment on one side; -Lower extremity impairment on both sides; -Mobility performance: Substantial/maximal assistance for roll left and right, and dependent for sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer; -Diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), drug-induced subacute (somewhat rapid change) dyskinesia (uncontrolled, involuntary muscle movement), unspecified intellectual disabilities (limits to a person's ability to learn at an expected level and function in daily life), mild mental retardation, unspecified abnormalities of gait and mobility, and weakness; -Two or more falls since last assessment. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting. Presents with diagnoses of schizophrenia, impulse control, mild mental retardation and bipolar disorder (mood disorder). Symptoms include verbal and physical aggression, paranoia, audio hallucinations, and isolative behaviors; -Problem: Resident requires total assistance with his/her activities of daily living (ADLs); -Problem: Resident is at risk for impaired cognitive function/dementia or impaired through processes related to diagnoses of mental retardation/intellectual disabilities; -Problem: Resident at risk for falls related to unsteady balance and use of psychotropic medication; -The care plan failed to identify the resident's use of side rails. Review of the resident's entrapment assessment, dated 2/22/24, showed: -Does the resident have cognitive and functional ability to remove the device: Yes; -Can the resident remove the device purposely: No; -Does the device allow the resident to do something that would improve their quality of life: Blank; -Is resident vulnerable to hazard: No; -Sections for diagnoses and identifying cause, care plan treatment and management, and monitoring: Blank; -How many rails does the resident's bed use: Two rails. Observation on 4/16/24 at 2:33 P.M., showed the resident on his/her back in bed. The bed was positioned to the floor and a U-shaped rail was raised on the right side at the head of the bed. During an attempted interview, the resident was unable to provide information regarding the rail. During an interview on 4/17/24 at 1:43 P.M., CNA B said the resident is confused at times. He/She has U-shaped rails on his/her bed for fall prevention. CNA B was unsure if the resident could move the U-rails. During an interview on 4/17/24 at 2:21 P.M., CNA C said the resident has some confusion. He/She has a history of falling out of bed and is on fall precautions. CNA C is not sure if the resident is supposed to have rails on his/her bed or not. During an interview on 4/18/24 at 12:21 P.M., the DON and Administrator said side rails were put on the resident's bed during a recent hospitalization in anticipation of him/her needing them due to a decline in health. 3. Review of Resident #30's medical record, showed his/her diagnoses included functional quadriplegia (the loss of motor function in all four extremities), myositis (a rare disease causing prolonged muscle fatigue and weakness) and spinal stenosis (narrowing of the spine causing stiffness and nerve pain). Review of the resident's Entrapment Assessments, found in the medical record, showed: -A quarterly assessment conducted on 5/23/23 showed the resident utilized bed rails for positioning and mobility, and was assessed to be safe for the use of these devices at that time; -No further assessments were conducted to evaluate the safety and appropriateness of the bed rails prior to the survey period. Review of the resident's quarterly MDS dated [DATE], showed: -No cognitive impairment; -The resident uses a wheelchair for locomotion; -The resident is dependent on staff for eating, oral hygiene, bathing tasks, dressing, and toileting hygiene. Review of the resident's care plan, in use at the time of survey, showed: -The resident utilizes two three-quarter rails to promote a sense of safety and security to resident as related to his/her significant physical impairment and requirement of total care by staff. Interventions included completing side rail assessments as required and to monitor for any change in condition and potential for improvement. Review of the resident's physician orders, showed an active order, dated 10/14/22 for three-quarter rails on both sides of the resident's bed for positioning and mobility. Observation on 4/14/24 at 8:43 A.M. showed the resident resting in bed. Side rails were assembled to the bed frame on both sides of the bed and were up in the mobility-assistance position. Observation on 4/16/24 at 2:38 P.M., showed the resident resting in bed with side rails up on both sides of the bed. The resident said he/she had utilized these rails for a very long time, and had no concerns with them. The resident said he/she was not sure if an assessment had been completed routinely to ensure the rails remained appropriate. Observation on 4/17/24 at 8:36 A.M., showed the resident resting in bed with side rails up on both sides of the bed. Observation on 4/18/24 at 9:01 A.M., showed the resident resting in bed with side rails up on both sides of the bed. During an interview on 4/18/24 at 11:03 A.M., CNA H said the resident has utilized side rails on both sides of the bed for a very long time and has reported no issues to staff. CNA H said residents are assessed for side rail use and appropriateness, but was not sure how often residents receive these assessments. During an interview on 4/18/24 at 11:07 A.M., Registered Nurse (RN) E said the resident utilized side rails for mobility and positioning, and residents are assessed for side rail usage and appropriateness upon admission and after a change in condition is reported. RN E expected for the usage of bed rails to be included on the care plan. 4. Review of Resident #46's medical record, showed his/her diagnoses included Type II diabetes, bilateral below the knee amputation (BKA, removal of the leg below the knee due to infection or injury), chronic kidney disease (CKD, a long-term condition in which the kidneys do not filter blood as efficiently as they should), and chronic atrial fibrillation (a-fib, a cardiac condition causing the atria to beat faster than normal, increasing the risk of blood clots). Review of the resident's assessments, showed: -A quarterly assessment conducted on 5/23/23 showed the resident utilized bed rails for positioning and mobility, and was assessed to be safe for the use of these devices at that time; -No further assessments were conducted to evaluate the safety and appropriateness of the bed rails prior to the survey period. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -The resident is dependent on staff for toileting and bathing tasks, and requires substantial assistance from staff with oral and personal hygiene; -The resident uses a wheelchair for locomotion. Review of the resident's care plan, in use at the time of survey, showed: -The resident uses two full side rails as requested for safety and positioning. Interventions included ensuring entrapment assessments were completed quarterly, and to evaluate safe use of the prescribed device. Review of the resident's physician orders, dated 5/24/23, showed an order for side rails at both sides of the bed for safety and positioning as requested by the resident. Observation on 4/14/24 at 8:37 A.M., showed the resident resting in bed. Side rails were assembled to the bed frame on both sides of the bed. The resident said he/she had been utilizing these rails for a year or so. The resident said he/she was not sure if an assessment had been completed routinely to ensure the rails remained appropriate. Observation on 4/15/24 at 7:46 A.M., showed the resident resting in bed with side rails up on both sides of the bed. Observation on 4/17/24 at 7:43 A.M., showed the resident resting in bed with side rails up on both sides of the bed. During an interview on 4/18/24 at 11:03 A.M., CNA H said the resident utilized side rails on both sides of the bed since admission. CNA H said residents are assessed for side rail use and appropriateness but was not sure how often residents receive these assessments. During an interview on 4/18/24 at 11:07 A.M., RN E said the resident utilized side rails for mobility and positioning, and residents are assessed for side rail usage and appropriateness upon admission and after a change in condition is reported. RN E expected the usage of bed rails to be included on the care plan for all residents. 5. During an interview on 4/17/24 at 2:45 P.M., Licensed Practical Nurse (LPN) D said nurses are responsible for completing side rail assessments on admission. The assessment should be completed accurately to determine a resident's safety for the use of side rails. The care plan should be updated to reflect the resident's use of side rails. The MDS Coordinator and nurses can update care plans. 6. During an interview on 4/18/24 at 8:44 A.M., RN E said nurses are responsible for completing side rail assessments on admission and upon a change in condition. Side rail assessments should be completed accurately to assess a resident's safety for the use of side rails. The care plan should be updated to show a resident's use of side rails. Care plans are updated by nurses, Social Services, and the Director of Nurses (DON). 7. During an interview on 4/18/24 at 12:21 P.M., the DON and Administrator said nurses are responsible for assessing residents for the use of side rails. It is expected that side rail assessments are completed accurately. Side rail assessments should be completed on admission, quarterly, and if there are any changes with the resident's use of side rails. The care plan should be updated to show a resident's use of side rails. Care plans are updated by the MDS Coordinator.

Based on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 133. Review of the facility's Medication Storage and Destruction Policy, reviewed 1/5/23, showed: -Narcotic and controlled drug storage; -A manual end of shift narcotic count must be completed with the oncoming nurse counting and the outgoing nurse verifying; -Because the narcotics may be stored in a number of different carts, different pairs of nurses may be conducting counts at the different carts; -In the event the nurse must leave prior to the end of their shift, the nurse may count with another nurse and/or supervisor before leaving the facility, and then that nurse/supervisor will conduct the end of shift narcotic count; -Any nurse leaving the facility without properly conducting the narcotic count will receive disciplinary action, up to and including termination; -The Director of Nursing (DON) must ensure the end of shift narcotics count is occurring, and the records of all items dispensed is current, with no missing signatures, and correctly counted. 1. Review of the controlled substance count sheet for the 400 hall, dated 3/1 through 3/31/24, showed a manual end of shift narcotic count was not completed and documented per facility policy when: -Four out of 31 days, staff counted one out of three shifts; -Thirteen out of 31 days, staff counted two out of three shifts; 2. Review of the controlled substance count sheet for the 400 hall, dated 4/1 through 4/15/24, showed a manual end of shift narcotic count was not completed and documented per facility policy when: -One out of 15 days, staff counted one out of three shifts; -Ten out of 15 days, staff counted two out of three shifts; 3. Review of the controlled substance count sheet for the 300 hall, dated 4/1 through 4/15/24, showed a manual end of shift narcotic count was not completed and documented per facility policy when: -Six out of 15 days, staff counted one out of three shifts; -Nine out of 15 days, staff counted two out of three shifts. 4. During an interview on 4/16/24 at 10:41 A.M., Certified Medication Technician (CMT) J said the narcotic count is to be completed with one oncoming staff member and one off-going staff member every shift, every day. 5. During an interview on 4/17/24 at 2:15 P.M., Licensed Practical Nurse (LPN) D said the nurses and the CMTs are to check the narcotic count with one oncoming staff member and one off-going staff member on every shift, every day. If a nurse or CMT leaves before the shift ends, that person is still required to count the narcotics before they leave for the day. 6. During an interview on 4/16/24 at 12:50 P.M., the DON said she expected CMTs and nurses to count the narcotics every day on every shift. The count should be completed with one oncoming staff member and one off-going staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food delivered to residents was palatable and at required temperatures for four residents (Residents #125, #84, #130 and #119) and additional residents who ate in their rooms on the 300 and 400 hallways. The sample was 26. The census was 133. Review of the facility's dietary food preparation policy, dated 7/5/23, showed: -Food temperatures: foods will be served at proper temperature to ensure food safety; -Acceptable serving temperatures are: meat should be higher than 135 degrees Fahrenheit (F) but preferably 160-175 degrees F, potatoes should be higher than 135 degrees F but preferably 160-175 degrees F; -Food tasting: the cook or Dietary Manager will taste food prepared before serving. 1. Review of Resident #125's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/13/24, showed: -Dependent (helper does all of the effort) on assistance with eating; -Diagnoses included stroke, dysphagia (swallowing disorder) following stroke, high blood pressure and diabetes. Observation on 4/15/24 at 9:00 A.M., showed Certified Nurse Aide (CNA) B sat next to the resident's bed, using a plastic fork to scoop food on the resident's Styrofoam plate. CNA B attempted to cut the grits with the fork. The grits appeared rubbery and slid across the plate in a solid unit, unable to be separated with a fork. During an interview, CNA B said he/she was having a hard time cutting up the resident's grits. The resident said the food did not look good. Observation on 4/16/24 at 6:08 P.M., showed CNA A brought a plate of food to the resident's room. The plate contained a beige pureed food, a dark green pureed food, and a scoop of mashed potatoes. CNA A said the beige pureed food appeared to be a meat product, but he/she was not sure what it was. CNA A used a spoon to scoop some of the beige pureed food and held the spoon to the resident's mouth. The resident took a bite, grimaced, and shook his/her head no. The resident said he/she wanted a health shake. During an interview, the resident said the food was not good and had no flavor. 2. Review of Resident #84's quarterly MDS, dated [DATE], showed: -Setup or clean up assistance needed with eating; -Diagnoses included stroke, dysphagia, high blood pressure, diabetes and depression. During an interview on 4/14/24 at 11:03 A.M., the resident said the food served at the facility is nasty. He/She is hungry because he/she cannot eat the food. He/She does not get to choose what he/she eats and cannot ask for anything else. Observation on 4/16/24 at 12:49 P.M., showed the resident sat in his/her room next to a bedside table containing a plate of food. The plate had a scoop of dark green cooked vegetables, a scoop of mashed potatoes, and diced beige meat in a dark brown, oily sauce. During an interview, the resident said the food does not look good. He/She is not sure what the meat is and he/she does not want to eat it. He/She is not given a choice on what to eat at meals. 3. Review of Resident #130's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses of essential hypertension and obesity. During an interview on 4/14/24 at 10:59 A.M., the resident said he/she usually eats in his/her room. He/She said his/her food is frequently lukewarm or cold by the time it is served to him/her. 4. Review of the Resident #119's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses of multiple sclerosis, bipolar disorder, and muscle weakness. During an interview on 4/14/24 at 11:21 A.M., the resident said the food is decent but does not always taste good. He/She said the food temperatures are not always consistent and sometimes his/her meal is cold when delivered. 5. Observation on 4/16/24 at 1:00 P.M. of lunch trays served on the 400 hallway, showed: -Fried chicken measured at 135 degrees F; -Mashed potatoes measured at 127 degrees F, and the taste was bland; -Green beans measured at 130.6 degrees F, and the taste was bland. 6. Observation on 4/17/24 at 1:00 P.M. of lunch trays served on the 300 hallway, showed: -Mushroom steak measured at 120.2 degrees F; -Mashed potatoes measured at 125.0 degrees F. The taste was bland; -Corn measured at 125.0 degrees F. 7. During an interview on 4/17/24 at 2:37 P.M., the Dietary Manager said she expected food served to be palatable and at the required temperatures. She expected for food to look and taste good. She said she does not always taste mechanical food once it is prepared. 8. During an interview on 4/18/24 at 2:07 P.M., the Administrator said she expected for food served to residents to be palatable and at the proper temperatures.

Based on observation, interview and record review, the facility failed to keep the kitchen floor, walk in refrigerator, and appliances clean, and failed to ensure the ice machine had an air gap. The sample was 26. The census was 133. Review of the facility's daily and weekly cleaning schedule, undated, showed: -The floors are to be swept and mopped daily; -The food storage bins are to be cleaned weekly; -The storage racks are to be cleaned weekly; -The kitchen appliances are to be cleaned daily/weekly. 1. Observation on 4/14/24 at 8:16 A.M., showed the following: -The bulk storage room had water pooling on the ground, various trash and food debris littered the floor and beneath the area of the storage rack, and all three bulk bins had dirty lids with a powder substance; -The walk in refrigerator had caked on grime and food debris on the floor and shelves in various areas, and wrapper trash under the storage rack; -The floor in the main part of the kitchen and pots room had food debris and various dried liquid stains. 2. Observation on 4/16/24 at 10:52 A.M., showed the following: -The floors in the main area of the kitchen, bulk storage area, and pots room had various trash items, food debris, and a white powder substance in various areas; -The oven doors were streaked with dried liquid matter. The deep fryer was caked with sticky grease spills on the front and sides; -The walk in refrigerator had caked on food debris on the rack shelves and on the ground in various spots, with trash and wrappers under the racks; -The bulk bin room had trash and a white powder substance on the ground, and the three bulk bins had a powder substance on the lids. 3. During an interview on 4/17/24 at 2:25 P.M., Dietary Aide Q said all dietary staff are in charge of deep cleaning the walk-in refrigerator, floors, and the bulk bin room. He/She said the cook is in charge of cleaning the deep fryer after each use. 4. During an interview on 4/17/24 at 2:33 P.M., the Dietary Manager said all dietary staff are responsible for daily cleaning of the floors and bulk bins. She said the kitchen appliances should be cleaned daily and weekly depending on the level of need. She expected the kitchen and kitchen appliances to be clean. 5. During an interview on 4/18/24 at 2:05 P.M., the Administrator said she expected kitchen staff to follow facility policies and cleaning schedules. She expected the kitchen and appliances to be clean. 6. Observation on 4/14/24 at 8:27 A.M., showed the ice machine in the kitchen did not have an air gap. The piping went straight into the drain. During an interview on 4/17/24 at 7:50 A.M., the Maintenance Director said he was not aware the ice machine in the kitchen did not have an air gap. He expected the ice machine to have an air gap to prevent possible contamination.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) received his/her PRN (administered as necessary) Oxycodone (opioid narcotic used to treat moderate to severe pain) timely. The medication was available in the facility Statsafe (an emergency drug dispensing system containing multiple commonly used medications that requires a code to access), but the nurse on duty did not have the code to access the system to obtain and administer the medication when the resident requested it. Four residents were sampled and problems were found with one. This had the potential to effect any resident with an order for a medication located in the Statsafe system. The census was 128. Review of the resident's admission face sheet, showed: -admission date of 8/25/23; -Diagnoses of malignant (tendency to become progressively worse, metastasize (to spread)) esophageal (esophagus: connects the throat to the stomach) cancer and anemia (a deficiency in the oxygen-carrying component of the blood). Review of the resident's pain evaluation, dated 8/25/23 at 7:07 A.M., showed: -Does the resident have any diagnosis which would give reason to believe they could be in pain?: Yes; -Diagnosis: Esophageal cancer; -What does the pain feel like?: Blank; -Times when pain is worse: Blank; -Pain location: Blank; -Is the resident on a pain management program?: No. Review of the resident's physician's order sheet (POS), showed: -Start Date, 8/25/23: Morphine sulphate 30 milligrams (mg) (opioid (narcotic), used to treat moderate to severe pain), one tablet two times a day. End Date: 8/29/23; -Start Date, 8/25/23: Oxycodone 10 mg/Acetaminophen (Tylenol) 325 mg, one tablet every four hours PRN. End Date: 8/29/23; -Start Date, 8/29/23: Oxycodone 10/325 mg, one tablet every six hours PRN. End Date: 8/31/23; -Start Date, 8/31/23: Oxycodone 10/325 mg, one tablet every four hours PRN. End Date: 10/28/23. Review of the resident's admission Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 9/4/23, showed: -Ability to express ideas and wants: Understood; -Understanding verbal content: Understands, clear comprehension; -Behavioral symptoms: Not exhibited; -Does not reject care; -Pain Management: -At any time in the last 5 days has the resident been on a scheduled pain medication intervention for pain?: No; -Received PRN pain medications?: Yes; -Pain Presence?: No; -High-Risk Drug Classes: Opioids (narcotic pain medication): Blank. Review of the resident's care plan, showed: -Problem: Terminal prognosis related to esophageal cancer. Currently receiving Hospice services. Desired Outcomes: The resident's comfort will be maintained. The resident's dignity and autonomy will be maintained at highest level through the review date; -Interventions: Assess resident's coping strategies and respect resident's wishes. Consult with physician and social services to have Hospice care for resident in the facility. Observe the resident closely for signs of pain, administer pain medications as ordered, and notify the physician immediately if there is breakthrough pain. Work with nursing staff to provide maximum comfort for the resident; -Problem: Activity of daily living (communication, walking, dressing, toileting, etc.) varies due to his/her terminal prognosis. Desired Outcomes: Resident will maintain current level of function; -Interventions: Encourage resident to participate to the fullest extent possible with each interaction. Monitor/document/report any changes, any potential for improvement, reason for self-care deficit, expected course, declines in function; -Problem: Receiving PRN pain medication as well as scheduled Fentanyl (Opioid) patches. Desired Outcome: Resident will be free from any discomfort or adverse side effects from pain medication; -Intervention: Administer pain medications as ordered by physician. Review of the resident's POS, showed: -Start Date, 9/8/23: Fentanyl transdermal patch (patch that contains and delivers medication through the skin) 25 micrograms (mcg), change every 72 hours. End Date: 9/26/23; -Start Date, 9/26/23: Fentanyl transdermal patch 50 mcg, change every 72 hours. Review of the resident's medication administration record (MAR), showed: -10/1/23 through 10/27/23, the resident received 21 doses of Oxycodone 10/325; -The last dose was administered on 10/27/23 at 8:45 P.M. Review of the resident's progress note's, showed: -10/28/23 (Saturday) at 5:25 A.M., and documented by agency Nurse C: Call out to Hospice nurse (Hospice Nurse D) regarding Oxycodone orders. Awaiting return call; -10/28/23 at 5:40 A.M., and documented by agency Nurse C: Spoke to Hospice Nurse D regarding Oxycodone orders. Nurse will follow-up with pharmacy on Monday (10/30/23); -10/28/23 at 7:01 A.M., and documented by agency Nurse C: Spoke with resident regarding his/her orders for Oxycodone-Acetamenaphen and informed him/her Hospice Nurse D will follow-up on medication. Tylenol offered to resident, but resident refused; -10/28/23 at 7:09 A.M., and documented by agency Nurse C: Call out to Hospice Nurse D regarding pain medication. Resident very upset and has family calling facility about pain medications. Spoke to resident personally and informed him/her we would need to clarify order before giving medication. Spoke to Hospice Nurse D again and was told he/she would have to reach out to the physician to obtain orders. This nurse will follow-up with day shift manager as well; -10/28/23 at 8:00 A.M., and documented by Nurse B: Resident came to this nurse and verbalized he/she is pissed because he/she didn't get his/her pain pill. This nurse explained to him/her that Nurse B is waiting for the confirmation order from Hospice for Oxycodone, since the resident refused to take the Acetaminophen. 8:15 A.M., contacted the Hospice nurse waiting call back. 8:33 A.M., received a call back from Hospice nurse and confirmed with him/her Oxycodone 10 mg every four hours PRN for pain. 9:25 A.M., resident ate his/her breakfast and came to this nurse and took his/her medications; -10/28/23 at 10:01 A.M., and documented by Nurse B: New order to discontinue the Oxycodone 10/325 mg, and start Oxycodone 10 mg, one tablet every four hours PRN. Review of the resident's Hospice progress note's, showed: -Start of Care: 8/31/23; -10/28/23, no time indicated, a handwritten progress note, documented by Hospice Nurse D: New order to discontinue Oxycodone 10/325 mg, one tab every four hours PRN. Start Oxycodone 10 mg, one tab every four hours PRN; -10/28/23, no time indicated, a typed progress note and documented by Hospice Nurse D: Follow-up with pain management, and clarification of medication. Resident had order for Oxycodone 10/325 mg, one tab every four hours PRN. Report from facility nurse (agency Nurse C), the medication that was on hand was Oxycodone 10 mg, every four hours PRN. Reports resident refused Tylenol 650 mg PRN until medication order clarified. Notified physician and orders were given to give Oxycontin (brand name for Oxycodone) 10 mg, every four hours PRN. Resident alert and oriented. Anxious while explaining today's events. Resident had PRN Ativan (antianxiety medication) prior to arrival. Resident also had Oxycontin 10 mg for pain. Given resident plenty of time to express himself/herself. States he/she just smoked three cigarettes which helped. All concerns addressed and resident is comfortable now. During a telephone interview on 11/16/23 at 10:06 A.M., agency Nurse C said he/she had been working at the facility on and off for about a year. He/She worked the 7:00 P.M. to 7:00 A.M. shift. He/She came to work around 7:00 P.M. on 10/27/23, and left a little bit after 7:00 A.M. on 10/28/23. The resident slept most of the night that shift. He/She went into the resident's room between 4:00 A.M. and 4:30 A.M., to flush his/her gastrostomy tube (a tube inserted into the stomach through the abdomen) and that's when the resident asked for his/her Oxycodone. When he/she went to get the Oxycodone from the narcotic drawer on the medication cart, he/she found Oxycodone 10 mg available, but the order was for Oxycodone 10/325 mg. He/She was not given an access code to access the Statsafe. The last time he/she needed a medication from the Statsafe system was several months ago for a different resident that needed an antibiotic or pain medication, he/she could not recall. When he/she called the supervisor on-call, he/she was told he/she could not have the access code, and the resident would have to wait until someone authorized came in the next morning. That was why he/she did not call the Director of Nurses (DON) or supervisor on-call and called Hospice Nurse D instead. He/She thought he/she could get the resident's medication faster. He/She called Hospice Nurse D and asked him/her to change the order to Oxycodone 10 mg, but the Hospice nurse said he/she would have to call the Hospice physician to have the order changed. He/She was not able to give Resident #1 his/her Oxycodone before he/she left that morning. Review of the facility's Statsafe, showed it contained Oxycodone 10 mg, 8 tablets. Review of the resident's POS, showed start date, 10/28/23: Oxycodone 10 mg, one tablet every four hours PRN. Review of the resident's MAR, showed: -10/28/23 through 10/30/23, the resident received 3 doses of Oxycodone 10 mg; -The first dose was administered on 10/28/23 at 9:24 A.M., approximately five hours after the resident requested the medication. During a telephone interview on 11/16/23, at 1:02 P.M., Hospice Nurse D said the resident's order was for Oxycodone 10/325 mg. Hospice provided the resident's medication. He/She had no idea how the resident had the Oxycodone 10 mg on hand rather than Oxycodone 10/325 mg. He/She had to have the physician change the resident's order to Oxycodone 10 mg every four hours PRN. The resident said he/she always had a lot of pain, but did not have visible signs of pain. It never changed from visit to visit. During an interview on 11/15/23 at 8:30 A.M., Nurse B said the resident requested to go to the hospital yesterday due to having thick phlegm in his/her throat. He/She had not returned yet. The resident complained of esophageal and leg pain frequently and would usually ask for the Oxycontin every four to six hours. During an interview on 11/15/23 at 11:18 A.M., Nurse A said he/she admitted the resident on 8/25/23. On admission the resident was not complaining of pain. A couple of days later the resident began to complain of pain and requested his/her PRN pain medications. Since then, the resident asked for his/her PRN Oxycontin routinely. Hospice provided the Oxycontin. The resident also had a fentanyl patch for pain. During a telephone interview on 11/16/23 at 10:37 A.M., the DON said there were two nurses on duty on the 7:00 P.M. to 7:00 A.M. shift on 10/28/23. Neither one had access to the Statsafe. She would have expected Nurse C to have called her. She could have given the access code over the phone. Currently, only she and three other nurses, one of which was a part-time nurse, had access to the Statsafe. She was going to start scheduling at least one nurse with access to the Statsafe on every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update care plans for two residents with falls (Residents #9 and #8). The sample was 9. The census was 130. Review of the facility's Comprehensive Care Plans and Baseline Care Plans, dated 1/19/22, showed the following: -Purpose: The purpose of this policy is ensure that the facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment; -Procedure: Comprehensive Care Plan; 1. A licensed nurse, that has been designated by the facility administration will coordinate each assessment with the appropriate participation of health professionals otherwise known for the purposes of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff)/Care Planning process the Interdisciplinary Team (IDT). This team shall include but not limited to MDS, Social Services, Dietary, Physical Therapy, Occupational Therapy, Speech Therapy, Activities and various staff of nursing; 2. Daily nursing meetings will occur Monday through Friday with a review of the resident's medical, functional and psychosocial problems. From this meeting, information will be individualized to the resident's plan of care. On Monday morning, the resident's status will be reviewed from the weekend to ensure all areas that need to be assessed for care plan needs are addressed; 3. The care plan will be oriented toward: offering alternative treatments and the care plan will be updated toward preventing declines in functioning, will reflect on managing risk factors and building on resident strengths. Review of the facility's Focus Risk Assessment Plan Scope/Severity for Falls (FRAPSS), revised date 7/9/2021, showed the following: -Purpose: To assess all residents for potential for falls in the facility. To ensure a comprehensive interdisciplinary plan of care is established for all resident who are identified for increased risk of falls. To identify precipitating factors for fall risk and to be proactive in implementing interventions to prevent or reduce the incident for further falls; -Procedure: Focus Risk Assessment Plan Scope/Severity for falls: 1. Resident will be assessed using the FRAPSS form fall risks upon admission, quarterly and in an acute situation where resident has fallen. The FRAPSS assessment guide measures area of precipitating factors such as age, use of assistive devices, diagnoses, medical antecedents, history of previous falls, sensory deficits, medications, and resident compliance with prescribed orders. Every resident who has a fall including those without injury will be screened by the therapy department and nursing interventions will be put in place to reduce the resident of further falls; 2. Nursing interventions will be individualized and addressed on the care plan for the resident. These interventions can be added to any FRAPSS level and may include but are not limited to the following: low bed, mattress on floor by bed, visual checks by nursing or intensive monitoring of the resident; -The policy did not define red risk. 1. Review of Resident #9's admission MDS, dated [DATE], showed the following: -Required limited assistance for most activities of daily living (ADLs); -Diagnoses included high blood pressure and diabetes; -Two or more falls with no injury. Review of the resident's care plan, dated 12/3/22, showed the following: -Problem: Resident is a FRAPSS risk for falls regards to gait balance problems. Unaware of safety need and wandering and chronic falls; -Desired Outcome: The resident will be free of minor injury and sustain serious injury through the next review date; -Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Educate the resident, family, caregivers about safety reminders and what to do if a falls occurs and follow the facility fall protocol. Review of the resident's progress notes, showed the following: -3/12/23 at 9:52 P.M., a staff member went to check on the resident at 8:15 A.M. The resident was observed laying on floor next to his/her bed sleeping with his/her left arm under his/her head. The resident said he/she rolled out of bed. The resident's bed was low to the floor. The resident said he/she was trying to go to bathroom. The resident had urine on floor. The resident had no injury noted, no complaint of pain and no signs or symptoms of distress. The resident refused to go to hospital to be evaluated. The resident was able to move all extremities without difficulty; -3/17/23 at 7:00 A.M., this writer walked into resident's room due to his/her roommate calling out. This writer observed the resident laying on floor. The resident said he/she rolled out of bed. The resident was asked if he/she hit his/her head and the resident said no. The resident refused to go to hospital for evaluation. The resident denies any pain or discomfort. The resident's physician and family was informed of incident. The resident was put back into bed; -3/25/23 at 2:00 P.M., the resident was observed by another resident while walking by and saw the resident slide to the floor out of bed, at 1:45 P.M. The resident was observed by this nurse when walking into his/her room. The resident was sitting on his/her buttocks next to bottom of his/her bed. The resident got him/herself up off of the floor with minimal assistance from a staff member. The resident said he/she was trying to go to bathroom with slippery socks on and without shoes. The resident had no injury noted and no discoloration. The resident was able to move all extremities without difficulty. The resident had no complaint of pain and no sign or symptoms of distress. The resident has been educated numerous times to ask for assistance. The resident continues to refuse and tries to get up on his/her own. This nurse asked family not to bring anymore slippery white socks to the resident. The resident's family still did bring in socks. This nurse educated family member to please let staff put non-skid socks on the resident, so it can help keep the resident from falling. The family member understood; -4/14/23 at 1:05 A.M., this writer was called into resident's room by a certified Nurses Aide (CNA) due to the resident being on floor. This writer observed resident on the floor laying on his/her right side. The resident said he/she was trying to go to bathroom and slipped. The resident said he/she hit his/her head. The resident was noted to have bleeding and abrasions to his/her right ear and complained of pain to right inner thigh of a level six for pain. The resident remains alert and oriented times four (to person, place, time and situation) and able to voice concerns. Passive ROM was completed with all extremities within normal limits. The resident has agreed to go to hospital for evaluation. The resident was escorted to bathroom by staff and dressed for transporting; -4/16/23 at 4:00 P.M., the resident was readmitted from the hospital; -4/21/23 at 6:09 A.M., EMS arrived at the facility at 5:36 A.M. The resident is going to the hospital to be evaluated. The resident's bleeding subsided to his/her nose. The resident's bed was in a low position with a helmet on the resident. The resident rolled out of bed and bumped his/her nose on night stand. EMS was called and the resident will be transported to the hospital. The resident's physician and family member was made aware; -4/21/23 at 4:50 P.M., the resident returned to facility at 10:45 A.M., with no complaint of pain, no sign or symptoms of distress. The resident had a laceration to top of his/her nose with no active bleeding noted. The emergency room put a skin adhesive to the laceration. The resident was observed walking behind his/her wheelchair when he/she came back from the hospital. This nurse educated the resident on not walking behind his/her wheelchair due to safety risk. The resident did have helmet in place. The resident did not want to sit in his/her wheelchair. This nurse had to redirect resident and the resident finally sat down in his/her wheelchair. The resident able to move all extremities without difficulty. -4/27/23 at 6:45 A.M., the resident's neighbor came to nursing station due to hearing something fall in resident's room. As this writer approached the room, resident was observed to be on right side of his/her bed on the floor. The resident had urine on floor next to him/her. The resident denies hitting his/her head or any pain. The resident is noted to have left side bruising and complaint of right knee up to right thigh pain. The resident remains alert and oriented and able to make his/her needs known. Passive ROM to upper and lower extremities within normal limits and resident remains weight bearing. The resident's physician was called and a new order to send the resident out to hospital for evaluation. The resident may have bed rails for safety. The resident's family member has been informed of the incident and being transferred to the hospital for evaluation; -4/27/23 at 7:30 P.M., the resident returned from hospital via EMS. This writer received no discharge paperwork from EMS, only verbal of no new orders and there was no new findings. This writer called the hospital for clarification, received no new orders per the hospital nurse. The resident remains alert and oriented and able to make needs known. The resident voices no pain or discomfort at this time. The resident was put in bed (center), with the bed low to the ground for safety and the call light within reach. Review of the resident's care plan showed no documentation regarding new interventions for the previous falls. During an interview on 5/1/23 at 11:05 A.M., the resident's roommate said the resident tries to get out of bed all the time and probably needs side rails so the resident does not fall. The resident has fallen numerous time and the facility has not done anything about it. Observation at that time, showed the resident did not have siderails on his/her bed. While the resident sat in his/her wheelchair, an attempt was made to interview the resident but he/she mumbled and seemed very confused. During an interview on 5/1/23 at 11:14 A.M., CNA B said the resident has a history of falls. The intervention is to keep an eye on the resident and make sure the resident has his/her helmet in place. CNA B said the resident will not keep still and goes back and forth to bed. He/She will get instructions of new interventions from the charge nurse. CNA B said he/she did not know of any new interventions. During an interview on 5/1/23 at 11:19 A.M. Nurse C said they have tried the helmet and removing the mat so the resident will not trip. The resident will sleep all day and be up all night, wandering in his/her room. Nurse C did not know of any new interventions for the resident. The interventions should be on the resident's care plan. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No moods or behaviors; -Required limited assistance with transfers, with one person physical assist; -Diagnoses included congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should), high blood pressure and malnutrition; -One fall with no injury. Review of the resident's care plan, revised date 12/30/22, showed the following: -Problem: Resident is FRAPSS red risk for falls with regards to gait balance problems. Psychoactive drugs use, unaware of safety needs. The resident often places him/herself on the floor mat next to his/her low bed and at times will scoot to the hallway; -Desired Outcome: Resident will be free of minor injury and will not sustain serious injury through the next review date; -Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Follow the facility's fall protocol. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Also remove any potential causes if possible. Educate the resident/family/caregiver/IDT as to causes. Review of the resident's progress notes, showed the following: -4/11/23, at 4:21 P.M., at approximately 2:00 P.M., the resident was witnessed by the CNA sitting back into his/her chair and missed chair and fell onto his/her buttocks. The resident had no injury noted. An assessment completed and no change in range of motion of extremities, no bruising or redness noted and the resident had no facial grimacing; -4/13/23 at 12:00 P.M., the nurse was summoned to location near aspiration (dining) room. The Resident Care Manager (RCM) said the resident was sitting on his/her bottom up against his/her wheelchair. The RCM said he/she was walking down hallway and noted the resident rolling down the hallway, then the resident proceeded to try and stand up and the wheelchair rolled from under him/her and he/she fell into fire door hitting his/her head. The resident was assessed with no bleeding or bruising noted to his/her head. The nurse holding both hands of the resident, the resident came into a standing position and denied any pain or discomfort. The resident was assisted off the floor with two staff members assisting he/her back into his/her wheelchair. The resident remains at baseline orientation of alert and oriented to self; -4/15/23 at 9:43 A.M., the nurse was called to resident's room by a housekeeper. The resident was lying on the floor next to his/her roommate's bed on his/her right side. The resident had several small drops of wet blood next to his/her head. The housekeeper said he/she was walking by and witnessed this resident sitting on the bed leaning to the right, and then fell onto the floor. He/She did not witness this resident hit anything other than the floor. A laceration to the right eyebrow measuring approximately five centimeters (cm). The bleeding quickly subsides with pressure in place, then a pressure dressing was applied. The resident refused to keep dressing in place. The resident refused to sit down to complete all of needed assessments. Staff was assigned to one on one until further notice. The resident had no other visible injuries. Normal range of motion (ROM) of all extremities noted with no cognitive changes. The Emergency Medical Services (EMS), the resident's physician and the Director of Nursing (DON) and family were notified. EMS arrived at 9:35 A.M. to take the resident to the hospital; -4/15/23 at 9:00 P.M., the resident returned via EMS on a stretcher with two assist to facility at approximately 8:00 P.M. from hospital with no new orders and a dressing covered to his/her right eyebrow and swelling noted to right side of face. Review of the resident's care plan, showed no documentation regarding new interventions for previous falls. During an interview on 5/1/23 at 1:07 P.M., Nurse A said the resident would get up alone and try to walk without assistance. Nurse A said he/she would stop the resident and have a CNA walk with the resident to ensure the resident would not fall. If the resident did fall, the resident would be sent to the hospital for evaluation due to his/her age. Nurse A did not know of any new interventions for the resident. Nurse A said someone from the upstairs management would inform him/her of any new interventions. New interventions should be on the resident's care plan. Nurse A did not know the name of the person in upstairs management who would add new interventions. During an interview on 5/1/23 at 1:36 P.M., the Administrator said she did not know about the order for the bedrails. The DON should have been made aware of the order and after the resident was assessed for bedrails, Maintenance would have been notified to put them in place. 3. During an interview on 5/1/23 at 1:36 P.M., the Administrator said the Care Plan Coordinator, who is part time and not present today, should complete the MDS assessment, update the care plan with new interventions and communicate the interventions to the Charge Nurse and the nursing management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide protective oversight for one of nine sampled residents (Resident #2) with a history of suicidal ideation who asked another resident (Resident #3) to purchase antifreeze (ethylene glycol). On 3/1/23, Resident #3 reported to the facility that Resident #2 gave him/her money to purchase antifreeze. Resident #2 was sent to the hospital on 3/1/23 for treatment and evaluation of mental status and returned to the facility on 3/7/23. During this time, the facility failed to educate and update the care plan of Resident #3 on the importance not purchasing harmful items for other residents. Resident #3 said he/she purchased the antifreeze and gave it to Resident #2. On 3/12/23, Resident #2 had a mental status change and was sent to the hospital for treatment. At the hospital, the resident was intubated and found to have elevated ethylene glycol levels and had to be admitted to Medical Intensive Care Unit (MICU). In addition, the facility failed to update care plans and place new interventions regarding one closed record resident review (Resident #8) and one resident (Resident #9), who each had multiple falls. The sample size was 9. The census was 130. Review of the facility's Comprehensive Care Plans and Baseline Care Plans, revision dated 1/19/22, showed the following: -Purpose: The purpose of this policy is ensure that the facility must develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment; -Procedure: Comprehensive Care Plan; 1. A licensed nurse, that has been designated by the facility administration will coordinate each assessment with the appropriate participation of health professionals otherwise known for the purposes of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff)/Care Planning process the Interdisciplinary Team (IDT). This team shall include but not limited to MDS, Social Services, Dietary, Physical Therapy, Occupational Therapy, Speech Therapy, Activities and various staff of nursing; 2. Daily nursing meetings will occur Monday through Friday with a review of the resident's medical, functional and psychosocial problems. From this meeting, information will be individualized to the resident's plan of care. On Monday morning, the resident's status will be reviewed from the weekend to ensure all areas that need to be assessed for care plan needs are addressed; 3. The care plan will be oriented toward: offering alternative treatments and the care plan will be updated toward preventing declines in functioning, will reflect on managing risk factors and building on resident strengths. Review of the facility's Focus Risk Assessment Plan Scope/Severity for Falls (FRAPSS), revised dated 7/9/2021, showed the following: -Purpose: To assess all residents for potential for falls in the facility. To ensure a comprehensive interdisciplinary plan of care is established for all resident who are identified for increase risk of falls. To identify precipitating factors for fall risk and to be proactive in implementing interventions to prevent or reduce the incident for further falls; -Procedure: Focus Risk Assessment Plan Scope/Severity for falls: 1. Resident will be assessed using the FRAPSS form fall risks upon admission, quarterly and in an acute situation where resident has fallen. The FRAPSS assessment guide measures area of precipitating factors such as age, use of assistive devices, diagnoses, medical antecedents, history of previous falls, sensory deficits, medications, and resident compliance with prescribed orders. Every resident who has a fall including those without injury will be screened by the therapy department and nursing interventions will be put in place to reduce the resident of further falls; 2. Nursing interventions will be individualized and addressed on the care plan for the resident. These interventions can be added to any FRAPSS level and may include but are not limited to the following: low bed, mattress on floor by bed, visual checks by nursing or intensive monitoring of the resident. 1. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Independent with activities of daily living (ADLs); -Diagnoses included cancer, high blood pressure, anxiety, depression and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Review of the resident's medical record, showed the following: -3/1/12 at 6:24 P.M., Another resident informed this nurse that the resident wanted antifreeze to be purchased for him/her. This nurse along with the Director of Nursing (DON) asked the resident what was the reason for the antifreeze? The resident said, I want to kill myself, with the reasons given of not being able to leave facility, visit family, or have freedom. The DON informed resident that his/her guardian will be contacted for lesser restrictions to be applied as well. The resident's Nurse Practitioner (NP) with psychiatric was made aware and a new order was received for the resident to be evaluated for suicidal ideation with a plan. The resident's guardian was made aware and the NP with the resident's primary care physician was also made aware. The resident is currently on close monitoring while awaiting arrival of ambulance services. The resident was transferred to emergency room via stretcher accompanied by two emergency medical technicians at approximately 8:00 P.M. Review of the resident's care plan, dated 3/1/23, showed the following: -Problem: Resident having suicidal ideation with a plan; -Desired Outcome: Provide protective oversight; -Interventions: Immediate one on one monitoring until discharge hospital and received orders to send resident to the hospital for evaluation of suicidal ideation with a plan. Review of the resident's medical record showed the following: -3/7/23 at 1:24 P.M., the resident was readmitted to the facility. The resident is in good spirits and smiling. This writer spoke with the resident regarding the hospital stay and how it went. The resident said he/she was excited about the things he/she was getting ready to be involved in. The resident inquired about a day program and outside privileges. The resident was asked how he/she was feeling and the resident said he/she felt great. The resident was asked if he/she was still having the feeling of not wanting to live? The resident said he/she was not. The resident was asked if he/she felt suicidal at anytime, would he/she come to staff and the resident said yes. The resident said he/she was happy to be back in the facility. The staff will continue to monitor the resident; -3/9/23 at 3:30 A.M., the Social Service Director (SSD) met with the resident regarding his/her psychosocial well being and his/her recent hospital stay for suicidal ideation. The resident appeared to be happy and smiling, and said he/she sometimes gets sad, and he/she misses his/her family, but he/she is ok now. The SSD asked him/her if there is anything the facility could provide that would alleviate some of those negative feelings. The resident said he/she needs more freedom, and he/she misses his/her family. The SSD then spoke to the resident about any internal coping skills he/she uses to feel better when he/she gets sad. The resident said that he/she reads her bible and gratitude list that he/she developed during the self-help group he/she attends on Thursdays. The SSD assured the resident that if he/she ever needed to talk to someone about his/her feelings of sadness, the SSD would be available. The resident agreed. The SSD will continue to monitor the resident's behaviors, reach out to his/her guardian to inquire about the possibility of some limited movement away from the facility and reach out to any family members for added support; -11:00 A.M., the resident is up with no difficulty or complaints. The DON met with the resident and the resident was happy and discussed day program attendance. The resident was wanted to live in a group home until able to live on her own. The resident understands his/her guardian had approve the request he/she is making. The resident said he/she was happy that things were moving forward. The resident shared that his/her family would be coming to see him/her with other members of the family this summer and the resident was excited; -3/10/23 at 4:53 P.M., the nurse met with resident for a wellness check. The resident was in good spirits and socializing. The resident asked this nurse could he/she attend church and this nurse notified him/her that the facility will reach out to the resident's guardian for permission. The resident was ok with that and said he/she really wanted to go. The nurse reached out the resident's guardian via email and waiting a response. It was discussed with the resident that expressed interest in the day program that he/she was not accepted because of his/her insurance. The nurse notified the resident's guardian as well. The resident spoke on wanting to see progress in his/her life and let's get start with requesting small outings like 30 minutes to an hour out of the facility. The nurse reiterated to the resident that elopement is in his/her file but that can be changed because it has not occurred since the last incident two years ago. Also, the resident is interested in his/her own apartment. It was explained to the resident that getting an apartment was a process but it can be done. The SSD and the resident's guardian will be informed of the resident's wishes. The resident was assured the facility would reach out to the resident's guardian for privileges; -7:00 P.M., the resident was made aware his/her guardian has not responded but the facility will continue to wait for a response of the resident's request. The resident was satisfied; -3/12/23, at 3:33 A.M., the resident came to nurse with complaint of indigestion. The resident was administered as needed (PRN) Mylanta (over-the-counter medication for digestive problems,); -3:35 A.M., the nurse looked in on the resident to assess the effectiveness of Mylanta. The resident was in bed resident quietly with no sign of distress; -7:72 A.M., the nurse was called to the resident's room. Upon arrival, the nurse witness the resident rolling all over the bed with emesis times one. The resident was unable to get in the bed properly. The resident had thrown all of his/her belongings all over the room. The resident could not speak properly. The resident had a complete mental status change. A call was made to the DON and she gave instruction to send the resident out 911. A call was made for transport. An ambulance arrived to transport the resident via stretcher with four emergency medical technicians. Review of the resident's hospital records, dated 3/12/23, showed the following: -Chief Complaint: Altered Mental Status -History of Present Illness: The resident was found at his/her care facility altered and naked after last being seen the night prior. There is documentation of prior suicidal ideation involving drinking antifreeze. He/She was brought to the emergency room and found to be obtunded (diminished responsiveness to stimuli, often due to a state of reduced consciousness) requiring intubation. The resident was treated empirically (originating in or based on observation or experience) with fomepizole (used as an antidote in confirmed or suspected methanol or ethylene glycol poisoning) while awaiting confirmatory testing and eventually was found to have markedly elevated ethylene glycol levels. Renal was consulted and the resident was transferred to the MICU for further care. During an interview on 4/17/23 at 10:20 A.M., the resident said he/she was doing ok. The resident said he/she tried to commit suicide by drinking some antifreeze because he/she was depressed. The resident said Resident #3 bought the antifreeze for him/her. The resident did not remember when he/she got the antifreeze. The resident said the antifreeze was in a regular size gallon bottle. Once he/she drank the antifreeze, he/she threw the bottle in the 300 hall dining room trash can. Observation at that time, with a staff escort, showed the resident walked to the 300 hall dining room and pointed to a large trash can in the dining room. The resident said he/she did not tell anyone about wanting to commit suicide because the last time the facility sent him/her hospital. There was nothing anyone could do to make him/her feel better. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -No behaviors; -Independent with ADLs; -Diagnoses included high blood pressure, depression and schizophrenia. Review of the resident's medical record, showed the following: 3/13/23, at 4:12 P.M., On March 1, 2023 this writer spoke with resident while sitting out in the smoking area. He/she came up to this writer and said that old crazy guy/girl asked me to go to the store and purchase him/her some anti-freeze. The resident was asked who he/she was talking about, and the resident said the peer's name. This writer asked why he/she would need anti-freeze when he/she doesn't have a car. I told the resident he/she should give him/her the money back and he/she said, I got to get my cut first. This writer went up front and stop by the DON office before leaving for the day and relayed my conversation with this resident to the administrator and DON and then left for the day. Review of the resident's medical record, showed no documentation addressing the resident on purchasing contraband for other residents until 3/13/23. During an interview on 4/17/23 at 10:14 A.M., the resident said he/she was getting the anti-freeze for Resident #2 to put in their car. Resident #2 has just come back from the hospital and reminded him/her about the money. The resident said he/she did not remember the day, but he/she went and got the anti-freeze that day. The resident said he/she came back to the facility, got buzzed in the front door by staff and went to Resident #2's room. The resident said no one checks his/her bags. Resident #2 was busy at that time so he/she came back later and gave Resident #2 the antifreeze. No one searched him/her when he/she came back to the facility and no one said anything about not buying things for another person. The resident feels staff lie on him/her. During an interview on 4/19/23 at 10:00 A.M., Receptionist E said when residents come back from outside privileges, he/she will check their bags for contraband. Receptionist E knows Resident #3 and he/she would check his/her bags. Receptionist E would have noticed if Resident #3 brought in antifreeze. Other staff who work the front know to check resident bags. During an interview on 4/19/23 at 1:27 P.M., Staff Member (SM) D said he/she was socializing with the residents in the smoke area and Resident #3 came up to him/her with a hand full of money and said this crazy guy/girl wants me to go buy anti-freeze for him/her. SM D asked the resident who he/she was referring to and the resident said Resident #2. SM D told the resident he/she should not be buying anything for another resident and should give the money back. SM D went to the Administrator's office but the door was closed. He/she then went to the DON's office and the DON and Administrator were both there so he/she reported the conversation and left the facility. SM D said later the DON told him/her Resident #3 gave the money back to Resident #2. SM D said he/she does not do much documentation. The DON asked him/her to put a note into Resident #3's medical record of what happen so he/she did. During an interview on 4/19/23 at 1:50 P.M., the DON said she did not address the issue of the anti-freeze with Resident #3. The DON said her main concerns were getting Resident #2 taken care of and safe. The DON said she saw Resident #3 give Resident #2 the money back. At that time, Resident #2's room was across from her office. The DON said she thought Resident #3 did the right thing by reporting so there was no further concern. During an interview on 5/1/23 at 1:36 P.M., the Administrator said Resident #2 is still on one on one monitoring. Resident #3 had a history of coming back to the facility intoxicated so she would not think the resident would bring alcohol back to the facility. The Administrator said she did not think the resident would bring antifreeze into the facility. The Administrator said she did not know how much they are able to search a resident other than looking through their bags. 3. Review of Resident #8's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No moods or behaviors; -Required limited assistance with transfers, with one person physical assist; -Diagnoses included congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should), high blood pressure and malnutrition; -One fall with no injury. Review of the resident's care plan, revised date 12/30/22, showed the following: -Problem: Resident is FRAPSS red risk for falls with regards to gait balance problems. Psychoactive drugs use, unaware of safety needs. The resident often places him/herself on the floor mat next to his/her low bed and at times will scoot to the hallway; -Desired Outcome: Resident will be free of minor injury and will not sustain serious injury through the next review date; -Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is with reach and encourage the resident to use it for assistance as needed. The resident's needs prompt response to all requests for assistance. Follow the facility's fall protocol. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate the resident/family/caregiver/IDT as to causes. Review of the resident's progress notes, showed the following: -4/11/23, at 4:21 P.M., at approximately 2:00 P.M., the resident was witnessed by Certified Nurse Aide (CNA) sitting back into his/her chair and missed chair and fell onto his/her buttocks. The resident had no injury noted. An assessment completed and no change in range of motion of extremities, no bruising or redness noted and the resident had no facial grimacing; -4/13/23 at 12:00 P.M., the nurse was summoned to location near aspiration room. The Resident Care Manager (RCMP) said the resident was sitting on his/her bottom up against his/her wheelchair. The RCMP said he/she was walking down hallway and noted the resident rolling down the hallway then the resident proceeded to try and stand up and the wheelchair rolled from under him/her and he/she fell into fire door hitting his/her head. The resident was assessed with no bleeding or bruising noted to his/her head. The nurse holding both hands of the resident, the resident came into a standing position and denied any pain or discomfort. The resident was assisted off the floor with two staff members assisting he/her back into his/her wheelchair. The resident remains at baseline orientation of alert and oriented to self; -4/15/23 at 9:43 A.M., the nurse was called to resident's room by a housekeeper. The resident was lying on the floor next to his/her roommate's bed on his/her right side. The resident had several small drops of wet blood next to his/her head. The housekeeper said he/she was walking by and witnessed this resident sitting on the bed leaning to the right, and then fell onto the floor. He/she did not witness this resident hit anything other than the floor. A laceration to the right eyebrow measuring approximately five centimeters (cm). The bleeding quickly subsides with pressure in place, then a pressure dressing was applied. The resident refused to keep dressing in place. The resident refused to sit down to complete all of needed assessments. Staff was assigned to one on one until further notice. The resident had no other visible injuries. Normal ROM of all extremities noted with no cognitive changes. The Emergency Medical Services (EMS), the resident's physician and the DON and family were notified. EMS arrived at 9:35 A.M. to take the resident to the hospital; -4/15/23 at 9:00 P.M., the resident returned via EMS on a stretcher with two assist to facility at approximately 8:00 P.M. from hospital with no new orders and a dressing covered to his/her right eyebrow and swelling noted to right side of face. Review of the resident's care plan, showed no documentation regarding new interventions for previous falls. During an interview on 5/1/23 at 1:07 P.M., Nurse A said the resident would get up alone and try to walk without assistance. Nurse A said he/she would stop the resident and have a CNA walk with the resident to ensure the resident would not fall. If the resident did fall, the resident would be sent to the hospital for evaluation due to his/her age. Nurse A did not know of any new interventions for the resident. Nurse A said someone from the upstairs management would inform him/her of any new interventions. New interventions should be on the resident's care plan. 4. Review of Resident #9's admission MDS, dated [DATE], showed the following: -Requires limited assistance for most ADLs; -Diagnoses of medically complex conditions, high blood pressure and diabetes; -Two or more falls with no injury. Review of the resident's care plan, dated 12/3/22, showed the following: -Problem: Resident is a FRAPSS risk for falls regards to gait balance problems. Unaware of safety need and wandering and chronic falls; -Desired Outcome: The resident will be free of minor injury and sustain serious injury through the next review date; -Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Educate the resident, family, caregivers about safety reminders and what to do id a falls occurs and follow the facility fall protocol. Review of the resident's medical record, showed the following: -3/12/23 at 9:52 P.M., a staff member went to check on the resident at 8:15 A.M. The resident was observed laying on floor next to his/her bed sleeping with his/her left arm under his/her head. The resident said he/she rolled out of bed. The resident's bed was low to the floor. The resident said he/she was trying to go to bathroom. The resident had urine on floor. The resident had no injury noted, no complaint of pain and no signs or symptoms of distress. The resident refused to go to hospital to be evaluated. The resident was able to move all extremities without difficulty; -3/17/23 at 7:00 A.M., this writer walked into resident's room due to his/her roommate calling out. This writer observed the resident laying on floor. The resident said he/she rolled out of bed. The resident was asked if he/she hit his/her head and the resident said no. The resident refused to go to hospital for evaluation. The resident denies any pain or discomfort. The resident's physician and family was informed of incident. The resident was put back into bed; -3/25/23 at 2:00 P.M., The resident was observed by another resident while walking by and saw the resident slide to the floor out of bed, at 1:45 P.M. The resident was observed by this nurse when walking into his/her room. The resident was sitting on his/her buttocks next to bottom of his/her bed. The resident got him/herself up off of the floor with minimal assistance from a staff member. The resident said he/she was trying to go to bathroom with slippery socks on and without shoes. The resident had no injury noted and no discoloration. The resident was able to move all extremities without difficulty. The resident had no complaint of pain and no sign or symptoms of distress. The resident has been educated numerous times to ask for assistance. The resident continues to refuse and tries to get up on his/her own. This nurse asked family not to bring anymore slippery white socks to the resident. The resident's family still did bring in socks. This nurse educated family member to please let staff put non-skid socks on the resident, so it can help keep the resident from falling. The family member understood; -4/14/23 at 1:05 A.M., this writer was called into resident's room by a CNA due to the resident being on floor. This writer observed resident on the floor laying on his/her right side. The resident said he/she was trying to go to bathroom and slipped. The resident did said he/she hit his/her head. The resident was noted to have bleeding and abrasions to his/her right ear and complained of pain to right inner thigh of a level six for pain. The resident remains alert and oriented times four and able to voice concerns. Passive ROM was completed with all extremities within normal limits. The resident has agreed to go to hospital for evaluation. The resident was escorted to bathroom by staff and dressed for transporting; -4/16/23 at 4:00 P.M., the resident was readmitted from the hospital; -4/21/23 at 6:09 A.M., Emergency Medical Services (EMS) arrived at the facility at 5:36 A.M. The resident is going to the hospital to be evaluated. The resident's bleeding subsided to his/her nose. The resident's bed was in a low position with a helmet on the resident. The resident rolled out of bed and bump his/her nose on night stand. EMS was called and the resident will be transported to the hospital. The resident's physician and family member was made aware; -4/21/23 at 4:50 P.M., the resident returned to facility at 10:45 A.M., with no complaint of pain, no sign or symptoms of distress. The resident had a laceration to top of his/her nose with no active bleeding noted. The emergency room put a skin adhesive to the laceration. The resident was observed walking behind his/her wheelchair when he/she came back from the hospital. This nurse educated the resident on not walking behind his/her wheelchair due to safety risk. The resident did have helmet in place. The resident did not want to sit in his/her wheelchair. This nurse had to redirect resident and the resident finally sat down in his/her wheelchair. The resident able to move all extremities without difficulty. -4/27/23 at 6:45 A.M., the resident's neighbor came to nursing station due to hearing something fall in resident's room. As this writer approached the room, resident was observed to be on right side of his/her bed on the floor. The resident had urine on floor next to him/her. The resident denies hitting his/her head or any pain. The resident is noted to have left side bruising and complaint of right knee up to right thigh pain. The resident remains alert and oriented and able to make his/her needs known. Passive ROM to upper and lower extremities within normal limits and resident remains weight bearing. The resident's physician was called and a new order to send the resident out to hospital for evaluation. The resident may have bed rails for safety. The resident's family member has been informed of the incident and being transferred to the hospital for evaluation; -4/27/23 at 7:30 P.M., the resident returned from hospital via EMS. This writer received no discharge paperwork from EMS, only verbal of no new orders and there was no new findings. This writer called the hospital for clarification, received no new orders per the hospital nurse. The resident remains alert and oriented and able to make needs known. The resident voices no pain or discomfort at this time. The resident was put in bed (center), with the bed low to the ground for safety and the call light within reach. Review of the resident's care plan, showed no documentation regarding new interventions for the previous falls. During an interview on 5/1/23 at 11:05 A.M., the resident's roommate said the resident tries to get out of bed all the time. The resident has fallen numerous times and the facility has not done anything about it. During an interview on 5/1/23 at 11:14 A.M., CNA B said the resident has a history of falls. CNA B said the intervention is to keep an eye on the resident and make sure the resident has his/her helmet in place. CNA B said the resident will not keep still and goes back and forth to bed. CNA B said he/she will get instructions of new interventions from the charge nurse. CNA B said he/she did not know of any new interventions. During an interview on 5/1/23 at 11:19 A.M. Nurse C said they have tried the helmet and removing the mat so the resident will not trip. Nurse C said the resident will sleep all day and be up all night wandering in his/her room. Nurse C said he/she did not know of any new interventions for the resident. The interventions should be on the resident's care plan. During an interview on 5/1/23 at 1:36 P.M., the Administrator said she did not know about the order for the bedrails. The DON should have been made aware of the order and after the resident was assessed for bedrails, Maintenance would have been notified to put them in place. 5. During an interview on 5/1/23 at 1:36 P.M., the Administrator said the Care Plan Coordinator, who is part time and not present today, should complete the MDS assessment, update the care plan with new interventions and communicate the interventions to the Charge Nurse and the nursing management. MO00215381

Based on interview and record review, the facility failed to ensure physician's orders for laboratory testing were followed for one of three sampled residents (Resident #1). The census was 131. Review of the facility's Medication Administration and Monitoring policy dated 9/17/21, showed the following: -Purpose: To ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. To ensure therapeutic guidelines are monitored in drugs that require laboratory (lab) and diagnostic studies; -It is necessary for the licensed staff and certified staff who administer medications to understand the potential side effects to the resident who is taking the prescribed medication(s). Monitoring the resident for any significant adverse reaction is a nursing responsibility; -The nurse will be responsible for ensuring that any abnormal lab values will be faxed to the primary care physician and any critical lab values will be called immediately to the primary care physician and/or the medical director; -All physician's orders will be followed including drug reductions, drug increases and repeat lab/diagnostic studies; -Resident who have critical lab values either, too low or too high, will be placed on the registered nurse (RN) High Priority list and be evaluated by the RN for nursing interventions and to ensure that the physician is made aware of any changes in baseline stability. The High Priority list is reviewed weekly by the Director of Nursing (DON) and changes are made weekly, to continue to address the resident's needs. Review of the facility's Notifying Clinicians policy dated 8/23/22, showed the following: -The physician is to be called regarding lab/diagnostic studies falling outside of clinical reference ranges; -Any labs that are ordered will be reviewed by the nurse/DON/designee. Any lab values that fall outside of their clinical reference range will be reported to the ordering physician. The ordering physician may assign a clinical reference range for a lab, radiology and other diagnostic service if not specified by the normal reference range in the report; -If the diagnostic study is within normal parameters, the facility will fax a copy of the report to the physician and flag the report to be read when the physician makes rounds, per physician protocol; -If the diagnostic study is not within normal parameters, the facility will fax a copy of the report to the physician and follow-up with a phone call notification within 24 hours of receiving the report; -If the diagnostic study is critical, the facility will contact the physician immediately after receiving the results, no later than four hours; -If a diagnostic lab is ordered and the physician has indicated clinical reference ranges and notification procedures, the facility will follow the physician's orders; -Ensure that there is documentation of time, phone number dialed and to whom you spoke with when you reached out to the physician's office. Document if you reached anyone or the number of attempts made and if messages were left. Review of Resident #1's face sheet, showed the facility admitted the resident on 1/31/22 with diagnoses which included high blood pressure, diabetes, below the knee amputation of the right and left legs, kidney failure and history of kidney transplant. Review of the resident's discontinued orders on 3/23/23, showed several orders for tacrolimus (immunosuppressive drug used to prevent rejection after organ transplant) with various start dates, end dates and doses. The resident was ordered to receive various doses of tacrolimus, once daily, since his/her admission to the facility. All of the discontinued orders, indicated the resident's tacrolimus was to be administered once daily and the orders did not specify a certain time of day the medication should be administered or any other special instructions for administration. Review of the resident's physician's orders on 3/23/23, showed the following: -An active order dated 4/26/22, for a monthly trough level (measures the lowest concentration in the resident's bloodstream and specimen collected just prior to administration of medication) lab on tacrolimus related to kidney transplant; -An active order dated 3/22/23, for tacrolimus, 2 milligrams (mg), in the morning before breakfast. Review of the resident's progress note dated 9/30/22, showed the lab drew specimens from the resident the morning of 9/30/22. Staff were waiting on lab results so they could be faxed to the kidney transplant clinic, where the resident had an appointment scheduled on Tuesday (actual date not referenced) at 11:00 A.M. Review of the resident's lab test results report dated 10/4/22, showed the resident's tacrolimus level was 1.0 and flagged as low. The reference range for trough tacrolimus levels in transplant patients (2 weeks or more post transplant) identified as 3.0-8.0 micrograms per liter (mcg/L). The lab specimen was drawn on 9/30/22 and the results were reported on 10/4/22 at 7:35 P.M. Further review of the resident's progress notes, showed the following: -No note regarding the resident's 10/4/22 lab results being reported to his/her physician and/or any physician recommendations, related to the resident's tacrolimus levels being outside the reference range; -On 10/5/22, the facility nurse practitioner (NP) saw the resident, per facility request. The progress note, completed by the facility NP, did not include any mention of the resident's 10/4/22 lab results or any information regarding management of the resident's tacrolimus levels. Review of the resident's medical record on 3/23/23 and 3/29/23, showed no documentation of lab tests completed to determine the resident's trough tacrolimus levels, during November and December of 2022 or during January of 2023. Further review of the resident's progress notes, showed the following: -No documentation the resident's physician was contacted regarding his/her trough tacrolimus level labs not being drawn during November or December of 2022; -On 12/7/22, the resident was seen by the facility's nurse practitioner (NP.) The progress note indicated the facility NP reviewed the resident's most recent labs but it did not specify what those labs were or if the resident's tacrolimus levels were reviewed, at that time. No concerns were noted regarding the resident's tacrolimus levels or lab testing for tacrolimus levels not being completed. Review of the resident's lab test results report dated 1/4/23, showed a complete blood count (CBC) was performed using a specimen collected from the resident on 1/4/23. No specimen was drawn, tested or reported for the resident's tacrolimus levels. Review of the resident's progress notes, showed the following: -On 1/9/23, the resident was seen by his/her physician. The notes section of the history and physical (H&P) progress note indicated abnormal labs addressed and no new orders. The progress note did not specify which labs were abnormal or what was done to address the abnormal labs. The progress note did not mention management of the resident's tacrolimus levels; -On 1/30/23, the resident was seen by the facility's NP. The labs section of the progress note indicated no new labs to review and no concerns were identified related to the resident's tacrolimus levels; -On 2/8/23, the resident asked when his/her next tacrolimus lab draw would be done. Staff called the lab due to the lab test results report from the resident's 1/4/23 lab draw not being available. Staff at the lab said the resident's trough tacrolimus level lab test was not completed because it was not ordered for the resident's 1/4/23 lab draw. No documentation of any notification made to the resident's physician, regarding his/her tacrolimus level lab not being completed for the month of January 2023; -On 2/10/23, the resident's trough tacrolimus level was drawn at 8:00 A.M. on 2/10/23, before any medications were given; -On 3/6/23, the resident's physician saw him/her for his/her annual H&P. The lab section of the H&P progress note indicated no new labs to review. The notes section of the H&P progress note indicated abnormal labs addressed but it did not specify which labs were abnormal or what was done to address the abnormal labs. Review of the resident's February 2023 medication administration record (MAR), showed the resident was administered tacrolimus, once daily during the 7:00 A.M. morning medication pass. Review of the resident's lab test results report dated 3/9/23, showed Problem: Lab accident, documented under the resident's tacrolimus level section of the lab report. The lab was Unable to perform testing due to a lab error. The report advised facility staff to call the lab to reschedule a redraw of the specimen. The lab specimen was originally drawn on 2/10/23 but the results were not reported until 3/9/23 at 8:00 A.M. The notes indicated the facility submitted a requisition for the lab to be redrawn on the next routine lab day. Review of the resident's progress notes, showed the following: -No documentation the resident's physician was contacted regarding the lab error on the resident's most recent trough tacrolimus lab drawn on 2/10/23 and reported on 3/9/23; -No notes regarding the 3/9/23 lab results report or the lab error related to the resident's trough tacrolimus lab drawn on 2/10/23; -On 3/14/23, emergency medical services transported the resident to the hospital, following a change in condition related to an altered mental status. Review of the resident's lab test results report dated 3/14/23, showed the resident's tacrolimus level was 2.9 and flagged as low. The suggested guideline range for trough levels of tacrolimus identified as 5.0-20.0 mcg/L. The lab specimen was drawn on 3/10/23 and the results were reported on 3/14/23 at 1:20 A.M. Review of the resident's March 2023 MAR, showed the resident was administered tacrolimus, once daily during the 7:00 A.M. morning medication pass. Review of the resident's post-acute care transfer report dated 3/17/23, showed the following: -Principal problem: Severe sepsis. The resident presented to the emergency department with symptoms of viral gastroenteritis and a possible urinary tract infection (UTI). Based on the resident's symptoms and multiple diagnosis lab tests, he/she received antibiotic treatment for severe sepsis; -Problem: Acute kidney injury (a sudden decline in the kidney's ability to function normally and filter waste from blood). The resident underwent a renal transplant in 2012. The resident's tacrolimus level was undetectable upon his/her admission to the hospital. The resident was given tacrolimus during his/her admission to the hospital and his/her tacrolimus levels improved. The resident's chronic kidney dysfunction may have been exacerbated by his/her UTI and dehydration. During an interview on 3/23/23 at 4:45 P.M., Licensed Practical Nurse (LPN) A said the resident has a history of a kidney transplant. The resident was on tacrolimus when he/she came to the facility and he/she has been on the medication the whole time he/she has been at the facility. The resident's dose changed when he/she was in the hospital recently. The resident's tacrolimus levels were out of range when he/she went to the hospital. LPN A was informed the resident needed to be taking the tacrolimus in the early morning, before meals because it absorbs better on an empty stomach. Before the resident went to the hospital, they were mostly giving him/her the tacrolimus after breakfast and that may be why it wasn't showing up on the resident's labs. The resident's tacrolimus was ordered for once daily before he/she went to the hospital. The resident normally sleeps in and eats breakfast in his/her room, in bed. They would usually catch him/her after breakfast, to administer medications. They were not very familiar with tacrolimus before the resident was admitted and he/she was not aware it was supposed to be taken early morning on an empty stomach, until it was pointed out to him/her by someone after the resident's most recent hospitalization. If the resident is ordered routine labs monthly, the lab should have an order for it and the order should be followed. Lab results that are out of range should be reported to the resident's physician and recommendations should be documented. During an interview on 4/3/23 at 2:45 P.M., the DON said the resident was a kidney transplant patient, prior to his/her admission to the facility. The transplant clinic did most of the management of the resident's anti-rejection medication, tacrolimus. When the resident came to the facility, they got in touch with the resident's transplant clinic. The transplant clinic controls any changes in the resident's tacrolimus dose. The resident needs to take the tacrolimus because it is an anti-rejection medication and it prevents his/her body from attacking and rejecting the transplanted kidney. The resident receives his/her tacrolimus, once daily and his/her dose was changed during his/her most recent hospitalization. She was aware the resident was supposed to have routine labs drawn to test his/her tacrolimus levels. She believed the resident was supposed to have the labs drawn every 4-6 weeks. When labs are drawn, it takes the lab a few days to process them. They have to wait on the lab results to come in, then they send them to the resident's transplant clinic. There should be documentation when the resident's labs are sent to the transplant clinic for review. She believed the resident's lab results were being sent to the transplant clinic but she was not sure if the transplant clinic ever made any recommendations regarding the resident's tacrolimus. Any recommendations made as a result of lab testing, should be documented in the resident's record. She was just recently informed the resident needed to take the tacrolimus in the early morning, before breakfast. When they initially got the order for the resident's tacrolimus, the information about when to take the medication was never mentioned. The order was just to administer the tacrolimus once daily. The DON or nurse designee is responsible to ensure all lab tests are completed as ordered. If the resident's order was for the tacrolimus level to be tested monthly, the nurses should have made sure the order was communicated to the lab correctly and drawn as ordered. The resident's labs should have been drawn and the results reported to the appropriate physician, in accordance with the resident's orders and the facility policy. It is important for the labs to be completed as ordered so they can see if the resident is getting enough medication. Any lab values that fall outside of the reference range should be reported to the physician so they can see what the physician recommends. The physician would probably recommend following up with the transplant clinic regarding the resident's tacrolimus levels. Any communication regarding the resident's labs should be documented in his/her medical record. If there is a lab error with a specimen, the lab will alert the facility of the error and they are supposed to come back to redraw the specimen. She would expect the lab to let them know within 48 hours, and they should send someone back out if there was an error and the lab specimen needed to be redrawn. It does not make any sense for the lab results to be delayed for a long period like the resident's lab results in February of 2023, which took over a month to get back. If they get critical lab values for any resident, it should be communicated to the physician and this should be documented. If the lab does not come out to do what is supposed to be a routine draw for labs on a resident with orders, the facility should call and follow up within 48 hours to find out why the labs were not drawn. If they do not get lab results back within 48 hours of when they were drawn, facility staff should call the lab to follow-up. MO00215833

Based on observation, interview, and review, the facility failed to treat the resident with dignity and respect, allow the resident to retain and use personal property, and to protect property from loss or theft for one resident (Resident #120) when staff confiscated their personal cell phone and then lost the phone. The sample was 27. The census was 135. Review of facility admission packet, showed: -Residents shall be permitted to retain and use personal clothing and possessions as space permits; -Telephones appropriate to the resident's needs shall be accessible at all times; -Residents shall be encouraged and assisted, throughout his/her stay to exercise his/her rights as a resident and as a citizen; -Facility shall maintain a record of any personal items accompanying the resident up admission to the facility; -Residents shall not have their personal lives regulated or controlled beyond reasonable adherence to meal schedules and other written policies which may be necessary for the orderly management of the facility and personal safety of the residents. Review of Resident #120's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/22/21, showed: -Resident cognitively intact; -It is very important to the resident to take care of personal belongings or things; -It is very important to the resident to have family or a close friend involved about care. During an interview on 8/24/22 at 10:41 A.M., the resident said he/she had a cellphone but was not allowed to keep it. The resident said he/she wants to call his/her son but the number is in his/her cellphone and he/she does not know the number by heart. Review of the resident's inventory of personal effects sheet, signed and dated 10/21/20, showed a Galaxy Note 8 cellphone, one white charger and one Blackweb charger. During an observation and interview on 8/24/22 at 8:37 A.M., showed the Life Enhancement Coordinator came to the Social Service Director (SSD) office and said Staff W signed for and took the resident's Galaxy Note 8 cellphone. At 8:52 A.M., the SSD said he does not know why the Galaxy Note 8 was taken away because residents are allowed to keep their personal property. He only found one cellphone in his office and he was not sure if that cellphone belonged to the resident, but would follow up. He would go through Medicaid to get resident a new phone, if that was an option. During an interview on 8/24/22 at 9:42 A.M., the Administrator and Director of Nursing (DON) both said the facility was on its 3rd social worker and they did not know why the Galaxy Note 8 cellphone was taken away. MO00189567 MO00193792

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide privacy during personal care for one resident who received care in view of a roommate (Resident #83). In addition, ,the facility failed to respect the resident's right to personal privacy and confidentiality, to include medical treatment and personal care for two of 27 resident (Residents #29 and #534) when a privacy curtain was not available. The census was 135. 1. Review of the facility housekeeping process showed: -Each housekeeper is to perform a morning walk-through; -Check trash in all resident rooms and bathrooms; -Check all supplies, restock when low or empty; -Spot check floors-clean any spills or trouble areas and pick up any trash; -Identify any odors and attend to them immediately; -Check curtains for damages, and/or stains. 2. Review of the facility deep cleaning policy showed: -Deep cleaning is to be completed as scheduled. This includes complete pull-outs of furniture in rooms, wall cleaning, floor cleaning, restrooms to be cleaned and disinfected, cob webs removed, beds and rails to be cleaned, sprinkler heads to be cleaned, light covers to be clean and free of bugs, over-bed light covers to be cleaned and free of bugs, sink clean, windows to be cleaned and ensure no spider webs, drapes and curtains to be cleaned (including privacy curtains), call lights to be clean and free from dust/dirt build-up, floors at closets and doorways are to be free from was/dirt build up, etc. 3. Review of the facility's Peri-Care (perineal care, the process of cleansing the areas between the legs to include the buttocks and genital area) policy, revised 2/26/21, showed: -The purpose of this policy is to ensure that the female and male resident [NAME] area is kept clean and proper techniques are used to prevent skin break down, infections and any other impairment that can be caused from not using proper aseptic technique; -Make every effort to respect the modesty of residents; -Provide privacy. Review of Resident #83's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/8/22, showed: -Should the Brief Interview for Mental Status (BIMS) be completed: Yes; -BIMS blank; -Extensive assistance required for toilet use; -Limited assistance required for personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses included schizophrenia. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: The resident requires extensive assistance with activities of daily living (ADLs); -Goal: Maintain current level of function; -Interventions included: Bed mobility, the resident uses full side rails to maximize independence with turning and repositioning in bed. Toilet use, the resident is totally dependent on staff for toilet use. Observation on 8/23/22 at 7:24 A.M., showed Restorative Aide D provided personal care to the resident. Four residents resided in the room. Two to the left and two to the right. The resident resided in the first bed to the left, closest to the door. The curtain on the side of door closed completely and provided privacy from the room door and the residents on the right side of the room. The privacy curtain between the resident and the roommate on the left side of the room remained completely opened. The roommate lay with his/her eyes closed and faced the direction of the resident. Restorative Aide D removed the residents brief and started to provide personal care to the resident. Restorative Aide D said he/she needed to pull the privacy curtain, covered the resident's genital area with his/her gown and attempted to pull the curtain located between the resident and the roommate. Restorative Aide D said the curtain gets stuck and it cannot close all the way. He/she pointed out the loops that appeared broken and hung down. He/she said the curtain should be pulled all the way around, but it was broken. The curtain only able to be pulled closed to provide privacy to approximately the resident's mid-thigh. Restorative Aide D continued to provide personal care by exposing the resident's genial area and then turning the resident to the left and right to remove soiled linen, resulting in the resident's buttocks to face the resident during care. While cleansing the resident's genital area, as the resident lay on his/her back, the roommate opened his/her eyes and looked in the direction of the resident before closing his/her eyes again. Observation of the resident when standing near the roommates head of bed, showed the resident exposed from mid-thigh up. Restorative Aide D said ideally, the resident's curtain should be able to be pulled to provide complete privacy. 4. Review of Resident #29's care plan, dated 5/23/22 showed the resident has Diabetes Mellitus. Review of the resident's electronic physician order sheet (ePOS), showed: -Insulin ASPART (short acting insulin) 100 unit (u)/milliliter (ml) inject as per sliding scale. Subcutaneously (under the skin) before meals and at bedtime related to Type 2 Diabetes Mellitus; -151-250=3u; -251-300=5u; -301-400=8u; -401-450-10u; -Invega Sustenna (antipsychotic) 234 milligrams (mg)/1.5, Inject 1.5 ml intramuscular (into the muscle) every day shift starting on the 2nd and ending on the 2nd of every month. During an interview on 8/26/22 at 11:37 A.M., the Director of Nursing (DON) and Administrator both said a resident should have a privacy curtain drawn in his/her room when receiving injections. Observation on 8/23/22 at 12:37 P.M., 8/24/22 at 8:29 A.M., and 8/25/22 at 8:59 A.M., showed the resident's door ajar as the resident lay in bed, eyes closed, and no privacy curtain available for use. 5. Review of Resident #534's admission MDS, reviewed on 8/26/22, showed in progress. Review of the resident's electronic care plan, created 8/24/22, showed no ADLs care planed. Observation on 8/22/2022 at 8:52 A.M., 8/23/22 at 9:53 A.M., 8/26/22 at 7:39 A.M., showed, no privacy curtains in resident's room. One resident resided in the resident room. During an interview on 8/23/22 at 9:53 A.M., the resident said when he/she was admitted to the facility on [DATE] he/she had a roommate. The resident said when he/she tested positive for COVID-19 on 8/18/22 his/her roommate was moved into another room. He/she has never had privacy curtains in the room. When staff provided care he/she was exposed to his/her roommate. 6. During an interview on 8/24/22 at 8:55 A.M., Licensed Practical Nurse (LPN) R said he/she would expect that a resident would have privacy in their room whether it be a curtain, door, or staff knocking. 7. During an interview on 8/24/22 at 9:29 A.M., Graduate Practical Nurse (GPN) X said, he/she was not aware of any resident rooms without curtains. If there was no curtain in a resident room to provide privacy he/she would remove the resident's roommate before providing personal care. If the resident's roommate was unable to leave the room GPN X would bring another staff member into the room to try to occupy the roommate while care was being completed. To report a resident room had no curtains he/she would put in a ticket for maintenance to replace the curtain. 8. During an interview on 8/24/22 at 9:29 A.M., Certified Nursing Assistant (CNA) Y said, the facility washes the privacy curtains so there may be resident rooms without privacy curtains. To provide privacy to a resident without a curtain he/she would take the resident to the bathroom to provide care or ask the roommate to step out of the room. If the resident was unable to go to the bathroom and the roommate was unable to leave the room CNA Y would have a second CNA assist in providing care and stand between the resident receiving care and the roommate and use the sheet to provide privacy. To get a privacy curtain in a resident room he/she would call maintenance and they would bring one and put it up in the resident's room. He/she could put in a maintenance ticket but calling is easier. 9. During an interview on 8/24/22 at 2:33 P.M., the DON said she would expect privacy curtains to be functional and provide complete privacy during care. Each resident should have a privacy curtain. When providing personal care, it is not acceptable for the resident to be visible to the roommate. On 8/26/22 at 11:38 A.M., the DON and Administrator both expected residents to have properly functioning privacy curtains. There is no real timeframe for changing or replacing privacy curtains. The DON and Administrator both expected the housekeeping staff to report to his/her supervisor when a privacy curtain needs to be replaced. 10. During an interview on 8/25/22 at 11:44 A.M., Housekeeping X said the privacy curtains in the rooms are changed every three to four weeks or when they are soiled and he/she expected that each room would have a privacy curtain. 11. During an interview on 8/25/22 at 11:49 A.M., the housekeeping/laundry supervisor said there is not an official policy for changing or removing the privacy curtain but housekeeping generally changes privacy curtains every five weeks or as needed. He expected all rooms to have privacy curtains. Sometimes residents in wheelchairs get tangled up in the privacy curtain and they have to be replaced, but for the most part, all rooms will have privacy curtains. MO00189567

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the grievance policy, which required the facility to complete an investigation within 7-14 days and to respond to the individual making the grievance within 30 days. This affected one resident whose family member reported missing personal belongings to the facility (Resident #85). The census was 135. Review of the facility Grievance Policy, dated 6/1/17 and revised on 9/17/21, showed: -Purpose: To set forth the Resident's Right to file a grievance and the process to be followed. -Resident Right to File a Grievance; -The Facility wants to hear and address any concern of a resident. A resident or their legal representative can bring concerns to a staff member, the resident concern group, or call the compliance hotline. Additionally each Resident has the right to use the formal grievance process. The formal grievance process is outlined in this policy; -Every resident has the right to voice their grievance with the Facility or other agency. Grievances could include care and treatment that was not provided, behavior of staff or other residents, or any other concerns regarding their stay. A grievance is a formal complaint, not a question or concern brought to a staff member or a call to the Compliance Hotline. To avoid any confusion the resident should make it clear that they are filing a formal grievance; -No resident shall be retaliated against in any way for voicing a grievance; -Notification to Residents; -Each resident shall be given information regarding the Grievance Policy when they are admitted to the Facility; -The attached flyer shall be posted in all resident areas; -Any resident, legal representative or family member/friend shall be given a copy of the Grievance Policy upon request to the Social Service Director/Grievance Officer; -Grievance Process; -The Social Service Director shall serve as the Grievance Officer and may be reached at the Facility Address and phone number. If the Facility does not have a Social Service Director, the Administrator shall appoint someone to serve as the Grievance Officer; -A resident, his/her legal representative, or family/friend may voice their grievance orally to the Grievance Officer or in writing. Written grievances can be given to any employee who will take them to the Grievance Officer. A form will be provided to residents to assist them in documenting their grievance, but use of that form is not required; -Grievances may be filed anonymously. If a resident requests to be anonymous, the Grievance Officer shall respect that request and will not disclose the resident's name to anyone else. However if the grievance is a reportable event under any rule or regulation, the Facility is unable to honor the request to be anonymous; -If the resident has a guardian, the guardian shall be notified of the grievance within five business days. If requested, the grievance response will also be provided to the guardian; -The Grievance Officer shall track all grievances received. This should include name of resident (if not anonymous), date of grievance, manner received, investigation and resolution. The Grievance Investigation Form can be used for this purpose; -The Grievance Officer shall endeavor to complete an investigation as soon as reasonable and within 7-14 days. The Grievance Officer or their designee may interview any resident or employee necessary to complete the investigation. The Grievance Officer shall inform the Administrator of the result of their investigation. The Administrator should determine if coordination with the interdisciplinary team (IDT) or the Care Plan Team is necessary. A response to individual making the grievance shall be provided as soon as possible but no later than thirty days after the grievance is made; -If requested by the resident or legal representative or family/friend, the response to grievance shall be put in writing. Any written response shall include the date the grievance was received, a summary statement of the resident's grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not, any corrective action taken or to be taken by the facility, and the date the written decision was issued; -If the grievance requires immediate action (prior to investigation) to protect the resident or others, the Grievance Officer shall immediately consult with the Administrator or Director of Nursing and be sure such action is taken. This action should be documented by the Grievance Officer; -If the grievance would constitute a reportable event under the Facility's abuse and neglect policy or the Elder Justice Act, the event should be reported as required by those policies; -All documentation of grievances shall be maintained for three years from the date of the grievance decision. Review of Resident #85's admission inventory sheets, dated 2/5/20, showed: -Shoes - 1; -Slacks - 1; -Sweaters - 1; -Eyewear - 1; -Rings - 4, (3 gold plated, 1 silver tone). Additional items included on the sheet, dated 12/8/20, showed: -Black and gray pajama set; -1 pair cream jogging pants; -1 multiple color sweat shirt; -1 [NAME] set (jogging suit); -1 lime green jogging suit; -1 pair of burgundy shoes, size 6; -1 Vaseline. Review of the resident's inventory sheet of items replaced by the facility, dated 7/11/22, showed: -Blouse/shirts - 6; -Bras - 2; -Dresses - 2 -Shoes - 2; -Slacks/trousers - 6; -Slippers - 1. -No jewelries listed. Review of the resident's re-admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/8/22, showed: -Short-term and long-term memory problems; -Usually understands; -Diagnoses included: heart failure, high blood pressure, diabetes, high cholesterol, depression and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of the resident's progress note, dated 5/31/22, showed the Director of Nursing (DON) documented the resident's family member or Power of Attorney (POA)/guardian, reported a missing pair of gold earrings, and two pair of shoes. He/she notified the POA they would look for the missing items and will be replaced if not found. No further documentation of the status of the reported missing belongings. During an interview on 8/25/22 at 8:08 A.M., the Social Service Director (SSD) said the facility has grievance forms for the residents or family to fill out. Verbal reports can also be done without filling out the form, then the DON has a list and keeps track of the grievances. The SSD said grievances are to be addressed immediately, within 24 hours. Family and/or POA are also notified immediately. He/she said the facility replaces missing items that were not found. The SSD said all staff should be responsible to report grievances if they received reports from residents or witnessed any incidents. He/she said grievances are to be addressed and resolved as soon possible. During an interview on 8/25/22 at 8:32 A.M., Certified Nurse Assistant (CNA) QQ said if he/she received a report of missing items from the residents, he/she would report it to the charge nurse. If missing clothes were reported, he/she would look for them in the laundry department first and report it if not found. During an interview and observation on 8/26/22 at 7:20 A.M., showed the resident was unable to verbalize if he/she had missing belongings. Certified Medication Technician (CMT) KK said the resident was non-verbal, but may understand at times. CMT KK was not aware of the resident's missing items. He/she said the resident had been moved from another hall and did not receive any reports of missing items. During an interview on 8/26/22 at 9:25 A.M., the resident's POA said the family has not received updates of the reported missing items. He/she said the issue had been reported approximately 2-3 months ago with no outcome since then. During an interview on 8/26/22 at 11:04 A.M., the DON said he/she spoke with the resident's POA regarding the missing items and had replaced them, except for the jewelries. The DON said the facility continued to work on resolving the issue. During an interview on 8/29/22 at 2:44 P.M., the Administrator said per facility's policy, the resident's grievance or report of missing items' investigation should be completed and resolved by this time. MO00189567 MO00198903

Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This affected two of two sampled newly admitted residents (Residents #484 and #534). The census was 135. Review of the facility's Comprehensive and Baseline Care Plans policy, revised on 1/19/22, showed: -Section II, #2: All baseline care plan must be completed within 48 hours of admission; -Section II, #3: The Baseline Care Plan must consist of the following: resident information, allergies, alarms, bowel and bladder needs, cognition, communication, diet and dining needs, discharge planning, hearing needs, mood and behavior, resident risks, medications, safety, weight monitoring needs, code status, physician orders, equipment needs, restorative needs, functional goals, skin condition, social service needs, therapy needs, and vision information and needs. 1. Review of Resident #484's electronic medical record (EMR), reviewed on 8/22/22 and 8/24/22 at 10:53 A.M., showed: -admission date of 8/20/22; -No code status on the face sheet; -No baseline care plan developed; -Diagnoses included: Type II diabetes, myelodysplastic syndrome (a group of cancers that keep your blood stem cells from maturing into healthy blood cells), high blood pressure, high cholesterol, human immunodeficiency virus (HIV, a virus that attacks the body's immune system). During an interview and observation on 8/22/22 at 11:12 A.M., the resident said he/she had not participated in a care plan meeting, and nobody discussed this with him/her. He/she had no family so nobody else is to be called for a meeting. He/she ambulated independently in the room with no adaptive device. A staff person wanted to assist him/her in going to the bathroom and he/she did not like it. He/she was confused because some staff let him/her do anything independently but sometimes they provided assistance that is not needed. 2. Review of Resident #534's EMR Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) record, reviewed on 8/26/22, showed, the resident's admission MDS in progress. Review of the resident's electronic care plan on 8/25/22 at 7:11 A.M., showed: -Problem: On 8/18/22 patient tested positive for COVID-19, date initiated 8/18/22, revised on 8/24/22, created date 8/24/22; -Problem: Oxygen continuous at 2 liters for chronic obstructive pulmonary disease (COPD, lung disease), date initiated 8/5/22, created date 8/24/22; -Problem: Decreased cardiac output heart failure, date initiated 8/5/22, revision on 8/24/22, created date 8/24/22; -Problem: Arrhythmia (irregular heart beat), date initiated 8/5/22, revision on 8/24/22, created date 8/24/22; -Problem: Risk for COPD complication, date initiated 8/5/22, revision on 8/24/22, created date 8/24/22. Review of the resident's electronic medical record, reviewed on 8/22/22 at 6:18 P.M. and 8/23/22 at 10:38 A.M., showed: -admission date of 8/4/22; -No code status on the face sheet; -No diet listed on face sheet; -No baseline care plan; -No comprehensive care plan developed; -No diagnosis listed on the face sheet; -Diagnosis listed under medical diagnosis tab: Congestive heart failure (CHF, impaired heart function), atrial fibrillation (A-fib, irregular heart rhythm), and COPD. Observation on 8/24/22 at 12:47 P.M., showed, no baseline care plan in the residents paper chart. During an interview on 8/23/22 at 9:53 A.M., the resident said he/she has not had any care plan meetings about goals or discharge since admission. On admission the admitting nurse thought he/she was going to be a long-term resident instead of only being at the facility short-term for rehabilitation. 3. During an interview on 8/24/22 at 12:47 P.M., Graduate Practical Nurse (GPN) X said the Resident Care Coordinator (RCC) is responsible for documenting the baseline care plan. The baseline care plan can be located in the electronic chart. During an interview on 8/25/22 at 8:53 A.M., Licensed Practical Nurse (LPN) R said usually the admission nurse will start the baseline care plan and the MDS Coordinator will complete it but the admission nurse or another nurse can complete the baseline care plan. The documentation for the baseline care plan can be located in the electronic medical record. During an interview on 8/26/22 at 11:04 A.M., Administrator and Director of Nursing (DON) said they would expect baseline care plans to be completed within 48 hours, and to include all components required for the baseline care plan. The absent MDS coordinator is responsible for documenting the baseline care plan. The baseline care plan documentation can be found in the electronic medical record. If the baseline care plan is not completed the staff would have to ask the nurse for information related to the residents wants and needs. The nurse would then need to look at the information sent from the hospital or previous facility to find that information.

Based on observation, interview and record review, the facility failed to develop the comprehensive care plan, with the interdisciplinary team and the resident, no later than 21 days after admission, for one of two sampled residents admitted within the past 30 days (Resident #534). The census was 135. Review of Resident #534's electronic medical record on 8/22/22 at 6:18 P.M., showed: -admission date of 8/4/22; -No baseline care plan; -No care plan developed; -Diagnosis listed under medical diagnosis tab: congestive heart failure (CHF, impaired heart function), atrial fibrillation (a-fib, irregular heart rhythm) and chronic obstructive pulmonary disease (COPD, lung disease). Review of the resident's electronic care plan on 8/25/22 at 7:11 A.M., showed: -Problem: 1. On 8/18/2022, patient tested positive for COVID-19, date initiated 8/18/22, revised on 8/24/22, created date 8/24/22; -Problem: Oxygen continuous at 2 liters for COPD, date initiated 8/5/22, created date 8/24/22; -Problem: Decreased Cardiac Output Heart Failure, date initiated 8/5/2022, revision on 8/24/2022, created date 8/24/22; -Problem: Arrhythmia, date initiated 8/5/2022, revision on 8/24/2022, created date 8/24/22; -Problem: Risk for COPD Complication, date initiated 8/5/2022, revision on 8/24/2022, created date 8/24/22. Review of Resident #534's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, reviewed on 8/26/22, showed it was in progress. Observation on 8/23/22 at 9:53 A.M., showed, the resident lay in bed with oxygen on. The oxygen concentrator was set at 2 liters. The oxygen tubing was dated 8/22/22. Record review on 8/24/22 at 12:47 P.M., showed no baseline care plan or comprehensive care plan in the resident's paper chart. On the date of exit, 8/26/22, showed, the comprehensive care plan was not complete and there was no baseline care plan. During an interview on 8/23/22 at 9:53 A.M., the resident said he/she has not had any care plan meetings about goals or discharge since admission. The resident said that on admission, the admitting nurse thought he/she was going to be a long term resident instead of only being at the facility short term for rehabilitation. During an interview on 8/26/22 at 11:04 A.M., the Administrator and Director of Nursing (DON) said they expected the comprehensive care plan and admission MDS to be completed by day 21, and the baseline care plan completed within 48 hours. It is the MDS coordinator's responsibility to ensure the care plan and MDS is completed timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate activities of daily living (ADLs) services for two of two sampled residents who required assistance with meals. (Residents #124 and #81). The census was 135. 1. Review of Resident #124's utilization review progress note, dated 5/22/22 at 12:11 P.M, showed: -The resident received physical therapy (PT)/occupational therapy (OT) four times per week; -The resident required set up assistance with eating; -Functional activities performed by therapy included transfers, safety and feeding; -He/she was not safe with ADLs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/22, showed: -Cognitive status not assessed; -Rejection of care not exhibited; -Functional limitations in range of motion: No impairment of upper extremity or lower extremities; -Independent with eating; -Diagnoses included stroke, high blood pressure, acute kidney failure, diabetes, dementia and seizure disorder; -Occupational therapy started on 5/2/22 and was ongoing; -Physical therapy started on 7/9/22 and is ongoing. Observation of 100 hall lunch meal service on 8/22/22 at 12:30 P.M., showed staff wheeled the resident into the dining room. The resident received his/her food at approximately 12:40 P.M. The resident received ground beef, two soft tortillas and Mexican rice on a Styrofoam plate covered in plastic wrap, a cup of juice in a Styrofoam cup, salad and fruit in Styrofoam bowls and plastic utensils. He/she could not remove the plastic wrap from his/her plate. After approximately five minutes, an unknown staff person removed the plastic wrap. The resident picked up the fork and attempted to eat the rice. His/her hand shook as he/she tried to get the food in his/her mouth. The rice fell off the fork and onto the table. He/she drank his/her juice, but did not touch the ground beef, soft tortillas, salad or fruit. Staff did not ask the resident if he/she needed assistance. At 12:55 P.M., he/she pushed his/her plate to the middle of the table and wheeled him/herself from the dining room. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident was at risk for acute confusional episodes; -Desired outcome: The resident will remain free of acute confusion; -Interventions included: Communication, staff used the resident's name, identify themselves, face the resident when speaking and make eye contact. The resident understood consistent, simple directive sentences. Staff provided the resident with necessary cues and stopped and returned if he/she was agitated. Observation of 100 hall lunch meal service on 8/23/22 at 12:41 P.M., showed staff wheeled the resident into the dining room. The resident received his/her food at approximately 12:50 P.M. The resident received a pork chop with gravy, roasted potatoes and Brussel sprouts on a Styrofoam plate covered in plastic wrap, tropical fruit with whipped topping in a Styrofoam bowl, a dinner roll and plastic utensils. He/she could not remove the plastic wrap from his/her plate and he/she pushed it to the side. The resident picked up the fork and attempted to eat the fruit. His/her hand shook as he/she tried to get the food in his/her mouth. The fruit fell off the fork, into the cup and on the table. At 12:56 P.M., an unknown staff person removed the plastic wrap from the resident's plate. The resident picked up the fork and attempted to eat the potatoes. His/her hand shook as he/she tried to get the food into his/her mouth. The potatoes fell off the fork and onto the table. He/she pushed the plate to the middle of the table, drank his/her juice. Staff did not ask the resident if he/she needed assistance. The resident wheeled him/herself from the dining room at 1:05 P.M. Observation of 100 hall lunch meal service on 8/25/22 at 12:36 P.M., showed staff wheeled the resident into the dining room. At 12:38 P.M., the resident wheeled him/herself out of the dining room and sat outside of room [ROOM NUMBER]. Certified medication technician (CMT) DD wheeled the resident back into the dining room. The resident received his/her food at approximately 12:40 P.M. The resident received chili mac, winter vegetables and a small square of cornbread, on a Styrofoam plate wrapped in plastic wrap, a cup of juice and a slice of strawberry cream pie. He/she also received a plastic knife and fork. He/she picked up the fork and ate the strawberry cream pie. His/her hand shook and the pie fell on the table. He/she used the fork and ate the pie off the table. He/she then picked up his/her untouched plate of food, placed it on his/her lap and attempted to leave the dining room. An unknown staff person took the plate from the resident and he/she wheeled him/herself from the dining room. Staff did not encourage the resident to eat or ask him/her if he/she needed assistance. During an interview on 8/26/22 at 7:30 A.M., CMT DD said some days the resident needed assistance with ADLs and some days he/she did not. The resident was confused and needed reminders for meals, but did not need assistance with eating. He/she did not think the resident struggled to eat his/her meals. The resident liked to pick up trays and try to throw them away, but staff had to assist him/her. He/she has assisted the resident with feeding once or twice. The resident was obsessed with the housekeeper and would leave the dining room during meals to look for him/her. Staff were supposed to redirect the resident. During an interview on 8/26/22 at 8:30 A.M., the administrator and Director of Nursing (DON) said the resident is strong and can move furniture around his/her room. The resident needed moderate care on most days, but did not need assistance with feeding. The resident needed staff to set up and open his/her plate. The resident does have tremors, but they are not gross. If a resident is experiencing difficulties with tremors, he/she should be referred to therapy and assessed for assistive devices. If a resident has issues eating, staff should assist them. When the resident leaves the dining room during meals, staff should pay close attention, and give the resident reminders and cues. 2. Review of Resident #81's annual MDS, dated [DATE], showed: - Diagnoses of post traumatic seizures, diabetes mellitus, non-Alzheimer's dementia, schizophrenia (a serious mental disorder in which people interpret reality abnormally) and history of falling; -Cognitively intact. Review of the resident's care plan, in use at the time of the survey, showed the resident needs assistance with ADLs such as dressing, bathing and assistance with eating. Observation on 8/24/22 at 12:40 P.M., showed the resident sat in the 100 hall dining room and complained to staff about not having his/her plate. At 12:42 P.M., staff brought the resident's plate. The resident was served turkey, mashed sweet potatoes, creamed peas, roll with butter, and fruited gelatin. Staff did not give the resident silverware. The resident asked for silverware but none of the staff responded or gave the resident silverware. The resident ate with his/her fingers. At 12:46 P.M., the resident continued to eat lunch with his/her fingers. He/she used two fingers to eat the meat and licked his/her fingers clean. 3. During an interview on 8/26/22 at 11:04 A.M., the Director of Nursing (DON) said staff should provide meal assistance as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one of one resident observed during a Hoyer (mechanical lift) transfer and one resident observed to be propelled in a wheelchair with his/her feet dragging (Residents #134 and #3). The census was 135. 1. Review of the facility's Resident Transfer with a Mechanical Lift policy, dated 4/20/21, showed: -Purpose: To ensure safe transfer of residents with the use of a mechanical lift; -Using the controls of the mechanical lift, lift the resident until their buttocks is clear from the bed, makes sure that the resident is aligned in the sling and is securely suspended in a sitting position with legs dangling over the bottom of the sling; -One staff should guide the resident's legs over the edge of the bed; -Move the lift away from the bed, turn the resident so that they face the lift device. The other staff is to guide the resident's body toward the chair by standing behind the resident; -Position the resident over the seat of the chair; -Lower the lift down slowly so that the resident will gradually be lowered into the chair; -The policy failed to clearly define that two staff are required at all times to assist with the mechanical lift transfer; -The policy failed to direct staff to lock the residents chair prior to lowering the resident into the chair. Review of Resident #134's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/10/22, showed: -Resident is rarely/never understood; -Extensive assistance required for bed mobil ity; -Total dependence of two staff required for transfer; -Diagnoses include cancer, aphasia (a language disorder that affects a person's ability to communicate), and hemiplegia (paralysis of one side of the body). Review of the resident's care plan, in use at the time of the survey, showed: -Problem: At risk for falls related to unsteady balance, the resident is dependent on staff for transfer with Hoyer; -Goal: Be fee form serious injury related to falls; -Interventions included: Provide assistance with transfer as needed. Observation on 8/23/22 at 5:31 A.M., showed Certified Nursing Assistant (CNA) I exited the resident's room and said he/she was getting ready to transfer the resident but needed to get assistance. Upon entering the room, observation showed the resident elevated in the Hoyer lift and hovered approximately 2 inches above the bed as CNA I stood in the hall and asked for assistance. CNA I re-entered the room with Licensed Practical Nurse (LPN) H. LPN H said, oh, my! You need to wait for me LPN H assisted with the Hoyer lift transfer. As the resident was transferred to his/her Broda chair (medical reclining chair), CNA I stood in front of the resident as LPN H stood behind the mechanical lift. Staff did not lock the chair and the chair started to propel backwards and out from under the resident, as the resident was lowered. During an interview on 8/24/22 at 2:33 P.M., the Director of Nursing (DON) said two staff should be present during all Hoyer transfers. It is not acceptable for residents to be elevated in the Hoyer lift with only one staff in the room or to be left alone while staff stepped out of the room. Staff should ensure the locks on the Broda chair are locked during the transfer. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed -Brief Interview of Mental Status not completed; -Supervision and one person assistance required for locomotion on the unit; -Mobility devices: [NAME] and wheelchair; -Diagnoses included Alzheimer's disease. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: At risk for falls related to use of psychotropic medication and poor safety awareness; -Goal: Will not sustain serious injury; -Interventions included: Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. Observation on 8/22/22 at 12:10 P.M., showed the resident sat in a wheelchair in the hall approximately 4 doors down from his/her room. Certified Medication Technician (CMT) N stood behind the resident and propelled him/her in the direction of his/her room. The resident's feet hovered less than an inch above the floor, no foot rests were in place. As the resident was propelled into the doorway of his/her room, his/her feet started to drag. The resident yelled ouch and CMT N said you need to pick your feet up. During an interview on 8/24/22 at 2:33 P.M., the DON said when propelling a resident in a wheelchair, foot rests should be used to prevent the resident's feet from dragging. The risk of not doing this, the resident could fall out of the wheelchair or get injured.

Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for one resident (Resident #74) who missed one human immunodeficiency virus (HIV) medication, had duplicate orders for a different HIV medication, and missed a phosphorous binder medication, due to the lack of follow-up by facility staff. The census was 135. Review of the facility's Medication Administration and Monitoring Policy, revised 9/17/21, showed: -Purpose: To ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. To provide guidelines and systems following procedures for medication errors including defining a medication error and the levels of medication errors. To ensure therapeutic guidelines are monitored in drugs that requires laboratory and diagnostic studies; -Procedure: -Medications are to be given per doctor's orders. All medications are recorded on the medication administration record (MAR) and signed immediately after the resident has taken the medications. The nurse or certified medication technician (CMT) will check each medication on the MAR noting correct name of medication, correct resident name, correct dose, correct time and correct route of administration. The nurse or CMT should note that if the medication is refused or not available, the nurse or CMT will initial and circle the time of the medication in questions. On back of the MAR the reason for the medication in question that is not given will be noted along with an explanation of the solution to the problem. The Director of Nursing (DON) or registered nurse (RN) designee will be notified immediately regarding the resident not receiving the medication. It will then become the DON or RN designee responsibility to ensure that the medication is received and that the licensed practical nurse (LPN) or CMT distributes the medication to the resident. The back-up pharmacy or primary pharmacy will be notified and the medication will be received. The physician will be notified if medication is given late and the nurses notes will indicate why the medication has a discrepancy. The nurse or CMT then will go to the progress notes and note the documentation of the medication discrepancy, also noting physician notified. The DON or RN will also be notified of the medication refusal or unavailability of the medication. The DON or RN will then investigate the medication in question and ensure that the process for medications not given to residents are followed. If the process is not followed including prudent follow-up to ensure that the resident gets the medication in a timely manner, then disciplinary action will take place. Review of the facility's Transcription of Orders/Following Physician's Orders policy, revised 7/9/21, showed: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. That a process is in place to monitor nurses in accurately transcribing and following physician's orders; -Procedure: -Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be written on the physician's order sheet (POS); -The licensed/registered nurse will check the emergency kit to verify if the medication is present in the facility to begin immediately. If the medication is not available, the facility may contact the backup pharmacy to deliver the medication sooner. If the medication is unable to be started within 24 hours of the order, the prescribing physician will be notified and further orders will be obtained; -Any new orders that are noted on the POS are to be documented in the nurse's notes and the 24 hour report sheet; -The Resident Care Coordinator (RCC)/unit director/LPN/DON/designee will audit all physician orders daily to ensure new physician's orders are recapped and followed completely and accurately; -The RCC/unit director/designated nurse will review all MARs and treatment administration records (TARs) daily to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. -In the event that the medication is unavailable, the RCC/unit manager/designated nurse will contact the pharmacy and have the medication delivered. If the resident is not going to receive their scheduled medication per physician's order, the RCC/unit manager, designated nurse will contact the DON, the administrator, physician and legal guardian, if applicable. The RCC/unit manager/designated nurse will then follow any further orders that may be provided by the physician; -The nurse or CMT in charge or medication administration must review all of their designated MARs and TARs prior to the end of their shift to ensure all medications/treatments scheduled to be given on their shift were administered according to the physician's order and that all necessary interventions were taken in the event of an omission; -The RCC/unit manager/designated nurse will review all medication/treatment administration records and compare all medications to the medications available for each resident in the facility weekly to ensure availability. Review of the prescribing information for Genvoya (an HIV medication), revised January 2022, showed: -Indications and usage: Genvoya is a four-drug combination of elvitegravir, an HIV integrase (enzyme found in HIV) inhibitor, cobi cistat, a CYP3A (specific gene location) inhibitor, and emtricitabine and tenofovir alafenamide, both HIV-1 inhibitors, and is indicated as a complete regimen for the treatment of HIV-1 (the most common type of HIV) infection; -Dosage and administration: On days of dialysis, administer Genvoya after dialysis. -Patient counseling information: -Missed dosage: Inform patients that it is important to take Genvoya on a regular dosing schedule with food and to avoid missing doses as it can result in development of resistance. Review of the prescribing information for Prezista (darunavir, an HIV medication), revised April 2022, showed: -Indications and usage: Prezista is a HIV protease (enzyme that breaks down protein) inhibitor indicated for the treatment of HIV-1 infection. Prezista must be co-administered with ritonavir (Prezista/ritonavir) and other antriretroviral agents; -Patient counseling information: -Instructions for use: Advise patients to take Prezista and ritonavir with food every day on a regular dosing schedule, as missed doses can result in resistance. Review of the prescribing information for Renvela (sevelamer carbonate, controls phosphorous levels in adults with chronic kidney disease), revised May 2021, showed: -Indications and usage: Renvela is a phosphate binder indicated for the control of serum phosphorous in adults and children six years of age and older with chronic kidney disease on dialysis; -No information regarding missed doses. Review of Resident #74's medical record, showed diagnoses included chronic kidney disease and HIV. Review of the resident's MAR and progress notes for July 2022, showed: -An order, dated 7/18/22, for Genvoya tablet 150-150-200-10 milligrams (mg) (elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide) give one tablet by mouth in the evening every Monday, Wednesday, Friday for HIV, must be given after dialysis on Monday, Wednesday, Friday. -Of six opportunities, six doses blank with no documentation to show medication administered; -No documentation the physician notified of the missed doses. Review of the resident's MAR and progress notes for August 2022, showed: -An order, dated 7/18/22 through 8/8/22, for Genvoya tablet 150-150-200-10 mg (elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide), give one tablet by mouth in the evening every Monday, Wednesday, Friday for HIV, must be given after dialysis on Monday, Wednesday, Friday; -An order, dated 8/8/22 through 8/10/22, for Genvoya tablet 150-150-200-10 mg (elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide), give one tablet by mouth one time a day for HIV, please give after dialysis; -An order, dated 8/12/22, for Genvoya tablet 150-150-200-10 mg (elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide), give one tablet by mouth in the evening every Monday, Wednesday, Friday for HIV, please give after dialysis; -Of a total of 11 opportunities to administer Genvoya, nine doses blank with no documentation to show the medication administered. On 8/8/22 and 8/10/22, staff documented a 9; -Chart codes: 9 = other/see nurse's notes; -No progress note on 8/10/22 regarding administration of Genvoya; -An order, dated 8/8/22, for darunavir tablet 600 mg, give one tablet by mouth two times a day for HIV. Take one with breakfast and one dinner; -Of 34 opportunities to administer darunavir, staff documented medication as administered 22 times, not given none on hand 11 times, and one dose blank with no documentation to show medication administered; -An order, dated 8/8/22, for Prezista 600 mg tablet, give one tablet by mouth two times a day for antiviral; -Of 48 opportunities to administer Prezista, staff documented medication as administered 43 times, not administered due to resident in hospital four times, and one dose blank with no documentation to show medication administered; -An order, dated 8/8/22, for sevelamer carbonate tablet 800 mg, give 3200 mg by mouth three times a day with meals; -Of 50 opportunities to administer sevelamer, staff documented medication as administered 40 times, absent from home without meds four times, medication not given none on hand two times, medication not given because may cause resident to not make it to toilet one time, three doses blank with no documentation to show medication administered. During an interview on 8/25/22 at 8:28 A.M., CMT JJ said when a medication is out of stock or unavailable, staff should document the medication as unavailable on the resident's MAR and make a progress note about why the medication was not administered. The resident has been prescribed sevelamer for at least the past year. Out of nowhere, his/her insurance would no longer pay for the medication. The pharmacy sent the facility a form about a comparable drug to use instead. CMT JJ faxed this form to the physician, but the physician has not responded. The resident has not been getting the sevelamer for several weeks. Darunavir is a new medication prescribed to the resident during his/her most recent hospitalization. Darunavir is not covered by insurance, either. CMT JJ faxed the physician about the medication and gave a copy to the DON. During observation and interview on 8/25/22 at 11:43 A.M., LPN AA said the resident's medications were on the CMT medication cart. The medication cart contained an unopened, sealed bottle of Genvoya, with a fill date of 7/18/22. LPN said the resident should receive the Genvoya at the facility in the evening, after dialysis. LPN AA pulled a second bottle of Genvoya, with a fill date of 5/13/22. The bottle contained 8 pills. LPN AA said the resident might not be getting the Genvoya as prescribed, due to the amount left on hand. LPN AA pulled a 60 count bottle of Prezista, with a fill date of 6/26/22. The bottle contained 22 pills. LPN AA pulled an unopened 12 count strip of pre-packaged darunavir, dated 8/12/22 evening through 8/18/22. LPN AA pulled an unopened 12 count strip of pre-packaged darunavir, dated 8/20/22 through 8/25/22. LPN AA said darunavir should be administered twice daily by the facility. The CMT might not have known darunavir and Prezista were the same medication. Genvoya and darunavir are HIV medications. They need to be taken routinely and cannot be missed. There is no sevelamer for the resident on the medication cart. The resident has not received sevelamer in a few weeks. Sevelamer is not covered by the resident's insurance. The pharmacy sent a denial letter to the facility, and he/she faxed it to the physician last week, but the physician has not responded. When a medication is unavailable, staff should document it as not administered on the resident's MAR and in the progress note. The physician should be notified and staff should document the notification in the resident's medical record. Further review of the resident's medical record, showed no documentation the physician notified about the resident's missed doses of Genvoya, duplicate orders for darunavir and Prezista, and sevelamer not administered due to not being covered by insurance. During an interview on 8/25/22 at 12:14 P.M. Pharmacist MM said the pharmacy filled a 30 count of Genvoya on 7/18/22. Genvoya should be taken three times a week, after dialysis. By this count, the bottle of Genvoya should not be sealed. Generally speaking, the medication should be administered consistently. The resident has a script for darunavir to be taken twice daily. The pharmacy filled a 14 day supply of darunavir on 7/28/22 and 8/17/22. This medication has to be taken consistently because it is important for the disease it treats; HIV. On 8/8/22, the pharmacy received a script for sevelamer. Insurance faxed a form to the pharmacy about trialing two other medications before sevelamer would be covered. On 8/8/22, the pharmacy faxed the facility a form that explained why the medication was not covered and how much the medication would cost to fill. Prior to 8/8/22, a 28 count of sevelamer was filled for the resident on 6/30/22. During an interview on 8/26/22 at 8:09 A.M., LPN AA said yesterday, he/she saw the duplicate orders for the resident to receive darunavir and Prezista, which are the same medication. This could be due to the resident's recent hospitalization. When a resident comes back from the hospital, the nurse working at the facility that day should review the resident's orders and make sure they are accurate. Ideally, the orders would be rechecked by a second nurse. When staff see duplicate orders, they need to clarify. The should check with the pharmacy and if needed, check with the doctor. The resident has had duplicate orders for three weeks and this should have been clarified by now. If a resident comes back to the facility from the hospital with the same orders and the medication is already on hand, staff should call the pharmacy and tell them not to fill the medication. With the resident having duplicate orders for darunavir and Prezista, there is no way to tell on the MAR if he/she received the correct doses. During an interview with the DON and administrator on 8/26/22 at 8:18 A.M., the DON said the resident's orders for darunavir and Prezista are duplicate. When residents are readmitted to the facility from the hospital, the licensed nurse should review their orders for accuracy within 24 hours and clarify with the physician. If the CMT has questions regarding orders, they should ask the nurse, nurse manager, or DON, and they can consult with the physician as needed. The orders have been duplicate for three weeks and should have been clarified by now. With the MAR showing both orders documented as administered, there is no way to tell if the medication was administered once or twice. The resident's MAR looks crazy, like he/she is not getting his/her sevelamer. Sevelamer is not covered by insurance. Last week, she received a form from the pharmacy that stated the medication would cost $935 and there were no recommendations. She called the rejection department yesterday and found out an alternative medication needed to be tried first. The resident received the order for sevelamer three weeks ago and she would have expected the nurse to notify her within at least three days if the medication could not be filled and she would have talked to the pharmacy, physician, and dialysis center, since the resident is on dialysis. She could not attest to whether or not the physician was notified. The administrator said she agreed with the DON's expectations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life when staff yelled at a resident during an interaction (Resident #107), laughed at a resident causing the resident to be angry (Resident #81), propelled the resident backwards and left the pants down exposing the resident's brief (Resident #3), assisted a resident to eat while standing, and did not keep the residents' clothes clean and free of food particles or stains (Resident #56). Other residents were observed in the dining area being assisted in eating by staff while standing. The sample was 27. The census was 135. Review of the facility's Nursing Home Residents' Rights, provided to residents upon admission, showed: -Residents of nursing homes have rights that are guaranteed by the federal nursing home reform law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination; -Resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 1. Review of Resident #107's medical record, showed diagnoses included seizure disorder, unspecified sequelae (aftereffect of disease, condition, or injury) following stroke, and bipolar disorder (mood disorder that can cause intense mood swings). Observation on 8/22/22 at 10:19 A.M., showed the resident seated in his/her wheelchair in the hall by the nurse's station. Certified Medical Technician (CMT) GG stood in front of a medication cart next to the nurse's station. Resident #107 asked CMT GG for his/her medication. In a loud voice, CMT GG said, I'm trying to log on, wait a minute! You need to stop distracting me. An unknown resident propelled in his/her wheelchair and stopped next to the medication cart. He/she asked CMT GG for his/her medication and CMT GG said, You need to leave me alone, y'all keep distracting me. The unknown resident asked for his/her medication again and in a loud voice, CMT GG said, Y'all are constant with this, you keep distracting me. Stop it now, stop it please! The unknown resident propelled away in his/her wheelchair. During an attempted interview, on 8/22/22 at 10:25 A.M., Resident #107 unable to respond appropriately regarding his/her interaction with CMT GG and discussed unrelated issues. Review of CMT GG's personnel file, showed he/she was previously employed by the facility. A separation notice, dated 4/11/17, showed he/she was terminated from his/her employment due to abused a resident and was not eligible for rehire. During an interview on 8/24/22 at 10:29 A.M., the administrator said the way CMT GG spoke to the residents on 8/22/22 was inappropriate. It would be a dignity issue, floating on the line of being abusive. If she had witnessed the conversation, she would have pulled the employee to the side and addressed the situation, possibly by sending them home. 2. Review of Resident #3's care plan, in use at the time of the survey, showed: -Problem: Resident has an activities of daily living (ADL) self-care performance deficit related to refusing showers and hygiene care. He/she is often incontinent of urine and will throw his/her soiled brief/insert on the floor. He/she is refusing to allow staff to assist to clean him/her up. Diagnosis of muscle weakness, other abnormalities of gait and mobility; -Outcome: Resident will maintain current level of function through review date; -Interventions: The resident is totally dependent upon staff for hygiene and oral care; resident is totally dependent upon staff for toilet use; encourage resident to use call bell for assistance; monitor/document/report as needed (PRN) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Observation on 8/22/22 at 8:57 A.M., showed a staff member propelled the resident into his/her room. The resident's eyes closed and his/her brief exposed and shorts pulled down to his/her knees. Staff left him/her in his/her room and left the room. Staff did not assist the resident to pull up his/her pants. Speech Therapist V, talked to the resident with his/her brief exposed and shorts pulled down to his/her knees. Speech Therapist V left without pulling up the residents' shorts. At 9:17 A.M., the resident sat in a wheelchair, in the hall outside his/her room. A staff person stood next to the resident and talked with the resident. The resident's pants remained pulled down to approximate mid-thigh as the resident sat in his/her chair. During an interview on 8/24/22 at 8:37 A.M., the Social Services Director said he would expect staff to assist a resident whose shorts were down to his/her knees if he/she needed assistance. Part of the reason staff are here is to help the residents. During an interview on 8/24/22 at 8:49 A.M., Licensed Practical Nurse (LPN) R said he/she would expect staff to assist a resident whose shorts are down but residents are encouraged to do what they can for themselves. At 8:54 A.M., LPN R said he/she would expect staff to assist with pulling up a residents pants if staff went into a room and saw the resident's pants down. During an interview on 8/24/22 at 9:44 A.M., the Director of Nursing (DON) and Administrator both expected staff to pull resident pants up they saw his/her shorts down to his/her knees. Further observation of the resident on 8/22/22 at 12:06 P.M., showed the resident sat in his/her wheelchair in the 100 hall dining room. A staff person propelled the resident backwards in his/her wheelchair out of the dining room, down the hall, around the corner and half way down another hall. During an interview on 8/24/22 at 2:33 P.M., the DON said it is not dignified to be pulled backwards in a wheelchair out of a dining room and down a hall. 3. Review of Resident #56's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/13/22, showed: -Severely impaired cognitively; -No speech; -Rarely understood; -One person physical assistance in bed mobility, locomotion on and off the unite, dressing, eating, toilet use, and personal hygiene; -Two or more physical assistance on transfers; -Always incontinent of bladder and bowel; -Diagnoses included: dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), manic depression (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of resident's care plan, in use at the time of survey, showed: -Problem: The resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to being nonverbal and unable to interact with staff: -Outcome: Will maintain involvement in cognitive stimulation, social activities; -Interventions: All staff to converse with resident while providing care; -Problem: The resident has impaired cognitive function or impaired thought processes related medical diagnoses: -Outcome: Will maintain current level of cognitive function; -Interventions: Administer medications as ordered, monitor side effects and effectiveness, ask yes/no questions in order to determine the resident's needs; -Problem: The resident has an ADL self-care performance deficit related to being mute and unable to make needs known: -Outcome: Will maintain current level of functions; -Interventions: The resident is totally dependent on staff to provide bath/shower and as necessary; -Problem: The resident is at risk for nutritional problem and is on puree diet, thin liquid: -Outcome: Will comply with recommended diet and be free of health complications; -Interventions: Monitor/document/report PRN any signs and symptoms of dysphagia (difficulty swallowing): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals, and provide and serve diet as order. Observation on 8/22/22 at 9:22 A.M., showed the resident up in a high-back reclined wheelchair at his/her bedside. He/she smiled but unable to respond verbally. Observed food particles and liquid stains on the chest area of his/her shirt and on pants, across the lap. Observation on 8/22/22 at 12:58 P.M., showed stains and food particles continued to be observed on the resident while in the Southern Kitchen dining room during lunch. A staff person applied a clothing protector to the resident, over the dirty shirt. LPN BB served and assisted the resident to eat while standing over the resident. LPN BB held up the plate, stood on the resident's left side, and fed the resident while talking to other staff in the room and did not interact with the resident. During an interview on 8/23/22 at 8:28 A.M., the resident's family member said the family had observed the resident with food particles or stains on resident's clothes during their visits multiple times. During an interview on 8/29/22 at 2:44 P.M., the Administrator said she expected staff to keep the residents' clothes clean and free of food particles or stains. 4. Observation on 8/22/22 at 12:55 P.M., showed Speech Therapist V assisted a resident in the Southern Kitchen dining room. He/she stood and fed the resident with the resident's chair tilted back and not in full upright sitting position. Observation on 8/24/22 at 12:40 P.M., showed inside the dining room adjacent to the assisted dining room, the Speech Therapist remained stood beside a seated resident while he/she assisted him/her with the meal. During an interview on 8/29/22 at 2:44 P.M., the Administrator said it is not acceptable for the staff to stand over the residents while assisting them to eat. 5. Review of Resident #81's admission MDS, dated [DATE], showed: -Cognitively intact; -Independent with eating; -Diagnoses included diabetes and dementia. Observation 8/24/22 at 12:40 P.M., showed the resident sat in the 100 hall dining room and complained to staff about not having his/her plate. The staff chuckled at the resident amongst themselves. The resident lifted a chair as though he/she would throw it. At 12:42 P.M., when staff brought the resident's plate over, the resident put the chair down. During an interview on 8/25/22 at 12:25 P.M., the DON said laughing at a resident is not an appropriate behavior intervention. The DON expected staff to redirect or talk the resident down if the resident who is angry in the dining room picked up a chair in the attempt to throw it. MO00191380

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain written authorization to hold personal funds from residents and/or their legal guardian, for 51 out of 82 residents for whom the facility holds funds. The facility failed to ensure residents had access to their trust account during regular business hours and on the weekends (Residents #91 and #55). These deficient practices affected all residents who had a resident trust account. The census was 135. Review of the facility's Resident Trust policy, revised 9/17/21, showed: -admission requirements regarding resident trust: Upon admission, an Authorization to Hold Resident's Funds form must be presented to the resident, guardian, or legal representative and must be signed by them if they choose to have the facility manage the Resident funds; -General Information Regarding Responsibilities of Holding Funds: -The facility shall allow the residents access to their personal possessions and funds during regular business hours, Monday through Friday. 1. Observation on 8/22/22 at 1:50 P.M., showed an announcement made on the overhead paging system, in which staff said, Bank is now open. Observation of the 200 hall dining room on 8/23/22 at 7:04 A.M. and 8/24/22 at 11:50 A.M., showed a sign posted, Bank will be Monday - Friday 2:00. 2. Review of Resident #91's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/22, showed: -Cognitively intact; -Diagnoses included high blood pressure, diabetes, high cholesterol, anxiety, depression, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 8/22/22 at 4:16 P.M., the resident said the facility holds his/her money. He/she doesn't remember if he/she signed a paper about them holding his/her money. He/she has to wait until the facility calls bank to get his/her money. The residents cannot get their money on the weekends, but it would be nice if they could. 3. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included paraplegia (paralysis of the lower half of the body), diabetes, high cholesterol, and depression. During an interview on 8/24/22 at 11:49 A.M., the resident said the facility holds his/her money. He/she has to wait until 3:00 P.M. to get his/her money from the facility bank. He/she cannot get his money on the weekends. 4. Review of the facility's representative payee list, showed the facility holds funds for 82 residents, including Residents #91 and #55. Review of the facility's Authorizations to Hold Resident's Funds forms, reviewed 8/24/22 at 1:23 P.M., showed signed authorizations to hold funds for 31 out of 82 residents. No authorizations to hold funds for Residents #91 and #55. 5. During an interview on 8/24/22 at 1:23 P.M., the Resident Trust Manager said all residents who have funds held by the facility are indicated on the representative payee list provided. All resident trust authorization forms have been provided. Authorizations should be completed by the Admissions Coordinator upon a resident's admission to the facility. If the resident has a legal guardian or a representative payee, the authorization to hold funds should be signed by them. Residents can access their personal funds when the facility's bank opens at 2:00 P.M., Monday through Friday. The Activity Director disburses the resident's money. Residents cannot access their funds until 2:00 P.M. Banking does not take place on the weekends because the Activity Director does not work every weekend. A couple months ago, she found out residents should have access to their money at all times during regular business hours. She is trying to work with the Activity Director on creating a plan to make this happen, but they do not have a plan at this time. 6. During an interview on 8/25/22 at 8:48 A.M., Certified Nurse Aide (CNA) CC said residents can get their money during banking hours between 2:00 and 3:00 P.M., Monday through Friday. The bank being open gets announced on the overhead paging system. 7. During an interview on 8/25/22 at 9:24 A.M., Activity Aide FF said the activity department does bank for the residents. Banking hours are in the afternoon, after 1:30 P.M., Monday through Friday. He/she works on the weekends and banking hours are not held on the weekends. 8. During an interview on 8/25/22 at 11:58 A.M., Activity Aide EE said the activity department does bank for the residents. He/she works throughout the week and on the weekends. Resident banking hours are from 10:30 A.M. to 2:00 P.M., during the week. Banking hours do not take place on the weekend. 9. During an interview on 8/25/22 at 2:58 P.M., the Activity Director said personal funds are available to residents anytime during banking hours, Monday through Friday. Official bank is called out to residents at 2:00 P.M., but residents can ask for their funds at any time and he will get them their money. He works Saturdays, too. 10. During an interview on 8/26/22 at 7:40 A.M., the administrator said residents who have funds held by the facility should have signed authorization forms. This is done during the admissions process. Money should be available to residents during regular business hours. Residents should be able to access petty cash on the weekends.

Based on interview and record review, the facility failed to ensure general accounting principles by failing to complete monthly account reconciliations in a timely manner. In addition, the facility failed to provide quarterly statements to residents and their representatives (Residents #91, #55, #57, and #102). This affected 82 residents whose funds were handled by the facility. The census was 135. Review of the facility's Resident Trust policy, revised 9/17/21, showed: -Purpose: Complete procedures on resident trust responsibilities; -Resident Trust Bank Reconciliation: -A reconciliation of the bank statement, checkbook, and trust funds module must be completed monthly. This will be completed by the facility's management company staff accountant responsible for the facility's financials. The reconciliation must be done by someone other than the Resident Trust Clerk; -On the first day of every month the Resident Trust Clerk must prepare a list of checks that were written from the resident trust account during the prior month. The list should be sent to the facility's management company staff accountant responsible for the facility's reconciliation no later than the third work day of each month; -As the staff accountant reconciling the account finds errors, he/she will email the Resident Trust Clerk to obtain information on them in order to make accurate corrections. The Resident Trust Clerk must respond the same day to ensure a timely reconciliation of the trust funds; -When the reconciliation is complete the staff accountant will send the Resident Trust Clerk a copy of the completed reconciliation and bank statement, which should be filed in the monthly resident trust folder; -Resident Statements: -A detailed written account of all transactions affecting each resident's trust account shall be maintained and made available upon request. All accounts shall be reconciled monthly. The individual financial record shall be made available by statements on a quarterly basis; -The Resident Trust Clerk is responsible for sending out quarterly statements; -Make copies of all statements and date stamp them with the date they were mailed. Retain the copies for your files; -Statements must be sent to the resident and his/her legal guardian or legal representative. 1. Review of Resident #91's medical record, showed the resident listed as his/her financial responsible party. During an interview on 8/22/22 at 4:16 P.M., the resident said the facility holds his/her money. He/she doesn't receive quarterly statements. 2. Review of Resident #55's medical record, showed the resident listed as his/her financial responsible party. During an interview on 8/24/22 at 11:49 A.M., the resident said the facility holds his/her money. He/she does not receive quarterly statements. 3. During an interview on 8/24/22 at 1:23 P.M., the Resident Trust Manager said the resident trust account must be reconciled monthly. She does the initial reconciliation and sends it to the accountant with the facility's management company for review. The reconciliation for July 2022 has not been completed, yet. During an interview on 8/24/22 at 5:00 P.M., the Resident Trust Manager said the resident trust account reconciliation should be completed by the 5th day of each month for the month prior. The reconciliation for June 2022 was completed this week and the reconciliation for July 2022 was completed today. The facility switched to a new system in July 2022, causing a delay in the completion of reconciliations. In July 2022, she became aware the facility should be sending out quarterly statements to residents who have funds held by the facility. If the resident has a legal guardian, they should receive the quarterly statement. She sent out quarterly statements to several guardians on 7/20/22. She has not sent out quarterly statements to residents who are their own responsible party, including Residents #55, #91, and #57. She sent Resident #102's family a copy of the resident's quarterly statement on 7/20/22, but did not give one to the resident. Residents should have been receiving their quarterly statements prior to 7/20/22. 4. During an interview on 8/26/22 at 7:40 A.M., the administrator said the Resident Trust Manager should be providing residents and/or their representatives with resident statements on a quarterly basis. She was not aware this was not being done. After the month ends, the resident trust account should be reconciled by the 15th of the following month. The Resident Trust Manager completes the monthly reconciliation and then it goes to the facility's management company for review. The reconciliation for June and July 2022 should have been done prior to this week. MO00198903

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide laundry services to ensure residents had the linen to meet their needs. In addition, the facility failed to provide a homelike environment when they served meals on Styrofoam dishes and provided plastic utensils. This affected eight resident (Residents #28, #29, #91, #74, #65, #55, #57, and #103). The sample was 27. The census was 135. 1. During the Resident Counsel interview on 8/23/22 at 10:30 A.M., seven residents who represent the resident population said the facility has run out of towels, sheets, and blankets. 2. Review of Resident #28's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/23/22, showed: -Cognitively intact; -Supervision and set up help required for dressing and personal hygiene; -Occasionally incontinent of bladder; -Diagnoses include arthritis, depression and seizure disorders. Observation on 8/22/22 at 8:50 A.M., showed the resident in his/her room and sat on the edge of his/her bed. No linen on the bed or either of the other two roommate's beds. He/she said staff stripped the beds to wash them, but there was not enough linen to put new sheets on the bed until it comes back up from laundry. Further observation at 1:04 P.M., showed the resident's bed and the two roommate beds without linen. At 3:58 P.M., all three beds remained without linen as the resident lay in bed with his/her eyes closed, on top of the uncovered mattress. 3. Review of Resident #29's annual MDS, dated [DATE], showed: -Cognitively intact; -Independent with all activities of daily living. During an observation and interview on 8/23/22 at 11:28 A.M., showed no linen on the resident's bed while the resident lay directly on the mattress. The resident said there was no linen on his/her bed because it was being washed. During an interview on 8/24/22 at 10:59 A.M., Certified Medication Technician (CMT) N said he/she would expect residents to have linen on the bed before laying on it. 4. Observation on the 100 hall linen cart 8/22/22 at 12:10 P.M., showed a resident looked through the linen on the cart. A staff person asked the resident what he/she was looking for and the resident said he/she was looking for a bottom sheet. The staff person said there were not any and he/she would have to wait until it came up from laundry. The linen cart appeared to have very few linen. At 12:55 P.M., during a detailed observation of the linen cart, showed it contained three incontinence pads, a stack of gowns, a stack of pillow cases, two rags, six towels, no flat sheets or top sheets. During an interview on 8/22/22 at 1:01 P.M., CMT N said the linen cart is the only linen storage on the floor. The laundry department will bring more. The floors run out of linen a lot in the morning, it is usually better in the evening. 5. Observation of all floor linen storage areas, on 8/23/22, showed: -On the 300 hall at 5:27 A.M., the linen carts contained six towels, two rags, several pillow cases. During an interview at this time, Licensed Practical Nurse (LPN) J said this linen is all of the linen for the 300 hall; -On the 200 hall at 5:29 A.M., the two linen carts contained several small towels, pillow cases, three incontinent pads, and a small stack of bottom and top sheets. During an interview at this time, Certified Nursing Assistant (CNA) I said the cart was the linen available on the 200 hall; -On the 100 hall at 5:37 A.M., the linen cart contained one medium sized stack of top sheets, four incontinent pads, several gowns, one pillow case and two bottom sheets. CNA G said that was all of the linen available on the 100 hall. The floors run out sometimes, but laundry usually brings more before they leave for the day. Staff can always go to other floor if they need more; -On the 400 hall at 6:07 A.M., the linen cart contained 12 towels, a stack of wash cloths, four incontinent pads, three bottom sheets, and six top sheets. CMT F said that is all of the linen storage for the 400 hall. During an interview on 8/23/22 at 8:24 A.M., Laundry Aide C said laundry staff either work on the 6:30 A.M. to 2:30 P.M. or 3:00 P.M. to 11:00 P.M. shift. There are no laundry staff who work the night shift. When soiled linen arrives to laundry, it is brought through the soiled linen door or down the laundry chute. Observation of the laundry room, showed a door labeled soil laundry room. Inside the door, two wash machines with linen washing. Laundry Aide C said the two machines is not enough to keep up with the laundry. Nursing staff do complain that they run out of linen, but if the laundry department do not have the linen to wash, they cannot get it back to the floor. Usually, when the morning shift arrives, there is a lot of laundry to do. The laundry department usually does not start to get the linen to the floor until 9:00 or 10:00 A.M. Observation showed 2 large trach cans full of towels. Laundry Aide C said those are the old worn out towels, they are clean. They are for housekeeping, not resident use. Observation of the next room, located between the dirty linen are and clean storage area were two dryers full of linen. Observation of the clean linen storage and sorting area, showed a large bin of blankets against the far wall and a bin against the exit wall. Laundry Aide C said the bin against the exit wall is the extra storage of linen that will go to the floor. It is from last night, the morning shift have not gotten their linen clean yet. It is either currently in the washers or dryers. Observation of the bin, showed four towels, five top sheets, and two incontinent pads. No other linen. 6. Observation on 8/23/22 at 7:12 A.M., showed Restorative Aide D gathered supplies from the 300 hall linen carts. He/she asked Quality of Life Advocate E to find an incontinence pad and that there were none on the cart. A resident approached and asked for a blanket. Restorative Aide D said he/she did not believe any were up from laundry yet, and that he/she will have to wait. The resident walked away without a blanket. 7. Observation on 8/23/22 at 7:20 A.M., showed four towels, one cloth pad, and one sheet on the 200 hall's linen cart. During an interview on 8/23/22 at 7:20 A.M., CNA CC said there have been issues with getting linens back from laundry. When nursing staff does not have enough linens, they have to wait to provide personal care to the residents. There is one more linen cart in the clean linen room on the 200 hall. Observation on 8/23/22 at 7:23 A.M., showed a linen cart inside the 200 hall clean linen room. The cart contained seven sheets, 15 small towels, three wash clothes. No large towels or cloth pads. 8. During an interview on 8/24/22 at 10:29 A.M., the administrator said laundry staff attend the Quality Assurance meetings. They are held monthly. During the meetings, the different departments take turns discussing concerns. They have discussed concerns with not enough linen. It has not been a performance improvement topic in the meetings but it is an issue that has been identified recently as an issue. New linen are ordered monthly. There is an issue with the timeliness turnaround from laundry. 9. During an interview on 8/24/22 at 12:58 P.M., the Housekeeping and Laundry Supervisor said he does receive complaints about not having enough linen at times. The facility purchases linen one to two times a month. The problem is not that the facility does not purchase enough linen, it is that it never makes it back down to the laundry department. Laundry staff can only wash what is sent back down. He would expect there to be enough clean linen to ensure residents have the linen they need. 10. During an interview on 8/26/22 at 11:04 A.M., with the Director of Nursing (DON) and administrator, they said they would expect linen to be available when needed. Residents should have linen on their beds. Personal care should not be delayed due to unavailability of linen. 11. Review of the lunch menu for 8/22/22, showed taco salad, Mexican rice, and fruit cup. Observation of the 100 hall lunch meal service, on 8/22/22 at 12:18 P.M., showed trays arrive on an insulated cart. Drinks and supplies on a rack style cart covered with plastic. At 12:23 P.M., staff passed plastic utensils to the resident's. Staff pour drinks from pitchers into Styrofoam cups and passed them to the resident's. At 12:37 P.M., staff began to pass trays to the residents. The lettuce served in a Styrofoam bowl, and the meat, rice and soft taco shells served on Styrofoam plates covered with plastic wrap. Staff walked around with a container of salsa and offered it to the residents. One resident sat near the center of the dining room attempted to cut the soft taco shell with the plastic knife and fork and broke his/her Styrofoam plate in half. He/she appeared frustrated and started to rip the taco shell with his/her hands. Fruit passed in Styrofoam bowls. 12. Observation of the 200 hall dining room on 8/22/22 at 12:34 P.M., showed 19 residents served meals on Styrofoam with plastic utensils, including Residents #91 and #74. Styrofoam plates contained two tortillas, rice, and ground beef. Styrofoam bowls contained lettuce and shredded cheese. Observation of the 200 hall dining room on 8/23/22 at 7:34 A.M., showed a warming cart filled with trays containing Styrofoam plates and bowls wrapped in plastic wrap. At 7:57 P.M., staff began passing out the plastic wrapped Styrofoam plates from the warming cart to residents seated in the dining room. Styrofoam plates contained scrambled eggs, a sausage patty, and pastry. 13. Review of Resident #91's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Independent with eating; -Diagnoses included high blood pressure, diabetes, high cholesterol, anxiety, depression, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 8/22/22 at 4:16 P.M., the resident said residents are getting served meals on Styrofoam. It doesn't feel nice to eat off of Styrofoam. The facility always runs out of towels and linens. 14. Review of Resident #74's admission MDS, dated [DATE], showed: -No cognitive impairment; -Independent with eating; -Diagnoses included high blood pressure, kidney failure, diabetes, and schizophrenia. During an interview on 8/23/22 at 7:04 A.M., the resident said residents are getting served meals on Styrofoam with plastic utensils. Residents cannot cut into everything with plastic utensils. He/she would prefer to have real dishes and silverware. 15. Review of Resident #65's quarterly MDS, dated [DATE], showed: -Supervision and setup help required for eating; -Diagnoses included cancer, heart disease, kidney failure, diabetes, Alzheimer's disease, anxiety, and depression. Observation on 8/23/22 at 12:46 P.M., showed the resident seated on the side of his/her bed, ate lunch with plastic utensils. On the bedside table in front of him/her, a Styrofoam plate contained mechanical soft meat, potatoes, Brussel sprouts, bread, and a Styrofoam cup contained mixed fruit. During an interview, the resident said he/she would prefer to be served meals on real plates because Styrofoam tears easily. He/she would prefer to use real silverware so he/she can cut his/her food. 16. Review of Resident #55's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Extensive assistance of one person physical assist required for eating; -Diagnoses included paraplegia (paralysis of the lower half of the body), diabetes, high cholesterol, and depression. Observation on 8/23/22 at 12:55 P.M., showed the resident seated upright in bed and ate lunch with a plastic fork. On the bedside table in front of him/her, a Styrofoam plate contained mechanical soft meat, potatoes, Brussel sprouts, and bread. During an interview, the resident said the Styrofoam plates do not look really nice and they look smaller. 17. Review of Resident #57's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Requires setup help only in eating; -Diagnoses included: anemia (lack of healthy red blood cells), coronary artery disease (CAD, damage or disease in the heart's major blood vessels), high blood pressure, end-stage kidney disease, diabetes, high cholesterol, and asthma. Observation on 8/23/22 at 8:18 A.M., showed the resident ate breakfast on Styrofoam plates and cups, and used plastic utensils. The resident said warm or hot food and drinks are cold most of the time due to being served on Styrofoam plates and cups. Further interview and observation on 8/24/22 at 12:09 P.M., showed the resident ate lunch on Styrofoam plates. He/she said nothing has changed, and has been eating on Styrofoam plates for a while with no reasons given by the management or the kitchen staff. He/she preferred to eat and drink on regular plates and silverware. The resident also reported shortage of linens and towels in the facility. He/she said there were usually no towels to wash his/her face before bedtime and in the morning. The resident added he/she had to wait all day, in multiple occasions, to get his/her bed made due to no clean linens available. 18. Review of Resident #103's quarterly MDS, showed: -Diagnoses of diabetes, anemia, stroke, and epilepsy (seizures); -Cognitively intact; -No assistance required with eating; During an interview on 8/23/22 at 10:17 A.M., the resident said he/she would prefer to eat on regular plates. The facility has been serving food on Styrofoam since about a month ago. 19. During an interview on 8/24/22 at 3:44 P.M., CNA Z said the facility has been serving meals on Styrofoam with plastic utensils off and on for the past year. Being served meals on Styrofoam with plastic utensils would not be considered homelike. It would be hard to cut through meat with plastic utensils. Linen has been in short supply at the facility and that means nursing staff cannot do what they need to do, such as provide care, especially at night. There just is not enough linen of any type, but especially cloth pads. 20. During an interview on 8/24/22 at 3:54 P.M., LPN AA said a short supply of linens has been an ongoing problem. The facility does not have enough linens and there is never enough available for nursing staff to provide the care they need. Linens always run out, especially in the morning. 21. During an interview on 8/25/22 at 9:31 A.M., the dietary supervisor said meals have been served on Styrofoam with plastic utensils for the past two weeks. Initially, this was due to being short staffed in dietary. 22. During an interview on 8/26/22 at 11:05 A.M., the DON and administrator said meals have been served on Styrofoam for maybe a few weeks, off and on since the recent storms and flooding. Styrofoam has also been used due to a shortage of dietary staff. It would not be considered homelike to serve meals on Styrofoam with plastic utensils. If staff observe a resident struggling with the use of plastic utensils and/or Styrofoam, they should offer the resident silverware. MO00189567 MO00198903

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to issue written transfer notices to residents and/or their representative upon transfer to a hospital when return to the facility was anticipated, for four of four residents investigated for hospital transfers (Residents #9, #63, #76 and #124) investigated for discharge notices. The census was 135. Review of the facility's resident transfer/discharge, immediate discharge, and therapeutic leave policy, revised 7/12/22, showed: -I. Reasons for discharge or transfer: C. Discharge after emergent transfers to acute care - residents who are sent emergently to the hospital are considered facility-initiated transfers because the residents return is generally expected; -II. Notice of discharge or transfer: A. Before any resident is transferred or discharged under a facility-initiated transfer or discharge, the facility must: 1. Notify the resident and the resident representative the reason for the transfer or discharge in writing in a manner they understand; -B. The written notice shall include the following information: -1. Reason for the transfer or discharge; -2. Effective date of the transfer or discharge; -3. Location to which the resident is being transferred or discharged , including specific address. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/22, showed: -admission date 7/26/21; -Cognitively intact; -Diagnosis included hypertension (high blood pressure), diabetes mellitus (DM, metabolic disease), anxiety and depression. Review of the resident's electronic medical record (EMR), showed: -discharge date [DATE]; -readmission date 1/18/22; -discharge date [DATE]; -readmission date 3/9/22; -discharge date [DATE]; -readmission date 4/15/22. Review of the resident's progress notes, dated 12/29/22 through 4/15/22, showed: -On 12/30/22 at 2:23 P.M., the resident was transferred to the hospital due to mental status change. The resident's physician was at the facility and requested the transfer; -The resident returned to the facility on 1/18/22; -On 3/4/22 at 12:47 P.M., the resident was transferred to the hospital for evaluation of an unwitnessed fall. Staff notified resident's physician and family; -The resident returned to the facility on 3/9/22; -On 4/12/22 at 7:32 P.M., the resident was transferred to the hospital due to an irregular heartbeat. Staff notified resident's physician and family; -Resident returned to the facility on 4/15/22. Further review of the resident's medical record, showed no notice of transfer to the hospital was provided to the resident and/or his/her representative. 2. Review of Resident #63's annual MDS, dated [DATE], showed: -admitted [DATE] from another nursing home or swing bed; -Cognitively intact; -Diagnosis included hypertension (high blood pressure), arthritis, depression and schizophrenia (mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). Review of the resident's EMR, showed: -discharge date [DATE]; -readmission date 12/3/21. Review of the resident's progress notes, dated 11/27/21 through 12/3/21, showed: -On 11/26/21 at 6:35 P.M., the resident was transferred to the hospital due to chest pain. Staff notified resident's physician; -The resident returned to the facility on [DATE]. Further review of the resident's medical record, showed no notice of transfer to the hospital was provided to the resident and/or his/her representative. 3. Review of Resident #76's quarterly MDS, dated [DATE], showed: -admission date 9/13/21 from another nursing home or swing bed; -Moderate cognitively impairment; -Diagnosis included atrial fibrillation (a-fib, irregular heart rhythm), heart failure, hypertension (high blood pressure), hyperlipidemia (high cholesterol) and DM. Review of the resident's electronic medical record on 8/23/22 at 6:48 A.M., showed: -discharge date [DATE]; -admission re-entry 1/20/22; -discharge date [DATE]; -admission re-entry 3/15/22. Review of the resident's progress notes, dated 1/16/21 through 3/15/22, showed: -On 1/16/22 at 1:19 P.M., the resident was transferred to the hospital due to shortness of breath (SOB). Staff notified the resident's Nurse Practitioner (NP); -The resident returned to the facility on 1/20/22; -On 3/10/22 at 8:27 P.M., the resident was transferred to the hospital due to chest pain. Staff notified resident's physician; -The resident returned to the facility on 3/15/22. Further review of the resident's medical record, showed no notice of transfer to the hospital was provided to the resident and/or his/her representative. 4. Review of Resident #124's medical record, showed: -admitted on [DATE]; -Diagnoses included stroke, high blood pressure, acute kidney failure, diabetes, dementia and seizure disorder. Review of the resident's progress notes, showed: -On 6/23/22 at 1:37 P.M., the resident was transferred to the hospital due to an unwitnessed fall. Staff notified the resident's physician and guardian. At 9:30 P.M., the resident returned to the facility; -On 6/24/22 at 1:24 P.M., the resident was transferred to the hospital due to left side weakness. Staff notified the resident's physician and guardian; -The resident returned to the facility on 6/25/22; -On 6/26/22 at 8:28 P.M., the resident was transferred to the hospital due to an unwitnessed fall. Staff notified the resident's physician and guardian; -The resident returned to the facility on 6/27/22; -On 7/19/22 at 8:35 A.M., the resident was transferred to the hospital for an unwitnessed fall. Staff notified the resident's physician and guardian. At 2:41 P.M., the resident returned to the facility; -On 7/24/22 at 1:35 P.M., the resident was transferred to the hospital due to a resident to resident altercation. Staff notified the resident's physician and guardian; -The resident returned to the facility on 7/25/22; -On 8/20/22 at 8:07 A.M., the resident was transferred to the hospital due to a resident to resident altercation. Staff notified the resident's physician and guardian. At 1:54 P.M., the resident returned to the facility. Further review of the resident's medical record, showed no notice of transfer to the hospital was provided to the resident and/or his/her representative. 5. During an interview on 8/24/22 at 9:29 A.M., Graduate Practical Nurse (GPN) X said when a resident is being discharged to the hospital, the facility sends a copy of the resident's face sheet and a list of the resident's medications and equipment if needed, such as wheelchair or walker. He/she did not mention providing the resident and/or resident representative with the written notice of transfer at the time of transfer or within 24 hours of transfer. 6. During an interview on 8/25/22 at 8:53 A.M., Licensed Practical Nurse (LPN) R said if a resident is discharged to the hospital, the facility sends a copy of the resident's face sheet, insurance information, and resident's current orders including code status, and labs or x-rays that relate to being sent to the hospital. The resident would also be provided with a transfer form on why he/she is being transferred with a bed hold form. A progress note would be documented in the resident's EMR listing everything that was sent with the resident including the transfer form and bed hold form. 7. During an interview on 8/26/22 at 7:10 A.M., the Social Service Director (SSD) said nursing is responsible for sending the transfer and bed hold notices but he follows up on them. Documentation related to the transfer and bed hold notices are located in the resident's EMR. 8. Durang an interview on 8/26/22 at 11:04 A.M., the Administrator and Director of Nursing (DON) said they expected the transfer and bed hold notices to be sent with the residents when they are sent to the hospital. If the transfer and bed hold notice were sent with the resident, it would be documented in the progress notes in the resident's EMR. They expected all staff, including agency staff, to be aware of the need to send the transfer and bed hold notice during discharge to the hospital. 9. During an interview on 8/26/22 at 11: 30 A.M., the Director of Nursing (DON) said the transfer notices were not completed and she did not know why.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** x Based on interview and record review, the facility failed to issue a written bed hold notice to residents and/or their representative upon transfer to a hospital when return to the facility was anticipated, for four of four residents investigated for hospital transfers (Residents #9, #63, #76 and #124) investigated for discharge notices. The census was 135. Review of the facility's Bed Hold policy, revised 12/10/21, showed: -When a resident is discharged to the hospital or goes on therapeutic leave, the facility will provide to the resident or their legal representative, a copy of the bed hold policy; -The policy failed to direct staff to provide the resident with a bed hold notice upon transfer to a hospital. 1. Review of Resident #9 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/22, showed: -admission date 7/26/21; -Cognitively intact; -Diagnosis included hypertension (high blood pressure), diabetes mellitus (DM, metabolic disease), anxiety and depression. Review of the resident's electronic medical record (EMR), showed: -discharge date [DATE]; -readmission date 1/18/22; -discharge date [DATE]; -readmission date 3/9/22; -discharge date [DATE]; -readmission date 4/15/22. Review of the resident's progress notes, dated 12/29/22 through 4/15/22, showed: -On 12/30/22 at 2:23 P.M., the resident was transferred to the hospital due to mental status change. The resident's physician was at the facility and requested the transfer. The resident returned to the facility on 1/18/22; -On 3/4/22 at 12:47 P.M., the resident was transferred to the hospital for evaluation of an unwitnessed fall. Staff notified resident's physician and family. The resident returned to the facility on 3/9/22; -On 4/12/22 at 7:32 P.M., the resident was transferred to the hospital due to an irregular heartbeat. Staff notified resident's physician and family. Resident returned to the facility on 4/15/22. Further review of the resident's medical record, showed no bed hold notice was provided to the resident and/or his/her representative. 2. Review of Resident #63's annual MDS, dated [DATE], showed: -admitted [DATE] from another nursing home or swing bed; -Cognitively intact; -Diagnosis included hypertension (high blood pressure), arthritis, depression and schizophrenia (mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). Review of the resident's EMR, showed: -discharge date [DATE]; -readmission date 12/3/21. Review of the resident's progress notes, dated 11/27/21 through 12/3/21, showed: -On 11/26/21 at 6:35 P.M., the resident was transferred to the hospital due to chest pain. Staff notified resident's physician. The resident return ed to the facility on [DATE]. Further review of the resident's medical record, showed no bed hold notice was provided to the resident and/or his/her representative. 3. Review of Resident #76's quarterly MDS, dated [DATE], showed: -admission date 9/13/21 from another nursing home or swing bed; -Moderate cognitively impairment; -Diagnosis included atrial fibrillation (A-Fib, irregular heart rhythm), heart failure, hypertension (high blood pressure), hyperlipidemia (high cholesterol) and DM. Review of the resident's EMR, showed: -Initial admission date 9/13/21; -discharge date [DATE]; -admission re-entry 1/20/22; -discharge date [DATE]; -admission re-entry 3/15/22. Review of the resident's progress notes, dated 1/16/21 through 3/15/22, showed: -On 1/16/22 at 1:19 P.M., the resident was transferred to the hospital due to shortness of breath (SOB). Staff notified the resident's Nurse Practitioner (NP); -The resident returned to the facility on 1/20/22; -On 3/10/22 at 8:27 P.M., the resident was transferred to the hospital due to chest pain. Staff notified resident's physician; -The resident returned to the facility on 3/15/22. Further review of the resident's medical record, showed no bed hold notice was provided to the resident and/or his/her representative. 4. Review of Resident #124's medical record, showed: -admitted on [DATE]; -Diagnoses included stroke, high blood pressure, acute kidney failure, diabetes, dementia and seizure disorder. Review of the resident's progress notes, showed: -On 6/23/22 at 1:37 P.M. the resident was transferred to the hospital due to an unwitnessed fall. Staff notified the resident's physician and guardian. At 9:30 P.M., the resident returned to the facility; -On 6/24/22 at 1:24 P.M., the resident was transferred to the hospital due to left side weakness. Staff notified the resident's physician and guardian. The resident returned to the facility on 6/25/22; -On 6/26/22 at 8:28 P.M., the resident was transferred to the hospital due to an unwitnessed fall. Staff notified the resident's physician and guardian. The resident returned to the facility on 6/27/22; -On 7/19/22 at 8:35 A.M., the resident was transferred to the hospital for an unwitnessed fall. Staff notified the resident's physician and guardian. At 2:41 P.M., the resident returned to the facility; -On 7/24/22 at 1:35 P.M., the resident was transferred to the hospital due to a resident to resident altercation. Staff notified the resident's physician and guardian. The resident returned to the facility on 7/25/22; -On 8/20/22 at 8:07 A.M., the resident was transferred to the hospital due to a resident to resident altercation. Staff notified the resident's physician and guardian. At 1:54 P.M., the resident returned to the facility. Further review of the resident's medical record, showed no documentation the resident or the resident's representative received information in writing of the facility's bed hold policy at the time of transfer. During an interview on 8/26/22 at 11: 30 A.M., the Director of Nursing (DON) said the resident and his/her representative were not notified of the bedhold policy each time he/she was transferred to the hospital and she did not know why. 5. During an interview on 8/24/22 at 9:29 A.M., Graduate Practical Nurse (GPN) X said when a resident is being discharged to the hospital, the facility sends a copy of the resident's face sheet and a list of the resident's medications and equipment if needed, such as wheelchair or walker. He/she did not mention providing the resident and/or resident representative with the written bed hold notice at the time of transfer or within 24 hours of transfer. 6. During an interview on 8/25/22 at 8:53 A.M., Licensed Practical Nurse (LPN) R said if a resident is discharged to the hospital, the facility sends a copy of the resident's face sheet, insurance information, current orders including the code status, and labs or x-rays that relate to being sent to the hospital. The resident would also be provided with a transfer form on why he/she is being transferred with a bed hold form. A progress note would be documented in the resident's EMR, listing everything that was sent with the resident including the transfer form and bed hold form. 7. During an interview on 8/26/22 at 7:10 A.M., the Social Service Director (SSD) said nursing is responsible for sending the transfer and bed hold notices but he follows up on them. Documentation related to the transfer and bed hold notices are located in the resident's EMR. 8. During an interview on 8/26/22 at 11:04 A.M., the Administrator and the DON said they expected the transfer and bed hold notices to be sent with the residents when they are sent to the hospital. If the transfer and bed hold notice was sent with the resident, it would be documented in the progress notes in the resident's EMR. They expected all staff, including agency staff, to be aware of the need to send the transfer and bed hold notice during discharge to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for eight residents (Residents #50, #14, #130, #86, #28, #52, #55 and #83). The sample was 27. The census was 135. Review of the facility's Bed rails policy, dated 2/26/21, showed: -Purpose: To ensure all bed side rails in use have been evaluated for safety; -All residents using any size side rail device on their beds will have a restraint/entrapment assessment completed to determine the restraining, enabling, or hazard effect of the device. This assessment will occur upon initial use, quarterly and as needed if there is a significant change in the resident's condition; -Using any device requires a care plan. 1. Review of Resident #50's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 6/7/22, showed physical restraints used in bed: Bed rails used daily. Review of the resident's care plan, in use at the time of the survey, showed the use of side rails not included in the care plan. Review of the resident's medical record, reviewed on 8/22/22, showed no restraint/entrapment assessment completed. Observation on 8/23/22 at 7:49 A.M., showed the resident sat on the edge of the bed. No side rails in use. 2. Review of Resident #14's annual MDS, dated [DATE], showed physical restraints used in bed: Bed rails used daily. Review of the resident's care plan, in use at the time of the survey, showed the use of side rails not included in the care plan. Review of the resident's medical record, reviewed on 8/22/22, showed no restraint/entrapment assessment completed. Observation on 8/23/22 at 7:05 A.M., showed the resident lay in bed. No side rails in use. 3. Review of Resident #130's significant change MDS, dated [DATE], showed physical restraints used in bed: Bed rails used daily. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: The resident has an ADL self-care performance deficit related to disease process; -Goal: Maintain current level of function in ADLs; -Interventions: Side rails: Full/half rails up as per physician order for safety during care provisions, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Review of the resident's medical record, reviewed on 8/22/22, showed no restraint/entrapment assessment completed. Review of the resident's electronic physician order sheet (ePOS), showed no order for side rail use. Observation on 8/23/22 at 6:35 A.M., showed quarter rails up near the head of the bed on both sides of the bed. During an interview on 8/23/22 at 6:39 A.M., Licensed Practical Nurse (LPN) J said the resident's side rails are used for mobility. 4. Review of Resident #86's quarterly MDS, dated [DATE], showed physical restraints used in bed: Bed rails used daily. Review of the resident's care plan, in use at the time of the survey, showed side rails not included in the care plan. Review of the resident's medical record, reviewed on 8/22/22, showed no restraint/entrapment assessment completed. Observation on 8/23/22 at 6:36 A.M., showed the resident not in his/her room. U rails up near the head of the bed on both sides of the bed. During an interview on 8/23/22 at 6:39 A.M., LPN J said the resident's side rails are used for mobility. 5. Review of Resident #28's annual MDS, dated [DATE], showed physical restraints used in bed: Bed rails used daily. Review of the resident's care plan, in use at the time of the survey, showed side rails not included in the care plan. Review of the resident's medical record, reviewed on 8/22/22, showed no restraint/entrapment assessment completed. Observation on 8/23/22 at 7:53 A.M., showed the resident lay in bed, no side rails in use. 6. Review of Resident #52's annual MDS, dated [DATE], showed physical restraints used in bed: Bed rails used daily. Review of the resident's care plan, in use at the time of the survey, showed: -ADL self-care performance deficit related to diagnoses of cervical spine stenosis (loss of mobility of the neck area) and is a quadriplegic (paralysis or weakness to al four extremities). Requires total care with all ADLs; -Goal: Maintain current level of function; -Interventions included: Bed mobility, the resident is totally dependent on staff for repositioning and turning in bed as necessary; -The use of side rails not addressed on the care plan. Review of the resident's medical record, reviewed on 8/22/22, showed no restraint/entrapment assessment completed. Observation on 8/23/22 at 6:23 A.M., showed the resident lay in bed asleep, full bedrails up times two on both sides of the bed. During an interview on 8/23/22 at 6:24 P.M., LPN H said the resident's side rails are used for safety because he/she has contractures. Further review of the resident's medical record, reviewed on 8/24/22, showed an entrapment assessment completed: -Description: Quarterly; -Effective date: 5/9/22; -Signed as completed on 8/24/22; -Device is not a restraint. 7. Review of Resident #55's quarterly MDS, dated [DATE], showed physical restraints used in bed: Bed rails used daily. Review of the resident's care plan, in use at the time of the survey, showed: -The resident has an ADL self-care performance deficit related to paraplegia (paralysis of the legs and lower body); -Goal: Maintain current level of function in ADLs; -Interventions included side rails, full/half rails up as per physician orders for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Review of the resident's medical record, reviewed on 8/22/22, showed no restraint/entrapment assessment completed. Observation on 8/23/22 at 6:21 A.M., showed the resident lay in bed on his/her back with half rails up times two, one on each side of the bed. The resident said he/she uses them to reposition in bed. During an interview on 8/23/22 at 6:24 P.M., LPN H said the resident's side rails are used for safety and mobility. Further review of the resident's medical record, reviewed on 8/24/22, showed an entrapment assessment completed: -Description: Quarterly; -Effective date: 7/27/22; -Signed as completed on 8/24/22; -Device is not a restraint. 8. Review of Resident #83's quarterly MDS, dated [DATE], showed physical restraints used in bed: Bed rails used daily. Review of the resident's care plan, in use at the time of the survey, showed: -Extensive assistance with ADLs and personal hygiene; -Goal: Maintain current level of function; -Interventions included bed mobility, the resident uses full side rails to maximize independence with turning and repositioning in bed. Review of the resident's medical record, reviewed on 8/22/22, showed no restraint/entrapment assessment completed. Observation on 8/23/22 at 6:27 A.M., showed the resident lay in bed asleep with half rails up on one side of the bed, positioned in the center of the bed. During an interview on 8/23/22 at 6:24 P.M., LPN H said the resident's side rails are used for mobility. Further review of the resident's medical record, reviewed on 8/24/22, showed an entrapment assessment completed: -Description: Quarterly; -Effective date: 7/1/22; -Signed as completed on 8/24/22; -Device is not a restraint. 9. During an interview on 8/22/22 at 5:04 P.M., the Director of Nursing (DON) said no residents in the facility use restraints. Side rails are only used as enablers. Corporate staff are completing MDS assessments. No residents should be coded for having restraints. 10. During an interview on 8/23/22 at 6:39 A.M., LPN J said Resident Care Coordinator (RCC) A is the person responsible for completing the entrapment assessments for side rail use. 11. During an interview on 8/23/22 at 7:06 A.M., RCC A said entrapment assessments are completed by either the DON or him/herself for any residents with side rails, to ensure they are appropriate. 12. During an interview on 8/26/22 at 11:04 A.M., with the DON and administrator, they said they have been without an MDS Coordinator since approximately October 2020, with exception to an approximate 6 month period when they had hired an MDS coordinator that since went to corporate. They would expect MDS assessments to be accurate. If the MDS indicates a BIMS (Brief Interview for Mental Status) assessment should be completed, they would expect to see it completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan to address residents' specific needs which included feeding assistance, behaviors, gastrostomy tube (g-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding) feedings and the use of bedrails, for four of 27 sampled residents. (Residents #2, #81, #113 and #52). The census was 135. Review of the facility's Comprehensive Care Plan policy, dated 1/19/22, showed: -The purpose of this policy is ensure that the facility must develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; -The comprehensive care plan (CPS) must be completed within 14 days of admission; -Facility will use the Resident Assessment Instrument (RAI) User Manual 3.0 as a reference to help the interdisciplinary team to look at residents holistically, as individuals for whom quality of life and quality of care are mutually significant and necessary; -The Minimum Data Set (a federally mandated assessment instrument completed by facility staff) MDS/CPC will facilitate a schedule of MDS's giving each discipline a monthly schedule that identifies the date the MDS is to be completed allowing each discipline to gather information that covers the observation period specified by the MDS items on the assessment for each individual resident. The interdisciplinary team (IDT) will then work together to validate the accuracy, (what the resident's actual status is during the observation period) of the information gathered. The IDT will meet at least once weekly and as needed (PRN); -Information to be gathered to assure accuracy of MDS are but may not be all inclusive are: -Direct observation; -Communication with the resident/responsible party; -Direct care staff from all shifts; -Resident's physician; -Resident's medical record; -Weight logs; -Incident Logs; -Committee meetings; -Nursing meetings which includes the MDS/CPC, social services, Resident-Care Coordinators (RCC), Assistant Director of Nurses (ADON) and Director of Nurses (DON); -Department head meetings; -Quality assurance (QA); -Daily nursing meetings will occur Monday through Friday with a review of the resident's medical, functional and psychosocial problems. From this meeting, information will be individualized to the resident's plan of care. On Monday morning, the resident's status will be reviewed from the weekend to ensure all areas that need to be assessed for care plan needs are addressed; -The care plan will be oriented toward: -Preventing avoidable declines in functioning or functional levels; -Managing risk factors; -Addressing resident's strengths; -Using current standards of practice in the care planning process; -Evaluating treatment objectives and outcomes of care; -Respecting the resident's right to refuse treatment; -Offering alternative treatments; -Using an IDT approach to care plan development to improve the resident's functional status; -Involving resident/family/responsible party; -Assessing and planning for care sufficient to meet the care needs of new admissions; -Involving the direct care staff with the care planning process relating to the resident's expected outcomes; -Addressing additional care planning areas that could be considered in the facility setting; -Utilizing the CAA's process to identify why areas of concern may have been triggered; -The care plan will be updated toward preventing declines in functioning; -It will reflect on managing risk factors and building on resident's strengths; -All treatment objectives will be measure-able and corroborate with the resident's own goals and wishes when appropriate; -IDT discussed realistic ways to revise care plans on a timely basis and tools needed to revise care plans to be accurate and individualized. Upon discussion the following tools, resources will be used to initiate and revise care plans to be individualized, timely and accurately: -Review Preadmission Screening and Resident Review (PASRR, a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability) when applicable, to include any past history into the resident's current plan of care; -Review initial psychosocial assessment and previous medical records as available including contacting family or legal guardian to ensure an accurate comprehensive assessment and plan of care is completed; -All residents will have a comprehensive care plan developed to address decompensation in mental and physical illness. This will include weight loss; -Copies of telephone orders will be forwarded to the MDS/CPC to facilitate revision of care plans; -The nurses meetings will review any behaviors, falls, weight losses, pain and any pertinent information or changes in resident's condition. Nurse meetings will be facilitated by the DON/designee, RCC's, ADON, MDS/CPC, social services (This list may not be all inclusive); -During each meeting, the care plan team will meet and address changes in resident's plan of care within 24 hours during the week and within 72 hours after the weekend. All changes will be reviewed with IDT, physician, dietician, psychiatrist, and will be added to the individualized plan of care; -All information including registered nurse investigations, incident reports and any pertinent information will be relayed and documented during the daily nurses meeting, Monday through Friday. The weekend will be reviewed on Monday in the daily nurses meeting; -Weekly weight reports and monthly weight reports will be forwarded to MDS/CPC as well as a copy of the registered dietician recommendations. Review of the facility's Behavioral Emergency Policy, revised on 2/26/21 and provided as the facility's Supportive Techniques Oversight Protection (STOP) program policy, showed: -Purpose: to provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished or disciplined for staff convenience; -Each resident who has an increased potential for aggressive behavior towards self or others, or shows a history of harm to self or others will have an assessment completed upon admission or prior to use of approved C.A.L.M. take down techniques. The resident who displays or is assessed as having physical/ medical limitations and is assessed to be clinically inappropriate to use C.A.L.M. supportive take down techniques will be placed on the Behavior Management/Care List with the acronym STOP (Supportive Techniques Oversight Protection). Other supportive methods to control behaviors will be outlined in the plan of care individually for those residents in a behavior emergency crisis. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/20/22, showed: -Cognitively impaired; -Behaviors not exhibited; -Required limited assistance of one person for eating; -Functional abilities: Eating, the resident required supervision or touching assistance, such as verbal cues or touching/steadying; -Diagnoses included cancer, dementia, seizures, hypocalcemia (low calcium), alcohol abuse and acute pain. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident was totally dependent on staff for all care such as feeding, bathing and incontinence care; -Interventions: Eating, the resident required one staff member to assist with feeding. Observation of 100 hall lunch meal service on 8/25/22 at 12:36 P.M., showed staff wheeled the resident into the dining room. The resident received his/her food at approximately 12:44 P.M. The resident received chili mac, winter vegetables and a small, square of cornbread on a Styrofoam plate, wrapped in plastic wrap, a cup of juice and a slice of strawberry cream pie. He/she also received a plastic knife and fork. A staff person removed the plastic wrap from the resident's plate. The resident picked up the fork with his/her right hand and used his/her left hand to push the chili mac on the fork. His/her right hand shook as he/she tried to get the food into his/her mouth. He/she held the fork with the chili mac over his/her plate, closed his/her eyes for approximately four minutes, opened his/her eyes and resumed eating. The resident then picked up the plate of pie and attempted to place the plate on top of his/her chili mac. The pie fell off the plate and into his/her lap. An unknown staff person said (He/she) dropped (his/her) pie and continued serving trays. The resident began using his/her fork to eat the pie off his/her lap. The resident dropped corn bread and veggies on the table and in his/her lap. Certified medication technician (CMT) DD approached the resident to give his/her medication and asked him/her if he/she needed assistance. CMT DD removed the plate of pie, corn bread and vegetables from the resident's lap, sat it on the table, gave him/her his/her medication and left the dining room. At 1:13 P.M., a staff person asked the resident if he/she needed help, removed his/her plate, retrieved another plate of chili mac, winter vegetables and cornbread, sat at the table next to the resident and fed him/her. During an interview on 8/26/22 at 7:30 A.M., CMT DD said the resident was total care and needed help eating. The resident needed help with the guidance of his/her food. Sometimes he/she gets stuck and just sits there. Some days he/she does good and some days he/she needs total assistance. It depends on the meal. When staff helped him/her eat, he/she ate 100% of his/her food. If he/she ate by him/herself, he/she left food on the plate. The resident did not have assistive eating devices, but he/she thought they might help. During an interview on 8/26/22 at 8:30 A.M., the DON said the resident needs assistance with ADLs, but staff does not have to feed him/her. Staff sets up his/her meal and gives him/her cues. He/she does not need assistance with spoon to mouth. Staff should have helped him/her if he/she was struggling to eat. 2. Review of Resident #81's annual MDS, dated [DATE], showed: -Diagnoses of post traumatic seizures, diabetes mellitus, non-Alzheimer's dementia, schizophrenia (a serious mental disorder in which people interpret reality abnormally) and history of falling; -Cognitively intact; -No behaviors. Review of the facility's resident roster, showed the resident resided on the 100 hallway secured unit. Review of the resident's care plan, in use at the time of the survey, showed behaviors not listed as a problem with no goals and/or interventions. Review of the resident's STOP determination review, dated 6/21/22 at 3:30 P.M., showed the resident was placed on the program due to having behaviors. Review of the resident's progress notes, on 8/25/22 at 2:06 P.M., showed late entry: On 8/24/22 at 1:56 P.M., staff reported the resident had picked up a chair in an attempt to throw it at staff. Writer approached the dining room and resident was calm, no chair seen in his/her hand. Staff reported resident was agitated because he/she wanted his/her food right away, once he/she saw his/her food coming he/she sat the chair down. Writer later spoke with resident about being patient and inappropriate behavior. During an interview on 8/24/22 at 12:26 P.M., Certified Nursing Assistant (CNA) S said the resident has behaviors. The resident is verbally abusive to staff and residents and he/she shakes and gets frustrated due to the shaking. When the resident is having behaviors, if the behavior is not a harm to themselves or other residents, staff should let the behavior blow over. Staff are to tell the nurse when residents have behaviors and the nurse will document for the CNAs. During an interview on 8/24/22 at 12:58 P.M., Licensed Practical Nurse (LPN) T said the resident does have behavioral issues. The resident just had a behavior concern. Nurses are expected to document resident behaviors in a nurse's note. During an interview on 8/24/22 at 1:02 P.M., the Director of Nursing (DON) said when residents are having behaviors, staff are required to calm the resident down with no touch techniques as much as possible. The nurses should document resident's behaviors in the progress notes. On 8/25/22 at 12:28 P.M., the DON said the assessment used to determine what services are best used for residents with behaviors is a psych assessment. She expected staff to make an individualized care plan for a resident who is displaying behaviors as soon as possible from when the resident arrives. When resident behaviors arise, the CNAs and nurses are to start out looking at medical reasons for behaviors by drawing labs. Possible interventions include placing the resident on a one on one with staff or being send out to the hospital. Staff will also use bribery with residents who are displaying behaviors with extra cigarettes or arts and crafts. Staff will try and use open ended questions to diffuse a resident's behaviors. Staff will include psych when necessary and they have a nurse practitioner who they can reach out to in that case. During an interview on 8/26/22 at 7:05 A.M. the social service director (SSD) said their involvement with residents' behaviors and interventions is to walk around the facility and make sure the residents get their medication on time. They also help the residents with coping skills and the SSD follows the STOP protocol with behaviors. They work with nursing staff to help them determine what each resident needs. The SSD said it is expected a resident with behaviors had an individualized care plan to ensure the resident's needs are being met. During an interview on 8/26/22 at 11:00 A.M., the DON said the resident is new to the facility. He/she is loud and raises his/her voice. He/she is verbally aggressive and also can appear to become physical in his/her behaviors. 3. Review of Resident #113's quarterly MDS, dated [DATE], showed: -Cognitive status not assessed; -Diagnoses included high blood pressure, orthostatic hypotension (low blood pressure when standing), diabetes, multiple sclerosis (MS, a disease in which the immune system eats away at the protective covering of nerves), seizures and schizophrenia; -The resident received 25% or less of his/her total calories through a feeding tube; -Liquid intake of 500 cubic centimeters (cc) per day or less via feeding tube. Review of the resident's electronic physician's orders (ePOS) dated 8/1/22 through 8/31/22, showed: -An order, dated 6/16/22 to flush g-tube with 250 cc of water every shift; -An enteral feed order, dated 2/1/22. Give 355 milliliter, two caloric at 5:00 A.M. and 9:00 P.M. Review of the resident's care plan, in use at the time of survey, showed no documentation of the resident's g-tube on his/her care plan and specific care interventions staff should provide. During an interview on 8/26/22 at 7:30 A.M., CMT D said the resident has a g-tube. The nurse did feedings at 5:00 A.M. and at night and flushed the feeding tube on the first shift. During an interview on 8/26/22 at 8:30 A.M., the DON said the resident had the g-tube when he/she arrived at the facility. The licensed nurse is responsible for the feeding and flushing of the tube. This should be on his/her care plan. She was not aware it was not on the resident's care plan. The facility's system changed over and she is not sure why if did not transfer over. 4. Review of Resident #52's annual MDS, dated [DATE], showed: -Cognitively intact; -Required extensive assistance of one person for bed mobility; -Functional limitations in range of motion: Impairment on both sides, upper and lower extremities; -Diagnoses included quadriplegia (paralysis from the neck down, including the trunk, legs and arms) and seizure disorder. Review of the resident's electronic medical record, showed: -The ePOS, no order for side rail use; -No side rail or entrapment assessment completed. Review of the resident's care plan, in use at the time of the survey, showed: -Activity of daily living (ADL) self-care performance deficit related to diagnoses of cervical spin stenosis (loss of mobility of the neck area) and is a quadriplegic. Requires total care with all ADLs; -Goal: Maintain current level of function; -Interventions included: Bed mobility, the resident is totally dependent on staff for repositioning and turning in bed as necessary; -The use of side rails not addressed on the care plan. Observation on 8/23/22 at 6:23 A.M., showed the resident lay in bed on his/her back, asleep. Full sized bedrails were positioned on both sides of the bed. During an interview on 8/23/22 at 6:24 P.M., LPN H said the resident's side rails are used for safety because he/she has contractures. Further review of the resident's medical record, reviewed on 8/24/22, showed an entrapment assessment completed: -Description: Quarterly; -Effective date: 5/9/22; -Signed as completed on 8/24/22; -Device is not a restraint. 5. During an interview on 8/26/22 at 11:05 A.M., the administrator and DON said care plans should identify a resident's care needs and preferences. They should have resident-specific interventions, including fall interventions, behavior interventions, supplements, side rails and med changes. MO189567

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, staff failed to ensure services being provided meet professional standards of quality care for four residents, when staff failed to document medications and weights as ordered, and failed to obtain physician orders for oxygen and diets (Residents #335, #124, #534, and #2). In addition, staff failed to document a resident's discharge for one of one resident investigated for discharge (Resident #500) who was discharged without a discharge progress note. The sample of residents was 27. The census was 135. Review of the facility's Transcription of Orders/Following Physician's Orders policy, revised 7/9/21, showed: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. That a process is in place to monitor nurses in accurately transcribing and following physician's orders; -Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be written on the physician order sheet; -Any new orders that are noted on the physician's order sheet are to be documented in the nurse's notes and the 24 hour report sheet; -Every month when the new change over arrives to the facility; the resident care coordinator/designated nurse will review the old physician order sheet and medication administration record to verify that all orders are correct on the new physician order sheet, medication administration record and treatment administration record. 1. Review of Resident #335's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 3/6/22, showed: -Cognitively intact; -Independent with all activities of daily living (ADLs); -Ambulatory/no mobility devices; -No behaviors; -Diagnoses included, diabetes, high blood pressure, Schizophrenia (combinations of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning) and depression. Review of the resident's care plan, undated, showed: -Focus: The resident has Diabetes; -Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Identify areas of non-compliance or other difficulties in resident diabetic management. Provide and document teaching to resident/family/caregiver address identified roadblocks to compliance. If infection is present, consult doctor regarding any changes in diabetic medications. Monitor/document/report as needed (PRN) compliance with diet and document any problems; -Focus: The resident has foot pressure ulcer (injury to the skin and/or underlying tissue, as a result of pressure or friction) due to disease process diabetes w/hyperglycemia (high blood sugar) an abnormally high glucose (sugar) in the blood, chronic osteomyelitis (an infection in the bone); -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing (each dressing change). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Review of the resident's electronic physician's orders (ePOS), dated 4/1/22 through 4/30/22, showed: -An order, dated 8/3/21, for Levemir (long-acting insulin), 100 international units (IU)/millimeter (ml), with evening meals; -An order, dated 11/22/21 for Humalog Solution (a fast-acting insulin), inject 16 IU, subcutaneously (under the skin), with meals; -An order, dated 1/17/2022, for accuchecks (measures blood sugar levels), three times a day (TID) before meals and at bedtime. Review of the resident's electronic medication administration record (eMAR), dated 4/1/22 through 4/30/22, showed: -An order for Levemir, 100 IU/ml vial, with evening meals, at 5:00 P.M.: On 4/13, 4/14, 4/21, and 4/28/22, blank (not documented as administered); -An order for Humalog Solution, 16 IU subcutaneously with meals: On 4/13, at 8:00 A.M, 12:30 P.M., and 5:30 P.M., on 4/14 at 8:00 A.M., 12:30 P.M. and 5:30 P.M., on 4/21 at 5:30 P.M., on 4/27 at 8:00 A.M., 12:30 P.M., and 5:30 P.M. and on 4/28/22 at 8:00 A.M., 12:30 P.M and 5:30 P.M., blank, -An order for Accuchecks, TID, before meals and at bedtime, on 4/13 at 11:00 A.M. and 4:00 P.M., on 4/14 at 11:00 A.M. and 6:00 P.M, on 4/21 at 4:00 P.M., on 4/27 at 11:00 A.M. and 4:00 P.M., and on 4/28/22 at 11:00 A.M. and 4:00 P.M., blank. Review of the resident's eMAR, dated 3/1/22 through 3/31/22, showed: -An order for Levemir, 100 IU/ml vial, with evening meals (5:00 P.M.), on 3/16, 3/17, 3/18, and 3/26/22, blank. -An order for Humalog Solution, 16 IU, subcutaneously, with meals, on 3/3 at 5:30 P.M., on 3/16 at 6:00 A.M., 12:30 P.M., and 5:30 P.M., on 3/17 at 5:30 P.M., on 3/18 at 8:00 A.M., 12:30 P.M., and 5:30 P.M., and on 3/26/22 P.M. at 5:30 P.M., blank; -An order for Accuchecks TID before meals and at bedtime, on 3/14 at 6:00 A.M., 3/16 at 11:00 A.M. and 4:00 P.M, on 3/18 at 11:00 A.M. and 4:00 P.M., on 3/22 at 8:00 P.M., and 3/26/22 at 6:00 A.M. and 4:00 P.M., blank. During an interview on 8/25/22 at 2:16 P.M., the Director of Nursing (DON) said she expected staff to follow physician orders, and to document why medications were not received. 2. Review of Resident #124's ePOS, showed: -An order dated 6/15/21, for Lantus (used to treat diabetes), 100 IU/ml, inject 10 units subcutaneously at bedtime; -An order dated 7/15/21, for weights monthly and record; -An order dated, 10/6/21, for insulin lispro (used to treat diabetes), 100 IU/ML, subcutaneously before meals and at bedtime. Review of the resident's eMAR, dated 7/1/22 through 7/31/22, showed: -An order for Lantus 100 IU/ml, inject 10 units subcutaneously at bedtime: On 7/11/22, blank; -An order for Insulin lispro 100 IU/ML, subcutaneously before meals and at bedtime: -On 7/1 at 4:00 P.M., on 7/3 at 11:00 A.M. and 4:00 P.M., on 7/8/22 at 4:00 P.M., on 7/15 at 6:00 A.M., on 7/17 at 11:00 A.M., on 7/24 at 6:00 A.M., and on 7/31/22 at 11:00 A.M and 4:00 P.M., blank; -On 7/4 at 11:00 A.M., 4:00 P.M. and 8:00 P.M., 7/6 at 6:00 A.M., on 7/15 at 11:00 A.M., and on 7/17/22 at 4:00 P.M. and 8:00 P.M., documented as refused. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitive status not assessed; -Rejection of care not exhibited; -Diagnoses included stroke, high blood pressure, acute kidney failure, diabetes, dementia and seizure disorder. Review of the resident's eMAR, dated 8/1/22 through 8/31/22, showed: -An order for Lantus 100 IU/ml, inject 10 units subcutaneously at bedtime: On 8/11/22, blank; -An order for Insulin lispro 100 IU/ML, subcutaneously before meals and at bedtime: On 8/11 at 8:00 P.M. and on 8/19/22 at 11:00 A.M. and 4:00 P.M., blank. Review of the resident's medical record, reviewed on 8/22/22, showed no documentation the facility notified the resident's physician he/she refused his/her insulin. Review of the resident's weights and vitals summary, showed no documented weights for February, through July 2022. During an interview on 8/26/22 at 7:30 A.M., a certified medication technician (CMT) DD said the resident was confused and sometimes he/she refused his/her insulin. When the resident refused his/her insulin staff were supposed to document the refusal in the progress notes, inform the charge nurse and notify the physician. He/she did not know if the resident refused monthly weights. During an interview on 8/26/22 at 8:30 A.M., the DON said the resident does refuse monthly weights and she was not aware he/she refused insulin. If a resident refuses insulin, staff should document it in the eMAR and if he/she refuses three consecutive days, the physician should be notified. 3. Review of Resident #534's MDS record, reviewed on 8/26/22, showed the admission MDS in progress. Review of the resident's electronic care plan, reviewed on 8/25/22 at 7:11 A.M., showed: -No care plan related to the resident's diet; -Problem: Oxygen continuous at 2 liters for chronic obstructive pulmonary disease (COPD, lung disease), date initiated 8/5/22, created date 8/24/22. Review of the resident's ePOS, dated 8/1/22 through 8/22/22, showed: -No active diet order; -No active order for oxygen. Review of the resident's paper diet order slip, submitted to dietary on 8/24/22 at 5:18 P.M., dated 8/4/22, showed regular diet and signed by the DON. Observation on 8/23/22 at 9:53 A.M., showed the resident lay in bed with oxygen on per nasal cannula. The oxygen concentrator set on 2 liters. Observation on 8/24/22 at 12:45 P.M., showed the resident's lunch tray had a dietary ticket on the tray that read: Diet Regular. During an interview on 8/24/22 at 5:18 P.M., the DON said she did the medication for the residents admission and nursing was supposed to put in the diet order. The DON acknowledged that the diet order was missing and said she would put the diet order in now. The DON said dietary gets their orders based on the order slip and nursing has to enter the order into the ePOS. During an interview on 8/24/22 at 12:47 P.M., Graduate Practical Nurse (GPN) X said the process for obtaining diet orders is looking over the orders that were sent with the resident and placing the orders into the ePOS, then filling out the diet slip and send it to dietary. Nursing is responsible for placing all orders in the ePOS. The timeframe for entering diet orders is before the first meal is served after admission. If a resident does not have a diet order the resident could not be given any meals or even go to the vending machine until the diet is verified and entered into the ePOS. Giving a resident a meal without having the diet order could result in the resident aspirating or having an allergic reaction. Further review of the resident's ePOS, reviewed on 8/25/22 at 1:41 P.M., showed: -Regular diet, regular texture, thin/regular consistency with start date of 8/24/22 at 5:19 P.M.; -No active order for oxygen. During an interview on 8/25/22 at 8:51 A.M., Licensed Practical Nurse (LPN) R said diet orders for new admissions should be entered immediately before the first meal after the admission. The resident could have an order for nothing by mouth (NPO) and staff do not want to give them the wrong diet. The admitting nurse is responsible for entering the diet order into the ePOS. Giving a resident the wrong diet could result in the resident choking all the way to death. LPN R said the appropriate time frame for entering oxygen orders is immediately. It should be a part of the orders that are entered after verifying all of the orders with the doctor. The orders should be completed on the shift the resident comes in, by the admitting nurse. If a resident did not receive the correct amount of oxygen it could slow their breathing down and cause them to not get enough oxygen and this could cause death. During an interview on 8/25/22 at 7:02 A.M., Certified Medication Technician (CMT) KK said he/she would expect resident's wearing oxygen to have a physician's order for oxygen. The appropriate time frame to enter orders for oxygen is immediately. If a resident was not receiving the correct amount of oxygen it could cause the resident to go into distress. During an interview on 8/26/22 at 7:24 A.M., LPN LL said he/she would expect resident's wearing oxygen to have a physician's order for oxygen. Oxygen orders should be entered immediately into the ePOS. Nursing would not know how many liters to place the oxygen on if a resident did not have a physician's order. If a resident was not receiving the correct amount of oxygen it could cause them to not get enough oxygen or get too much which would cause distress to the resident. During an interview on 8/26/22 at 11:04 A.M., the Administrator and DON said they would expect orders to be entered timely into the ePOS, within an hour after receiving the order. They would expect all resident's to have a diet order. If a diet order was not entered into the ePOS, the nursing staff would have to call dietary or ask the nurse what the resident's diet order was. They would expect resident's wearing oxygen to have a physician's order for oxygen. If a resident was wearing oxygen and did not have an order oxygen the nurse would need to call the residents physician and get clarification for the oxygen order. 4. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Behaviors not exhibited; -Diagnoses included cancer, dementia, seizures, hypocalcemia (low calcium levels), alcohol abuse and acute pain; -Psychiatric/mood disorders, blank. Review of the resident's ePOS, showed an order dated 7/20/22, for Zyprexa (used to treat mental disorders) tablet 15 milligrams (mg). Give one tablet by mouth one time a day related to unspecified dementia without behavioral disturbance. During an interview on 8/26/22 at 8:30 A.M., the DON said she is not sure if the resident has dementia and the Zyprexa is given for behaviors. She thinks the resident has alcohol induced schizophrenia. Zyprexa is not an acceptable medication for dementia. 5. Review of the facility's Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, dated 7/12/22, showed: -Purpose: Establish policy and procedure regarding the transfer and discharge of resident; -Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected; -The policy did not address documentation at the time of discharge. Review of Resident #500's discharge MDS, dated [DATE], showed: -admission date on 3/12/22; -Diagnoses include: high blood pressure, chronic obstructive pulmonary disease (COPD, lung disease,) major depressive disorder, and bipolar disorder (disorder with mood swings from very low to high); -Discharge to the community on 7/21/22 with return not anticipated. Review of the resident's progress notes, showed: -On 6/29/22, returned from the doctor's appointment with no new orders. Declined reconstructive surgery. Will continue working until 7/16 /22 and move in with his/her family member; -On 7/18/22, the resident states he/she is leaving this facility in 2 days. This nurse has not heard this from management as of this day; -No nurse note for discharge on [DATE] or 7/21/22 to identify when the resident left the facility, the condition of the resident when he/she discharged , how the resident was transported from the facility and/or with who and if the resident's personal belongings were sent with the resident. During an interview on 8/24/22 at 8:30 A.M., with the Social Service Director (SSD) said he would expect to see a discharge note from nursing when a resident discharges from the facility. The resident discharged from the facility on 7/21/22. During an interview on 8/24/22 at 3:30 P.M., the DON said she would expect the nurse to document a nurse's note when a resident is leaving the facility, to address how, when and who the resident left with upon discharge. Something to show the resident was no longer in the facility. The resident left in the morning on 7/21/22 with family. MO00200669

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide diets and supplements as ordered to ensure residents maintained acceptable nutritional status for six residents with recent or a history of weight loss (Residents #65, #56, #132, #52, #48, and #2). The sample was 27. The census 135. Review of the facility's Weight Loss policy, revised 2/26/21, showed: -Purpose: To ensure all residents maintain acceptable parameters of nutritional status, such as body weight and protein level, unless the resident's condition demonstrates that this is not possible; -Procedure: -5% weight loss in 30 days will involve doctor notification and possible orders for dietary supplement, the dietician may be notified; -7.5% weight loss in 3 months will involve doctor notification, dietician to consult and any orders to increase dietary intake, supplements, etc; -10% weight loss in 6 months requires doctor notification, dietician to consult, and any orders to increase dietary intake, supplements to be increased, changed etc.; -The dietician can be consulted anytime, ensure that documentation with recommendations are charted after any consultation with the physician or dietician; -The nursing staff shall follow all recommendations and physician orders; -If the resident is refusing his/her meal or portions of his/her meal/snack then alternative foods will be offered to ensure that adequate intake is provided to the resident. The Quality Assurance Performance Improvement (QAPI) meeting will address offering other food choices and different types of snacks that continue to meet the residents required nutritional diet/intake. This should also be added to the resident care plan; -Residents who have concerns for weight loss will be discussed in the Quality Assurance (QA)/QAPI meetings held weekly, this will involve reviewing intakes of both meals and snacks, interventions for increasing nutritional intakes, the care plan coordinator will address concerns in care plan as needed. 1. Review of Resident #65's quarterly Minimum Data Set (MDS), a federally mandate assessment instrument completed by facility staff, dated 6/17/22, showed: -Diagnoses included cancer, chronic obstructive pulmonary disease (COPD, lung disease), heart disease, anemia (low number of red blood cells), diabetes, kidney failure, Alzheimer's disease, depression, and anxiety; -Set up help required for eating; -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months; -Not on a physician prescribed weight loss regimen. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 4/3/22, for regular diet, mechanical soft texture, super cereal with breakfast, house supplement three times daily with meals; -An order, dated 4/26/22, for Med Pass (a supplement drink high in calories and protein) 2.0 three times daily for nutritional supplement related to left ear cancer, give 90 cubic centimeters (cc) three times a day. Review of the resident's weight summary, showed: -On 3/23/22, weighed 220 pounds (lbs).; -On 4/12/22, weighed 205.0 lbs.; -A weight loss of 6.82% in one month. Review of the resident's dietician note, dated 4/29/22, showed follow-up for weight. Weight 4/20/22: 198.2 lbs. (significant loss, -22 lbs. since admission). Denies recent change in appetite. Resident continues mechanical soft diet with fair-good intake. Preferences obtained by dietary management and provided to maximize intakes. Remote recommendations sent for super cereal, health shakes, and med Pass. Resident continues to receive infusions related to ear cancer - suspect this to have impacted taste perception, possibly leading to decreased intakes. Supplements and extra portions now provided to fortify intakes. Encourage intakes. Dislikes magic cups due to consistency when melted. Further review of the resident's weight summary, showed: -On 5/16/22, weighed 192.2 lbs.; -On 6/10/22, weighed 188.0 lbs.; -Weight loss of 14.55% in three months, from March to June 2022. Review of the resident's dietician note, dated 6/23/22, showed resident tolerating diet with fair intake. Feeds him/herself at meals. Receives fortified foods and supplements to maximize protein/calorie intake. Labs reviewed. June weight: 188 lbs., down 17 lbs. from May weight and down 32 lbs. in three months. Spoke with resident about weight and intake. Consumes supplements. Likes cottage cheese. Will pass to dietary and add to diet card. Continue to encourage intake and offer snacks as needed. Will monitor. Review of the resident's dietician note, dated 7/13/22, showed resident tolerating diet consistency with supplements and fortified foods given. Food preferences provided to maximize intake. July weight: 185.8 lbs., down 2.2 lbs. in past month, down 19 lbs. in three months. Encouraged resident to continue good intake. Will monitor weight. Weight loss appears to be slowing. Review of the resident's August 2022 medication administration record (MAR), showed of 72 opportunities, staff documented Med Pass as administered on 68 occasions. Review of the resident's diet tickets, in use at the time of survey, showed: -Diet: large portion, mechanical soft texture; -Breakfast: magic cup and super cereal; -Lunch: magic cup and super cereal, cottage cheese for lunch only; -Supper: magic cup and super cereal. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident is at risk for altered nutrition and infection related to diagnosis of ear cancer; -Interventions included encourage proper intake of food and fluid, and medication provided as prescribed; -Problem: Resident is at risk for alteration in health related to being above his/her ideal body weight and at risk for non-compliance with his/her therapeutic diet. He/she is prescribed a mechanical soft diet; -Interventions included dietician to screen quarterly and as needed, educate related to maintaining therapeutic diet now through next review, and monitor weight as ordered; -The care plan failed to identify the resident's weight loss, dietary preferences, and interventions to address weight loss, including the provision of large portions and nutritional supplements. Observation on 8/22/22 at 12:50 P.M., showed 19 residents served lunch in the dining room on the resident's hall. Lunch consisted of a scoop of ground or mechanical soft meat, two tortillas, rice, a cup of fruit, and a cup of shredded lettuce and cheese. Observation on 8/22/22 at 1:30 P.M., showed the resident seated on the side of his/her bed, eating lunch. The resident had one cup of fruit, one cup of shredded lettuce and cheese, and a plate containing a scoop of mechanical soft meat, two tortillas, and rice. No cottage cheese. All food items the same portion size as the portions served to the residents in the dining room. Observation on 8/23/22 at 7:57 A.M., showed residents served breakfast in the 200 hall dining room. Breakfast consisted of a scoop of scrambled eggs, a sausage patty, a pastry, and a bowl of hot or cold cereal. Observation on 8/23/22 at 8:35 A.M., showed the resident's plate contained a scoop of scrambled eggs, one pastry, and a bowl of hot cereal. The portions were similar to the portions served to residents in the dining room, and without a sausage patty. The resident had no magic cup or health shake. Observation on 8/23/22 at 12:46 P.M., showed the resident seated on the side of his/her bed, eating lunch. His/her plate contained a scoop of mechanical soft meat, a scoop of potatoes, four Brussel sprouts, and a slice of bread. His/her cup contained a scoop of diced fruit. The resident had no magic cup, health shake, or cottage cheese. During an interview, the resident said he/she does not like the magic cups; they are stringy. He/she does like health shakes. Observation on 8/24/22 at 4:31 P.M., showed no Med Pass on the medication cart on the resident's hall. During an interview, certified medication technician (CMT) PP said he/she does not think they had Med Pass yesterday, either. When the facility is out of med pass, the CMT gives the residents a health shake from dietary. When a medication or treatment is unavailable, staff should document it as such on the resident's MAR, and not that it was administered. 2. Review of Resident #56's quarterly MDS, dated [DATE], showed: -Severely impaired cognition; -No speech; -Rarely understood; -One person physical assistance in bed mobility, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene; -Two or more physical assistance with transfers; -Always incontinent of bladder and bowel; -Diagnoses included: dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), manic depression (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of resident's care plan, in use at the time of survey, showed: -Problem: The resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to being nonverbal and unable to interact with staff; -Desired Outcome: Will maintain involvement in cognitive stimulation, social activities; -Interventions: All staff to converse with resident whole providing care; -Problem: The resident has impaired cognitive function or impaired thought processes related medical diagnoses; -Desired Outcome: Will maintain current level of cognitive function; -Interventions: Administer medications as ordered, monitor side effects and effectiveness, ask yes/no questions in order to determine the resident's needs; -Problem: The resident is at risk for nutritional problem and is on puree diet, thin liquid; -Desired Outcome: Will comply with recommended diet and be free of health complications; -Interventions: Monitor/document/report as needed (PRN) any signs and symptoms of dysphagia (difficulty swallowing): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals, and provide and serve diet as order. Review of resident's weight documentation within a year, showed: -8/13/21 - 145.3 lbs; -9/15/21 - 142.0 lbs; -10/15/21 - 140.0 lbs; -11/17/21 - 139.0 lbs; -12/22/21 - 143.1 lbs; -1/18/22 - 139.6 lbs; -2/13/22 - 136.8 lbs; -3/14/22 - 138.4 lbs; -4/10/22 - 136.8 lbs; -5/16/22 - 139.2 lbs; -6/10/22 - 131.2 lbs; -7/8/22 - 133.0 lbs; -8/15/22 - 126.6 lbs. Review of the resident's electronic physician's orders sheet (ePOS), dated 12/21/22, showed: -Med Pass 2.0, 90 milliliters (mL) three times a day; -Boost VHC (a supplement drink high in calories), two times a day. Observation and interview on 8/24/22 at 3:14 P.M., showed no Med Pass on the 300 hall medication cart. Licensed practical nurse (LPN) R said Med Pass and Boost supplements are stored in the refrigerator after every medication administration. He/she said Resident #56 received Med Pass and Boost as ordered. He/she added the resident never refused or missed doses, and would consume anything offered to him/her. He/she said the CMT assigned in 300 hall had a couple of Med Pass in the cart to administer for the residents' morning and noon doses, including Resident #56. LPN R said all floor supplies of Med Pass had been used and will check with central supply for more supplies. Further observation and interview on 8/24/22 at 3:35 P.M., showed no Med Pass and Boost in the refrigerator on the resident's hall. LPN R said the central supply staff notified him/her that the facility did not have any Med Pass available, and had placed orders to be delivered soon. Review of the resident's MAR, showed the staff documented all medications and supplements were administered as ordered, including Med Pass three times daily. 3. Review of Resident #132's quarterly MDS, dated [DATE], showed: -Independent with eating; -Diagnoses included heart failure, high blood pressure, diabetes, seizures, dementia, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's ePOS, showed an order, dated 4/27/21, for no added salt (NAS) diet, regular texture, low concentrated sweets (LCS), magic cup twice daily (BID). Review of the resident's weight summary, showed: -On 2/13/22, weighed 187.6 lbs.; -On 3/14/22, weighed 181.0 lbs. Further review of the resident's ePOS, showed: -An order, dated 4/3/22, for Remeron 15 milligrams (mg), give 15 mg by mouth at bedtime related to diabetes, appetite stimulant; -An order, dated 4/3/22, for Boost three times (TID) a day related to diabetes. Further review of the resident's weight summary, showed: -On 4/12/22, weighed 178.0 lbs.; -On 5/16/22, weighed 170.0 lbs.; -A weight loss of 9.38% in three months, from February to May 2022. Review of the resident's dietician note, dated 6/23/22, showed resident tolerating diet consistency. Resists care from staff. Labs reviewed. June weight: 176.4 lbs. up 6 lbs. in past month, down 4.6 lb. in three months, and down 20 lbs. in six months. Supplements provided and encouraged. Continue with plan of care. Will monitor weight and intake. Goal: maintain stable weight. Further review of the resident's weight summary, showed: -On 7/7/22, weighed 171.8 lbs.; -On 8/15/22, weighed 171.0 lbs.; -A weight loss of 8.85% in six months, from February to August 2022. Review of the resident's diet tickets, in use at the time of survey, showed: -Diet: Regular, NCS, NAS, magic cup BID; -Breakfast, lunch and supper notes: health shakes TID every day. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident is at risk for unstable blood glucose (blood sugar) and ineffective therapeutic regimen related to diabetes; -Interventions included dietary consult for nutritional regimen and ongoing monitoring, and discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen; -The care plan failed to identify the resident's weight loss and interventions to address the weight loss, including use of an appetite stimulant and nutritional supplements. Observation on 8/22/22, showed at approximately 1:13 P.M., staff delivered a tray of food to the resident's room. The resident received a plate containing two tortillas, a scoop of ground beef, and rice, as well as a cup of fruit and a cup of lettuce and shredded cheese. The resident received no magic cup or health shake. At 1:29 P.M., the resident's plate remained untouched, the fruit and half the lettuce had been consumed. During an interview, the resident said the food did not taste good and was cold. The resident was unable to recall if staff offered an alternative. Observation on 8/23/22 at 12:43 P.M., showed staff delivered a tray of food to the resident's room. The resident received a pork chop, potatoes, four Brussel sprouts, a cup of pears, and a cup of juice. The resident received no magic cup or health shake. During an interview at 1:08 P.M., the resident said he/she did not receive a magic cup or health shake. 4. Review of the Resident #52's annual MDS, dated [DATE], showed: -No cognitive impairment; -Requires extensive assistance of one person physical assist for eating; -Upper and lower extremity impairment on both sides; -Diagnoses included spinal stenosis (narrowing of the spine), quadriplegia (paralysis of all four limbs), seizures, depression, Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) of unspecified part of back, unstageable pressure ulcer (slough (dead tissue) is present, the actual base and condition of the ulcer cannot be determined) of sacral region (area at the bottom of the spine), unstageable pressure ulcer of unspecified hip. Review of the resident's weight summary, showed: -On 2/13/22, weighed 103.2 lbs.; -On 3/14/22, weighed 102.5 lbs.; -On 4/12/22, weighed 102.4 lbs. Review of the resident's ePOS, showed, an order, dated 5/9/22, for regular diet, regular texture, large portions all meals. Review of the resident's dietician note, dated 5/10/22, showed resident continues regular diet with variable intakes. Food preferences offered to maximize intakes. Fed by staff. Continues treatment to wound. Recommend restarting large portions until healed. Further review of the resident's weight summary, showed on 5/16/22, weighed 103.7 lbs. Review of the resident's dietician note, dated 6/7/22, showed resident continues regular diet. Variable intakes, staff encourages intakes/fluids. Diet remains fortified with extra portions and supplements. Meal ticket audit completed, suggestions passed to dietary management. Further review of the resident's weight summary, showed: -On 6/13/22, weighed 100.1 lbs.; -On 7/7/22, weighed 96.0 lbs; -A weight loss of 6.25% in three months, from April to July 2022. Review of the resident's dietician note, dated 7/13/22, showed resident food preferences provided and encouraged. July weight: 96 lbs., down 4.1 lbs. past month. Usual body weight history 90-100 lbs. Supplements given to maximize intake. Diet remains appropriate. Continue with plan of care. Review of the resident's nutrition note, dated 7/31/22, showed resident has had a weight loss of 4.1 lbs. Resident has not had a change in mobility, consumes regular diet. Physician notification completed. Dietician to be notified. Appetite fair. Review of the resident's meal intake for August 2022, reviewed on 8/24/22, showed: -Staff documented the resident consumed 0-25% for four meals; -Staff documented the resident consumed 25-50% for one meal; -Staff documented the resident consumed 51-75% for one meal; -Staff documented the resident consumed 76-100% for four meals. Review of the resident's diet tickets, in use at the time of survey, showed: -Diet: large portions, regular texture; -Breakfast, lunch and supper notes: large portion, magic cup. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident is at risk for unstable blood glucose and ineffective therapeutic regimen related to diabetes; -Interventions included dietary consult for nutritional regimen and ongoing monitoring; -The care plan failed to identify the resident's weight loss and interventions to address weight loss, including the provision of large portions and nutritional supplements. During an interview on 8/22/22 at 12:34 P.M., the resident said he/she has had weight loss, off and on. Observation on 8/22/22 at 1:17 P.M., showed the resident sat upright in his/her wheelchair in the hall while lunch served to other residents in the dining room. During an interview at that time, the resident said he/she did not want the meal served at lunch. Staff offered him/her a sandwich, but he/she did not want that, either. No other options were offered. Staff don't ask him/her what he/she wants to eat. Observation and interview on 8/23/22 at 12:56 P.M., showed the resident sat upright in his/her wheelchair in his/her room with lunch on his/her bedside table. Lunch consisted of a cup of fruit, a scoop of mechanical soft meat, potatoes, four Brussel Sprouts, and two rolls. The meat, potatoes, and Brussel sprouts appeared to be the same portion size as the portions served to the residents in the dining room. The resident said he/she was supposed to get double portions but the portions were not double to him/her. He/she never gets magic cups or health shakes. 5. Review of Resident #48's quarterly MDS, dated [DATE], showed: -Independent with eating; -Diagnoses included high blood pressure, diabetes, schizophrenia, anxiety, habit and impulse disorder, and mild intellectual disability. Review of the resident's ePOS, showed an order, dated 6/29/22, for regular diet. Review of the resident's diet tickets, in use at the time survey, showed: -Diet: Regular, NAS/LCS; -Breakfast, lunch, and supper notes: health shake BID, large portion lunch and dinner. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident has potential nutritional problem related to history of weight loss, edentulous (without teeth), poor oral hygiene; -Interventions included provide and serve diet as ordered, and provide and serve supplements as ordered: health shakes BID. Observation on 8/22/22, showed at approximately 12:34 P.M., the resident sat at a table in the dining room. Staff served him/her a plate containing two tortillas, a scoop of ground beef, rice, as well as a cup of fruit and a cup of shredded lettuce, cheese, and salsa. The portions appeared to be the same as the portions served to the other 18 residents seated in the dining room. At 12:46 P.M., the resident asked for more salsa. Certified nurse aide (CNA) II told him/her to wait because he/she was busy. The resident called out for another plate of food. The food on his/her plate over 50% consumed. At 12:53 P.M., the resident asked CNA RR for more salsa and the CNA said, Not now. Another resident at the table offered his/her rice to Resident #48. The resident took the plate and ate the rice. At 12:55 P.M., the resident asked CNA RR for another plate of food. CNA RR said to wait a minute, he/she had to do the room trays first and then would check the kitchen. Both plates in front of the resident empty. At 1:01 P.M., CNA RR handed the resident a plate of food from the food warmer. During an interview, LPN AA looked at the resident's diet ticket and said the resident eats a lot and is supposed to receive double portions. Dietary does not send large portions as they should. At 1:03 P.M., 50% of the food on the resident's plate was consumed. The resident asked for another plate and CNA RR said they didn't have anymore. At 1:08 P.M., the resident consumed 97% of the food on the plate and left the table. The resident did not receive a health shake during the meal. During an interview on 8/24/22 at 11:42 A.M., the resident said he/she does not get enough to eat. He/she is supposed to get double portions, but doesn't. 6. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Diagnoses included lung cancer, dementia, seizures, hypocalcemia (low calcium), alcohol abuse and acute pain. Review of the resident's medical record, reviewed on 8/22/22, showed an order for health shakes, three times per day. Review of the resident's weight summary, showed: -On 5/16/22, weighed 185.5 lbs.; -On 6/10/22, weighed 182.6 lbs.; -On 7/5/22, weighed 181.4 lbs.; -On 8/15/22, weighed 181.0 lbs. Review of the resident's breakfast, lunch and dinner diet tickets, showed: -Regular diet; -Regular consistency; -Health shakes and large portions three times per day, with each meal. Observation of lunch services on 8/22/22 at 12:30 P.M., 8/23/22 at 12:41 P.M. and 8/25/22 at 12:36 P.M., showed the resident received a cup of juice with his/her meal and did not receive his/her health shake. During an interview on 8/25/22 at 7:30 A.M. CMT DD said the resident received health shakes with two meals. During an interview on 8/26/22 at 8:30 A.M., the DON said the resident gets health shakes three times per day and she was not sure why he/she did not receive them. 8. During an interview on 8/24/22 at 3:44 P.M., CNA Z said if a resident does not like what is served, staff should offer an alternative, which is a cold sandwich. Dietary staff sends the meal trays to the floor and nursing staff sets up the trays for each resident. He/she sees magic cups sent up from dietary sometimes. Residents get magic cups and health shakes from the nurse. Meal intake is monitored mainly by the nurse. 9. During an interview on 8/25/22 at 8:48 A.M., CNA CC said nursing staff should check the resident's meal ticket before handing out their tray. Health shakes and magic cups are not consistently provided by dietary. Health shakes and magic cups are important for the extra nutrients. if a resident doesn't like the meal served, staff should offer them a sandwich. A resident's care plan should show all the resident's care needs and use of health supplements. 10. During an interview on 8/24/22 at 3:54 P.M., LPN AA said Resident #132's appetite is poor. He/she has dementia and is a diabetic. He/she should be getting supplements. Resident #52 chooses not to eat because he/she doesn't like the food. He/she will drink the health shakes. Resident #48 needs double portions because he/she walks all day and burns all his/her calories. Resident #65's appetite is fair and he/she should get a supplement and Med Pass. The CMT administers Med Pass. The facility is out of Med Pass at this time, and has been out for a couple of months. When the facility is out of Med Pass, staff substitute with a health shake, if they are available. If a resident does not like what is served during a meal, staff should call dietary and see that else they have. The nurse is responsible for monitoring resident meal intake. If a resident's meal intake is poor, staff should offer a health shake or magic cup and report it to the dietician and physician. Nutritional supplements are determined by the dietician or physician. Nutritional supplements are important to address weight loss. If a resident does not like a specific nutritional supplement or flavor, staff should offer an alternative. Dietary is responsible for bringing nutritional supplements to the floor, like health shakes and magic cups. There are times dietary does not have these nutritional supplements. Specific interventions to address weight loss, such as supplements and large portions, should be documented on the resident's care plan. 11. During an interview on 8/25/22 at 8:28 A.M., CMT JJ said the facility has been out of Med Pass for a month for two now. As a substitute, staff have been giving residents health shakes because they are comparable. Staff don't necessarily have to call the physician about the substitute, but should just to be sure. When a medication is out of stock or unavailable, staff should document the medication as unavailable on the resident's MAR and make a progress note about why the medication was not administered. 12. During an interview on 8/25/22 at 9:00 A.M., the Central Supply Coordinator said every resident in the facility gets Med Pass. The facility has been out of Med Pass since 7/6/22. 13. Review of the facility's supply order sheet, reviewed on 8/25/22, showed Med Pass 2.0 was backordered on 7/6/22. No further information or follow-up on the order. 14. During an interview on 8/24/22 at 3:48 P.M., the Director of Nursing (DON) said she was not sure how long the facility has been out of Med Pass, and was also not sure if staff had it available to administer that day. The DON said it was not acceptable for the staff to document orders not given. 15. During an interview on 8/25/22 at 9:31 A.M., the Food Service Director said the dietician visits the facility at least monthly. He gives his recommendations to her, and maybe the DON. The Food Service Director enters the dietician's recommendations into a program that generates the diet tickets for each resident. Dietary sets up each resident's plate, based on their diet tickets, and nursing checks the plates when they hand them out during meals. The facility does not have a shortage of supplemental food items, such as health shakes or magic cups. Supplemental items are given to some residents to ensure they receive the proper nutrition. The resident's meal ticket should specify if a resident prefers a certain flavor or type of supplemental item. She thought large portions on a diet ticket meant the resident should receive large portions of any food item, and dietary could pick if that was a protein or a starch. Yesterday, she found out large portions meant extra portions of everything served to the resident. 16. During an interview with the DON and administrator on 8/24/22 at 4:39 P.M., the DON said the facility has been out of Med Pass. Nurses should report it immediately if the Med Pass runs out. The nurse should consult with the physician about possibly substituting Med Pass for a health shake, to ensure the two are nutritionally comparable. If a medication or treatment is unavailable, staff should not document it as administered. Staff should use the appropriate code on the MAR to document the reason why the medication or treatment was not administered. Dietary staff should follow each resident's meal ticket and make sure everything they need is on the resident's tray, including large portions. Nursing should verify the meal tickets and make sure residents are served what is on there. Health shakes and magic cups come from dietary and are handed out by nursing staff. If a resident does not like a specific flavor or the type of supplement ordered, staff should report it to the nurse, see what the resident would prefer, and obtain a physician order to have the supplement changed. Nutritional supplements are used for weight maintenance and nutritional stability. A resident's individual needs, preferences, and interventions, including nutritional supplements, should be documented on their care plan. The administrator said she agreed with the DON. During an interview with the DON and administrator on 8/26/22 at 8:18 A.M., the DON said Resident #65's weight loss started right after admission. He/she has ear cancer, which might affect his/her taste. He/she does try to eat and doesn't refuse meals. Dietary met with him/her to determine his/meal preferences, which should be provided to the resident. Resident #132 has not had weight loss. He/she should be getting his/her supplements as ordered. Resident #52 had some weight loss before, but is back on the upslope. He/she should be getting large portions as ordered. Large portions are an extra half serving of each food item served during a meal. Resident #48 has not had weight loss. He/she walks all day long and should be getting large portions as ordered. The administrator said she agreed with the DON. 17. During an interview on 8/26/22 at 9:37 A.M., the dietician said he completes reviews on the residents at the facility three times a month. He reviews residents who are new or re-admitted , who have had significant weight loss or gain, and whoever the facility asks him to look at. He makes recommendations for portion size and supplements, such as Med Pass, health shakes, and magic cups. Supplements like this are ordered for residents with weight loss or nutritional deficiencies. If a resident doesn't like the supplement, staff should offer an alternative. If the resident likes the alternative, staff should contact him or the physician to obtain new orders. He was not aware the facility has been out of Med Pass for over a month. If the facility was aware an item would be unavailable for an extended period of time, he would have expected staff to notify him or the physician to get an order for an alternative. He would expect residents to receive their nutritional supplements as ordered. He would expect dietary staff to follow his recommendations for portion size. Large portions means the resident should receive an extra ounce of protein. If the resident does not like the meal served, he would expect staff to offer them something that is nutritionally comparable, substituting a starch for another starch, a protein for another protein, and a vegetable for another vegetable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document the attempt to use appropriate alternatives prior to installing a side rail. The facility failed to complete an assessment of side rails to ensure correct installation, use, and maintenance including risk of entrapment from bed rails prior to installation, and failed to ensure the bed's dimensions were appropriate for the resident's size and weight, for seven of 10 residents investigated for side rail use, resulting in the bed rails of two residents being lose and ill fitting (Resident's #82, #124, #130, #86, #52, #55, and #83). The census was 135. Review of the facility's Bed rails policy, dated 2/26/21, showed: -Purpose: To ensure all bed side rails in use have been evaluated for safety; -All residents using any size side rail device on their beds will have a restraint/entrapment assessment completed to determine the restraining, enabling, or hazard effect of the device. This assessment will occur upon initial use, quarterly and as needed if there is a significant change in the resident's condition; -Each resident using a side rail device will be assessed to determine if the side rail has a restraining affect and/or enabling affect; -Each resident using a side rail device will have a detailed history documented, including the symptoms or reasons for using a device; -All possible negative effects and safety hazards of the device will be considered in the assessment; -If the resident is using a specialty mattress which inflates based on residents' weight, follow all manufacturer recommendations. The gap between the mattress and rail widens when the mattress compresses. As residents change position, the mattress may inflate and trap the resident's head, chest, neck or limbs between the mattress and side rail, resulting in fractures, asphyxiation or even death; -Using any device requires a care plan. 1. Review of Resident #82's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/5/22, showed: -No cognitive impairment; -Independent with bed mobility; -Extensive assistance of two (+) person physical assist required for transfers; -Upper and lower extremities impaired on one side; -Diagnoses included stroke, unspecified sequelae (aftereffect of disease, condition, or injury) following stroke, hemiplegia (weakness affecting one side) or hemiparesis (paralysis affecting one side), depression, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves); -Side rails not used. Review of the resident's entrapment assessment, dated 8/3/22, showed: -Does resident have cognitive and functional ability to remove the device: No; -Can the resident remove the device purposely: No; -Does the device allow the resident to do something that would improve their quality of life: No; -Does it allow the resident to participate in an activity otherwise incapable of:No; -No enabling effect; -Is resident vulnerable to hazard: Yes; -What alternatives were used to manage the problem before using the device: n/a; -Have you communicated risk versus benefits to resident and family related to device: No; -Identify likely causes for using the device: n/a; -Have you obtained physician order for use of device: No; -Document rationale for use: n/a; -Type of side device used not indicated. Review of the resident's medical record, showed: -No physician order for the use of side rails; -No documentation of alternatives attempted prior to use of side rails; -No documentation of resident's consent for use of side rails. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident requires assistance with activities of daily living (ADLs) related to ADL self-care performance deficit related to hemiplegia from stroke and sequelae of stoke, left side hemiplegia; -Interventions included side rails, full/half rails up as per physician order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition (frequency) and as necessary to avoid injury. Observation on 8/22/22 at 11:39 A.M., showed the resident on his/her back in bed. Quarter-length rails raised on both sides of the bed, at the head of the bed. The left rail loose and able to move one to two inches from side to side. The right rail loose and able to move forward and backward approximately three inches. During an interview, the resident said he/she can hold onto the right side rail while receiving care. The rails do not feel stable to him/her. Observation on 8/23 of the bed, at the head of the bed. Certified nurse aide (CNA) HH and CNA II positioned the resident at 7:41 A.M., showed the resident on his/her back in bed with quarter-length rails raised on both sides on top of a Hoyer (mechanical lift) pad. With his/her right hand, the resident grabbed the right rail, which moved approximately two inches toward the resident. CNA HH moved the resident's right arm from the rail and placed it on the Hoyer lift bar. Observation on 8/24/22 at 11:51 A.M., showed the resident on his/her back in bed with quarter-length rails raised on both sides of the bed, at the head of the bed. Both rails remained loose. During an interview on 8/24/22 at 3:54 P.M., licensed practical nurse (LPN) AA said he/she was not sure why Resident #82 had a side rail. Side rails should not be loose because it is not safe. Nurses assess residents for the use of side rails on admission. Alternatives should be attempted first before installing side rails. A resident should have physician orders for the use of side rails. If staff observe a side rail is loose, they should submit a work order to have it fixed. 2. Review of Resident #124's quarterly MDS, dated [DATE], showed: -Cognitive status not assessed; -Independent with bed mobility; -Rejection of care not exhibited; -Limited assistance of one person required for transfers; -Diagnoses included stroke, high blood pressure, acute kidney failure, diabetes, dementia, and seizure disorder; -Side rails not used. Observation on 8/22/22 at 9:15 A.M., showed quarter rails up near the head of the bed on both sides of the bed. Review of the resident's medical record, reviewed on 8/22/22, showed: -No restraint/entrapment assessment completed; -No documented attempt to use appropriate alternatives prior to installing a side rail; -No order for side rail use. Observation on 8/23/22 at 12:35 P.M., showed quarter rails up near the head of the bed on both sides of the bed. The rails were loose and able to move from side to side. Observation on 8/24/22 at 12:35 P.M., showed quarter rails up near the head of the bed on both sides of the bed. During an interview, the resident said he/she used the side rails to pull up his/her pants. Review of the resident's care plan, in use at the time of the survey, showed side rails not included in the care plan. 3. Review of Resident #130's significant change MDS, dated [DATE], showed: -Cognitively intact; -Extensive assistance required for bed mobility; -Diagnoses included multiple sclerosis (an autoimmune disease that affects the nerves and movement). Review of the resident's care plan, in use at the time of the survey, showed: -Problem: The resident has an ADL self-care performance deficit related to disease process; -Goal: Maintain current level of function in ADLs; -Interventions: Side rails: Full/half rails up as per physician order for safety during care provisions, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Review of the resident's medical record, reviewed on 8/22/22, showed: -No restraint/entrapment assessment completed; -No documented attempt to use appropriate alternatives prior to installing a side rail; -No order for side rail use. Observation on 8/23/22 at 6:35 A.M., showed quarter rails up near the head of the bed on both sides of the bed. During an interview on 8/23/22 at 6:39 A.M., LPN J said the resident's side rails are used for mobility. 4. Review of Resident #86's quarterly MDS, dated [DATE], showed: -Resident is rarely/never understood; -Limited assistance required for bed mobility; -Diagnoses included dementia and seizure disorder. Review of the resident's care plan, in use at the time of the survey, showed side rails not included in the care plan. Review of the resident's medical record, reviewed on 8/22/22, showed: -No restraint/entrapment assessment completed; -No documented attempt to use appropriate alternatives prior to installing a side rail; -No order for side rail use. Observation on 8/23/22 at 6:36 A.M., showed the resident not in his/her room. U rails were up near the head of the bed on both sides of the bed. During an interview on 8/23/22 at 6:39 A.M., LPN J said the resident's side rails are used for mobility. 5. Review of Resident #52's care plan, in use at the time of the survey, showed: -ADL self-care performance deficit related to diagnoses of cervical spin stenosis (loss of mobility of the neck area) and is a quadriplegic (paralysis or weakness to al four extremities). Requires total care with all ADLs; -Goal: Maintain current level of function; -Interventions included: Bed mobility, the resident is totally dependent on staff for repositioning and turning in bed as necessary; -The use of side rails not addressed on the care plan. Review of the resident's medical record, reviewed on 8/22/22, showed: -No restraint/entrapment assessment completed; -No documented attempt to use appropriate alternatives prior to installing a side rail; -No order for side rail use. Observation on 8/23/22 at 6:23 A.M., showed the resident lay in bed asleep, full bedrails up, on both sides of the bed. During an interview on 8/23/22 at 6:24 P.M., LPN H said the resident's side rails are used for safety because he/she has contractures. Further review of the resident's medical record, reviewed on 8/24/22, showed an entrapment assessment completed: -Description: Quarterly; -Effective date: 5/9/22; -Signed as completed on 8/24/22; -Device is not a restraint. 6. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Cognitive status not assessed; -Limited assistance required for bed mobility; -Diagnoses included paraplegia (paralysis). Review of the resident's care plan, in use at the time of the survey, showed: -The resident has an ADL self-care performance deficit related to paraplegia (paralysis of the legs and lower body); -Goal: Maintain current level of function in ADLs; -Interventions included side rails, full/half rails up as per physician orders for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Review of the resident's medical record, reviewed on 8/22/22, showed: -No restraint/entrapment assessment completed; -No documented attempt to use appropriate alternatives prior to installing a side rail; -No order for side rail use. Observation on 8/23/22 at 6:21 A.M., showed the resident lay in bed on his/her back. Half rails up, one on each side of the bed. The resident said he/she uses them to reposition in bed. During an interview on 8/23/22 at 6:24 P.M., LPN H said the resident's side rails are used for safety and mobility. Further review of the resident's medical record, reviewed on 8/24/22, showed an entrapment assessment completed: -Description: Quarterly; -Effective date: 7/27/22; -Signed as completed on 8/24/22; -Device is not a restraint. 7. Review of Resident #83's quarterly MDS dated [DATE], showed: -Cognitive status not assessed; -Limited assistance required for bed mobility; -Diagnoses included schizophrenia. Review of the resident's care plan, in use at the time of the survey, showed: -Extensive assistance with ADLs and personal hygiene; -Goal: Maintain current level of function; -Interventions included bed mobility, the resident uses full side rails to maximize independence with turning and repositioning in bed. Review of the resident's medical record, reviewed on 8/22/22, showed: -No restraint/entrapment assessment completed; -No documented attempt to use appropriate alternatives prior to installing a side rail; -No order for side rail use. Observation on 8/23/22 at 6:27 A.M., showed the resident lay in bed asleep. Half rails up on one side of the bed, positioned in the center of the bed. During an interview on 8/23/22 at 6:24 P.M., LPN H said the resident's side rails are used for mobility. Further review of the resident's medical record, reviewed on 8/24/22, showed an entrapment assessment completed: -Description: Quarterly; -Effective date: 7/1/22; -Signed as completed on 8/24/22; -Device is not a restraint. 8. During an interview on 8/22/22 at 5:04 P.M., the Director of Nursing (DON) said no residents in the facility use restraints. Side rails are only used as enablers. The entrapment assessment is used as the side rail assessment. On 8/24/22 at 2:33 P.M., the DON said she would expect each resident with bed rails to have an entrapment assessment completed. 9. During an interview on 8/23/22 at 6:39 A.M., LPN J said Resident Care Coordinator (RCC) A is the person responsible for completing the entrapment assessments for side rail use. 10. During an interview on 8/23/22 at 7:06 A.M., RCC A said entrapment assessments are completed by either the DON or him/herself for any residents with side rails, to ensure they are appropriate. 11. During an interview on 8/24/22 at 3:44 P.M., CNA Z said if staff observe a side rail wiggles, they put in a work order for maintenance because it is not safe. He/she does not know of any side rails that are loose at this time. 12. During an interview on 8/26/22 at 11:04 A.M., with the DON and administrator, they said when the facility uses beds, they usually do not put side rails on them. Some residents prefer to use side rails or they use them for mobility. Nursing is responsible to complete the side rail assessments. They should be done quarterly or if requested by staff. Alternatives for the use of side rails should be trialed first and documented. Some resident use bumper mattresses or have fall mats on the floor. The facility can also try low beds first. When it is determined side rails are needed, there should be a physician order. The orders should specify the type of side rails used and their purpose. The resident should be educated on the use of the side rails. Staff should check side rails when they move them to provide assistance. If staff went to care for someone and they were loose, they would make a maintenance request. Side rails should not be loose for safety purposes.

Based on observation, interview and record review, before allowing an individual to serve as a nurse aide, the facility failed to ensure the individual has met competency evaluation requirements unless the individual is in a training and competency evaluation program approved by the State, when the facility assigned three of three Nursing Assistants (NAs) employed by the facility to work on the floor in the capacity of a certified nursing assistant (CNA) when no current approved nursing instructors were in the building and when no current CNA training courses were in progress. The census was 135. Review of the Missouri Department of Health and Senior Services safety, CNA registry, CNA agency website, showed -In order to be approved to be a CNA Training Agency, the facility must meet these requirements: -Have approved instructors and clinical supervisors. Review of the facility's Facility Assessment Tool, updated March 2022, showed: -Facility resources needed to provide competent support and care for our resident population every day and during emergencies; -Identify the type of staff members need to provide support and care for residents; -Nursing services: Director of Nursing (DON), assistant DON, Minimum Data Set (MDS) coordinator, Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Medication Technician (CMT), Resident Care Coordinators (RCC), management team, CNA; -The facility did not identify Nursing Assistants (NAs) as a type of nursing staff utilized by the facility. 1. Review of NA K's employee file, showed: -Date of hire (DOH) 11/20/18 as housekeeping/laundry; -No documentation when the employee changed to an NA. Review of the Missouri Registry Search site, reviewed on 8/23/22, showed NA K not listed as a CNA. During an interview on 8/23/22 at 1:04 P.M., the human resource director said NA K transitioned to an NA on 2/24/22. During an interview on 8/22/22 at 8:52 A.M., NA K said he/she was working on the 400 floor by him/herself. He/she started working as an NA in February, 2022. He/she is the only aide on the floor and is responsible to provide care to the residents. He/she was not sure how to go about becoming a CNA. The facility is not assisting him/her to become certified and he/she cannot get an answer from the facility regarding when he/she will receive the training. 2. Review of NA L's employee file, showed: -DOH 6/22/21 as an activity aide; -No documentation when the employee changed to an NA. Review of the Missouri Registry Search site, reviewed on 8/23/22, showed NA L not listed as a CNA. During an interview on 8/23/22 at 1:04 P.M., the human resource director said NA L transitioned to an NA on 2/25/22. 3. Review of NA M's employee file, showed: -DOH 1/7/20 as housekeeping; -On 10/8/21, personnel action form update: Department CNA, new title, NA. Comments: employee passed her CNA online course; -No documentation CNA M passed the CNA certification test. Review of the Missouri Registry Search site, reviewed on 8/23/22, showed NA M not listed as a CNA. 4. Review of the facility's Daily Staffing Pattern for the dates of 8/22/22 through 8/26/22, showed: -On 8/22/22: -NA K assigned on division 400, day shift; -NA L assigned on division 200, evening shift; -On 8/23/22: -NA M assigned on division 100, evening shift; -NA L assigned on division 200, evening shift; -On 8/24/22: -NA L assigned on division 200, evening shift; -On 8/25/22: -NA L assigned on division 200, evening shift; -On 8/26/22: -NA K assigned on division 200, day shift. 5. During an interview on 8/26/22 at 11:04 A.M., with the DON and administrator, they said the facility is a state approved CNA training site. They had an instructor onsite, but they are no longer onsite at the facility. They work out of a different building. There are currently no CNA classes in progress. The instruction has been gone for not quite a year. They were not aware an approved instructor was required to be in the facility when NAs are working in the roll of a CNA.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities for error, 3 errors occurred resulting in a 10% medication error rate (Residents #61 and #18). The census was 134. Review of the facility's Medication and Administration Policy, updated 9/17/21, showed the following: -Purpose: To ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. To provide guidelines and systems for following procedures for medication errors including defining a medication error and levels of medication errors. To ensure therapeutic guidelines are monitored in drugs that require laboratory and diagnostic studies; -Procedure: Medications are to be given per physician's orders. All medications are recorded on the Medication Administration Record (MAR) and signed after the resident has taken the medication. 1. Review of Resident #61's physician order sheet (POS), dated 8/22, showed an order dated 8/4/22, for Aspirin (ASA) enteric coated (EC) 81 milligram (mg) by mouth once a day. Observation on 08/23/22 at 7:58 A.M., showed certified medication technician (CMT) JJ prepared and administered the resident's morning medication which included ASA chewable 81 mg. During an interview on 08/23/22 at 1:15 P.M., CMT JJ said he/she should have given ASA EC. 2. Review of Resident #18's POS, dated 8/22, showed orders for the following: -Amlodipine (medication used to treat high blood pressure) 10 mg once a day; -Citalopram Hydrobromide (medication used to treat depression) 20 mg once a day; -Divalproex Sodium (medication used to treat bipolar disease)125 mg by mouth twice a day; -Losartan Potassium (medication used to treat high blood pressure) 100 mg by mouth once a day; -Risperdal (medication used to treat mental/mood disorders) 0.5 mg by mouth once a day. Observation on 8/23/22 at 10:01 A.M., showed the resident lay in bed. CMT GG removed the resident's medication from the cart. While placing the medication in the cup, he/she dropped one of the medications on the floor. CMT GG picked the pill up off the floor, placed it in the medication cup along with the resident's other medications. CMT JJ administered the medication, checked to ensure the resident swallowed the medication and left the room. CMT JJ locked the medication cart and walked down the hall and returned with the blood pressure machine. He/she reentered the resident's room and took his/her blood pressure. During an interview on 8/23/22 at 10:14 A.M., CMT JJ said he/she took the resident's blood pressure earlier but was unable to find it. He/she said the resident's blood pressure should have been checked prior to administering blood pressure medications. He/she did not respond to whether he/she should use medication after it was dropped on the floor. 3. During an interview on 8/24/22 at 10:12 A.M., the Director of Nurses said she expected staff to administer medications as ordered. She expected staff to check the resident's blood pressure prior to receiving blood pressure medications. In addition, staff should discard medication after dropping it on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff documented nutritional supplements administered for two residents (Residents #56 and #65), antibiotics administered for one resident (Resident #82), and a phosphorous binder administered for one resident (Resident #74), when the supplements and medications were unavailable. The census was 135. Review of the facility's Medication Administration and Monitoring Policy, revised 9/17/21, showed: -Purpose: To ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. To provide guidelines and systems following procedures for medication errors including defining a medication error and the levels of medication errors. To ensure therapeutic guidelines are monitored in drugs that requires laboratory and diagnostic studies; -Procedure: -Medications are to be given per doctor's orders. All medications are recorded on the medication administration record (MAR) and signed immediately after the resident has taken the medications. The nurse or certified medication technician (CMT) will check each medication on the MAR noting correct name of medication, correct resident name, correct dose, correct time and correct route of administration. The nurse or CMT should note that if the medication is refused or not available, the nurse or CMT will initial and circle the time of the medication in questions. On back of the MAR the reason for the medication in question that is not given will be noted along with an explanation of the solution to the problem. The Director of Nursing (DON) or registered nurse (RN) designee will be notified immediately regarding the resident not receiving the medication. It will then become the DON or RN designee responsibility to ensure that the medication is received and that the licensed practical nurse (LPN) or CMT distributes the medication to the resident. The back-up pharmacy or primary pharmacy will be notified and the medication will be received. The physician will be notified if medication is given late and the nurses notes will indicate why medication has a discrepancy. The nurse or CMT then will go to the progress notes and note the documentation of the medication discrepancy also noting the physician notified. The DON or RN will also be notified of the medication refusal or unavailability of the medication. The DON or RN will then investigate the medication in question and ensure that the process for medications not given to residents are followed. If the process is not followed including prudent follow-up to ensure that the resident gets the medication in a timely manner then disciplinary action will take place. Review of the facility's Transcription of Orders/Following Physician's Orders policy, revised 7/9/21, showed: -Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. That a process is in place to monitor nurses in accurately transcribing and following physician's orders; -Procedure: -The Resident Care Coordinator (RCC)/unit director/designated nurse will review all MARs and treatment administration records (TARs) daily to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. -In the event that the medication is unavailable, the RCC/unit manager/designated nurse will contact the pharmacy and have the medication delivered. If the resident is not going to receive their scheduled medication per physician's order, the RCC/unit manager, designated nurse will contact the DON, the administrator, physician and legal guardian, if applicable. The RCC/unit manager/designated nurse will then follow any further orders that may be provided by the physician; -The nurse or CMT in charge or medication administration must review all of their designated MARs and TARs prior to the end of their shift to ensure all medications/treatments scheduled to be given on their shift were administered according to the physician's order and that all necessary interventions were taken in the event of an omission; -The RCC/unit manager/designated nurse will review all medication/treatment administration records and compare all medications to the medications available for each resident in the facility weekly to ensure availability. 1. Review of Resident #56's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/13/22, showed: -Severely impaired cognition; -No speech; -Rarely understood; -Diagnoses included dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), manic depression (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Post Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the resident's electronic physicians order sheet (ePOS), dated 12/21/22, showed: -Med Pass 2.0 (a supplement drink high in calories and protein), 90 milliliters (mL) three times a day; -Boost VHC (a supplement drink high in calories), two times a day. Observation and interview on 8/24/22 at 3:14 P.M., showed no Med Pass on the 300 hall medication cart. LPN R said Med Pass and Boost supplements are stored in the refrigerator after every medication administration. He/she said Resident #56 received Med Pass and Boost as ordered. He/she added the resident never refused or missed doses, and would consume anything offered to him/her. He/she said the CMT assigned in 300 hall had a couple of Med Pass in the cart to administer to residents for their morning and noon doses, including Resident #56. LPN R said all floor supplies of Med Pass had been used and will check with central supply for more supplies. Further observation and interview on 8/24/22 at 3:35 P.M., showed no Med Pass and Boost in the refrigerator on the resident's hall. LPN R said the central supply staff notified him/her that the facility did not have any Med Pass available, and had placed orders to be delivered soon. Review of the resident's MAR, showed the staff documented all medications and supplements were administered as ordered, including MedPass three times daily. 2. Review of Resident #65's quarterly MDS, dated [DATE], showed: -Diagnoses included cancer, chronic obstructive pulmonary disease (COPD, lung disease), heart disease, anemia, diabetes, kidney failure, Alzheimer's disease, depression and anxiety; -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months; -Not on a physician prescribed weight loss regimen. Review of the resident's August 2022 MAR, showed: -An order, dated 4/26/22, for Med Pass 2.0, three times a day for nutritional supplement related to ear cancer, give 90 cubic centimeters (cc) three times a day; -Of 72 opportunities, staff documented the supplement administered on 68 occasions. Observation on 8/24/22 at 4:31 P.M., showed no Med Pass on the 200 hall medication cart. During an interview, CMT PP said he/she does not think they had Med Pass yesterday, either. When a medication or treatment is unavailable, staff should document it as such on the resident's MAR, and not that it was administered. 3. During an interview on 8/24/22 at 3:54 P.M., LPN AA said the facility is out of Med Pass at this time, and has been out for a couple of months. 4. During an interview on 8/25/22 at 8:28 A.M., CMT JJ said the facility is out of Med Pass at this time. They have been out of Med Pass for a month or two. 5. During an interview on 8/25/22 at 9:00 A.M., the Central Supply Coordinator said every resident in the facility gets Med Pass. Med Pass has been out since 7/6/22. 6. Review of the facility's Supply Order sheet, showed Med Pass 2.0 was backordered on 7/6/22. No further information or follow-up on the order. 7. During an interview on 8/24/22 at 3:48 P.M., the DON said he/she was not sure how long the facility has been out of Med Pass, and was also not sure if staff had it available to administer that day. The DON said it was not acceptable for the staff to document orders as administered when not given. During an interview with the DON and administrator on 8/24/22 at 4:39 P.M., the DON said the facility has been out of Med Pass. Nurses should report it immediately if the Med Pass runs out. The nurse should consult with the physician about possibly substituting Med Pass for a health shake, to ensure the two are nutritionally comparable. If a medication or treatment is unavailable, staff should not document it as administered. Staff should use the appropriate code on the MAR to document the reason why the medication or treatment was not administered. The administrator said she agreed with the DON. 8. Review of Resident #82's re-admission MDS, dated [DATE], showed: -re-admission date of 8/3/22; -Adequate hearing, speech and vision; -Cognitively intact; -Diagnoses included: high blood pressure, kidney disease, hemiplegia or hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), seizure disorder, depression and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Review of the resident's ePOS, dated 8/3/22, showed an order of Nitrofurantoin Mono-MCR (antibiotic used to treat bladder infections) 100 milligram (mg), to be taken by mouth twice daily. Review of the resident's MAR, showed the Nitrofurantoin Mono-MCR 100 mg twice daily, was administered from 8/4/22 through 8/14/22, twice daily, for a total of 22 doses. During an interview on 8/25/22 at 9:22 A.M., Pharmacist NN said they received an order of Nitrofurantoin Mono-MCR 100 mg for Resident #82, on 8/3/22, and delivered 12 doses to the facility. The pharmacist said they did not provide more than what was ordered. During an interview on 8/25/22 at 9:46 A.M., LPN AA said the stop-date for the resident's medication should be automatically entered in the electronic MAR when orders are received. He/she agreed staff should not document medications as given when they were not. During an interview with the DON and administrator on 8/25/22 at 9:40 A.M., the administrator said she verified the documentation in the resident's MAR, which showed the medication was administered for a total of 22 doses. She said the facility did not have antibiotics in their stock medications storage, including Nitrofurantoin Mono-MCR 100 mg. The DON said the staff documented inappropriately, and she did not believe the resident received more doses than ordered since there were no extra medications available. She said it was not acceptable for the staff to document medications as given when not administered. 9. Review of Resident #74's medical record, showed diagnoses included chronic kidney disease. Review of the resident's MAR and progress notes for August 2022, showed: -An order, dated 8/8/22, for sevelamer carbonate (controls phosphorous levels in adults with chronic kidney disease) 800 mg, give 3200 mg by mouth three times a day with meals; -Of 50 opportunities to administer sevelamer, staff documented medication as administered 40 times; absent from home without meds four times; medication not given, none on hand two times; medication not given because may cause resident to not make it to toilet one time; three doses blank with no documentation to show medication administered. During an interview on 8/25/22 at 8:28 A.M., CMT JJ said when a medication is out of stock or unavailable, staff should document the medication as unavailable on the resident's MAR and make a progress note about why the medication was not administered. The resident has been prescribed sevelamer for at least the past year. Out of nowhere, his/her insurance would no longer pay for the medication. The resident has not been getting the sevelamer for several weeks. During observation and interview on 8/25/22 at 11:43 A.M., LPN AA said the resident's medications were on the CMT medication cart. There is no sevelamer for the resident on the medication cart. The resident has not received sevelamer in a few weeks. Sevelamer is not covered by the resident's insurance. When a medication is unavailable, staff should document it as not administered on the resident's MAR and in the progress note. During an interview on 8/25/22 at 12:14 P.M. Pharmacist MM said on 8/8/22, the pharmacy received a script for sevelamer. Insurance faxed a form to the pharmacy about the medication not being covered. The medication has not been filled. Prior to 8/8/22, a 28 count of sevelamer was filled for the resident on 6/30/22. During an interview with the DON and administrator on 8/24/22 at 4:39 P.M., the DON said if a medication or treatment is unavailable, staff should not document it as administered. Staff should use the appropriate code on the MAR to document the reason why the medication or treatment was not administered. The administrator said she agreed with the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed implement written policies and procedures regarding the residents' right to formulate an advance directive when staff failed to follow policies and procedures regarding accurate documenting of residents code status, for 13 of 27 sampled residents (Residents #120, #29, #76, #66, #9, #69, #65, #534, #63, #484, #81, #16, and #103). The census was 135. Review of the facility's Code Status/emergency Procedures/Medical Emergencies policy, revised on [DATE], showed: -Purpose: To outline procedures to be followed during a medical emergency, to establish guidelines for the initiation of cardiopulmonary resuscitation (CPR), and notification of emergency medical services (EMS), attending physician, administrator, Director of Nursing (DON) and legal guardian/family; -The code status documentation will be uploaded to the resident's electronic record and appropriately signed; -If do not resuscitate (DNR, no life saving measures performed) the Out of Hospital DNR (OHDNR) form will be completed on universal purple paper and appropriately signed; -All other code status forms, such as the full code form, will be on white paper. Appropriately signed and uploaded to the resident's electronic record under the documents tab; -If the physician has ordered a DNR code status, it will be listed In the EMR under user defined fields, in the section of code status; -If nothing is listed under user defined fields, the resident is considered a full code (life-saving measures performed); -All residents with unknown code status will be treated as a full code and heroic measures will be taken until otherwise determined by verification of no code status; -The registered or licensed nurse will assess the resident for breathing and pulse. If no active exchange of air or no carotid (artery of the neck) pulse is detected, the nurse with then direct staff: -Assess if resident is a full code or DNR. If the resident is not a full code, then the doctor will be notified and comfort measures and physician orders will be followed. If CPR was initiated on a no code resident due to an undetermined code status, the doctor will be notified and orders including discontinuing CPR will be followed; -Page a code blue overhead; -Direct staff to obtain an emergency crash cart and Automated External Defibrillator (AED). Ask staff to bring secondary crash cart if staff available to do so; -Direct staff to obtain resident's chart; -Designate person to document timelines of events; -All DNR/no code residents will have a black dot on the name plate are of resident room door. Additionally, the care plan and face sheet will reflect the DNR order; -The social service director (SSD) or designee will complete a weekly audit of all DNR residents as follows: -Ensure the OHDNR form is signed by the resident (if able), legal guardian and physician on purple paper and uploaded to the residents electronic record; -There is a black dot on the resident name plate on the door; -DNR is stated on the care plan and face sheet; -There is an order from the physician stating the code status of DNR/no code under the orders tab; -The DNR list will be updated weekly and as needed and placed on every crash cart and nurses station in a way that does not violate privacy. Review of the facilities name plate sticker key, showed: -A red dot indicates no take downs for behaviors; -A black dot indicates DNR; -No green dots utilized. 1. Review of Resident #120's electronic medical record, reviewed on [DATE], showed: -A physician order sheet, showed an order dated [DATE], full code; -A face sheet, showed full code; -A care plan, in use at the time of the survey, showed: -Problem: The facility will follow the resident's advanced directives for code status. The resident is a full code; -Goal: Staff will comply with resident wishes and physician's order regarding code status; -Intervention: Activate 911 for advanced assistance and CRP. Initiate full code measures per resident's wishes; -No signed code status sheet. Review of the resident's paper medical record, located in the nurse's station, showed: -Full code written in large letters on orange sheet; -No signed code status sheet. 2. Review of Resident #29's electronic medical record, reviewed on [DATE], showed: -A physician order sheet, showed an order dated [DATE], for full code; -A face sheet, showed full code; -A care plan, in use at the time of the survey, showed: -Problem: The facility will follow the resident's advanced directives for code status. The resident is a full code; -Goal: Staff will comply with resident wishes and physician's order regarding code status; -Intervention: Activate 911 for advanced assistance and CPR. Initiate full code measures per resident's wishes; -No signed code status sheet. Review of the resident's paper medical record, located in the nurse's station, showed: -Full code written in large letters on orange sheet; -No signed code status sheet. 3. Review of Resident #76 quarterly MDS, dated [DATE], showed: -admission date [DATE] from another nursing home or sling bed; -Moderate cognitively impairment; -Diagnosis included atrial fibrillation (A-Fib, irregular heart rhythm), heart failure, high blood pressure, high cholesterol, and Diabetes. Review of the resident's electronic care plan, showed: -Problem: Initiated [DATE]: The resident is a full code; -Desired Outcome: Staff will comply with resident and physician's order regarding code status; -Interventions: initiated [DATE]: Initiate full code measures per resident wishes. Review of the resident's electronic medical record on [DATE] at 6:48 A.M., showed: -Initial admission date [DATE]; -admission re-entry [DATE]; -admission re-entry [DATE]; -admission re-entry [DATE]; -No physician order for code status. Review of resident's paper chart at nurse's station, on [DATE] at 3:50 P.M., showed full code written in large letters on orange sheet. During further record review on [DATE] at 11:09 A.M., the facility provided the resident's code status sheet and it showed: -Full code marked; -Signed by resident on [DATE]. 4. Review of Resident #66 quarterly MDS, dated [DATE], showed: -Rarely or never understood; -Diagnosis included heart failure, high blood pressure, and asthma. Review of the resident's electronic care plan, in use at the time of the survey, showed -Problem: Initiated [DATE]: The resident is a full code; -Desired Outcome: Staff will comply with resident and physician's order regarding code status; -Interventions: initiated [DATE]: Initiate full code measures per resident wishes. Review of the resident's electronic medical record, showed: -Initial admission date [DATE]; -Physician order dated [DATE] for full code. -admission re-entry date [DATE]. Review of resident's paper chart, located at nurse's station on [DATE] at 3:50 P.M., showed: -Code status sheet with full code marked -Signed by resident's guardian on [DATE]; -Full code written in large letters on orange sheet. Further review on [DATE] at 11:09 A.M., showed the facility provided the resident's code status sheet and it showed: -Full code marked; -Signed by resident's guardian on [DATE]; -Signed by social worker on [DATE]; -Signed by physician on [DATE]. 5. Review of Resident #9 quarterly MDS, dated [DATE], showed: -admission date [DATE]; -Cognitively intact; -Diagnosis included high blood pressure, diabetes, anxiety, and depression. Review of the resident's electronic care plan, in use at the time of the survey, showed:-Problem: Initiated [DATE]: The resident is a full code; -Desired Outcome: Staff will comply with resident and physician's order regarding code status; -Interventions: initiated [DATE]: Initiate full code measures per resident wishes. Review of the resident's electronic medical record, showed a physician order dated [DATE] for full code. Review of resident's paper chart, located at the nurse's station on [DATE] at 3:50 P.M., showed a blank code status form. Further review on [DATE] at 11:09 A.M., the facility provided the resident's code status sheet and it showed: -Full code not marked; -Signed by resident on [DATE]. 6. Review of Resident #69 annual MDS, dated [DATE], showed: -admission date [DATE] from another nursing home or sling bed; -Cognitively intact; -Diagnosis included hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and depression. Review of the resident's electronic care plan, in use at the time of the survey, showed: -Problem: Initiated [DATE]: The resident is a full code; -Desired Outcome: Staff will comply with resident and physician's order regarding code status; -Interventions: initiated [DATE]: Initiate full code measures per resident wishes. Review of the resident's electronic medical record, showed: -Initial admission date [DATE]; -Physician order dated [DATE] for full code. Review of resident's paper chart, located at the nurse's station on [DATE] at 3:50 P.M., showed: -Blank code status form; -Full code written in large letters on orange sheet. Further review on [DATE] at 11:09 A.M., the facility provided the resident's code status sheet and it showed: -Full code not marked; -Signed by resident on [DATE]. 7. Review of Resident #65's electronic medical record, reviewed on [DATE], showed: -A physician order sheet, no ordered code status; -A face sheet, showed no code status listed; -A care plan, in use at the time of the survey, showed no code status listed. Review of the resident's paper chart, reviewed on [DATE] at 4:06 P.M., showed no documented code status for the resident. During an interview on [DATE] at 4:14 P.M., the resident said if he/she had a medical emergency, he/she would want staff to perform CPR on him/her. 8. Review of Resident #534's MDS record, reviewed on [DATE], showed, admission MDS in progress. Review of the resident's electronic care plan, created [DATE], showed, no advanced directive care planned. Review of the resident's electronic medical record, reviewed on [DATE] at 6:18 P.M. and [DATE] at 1:41 P.M., showed: -admission date of [DATE]; -No physician order for code status. Review of resident's paper chart, located at the nurse's station on [DATE] at 3:50 P.M., showed a blank code status form in chart. Further record review on [DATE] at 11:09 A.M., the facility provided the resident's code status sheet and it showed: -Full code marked; -Signed by resident on [DATE]. 9. Review of Resident #63 Annual MDS, dated [DATE], showed: -admitted [DATE] from another nursing home or swing bed; -Cognitively intact -Diagnosis included hypertension (high blood pressure), arthritis, depression, and schizophrenia (mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). Review of the resident's electronic care plan, showed: -Problem: Initiated [DATE]: The resident is a full code; -Desired Outcome: Staff will comply with resident and physician's order regarding code status; -Interventions: initiated [DATE]: Initiate full code measures per resident wishes. Review of the resident's electronic medical record, showed: -admission date [DATE]; -readmission date [DATE]; -Physician order dated [DATE] for full code. Review of resident's paper chart, located at the nurse's station on [DATE] at 3:50 P.M., showed: -Code status sheet with full code marked; -Signed by resident on [DATE]. 10. Review of Resident #484's electronic medical record, reviewed on [DATE] showed: -admission date of [DATE]; -No code status on the face sheet; -No physician ordered of code status; -No care plan developed; -Diagnoses included: diabetes, myelodysplastic syndrome (a group of cancers that keep your blood stem cells from maturing into healthy blood cells), high blood pressure, high cholesterol, human immunodeficiency virus (HIV, a virus that attacks the body's immune system). During an interview and observation on [DATE] at 2:10 P.M., showed no code status sheet in the resident's paper chart, located at the nurse's station. Licensed Practical Nurse (LPN) BB said all residents' code status should be in the paper chart. Staff look in the resident's paper chart for their code status. He/she did not find resident #484's code status sheet. He/she showed a hospital discharge summary sheet with full code status. No physician order of code status on admission. During an interview on [DATE] at 3:01 P.M., the resident said nobody had talked to him/her regarding code status since admitted to the facility. He/she wanted to be full code. He/she wanted everything done to keep him/her alive. 11. Review of Resident #81's electronic medical record, reviewed on [DATE], showed: -A physician order sheet, no ordered code status; -A face sheet, showed no code status listed; -A care plan, in use at the time of the survey, showed no code status listed. Review of the resident's code status sheet, provided on [DATE], showed full code. The code status sheet was signed on [DATE] by the Social Service Director (SSD) with a note stating that the resident was unable to sign for themselves. Observation of the resident's nurse's station, on [DATE] at 3:48 P.M., showed no paper chart for the resident. Observation on [DATE] at 8:10 A.M., showed the resident's hard chart observed to be in 400 hall nurse's station. The code status sheet is blank and not filled out. Resident resided on the 100 hallway. 12. Review of Resident #16's electronic medical record, reviewed on [DATE], showed: -A physician order sheet, showed an order dated [DATE], full code; -A face sheet, showed full code; -A care plan, in use at the time of the survey, showed: -Problem: The facility will follow the resident's advanced directives for code status. The resident is a full code; -Goal: Staff will comply with resident wishes and physician's order regarding code status; -Intervention: Activate 911 for advanced assistance and CRP. Initiate full code measures per resident's wishes; -No signed code status sheet. Review of the resident's paper medical record, located in the nurse's station, showed: -An orange full code status sheet; -No signed code status. -Diagnoses of diabetes and high blood pressure. 13. Review of Resident #103's electronic medical record, reviewed on [DATE], showed: -A physician order sheet, showed an order dated [DATE], full code; -A face sheet, showed full code; -A care plan, in use at the time of the survey, showed: -Problem: The facility will follow the resident's advanced directives for code status. The resident is a full code; -Goal: Staff will comply with resident wishes and physician's order regarding code status; -Intervention: Activate 911 for advanced assistance and CRP. Initiate full code measures per resident's wishes; - Diagnoses of diabetes mellitus, anemia, cerebral infarction, and epilepsy; -No signed code status sheet. Review of the resident's paper medical record, located in the nurse's station, showed: -An orange full code status sheet; -A code status sheet, blank. 14. During an interview on [DATE] at 3:51 P.M., Certified Nursing Assistant (CNA) I said if staff need to know the resident's code status, staff look in the paper chart. If there was an emergency, since there is no code status in the paper chart, he/she would not know the resident's code status. 15. During an interview on [DATE] at 12:47 P.M., Certified Medication Technician (CMT) N said the code status is in the paper chart is where he/she would go to determine code status. 16. During an interview on [DATE] at 3:56 P.M., CMT N said a list of all residents who are DNRs are on the crash cart. If someone crashes and staff get the crash cart, they would immediately know if a resident is a DNR, otherwise, they treat them as a full code. Review of the list at this time, showed Residents #120, #29, #76, #66, #9, #69, #65, #534, #63 #81, #16, and #103 not listed on the DNR list, to indicate a full code status. 17. During an interview on [DATE] at 3:48 P.M., CMT N said resident's with a red sticker on their name plate are DNR and green are full code. That is how he/she knows a resident's code status. During an interview on [DATE] at 3:51 P.M., CNA I said the red sticker mean no take down. There are no full code stickers used. Not sure what is used for DNR. 18. Observation on [DATE] at 4:06 P.M., showed a DNR list of residents for the entire facility sitting on top of the 400 hall crash cart. Six residents were listed as having a DNR code status for the entire facility. Date of [DATE] for last time DNR list was updated. 19. During an interview on [DATE] at 4:07 P.M., LPN AA said the resident's code status is listed in the electronic medical record. If a resident has a medical emergency, staff should look for the resident's code status in their paper chart first. If the code status is not in the paper chart, staff should check the EMR. If the code status is not listed in the EMR, staff should ask their supervisor what to do and start CPR while someone calls 911. A resident's code status should be obtained upon admission by the nurse on the floor who accepts the admission. There is a list of DNR residents on the crash cart. 20. During an interview on [DATE] at 8:14 A.M., the Staffing Coordinator said that a resident's code status is located on the hard chart and if the resident does not have a chart it is located in the electronic medical record system, but that everyone has a hard chart. 21. During an interview on [DATE] at 9:29 A.M., Graduate Practical Nurse (GPN) X said, to locate a code status for a resident he/she would look in the paper chart or in the electronic chart. GPN X said the facility provides a DNR list for the entire facility and said it is usually posted at the nurse's station. The DNR list was not posted at the nurse's station. GPN X said if a resident was found unresponsive and he/she was unable to locate a code status he/she would treat the resident as a full code. GPN X said the Resident Care Coordinator (RCC) is responsible for obtaining and documenting the code status for admissions. GPN X said the code status should be completed immediately on admission because not having the code status for residents could result in the resident's wishes not being followed. 22. During an interview on [DATE] at 9:49 A.M., CNA Y said the black dot on name plates means the resident is a DNR. CNA Y said there is a list of all resident's code status on the crash cart at the nurse's station. 23. During an interview on [DATE] at 10:07 A.M., the SSD said he makes sure the DNR lists are in place in the building. He said obtaining a code status is done immediately on admission. SSD said nursing is responsible for placing the order in the electronic medical record and in the paper chart. If a resident is admitted and has a guardian in place and the guardian is not present on admission the code status is sent to the guardian. The resident is treated as a full code until the signed code status is received from the guardian. SSD said not having a code status may result in a resident not having their wishes followed. SSD said the process for reviewing the residents code status is after the code status is obtained on admission the SSD interviews the residents and makes sure they understand the process and what the code status means. SSD said he interviews all the resident's once a week. SSD said that the residents do not change their code status often. SSD said the code status sheets that were provided by the facility on [DATE] was the first code status the residents had and he did not have any other code status sheets from a previous date. 24. During an interview on [DATE] at 8:51 A.M., LPN R said the social worker, admission coordinator and DON is responsible for obtaining a code status. LPN R said If a resident is admitted in the evening and the code status is not completed the admitting nurse will put the resident as full code even if the hospital paperwork says DNR. The time frame for obtaining a code status is on admission or before the resident arrives. LPN R said the admission coordinator or social worker usually already has the code status filled before the admission packet is brought to the nurse's station. If a resident was found unresponsive and a code status could not be located the resident would be treated as a full code. LPN R said if the resident does not have a code status it could result in the resident getting the wrong care. 25. During an interview on [DATE] at 11:04 A.M., Administrator and DON said for new admissions the admission coordinator has the resident sign the code status sheet. Nursing will obtain a physician's order for the code status and enter it in the electronic medical record. When an order is received from a physician it should be entered into the electronic medical record within the hour. Code status should be obtained immediately but at least within 24 hours. The DNR list is located on the crash carts at the nurse's stations and the list is updated weekly with new admissions. A black dot is placed by the residents name outside the resident's room if they are a DNR. If there is no documentation related to code status the resident is treated as a full code. Code status should be reviewed and documented annually. Every resident that is a full code should have an orange sheet labeled full code. Medical records and social services are responsible for updating the orange full code sheet in resident's paper charts. Staff should be aware of where to find the code status and what the dot's mean next to the resident's names on the doors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide alternate meals to residents. The facility did not have a documented alternate meal plan for six out of 27 sampled residents (Residents #16, #55, #65, #91, #74, and #103). The facility census was 135. 1. Review of the facility's resident council minutes, dated 6/23/22, showed: -Dietary: They have gotten worse. Can they have a choice between a sandwich or salad for substitutes; -Department heads in attendance included Food Services Director. During a resident council interview on 8/23/22 at 10:30 A.M., seven of seven residents in attendance who represent the resident population said if they do not like what is served during a meal, they are given a sandwich. 2. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed: -Diagnoses of diabetes, high blood pressure, and dysphagia (difficulty swallowing); -Moderately impaired cognition; -Assistance may be needed when eating. During an interview on 8/22/22 at 11:30 A.M., the resident said there is no alternate menu to their knowledge. Some of the food tastes horrible and he/she would like different options. 3. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included paraplegia (paralysis of the lower half of the body), diabetes, high cholesterol, and depression. During an interview on 8/25/22 at 8:24 A.M., the resident said if residents do not like what is served that day, they do not get any other choices other than a cold sandwich. They are not offered something hot as an alternative. He/she would like to have choices other than the same cold sandwich. 4. Review of Resident #65's quarterly MDS, dated [DATE], showed diagnoses included cancer, heart disease, kidney failure, diabetes, Alzheimer's disease, anxiety, and depression. During an interview on 8/22/22 at 4:14 P.M., the resident said residents do not receive menus or alternative meal options. If a resident asks for something other than what is served, they are given a sandwich and that is their only choice. 5. Review of Resident #91's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, diabetes, high cholesterol, anxiety, depression, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 8/22/22 at 4:16 P.M., the resident said residents are not given menus or choices at meals. If a resident asks for something other than what is being served, they get a turkey sandwich and that is it. 6. Review of Resident #74's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, kidney failure, diabetes, and schizophrenia. During an interview on 8/23/22 at 7:04 A.M., the resident said if residents do not like what is served that day, they get offered a sandwich. There are no other options. 7. Review of Resident #103's quarterly MDS, showed: Diagnoses of diabetes, stroke, and epilepsy (seizure disorder); -Cognitively intact; -No assistance with eating needed. During an interview 8/23/22 at 10:17 A.M., the resident said if he/she does not like what is offered for meals, he/she will not eat. The facility does not provide an alternate menu. 8. During an interview on 8/22/22 at 1:00 P.M. Certified Nursing Assistant (CNA) O said for alternates, residents have to look at the menu posted on the wall and decide if they want it or not. The residents have to tell staff that they want something else, then nursing staff then have to contact the kitchen for the resident. Kitchen staff will make something for the resident based off of the resident's diet plan. To his/her knowledge, the alternate choices are sandwiches or soup. There is not a written alternate menu that is passed out or posted for residents to use. 9. During an interview on 8/24/22 at 3:54 P.M., Licensed Practical Nurse (LPN) AA said if a resident does not like what is served during a meal that day, nursing staff should call dietary and see what they have, which is always a cold sandwich. It is not fair to the residents that they cannot receive a different hot meal instead. There is no alternate menu for the residents to choose from. The facility used to have an alternate menu, but that was a long time ago. 10. During an interview on 8/25/22 at 8:48 A.M., CNA CC said many residents do not like the lunches served at the facility. When the residents do not like the meal they are served, staff offer them a sandwich. There are no other meal substitutes offered. 11. During an interview on 8/25/22 at 9:31 A.M., the dietary supervisor said if a resident does not like what is served during a meal that day, dietary will send up a cold sandwich for them. There is no alternate menu for residents to choose from and residents would not be offered a hot meal as a substitute to what is served that day. He/she has not been able to attend a resident council meeting during the past three months due to being short staffed in dietary. 12. During an interview on 8/26/22 at 11:05 A.M., the Director of Nursing (DON) and administrator said the facility does not have an alternate menu, but there are alternative choices served if a resident does not like what is served during a meal. Alternate choices include lunchmeat plates, cheese and crackers, hamburgers, and cheese toast. Dietary sends around five to six alternatives with the meal cart. If a resident does not like what is served during a meal, staff should offer them something that is nutritionally comparable to what is served.

Based on observation, interview and record review, the facility failed to prepare and serve food under sanitary conditions when staff donned gloves without washing hands, prepared food underneath dust coated ceiling lights and peeling paint, failed to label and date food when it was removed from the original container, failed to date health shakes to ensure they were not used beyond 14 days of the thaw date, failed to air-dry dishes and failed to ensure there was an air gap for the ice machine to prevent back flow. This had the potential to affect all residents who consumed food from the facility's kitchen. The census was 135. Review of the facility Dietary - Sanitary Procedures policy, dated 1/29/2018, revised on 10/12/2021, showed: -Hand Washing and Glove Use: Guidelines for hand washing and glove use to promote safe and sanitary conditions throughout department; -Hand washing is a priority for infection control; -Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food substances i.e. raw chicken to fresh fruit, following contact with any unsanitary surface i.e. touching hair, sneezing, opening doors, etc.; -Washing procedure. Check to see that there is an adequate supply of hand soap, a fingernail brush, and clean, disposable paper towels at the hand sink; -Do not use germicidal soaps because these preparations destroy beneficial resident skin microorganisms that are necessary to maintain healthy skin and inhibit the growth of foreign bacteria; -Wet Hands; -Go to the hand wash sink in the kitchen. Turn on the water. Let it flow until warm (110° F to 120°F). Place hands under the flowing water to thoroughly wet the surface of the hands, fingernails and lower arms; -Apply soap; -Place enough hand soap or detergent (1/8th to 1/4th teaspoon) to build a good lather on a fingernail brush and palms of hands; -Scrub and lather, particularly fingertips and fingernails. Vigorously scrub and lather the fingertips and under the fingernails of both hands. Scrub the back and palms of hands. Scrubbing loosens the feces and dirt and this soil is transferred to the lather; -Rinse hands. Rinse the lather and soap from the hands in the flowing warm water. As the soap is rinsed off, the water flushes dirt and fecal material from the fingertips and under the fingernails down the drain; -Dry hands using paper towel(s); -Use clean, disposable paper towels, to thoroughly dry hands and arms and turn off faucet valves. Discard paper towels in waste container without touching the container; -Hands must always be washed prior to beginning work. Hands must always be washed after smoking, using the restroom, or handling any unsanitary items; -Fingernails must be kept short and clean at all times; -Gloves: Gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching any ready-to-eat food; -When gloves are used, hand washing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed, see above. Gloves may be used for one task only; -Important to remember that gloves can often give a false sense of security and can carry germs same as our hands; -Gloves must be non-latex, single use, powdered or non-powdered; -Pots and Pans -Sanitizing Solution; -SANITATION OF EQUIPMENT; -NOTE: Allow all items to air dry. Towels shall never be used for drying; -When items are dry, store in proper storage area; -Walls and ceilings must be free of chipped and/or peeling paint. 1. Observation of the kitchen, from 8/23/22 through 8/26/22, showed: -Peeling paint above the food preparation table, two smaller areas, which exposed the paint underneath, measured approximately 3 inches wide by 2 inches long, and three additional areas, measured approximately 1 1/2 inches wide by 20 inches long; -Dust covered light fixtures with small strands of dust hanging from the lights, hung in close proximity to stove and food preparation table, and under an area where open food would be transported from the preparation table to the stove; -No air gap between the ice machine drain hose and the floor drain. The ice machine drain hose was positioned inside the floor drain, which provided no air gap (protection from the floor drain's back flow, should the floor drain become clogged and/or overflow); -On 8/24/22 at 8:40 A.M., clear plastic cups stacked wet, with visible droplets inside and pans stacked wet, which when lifted, visible droplets of water ran down the inside of the pan. On 8/25/22 at 4:00 P.M., pans stacked wet, with visible water droplets inside the pans. 2. Observation and interview on 8/23/22 at 7:56 A.M., inside the refrigerator, closest to the dishwasher, showed five health shakes in a plastic tub on the bottom shelf, undated. Dietary aide OO, opened a box of 50 count/6 ounce strawberry mighty shakes (supplements) and said he/she didn't know when they were thawed, but he/she is supposed to date them when the box is opened. He/she then removed the five undated health shakes from the plastic tub and added the date to the shakes, 9/6/22. 3. Observation on 8/23/22 at 7:48 A.M., showed a pan of sliced cooked roast beef covered with plastic wrap on the preparation table, with a sticker on the plastic wrap dated 8/21/22. The cook said the dates on the stickers are the throw away date. The roast beef was cooked on Saturday and the pan should have been dated for three days. She said she would throw away the leftovers. She then put on a pair of gloves, without washing his/her hands prior to donning the gloves, and using his/her gloved hand, removed three large handfuls of cooked roast beef and placed the roast beef into the puree blender. She then added one cup of thickener and with his/her gloved right hands, turned on the faucet, added two cups of water to the blender, and touched the roast beef with his/her right gloved hand. She then added more water, blended the contents of the blender, removed his/her gloves, and without washing his/her hands, removed the blender from its base. He/she picked up the blender, with his/her fingers inside the blender, and used a spatula with the opposite hand to remove the puree and place the contents into a pan. Observation and interview on 8/24/22 a 8:40 A.M., showed the cook added one large can each of cheese sauce, pasta sauce and beans to two large pans of cooked noodles. The third pan of cooked noodles contained no pasta sauce. The cook said the third pan is for people who can't eat tomato sauce. He/she then donned a pair of gloves, without washing his/her hands prior to donning the gloves, and used his/her gloved hands to scoop up and stir the mixture of cheese sauce, beans and cooked noodles inside the pan without the pasta sauce. 4. During an interview on 8/26/22 at 10:12 A.M. the dietary manager said she expected staff to wash hands before donning gloves and after doffing gloves. She said the pans and cups should not be stacked wet because of the possibility of bacterial growth and she expected the ice machine to have an air gap to prevent any possibility of the drain backing up into the ice machine, causing possible contamination. The health shake box should be dated when placing in the refrigerator to thaw and the health shakes should be dated when they are removed from the box with a 14 day expiration date. She was not aware of the dust or chipped paint above the prep table, which should be addressed.

Based on interview and record review, the facility failed to ensure quality assurance performance improvement (QAPI) meetings consisted of the required committee members when the medical director failed to attend the facility's QAPI meetings. The census was 135. Review of the facility's QAPI plan policy, undated, showed: -Purpose of your organization's QAPI plan: -To provide quality excellence in resident care and do a route cause analysis for identified areas of concern and improvement; -Our facility written QAPI plan provides guidance for our overall quality improvement program. Quality assurance performance improvement principles will drive decision making within our organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions; -Our QAPI framework: -All department managers, the administrator, the director of nursing (DON), antibiotic steward, the infection prevention officer, medical director, consulting pharmacist, resident and/or family representative (if appropriate), and three additional staff will provide QAPI leadership by being on the Quality Assessment and Assurance (QAA) committee; -The QAA committee will meet monthly. QAPI activities and outcomes will be on the agenda of every staff meeting and will be shared with residents and family members through their respective councils and monthly newsletter. Review of the facility's QAPI meeting sign-in sheets since August 2021, showed meetings held monthly and the facility's medical director did not attend any meetings. During an interview on 8/24/22 at 10:29 A.M., the administrator said she would expect QAPI meetings to be held monthly. Topics of concern are discussed during QAPI meetings. QAPI meetings should be attended by the facility's department heads, including the administrator, DON, housekeeping, laundry, human resources, and central supply. She would expect the facility's medical director to attend at least quarterly. The medical director has not attended any of the QAPI meetings held during the past year.

Based on observation, interview and record review, the facility failed to ensure residents who had a urostomy (a surgically created opening in the abdominal wall though which urine passes), received care consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences by failing to provide appropriate urostomy supplies, and not monitoring the urostomy site and output each shift. This affected one of one resident in the facility who had a urostomy (Resident #81). The census was 137. Review of Resident #81's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/5/19, showed: -Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive impairment) score of 15 out of 15; -A BIMS score of 8-15 shows the resident understands and is able to make self-understood; -Supervision of one staff member for toileting; -Presence of urine ostomy in the last seven days; -Active diagnoses included: neurogenic bladder (loss of bladder control due to brain, spinal cord or nerve problem), acquired absence of right leg above the knee, Spina bifida (birth defect in which a developing baby's spinal cord fails to develop properly) and acquired absence of left leg above the knee. Record review of the resident's paper physician's order sheets dated 6/15/19 - 7/14/19, showed no orders to care for or monitor the urostomy. Review of the resident's progress notes, showed an entry on 3/28/19, that the resident had an intact ileostomy (a surgically created opening in the abdominal for a portion of the small intestine to pass stool) draining yellow urine to gravity. There were no daily notes monitoring the skin surrounding the urostomy nor the output of urine. Record review of the resident's care plan dated 4/15/19, showed: -Problem: Incontinent of bowel and has an ileostomy. He/she is dependent on staff for toileting including lower extremity dressing, perineal care (Peri-care, washing the front and back of the hips, genitals, anal area and buttocks), and care of ileostomy; -Goal: The resident will remain clean, dry and free of odor now through next review; -Approaches included: Monitor output of ileostomy every shift; Monitor for skin breakdown and pressure injury (injuries to the skin and underlying tissue resulting from prolong pressure on the skin); -The care plan did not address the urostomy. Observations of the resident, showed: -On 6/24/19 at 1:10 P.M., he/she sat in alone, in his/her wheelchair, outside of his/her room; -On 6/25/19 at 6:22 A.M., he/she was outside smoking cigarette. The resident was not sitting next to the other residents in the smoking area; -On 6/26/19 at 2:15 P.M., he/she sat alone, in his/her wheelchair, in the hallway. During an interview on 6/24/19 at 1:11 P.M., the resident said: -He/she was able to take care of his/her urostomy by himself/herself; -He/she did not have the appropriate urostomy supplies to take care of himself/herself for the past four months and was using incontinence briefs to absorb the urine from the urostomy. During an interview on 6/25/19 at 6:32 A.M., the resident's roommate said the room always smells of urine, and he/she has gotten used to the smell, but preferred the room did not constantly smell of urine. Interview on 6/26/19 at 7:21 A.M., Nurse C said: -The resident took care of his/her urostomy and received supplies from the facility; -The resident told Nurse C he/she needed supplies for his/her urostomy last week; -Nurse C assumed the Assistant Director of Nursing (ADON) had followed up with the resident as the ADON orders supplies; -The ADON told the nurse the supplies were on order; -The resident was not wearing a urine collection bag on his/her urostomy. The resident wore incontinent briefs (disposable undergarment, fastened with tape tabs, used to absorb urine) and incontinence underwear (disposable undergarment, designed to look like traditional underwear, used to absorb urine) to absorb the urine from the urostomy; -Nursing staff did not assess the resident's urostomy or monitor the amount of urine draining from the urostomy. During an interview on 6/26/19 at 2:16 P.M., the resident said the following when asked how does/he/she feel when he/she does not have the appropriate supplies for his/her urostomy, It's hard because I have to worry about keeping my pants dry and it smells. It makes me not want to be around people because I am afraid they will judge me. It makes me insecure so I isolate myself. I am already insecure about being in a wheelchair and having no legs. During an interview on 6/26/19 at 2:49 P.M., the ADON said: -The nursing staff didn't know why the resident was asking for so many briefs as he/she likes to care of himself/herself; -The ADON was not aware until a few weeks ago that the resident had a urostomy. The ADON saw the urostomy when she was assisting the resident with an antibiotic treatment; -The ADON ordered urostomy supplies two or three weeks ago. When the supplies came in, they were the wrong product so they were sent back; -New urostomy supplies arrived yesterday on 6/25/19; -Nursing staff are expected to assess urostomy sites and monitor urine output per shift; -The facility has a list of special care resident's which identifies residents who have a urostomy. During an interview on 7/2/19 at 12:45 P.M., the DON stated the facility does not have a policy specific to a urostomy. During an interview on 7/2/19 at 2:39 P.M., the DON stated the following: -The resident has a urostomy; -The documentation showing the resident had an ileostomy was incorrect; -Nursing staff is expected to use the correct diagnoses and the correct terminology when referring to the resident's urostomy.

Based on observation, interview and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. The facility failed to acknowledge and assess the underlying causes of the resident's expressions of distress or develop and implement a care plan that addressed this distress. This affected one of 27 sampled residents (Resident #68). The census was 137. Review of Resident #68's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/24/19, showed: -admission date of 4/2/16; -Brief Interview for Mental Status (BIMS, a screening tool used to detect cognitive impairment) score of 15 out of 15; -A BIMS score of 8-15 shows the resident understands and is able to make self-understood; -Total dependence with assistance of two staff members for transfers; -Extensive assistance of one staff member for bed mobility, toileting, dressing and personal hygiene; -Impairment on both sides of upper and lower body; -No symptoms of psychosis (a mental disorder characterized by a disconnection from reality, can have delusions or hallucinations) noted; -Verbal behaviors directed at others, physical behaviors not directed at others, and rejection of care occur daily; -Wheelchair for locomotion; -Active diagnoses included: Paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), depression, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (breakdown in relation between thought, emotion and behavior leading to faulty perception, inappropriate actions and feelings) and personality disorder (a mental disorder characterized with rigid and unhealthy patterns of thinking, functioning and behaving). Review of the resident's care plan dated 3/27/19, on 6/25/19 at 1:19 P.M., showed: -Problem onset 3/27/19: PASARR (Pre-admission Screening and Resident Review) to identify possible serious mental disorders or intellectual disabilities and related conditions - client denies prior psychiatric history but on 10/16/14, was diagnosed with depression after becoming verbally aggressive at a nursing home. He/she used his/her electric wheelchair as a weapon toward staff. He/she was admitted to inpatient psychiatry. The resident was then diagnosed with major depression, bipolar disorder, personality disorder, paraplegia due to childhood polio and quadriplegia after traumatic fall in 2014. He/she has behaviors of aggression, irritability, forgetfulness, delusional and paranoia; -Goal: Resident will not cause harm to self or others; -Approaches: Psychiatrist will follow up with resident as needed, however, resident refuses to see a psychiatrist; Monitor for behavior changes and mental decline; -Problem onset 12/20/18: At risk for injury related to history of verbal aggression toward staff and peers. Has behaviors of being demanding, impatient and paranoid with staff. Has been cursing at the staff and refusing treatments, medications and care at times; -Goal: The resident will not cause himself/herself or others serious injury now through next review; -Approaches included: Monitor for behaviors; Follow up with physician and psychiatrist as needed; Redirect negative behaviors; Allow time to voice concerns and behaviors; -Problem onset 12/3/18: Is verbally abusive to staff on a regular basis. Often lies on the staff. The resident feels as if the staff is lying on him/her. He/she is very delusional about current reality but appears to be alert and orientated to person, place, time and situation. The resident stopped taking psychiatric medication in Spring 2018, after he/she saw his/her medication list when out to an appointment. The resident does not have a guardian to assist with compliance; -Goal: The resident will not cause harm to others; -Approaches: The resident often paces through halls via electric wheelchair when angry. Is unsafe with wheelchair because he/she comes close to running staff over, possibly on purpose. When educated and/or redirected, the resident starts to be verbally aggressive to staff. Refuses to take psychiatric medication. Questions all medications when they are given to him/her. Attempt to give resident antipsychotic; -The facility failed to create a comprehensive care plan specific to the resident with meaningful interventions that would promote the highest practical health and psychosocial well-being of the resident; -The facility failed to assess the underlying cause for the resident's behaviors. Review of the resident's progress note from a long term psychiatric management company dated 4/9/18, showed: Assessment: Patient is compliant with the treatment recommendations. In our clinical opinion patient is at baseline. Review of the resident's physician's visit note dated 6/3/19, showed: -Medication list reviewed, the patient has no new or worsening medical problems over the last month; -Plan: Continue current medications as recorded and documented on nursing home medication list at facility. Follow up in one month; -Active diagnoses included: Quadriplegia (partial or total loss of use of all four limbs and torso). Review of the resident's progress notes, showed: -On 5/13/19, the resident had been displaying extreme behaviors and was non-compliant with care, treatment plan and medication. The resident had displayed aggressive behaviors every day. He/she cursed at staff and made very offensive and derogatory comments to the staff. The physician was aware of behaviors. Directions to allow the resident to vent to staff that he/she likes and continue to attempt to redirect unmanageable behaviors; -On 5/21/19, a note by Social Worker showed the care meeting was held on 4/24/19, and the resident was not in attendance. The resident had been displaying many aggressive behaviors towards the staff, rejecting care and medications. At times staff could find the resident rolling around the facility, in his/her room, and sometimes he/she would chill out in the court yard. The resident will usually talk to himself/herself very loudly. The other resident's just ignore him/her. Staff will continue to monitor for any issues; -The Social Worker failed to update the care plan with new interventions that promote the health, and psycho social well being of the resident and failed to identify the underlying cause for the resident's distress; -On 6/14/19, the resident was extremely upset, agitated, yelling as he/she rolls throughout the facility using profanity, very belligerent. The resident was not able to be re-directed. The resident was being sent out to the hospital but stated he/she was not going. Immediate discharge letter would be sent with resident to receiving hospital. Observations and interviews, showed: -On 6/24/19 at 8:32 A.M., the resident lay in bed eating breakfast from the bedside tray positioned over him/her. He/she had a pleasant affect and spoke politely; -On 6/25/19 at 6:37 A.M., the resident lay in bed, talking and cursing to himself/herself. The resident complained how police officers came to get him/her, putting people at risk, because the resident was in the wheelchair cursing. He/she used profanity when describing the facility's owners and the administrator. The resident stated he/she was not a threat as he/she was a quadriplegic in a wheelchair; -On 6/25/19, the resident was in his/her electric wheelchair on the sidewalk outside the facility, shouting curse words and profanity about various staff members and topics. The administrator said the facility was preparing a 30 day discharge notice and another facility was accepting the resident. The resident had not been told yet or asked if that was his/her preference; -On 6/26/19 at 2:32 P.M., the resident lay in bed, quietly answering questions; -On 6/27/19 at 7:20 A.M., the resident lay in bed, looking out the window. He/she had a pleasant affect, smiled and spoke about a business he/she wanted to start. During an interview on 6/25/19 at 6:44 A.M., Nurse I said the resident often has conversations with himself/herself, cursing and talking about staff. Staff attempts to redirect him/her by walking into the resident's room and bringing him/her back to the present. The resident is a quadriplegic and allowed staff to care for him/her the majority of the time, but he/she would sometimes escalate, get angry and speed up and down the unit hall in his/her electric wheelchair. The resident has never hit staff or other residents with his/her wheelchair. The other residents do not get upset, they ignore the resident when he/she is on a rampage. The intervention staff was directed to use was to ask the resident to slow down, which makes him/her go faster. During an interview on 6/26/19 at 6:29 A.M., Nurse J said when he/she started work at the facility a year ago, he/she was told the resident often curses to himself/herself and Nurse J was instructed to ignore the behavior. Certified Nurse Aide (CNA) K and CNA L said if the resident refuses care with one care taker, the CNAs get someone else to work with the resident. CNA K and CNA L said they do not have issues working with the resident. During an interview on 6/26/19 at 7:45 A.M., CNA G and CNA H said the resident does curse at staff at times and is sometimes depressed. CNA G will ask the resident what is bothering him/her and sometimes the resident will share with CNA G. When the resident curses to himself/herself during care, the CNAs continue to take care of the resident. The resident does not often refuse care. The CNAs deny seeing the resident try to knock staff or residents down with his/her electric wheelchair. The other residents ignore the resident when he/she is upset and yelling. CNA G and CNA H were not given any training specific to the resident or told of any specific interventions to help the resident when he/she has behaviors. During an interview on 6/26/19 at 9:08 A.M., the Assistant Director of Nursing (ADON) said the resident has a CNA that he/she prefers and when the CNA was no longer caring for him/her, the resident thought the CNA was angry with him/her. The resident recently saw a physician regarding his/her bowel movements. The physician prescribed medications for the resident without ensuring the resident understood what the medications were for and why they were prescribed. The resident was angry and refused the medications. During an interview on 6/26/19 at 11:55 A.M., the resident said: -He/she is upset that the nursing staff were not giving him/her a name-brand bowel softener; -He/she refused medications because the staff were not giving him/her the right medications; -The facility did not listen to his/her concerns, did not care for him/her appropriately and was neglectful; -He/she felt he/she should be in an area of the facility that cares for residents with spinal cord injuries and strokes; -There was another resident on the unit who threatened the staff all the time. That resident could walk and got in the staff's face and the facility was not putting that resident out. The resident felt as a wheelchair bound quadriplegic, he/she could not harm anyone. I cuss and fuss but that is verbal not physical. The resident felt the facility was singling him/her out for his/her behaviors. During an interview on 6/26/19 at 1:30 P.M., the facility's Social Worker said: -The resident's history included adoption as a young child, being a paraplegic and later a quadriplegic, due to an accident when he/she fell down a flight of stairs, he/she was responsible for self, and did not have any family involvement or visits; -All social service notes are in the resident's medical file under progress notes; -The only behavior interventions listed for the resident are on his/her care plan; -The resident stopped taking Risperdal (antipsychotic used to treat schizophrenia, bipolar disorder and irritability caused by autism) last spring and since then had escalated behaviors and was non-compliant with treatments by refusing to take medications and receive care from staff; -The intervention of talking to the resident was used when the resident was verbally aggressive to staff or rode his/her electric wheelchair fast up and down the halls; -There are no specific triggers identified that cause the resident to escalate behaviors; -If the resident responded verbally to the Social Worker it was documented in the medical record under progress notes; -Psychiatric counseling was not sought for as the resident denies having psychiatric issues. During an interview on 6/26/19 at 2:33 P.M., the resident said he/she remembered the ADON talking to him/her about an immediate discharge. He/she did not receive a copy and refused to sign it. The police came in and talked to the resident about the immediate discharge and the resident continued to refuse to sign the document. The ADON asked the resident what he/she wanted to do and said if the ambulance didn't come, the resident should just go to his/her room and behave. During an interview on 6/27/19 at 11:51 A.M., the Director of Nursing (DON) and the administrator said: -The resident last saw the long term psychiatric management company on 4/18/19; -Care plans should have interventions specific to the resident that are person centered and evaluated to ensure the interventions are appropriate and effective; -The facility's social worker did not show proper documentation and care for the resident; -Nurses are expected to document behaviors and non-pharmaceutical interventions.

Based on observation, interview and record review, the facility failed to ensure medication error rates are not 5 percent or greater. Out of 29 opportunities observed, there were three errors resulting in a 10.34% medication error rate (Resident #105). The census was 137. Review of Resident #105's physician's order sheet (POS), dated 6/15/19 through 7/14/19, showed: -Carvedilol (medication used to treat high blood pressure and heart failure) 25 milligrams (mg) by mouth twice a day with food, at 8:00 A.M. and 5:00 P.M.; -Calcium Antacid 500 mg, chew one tablet three times a day, at 8:00 A.M., 12:00 P.M. and 5:00 P.M.; -Tamsulosin (medication used to treat enlarged prostate) 0.4 mg, once a day with food. Observation on 6/26/19 at 10:29 A.M., showed the resident at the bedside. Nurse C administered the resident's morning medications, which included tamsulosin 0.4 mg, carvedilol 25 mg and calcium antacid 500 mg chew tablet with a cup of water. The resident said he/she had eaten breakfast earlier in the morning. Breakfast was served between 8:00 A.M. and 9:00 A.M. During an interview on 6/26/19 at 10:45 A.M., Nurse C said he/she should have administered the medication within the time frame and with food as ordered. He/she did not have a Certified Medication Technician (CMT) to pass the medicine. He/she was completing the nurses's duties in addition to passing the medication which caused the medication pass to be late. Review of the facility's policy on Medication Administration, updated 4/6/17, showed: -Procedure: Medications are to be given per doctor's orders; -It is imperative that all medications are given using the five rights to medication administration: Right resident. Right medication. Right time to dispense medication. Right dose of medication and right dose form; -Steps to follow: Dispense the medication. If time is specific, give medication as ordered on time. Medications to be given with food will be given within the 30 minutes before or 30 minutes after the meal. If the medication must be given with food and it is outside of the 30 minute window then a snack will be offered to prevent stomach upset. During an interview on 6/27/19 at 11:00 A.M., the Director of Nurses said she would expect the staff to administer medication as ordered.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards in four of the seven facility medication/treatment carts. The census was 137. Review of the facility's undated narcotic medication management, storage and destruction of controlled substances policy, showed: -Controlled medications are to be kept in the medicine cart's special secure drawer with a double-locking system; -Narcotics and controlled substances should not be placed in regular medicine drawers, as these drawers are not adequately secure. Review of the facility's administration of eye drops policy dated 4/6/17, showed: Upon opening a new bottle of eye drops, you must date the bottle for the date you opened it. The opened bottle of eye drops must be discarded six months from the date it was opened and/or per manufacturer's recommendation. The bottle must be stored appropriately in the mediation cart or the medication room in the appropriate label at all times. Review of the facility's insulin storage policy dated 1/11/14, showed: -You must date all bottles, cartridges and pens after you opened them using the date opened; -Never use insulin if it is not dated! Discard the bottle, cartridge or pen immediately. 1. Observation of the treatment cart for the 300 hall on 6/24/19 at 11:37 A.M., showed: -An unopened vial of Novolog (a short acting insulin used to treat diabetes mellitus (DM)), undated; -A bottle of morphine sulfate (narcotic) stored in an unlocked drawer. 2. Observation of the medication cart for the 300 hall on 6/24/19 at 11:41 A.M., showed: -Five undated opened bottles of eye-drops; -An opened Spiriva inhaler (used to treat the symptoms of chronic obstructive pulmonary disease (COPD, lung disease)) not in pharmacy packaging, loose in a drawer. 3. Observation of the treatment cart for the 200 hall on 6/24/19 at 12:12 P.M., showed one opened Novolog flex pen, undated. 4. Observation of the treatment cart for the 100 hall on 6/24/19 at 1:44 P.M., showed: -An opened bottle of haloperidol (antipsychotic used to treat certain types of mental disorders) loose in a drawer without a pharmacy label; -One opened Incurse Ellipta inhaler (used to treat the symptoms of COPD), loose in a drawer without pharmacy label. 5. During an interview on 6/27/19 at 11:51 A.M., the Director of Nursing and the administrator said: -Narcotics are secured under two different locks for safety purposes; -All medications are kept in pharmacy packaging; -Nurses are educated to date insulin when it is opened but don't believe the nurses understand that once insulin is out of refrigerator and up to room temperature, it begins to degrade. Insulin should be stored in the refrigerator until it is ready to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure acceptable accounting procedures were followed when residents' trust fund balances were negative for at least two months for 10 of 166 residents who had a trust account held by the facility. The census was 137 Review of the residents' trust fund open balance report, which included residents who were discharged , showed: -Resident #192's account for 3/31 - [DATE], had a negative balance of $1616.08. The ledger showed he/she was discharged on [DATE]; -Resident #125's account for 3/31 - [DATE], had a negative balance of $192.42; -Resident #30's account for 3/31 - [DATE], had a negative balance of $200. The ledger showed he/she was discharged on [DATE]; -Resident #191's account for 3/31 - [DATE], had a negative balance of $17.00. The ledger showed he/she was discharged on [DATE]; -Resident #193's account for 3/31 - [DATE], had a negative balance of $62.00. The ledger showed he/she was discharged on [DATE]; -Resident #95's account for 3/31 - [DATE], had a negative balance of $90.00. On [DATE], he/she had a negative balance of $120.00 in his/her account; -Resident #194's account for 3/31 - [DATE], had a negative balance of $45.00. The ledger showed he/she was discharged on [DATE]; -Resident #195's account for 3/31 - [DATE], had a negative balance of $32.99. The ledger showed he/she was discharged on [DATE]; -Resident #22's account for [DATE], had a negative balance of $20.00. On [DATE], he/she had a negative balance of $50.00 and on [DATE], he/she had a negative balance of $20.00 in his/her account; -Resident #191's account for [DATE], had a negative balance of $64.45. On [DATE], he/she had a negative balance of $63.45 in his/her account. During an interview on [DATE] at 2:25 P.M., the business office manager said she contacts the corporate office when there is a negative balance and they have to write a check. She has not contacted them in a while, probably at least a couple of months. Regarding Resident #192, she paid for his/her rent before they received the check and then he/she expired. With Resident #30, she wrote a check to his/her sibling but could not recall why and he/she did not have money in his/her account. She posts the surplus between the 10 - 15th of each month. She has learned not to post until she received the money and knew there should not be negative balances. If there were negative balances they were overlooked by her. On the first of the month, the residents come up and get money and some may have not received money in their account, if the facility was not the payee. She knew not to have negative balances in the residents' accounts. She has been trained on the policy. Review of the Resident Trust policy and procedure updated 12/2018, showed: -All balances are to be reviewed at the end of each day to ensure that no balances were negative; -A negative balance should never occur on a resident's ledger. When this occurs, this means the facility is lending funds to that resident from other residents using the resident trust account. This is a violation of Social Security Administration's (SSA) policy and could affect the facility's ability to have an approved resident trust account from SSA; -If any resident has a negative balance on the last day of the month a positive adjustment must be posted to make their balance zero. The Department of Health and Senior Services will cite the facility for any overdrawn resident accounts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean and sanitary environment by not ensuring floors, walls, doors, air conditioner units, a sink and a mattress were kept clean and in good repair. This affected two of four resident dining rooms and 11 of 27 sampled resident rooms. The census was 137. 1. Observations on 6/25/19 at 7:28 A.M. and 6/27/19 at 7:52 A.M., of the 100 unit dining room, showed black scuff marks on the floor. In addition, the floor was sticky. 2. Observations on 6/24/19 at 8:49 A.M. and 6/26/19 at 6:49 A.M., of the bathroom in room [ROOM NUMBER], showed the floor was dirty and sticky. In addition, the caulk surrounding the toilet was black. 3. Observations on 6/25/19 at 11:27 A.M., 6/26/19 at 2:44 P.M. and 6/27/19 at 7:00 A.M., of room [ROOM NUMBER], showed the floors were sticky and dirty. Scuff marks were on the bottom of the door leading into the room. 4. Observations on 6/24/19 at 8:49 A.M., 6/26/19 at 6:49 A.M. and 6/27/19 at 7:00 A.M., of the bathroom in room [ROOM NUMBER], showed the black base board of the wall close to the floor was peeling off the wall. In addition, black substance surrounded the toilet. During an interview on 6/26/19 at 7:00 A.M., Housekeeper B said they clean the rooms daily and for any problems related to maintenance, they report to the maintenance supervisor. When shown room [ROOM NUMBER], he/she said the black substance surrounding the toilet was something he/she tried to clean but could not. He/she reported it to maintenance. The base boards on the wall was something he/she reported to maintenance as well. 5. Observation of room [ROOM NUMBER], shared by four residents, on 6/24/19 at 1:11 P.M. and 6/25/19 at 6:22 A.M., showed a heavy buildup of grime and dirt on the floor with large accumulations in the corners of the room. The room had a heavy odor of urine and there were flies present. The trash can in the bathroom did not have a liner and was full of soiled briefs. The blinds over the window and the air conditioning unit were coated in a thick layer of dust. 6. Observation of room [ROOM NUMBER] on 6/26/19 at 7:52 A.M., showed a heavily stained and worn mattress. During an interview at that time, Nurse E said he/she did not know how long the mattress had looked that way, but he/she would not want to sleep on it. He/she thinks the facility had ordered more mattresses and he/she would have the mattress replaced. Housekeeper F said he/she had worked at the facility for a few years and the mattress had been that way for a long time. He/she had not told anyone or completed a work order to have the mattress replaced. He/she thought the maintenance department was supposed to inspect the mattresses. 7. Observation of room [ROOM NUMBER], a room occupied by three residents, on 6/24/29 at 10:15 A.M., 6/25/19 at 11:27 A.M. and 6/26/19 at 8:04 A.M., showed a thick black grime build-up of dirt between the wall and the floor next to the sink in the room. A long horizontal black scuff mark stretching the entire width of the inside of the bathroom door, an 8 inch section of loose mop board in the bathroom and a round metal plate in the bathroom wall that was broken away from the drywall. 8. Observation of room [ROOM NUMBER], the locked unit's dining room, on 6/24/19 at 9:30 A.M. and 6/26/19 at 8:22 A.M., showed a dirty hand sink where staff washed their hands. An air conditioner in the wall and close to the floor showed the vent with a heavy build-up of dust and dirt. 9. Observation of room [ROOM NUMBER], a room occupied by two residents, on 6/24/19 at 9:18 A.M. and 6/25/19 at 1:20 P.M., showed a heavy build-up of black dirt and grime on the floor in the room entrance and on the floor where the floor adjoins to the wall throughout the room. A large area of the wall underneath the sink counter top was spackled and not painted the color of the room. The bathroom, shared with two more residents in room [ROOM NUMBER], had a rusted door frame with peeling paint and a missing toilet paper holder. During an interview on 6/24/19 at 9:18 A.M., Certified Nurse Aide D said the spackling had been like that for a long time. 10. Observation of room [ROOM NUMBER], a room occupied by two residents, on 6/24/19 at 9:32 A.M. and 6/25/19 at 1:14 P.M., showed a hole in the wall approximately 4 inches long and wide, between the sink and the closet. 11. Observation of room [ROOM NUMBER], a room occupied by two residents, on 6/24/19 at 9:17 A.M. and 6/25/19 at 12:51 P.M., showed a heavy build-up of black dirt and grime on the floor at the entrance to the room. 12. Observation of room [ROOM NUMBER], a room occupied by two residents, on 6/24/19 at 9:14 A.M. and 6/25/19 at 12:51 P.M., showed a heavy build-up of black dirt and grime on the floor at the entrance to the room. The air conditioner's vent cover was completely broken and missing and the bathroom had a broken toilet paper holder and a missing light fixture. The bathroom was shared by a total of four residents. 13. During an interview on 6/27/19 at 6:50 A.M., Housekeeper A said his/her duties were to clean the rooms daily by dusting the furniture, mopping the floors and checking under the bed. They were scheduled to deep clean the rooms twice per week. They check the bathrooms and report any leaks to maintenance. When he/she saw gunk on a toilet, he/she tried to clean it. If it did not come off, he/she reported it to maintenance so they could replace the caulk on the toilet. 14. During an interview on 6/27/19 at 8:07 A.M., the housekeeping supervisor said there are three full time and two part time housekeepers. Additionally, there are two floor technicians. There is a schedule for deep floor cleaning and to disinfect and scrub the bathrooms. They have scraping tools that should be used to remove the dirt and grime between the floors and walls. He said the above areas were not as clean as they should be. The air conditioner vent in the 406 dining room needed to be cleaned. The mattress in room [ROOM NUMBER] should be replaced. 15. During an interview on 6/27/19 at 9:39 A.M., the Maintenance Director said there were three part time maintenance employees not including him. The facility had a painter, but he had to let him go, that's why the spackled area on the wall in room [ROOM NUMBER] had not been repainted yet. If something is broken or missing, staff should complete a work order so it can be fixed or replaced. 16. During an interview on 6/27/19 at 11:47 A.M., the administrator said she expects the facility to be clean and in good repair.