**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 by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS)), for four residents who required EBP for wound treatment or a medically inserted device (urinary catheter, a sterile tube inserted into the bladder through the urinary tract to drain urine). The facility identified eleven residents requiring EBP, four residents were sampled and problems were found with all four residents (Residents #1, #2, #4, and #5). The census was 77. Review of the facility's Isolation Precautions/Enhanced Barrier Precaution (EBP) policy, dated, 4/2/24, showed: -Policy: It is the policy of the facility to make every effort to prevent the spread of infection in the facility. Standard Precautions require the health care worker (HCW) to estimate the degree of risk associated with a given task and plan for appropriate personal protective equipment. Enhanced Barrier Precautions is used in combination with Standard Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -Procedure:EBP will be used for any resident who meets the following criteria: -Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. -Chronic wounds, such as, pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence), venous stasis ulcers (ulcers caused by decreased blood circulation), diabetic ulcers (ulcers caused by decreased blood circulation), -unhealed surgical wounds; -Indwelling medical devices, such as, central lines (a long, flexible tube your provider inserts into a vein in your neck, chest, arm or groin for administration of blood, medications or dialysis), urinary catheters, feeding tubes (g-tube, a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications), and tracheostomies (tube surgically inserted into the trachea for the purpose of breathing); -Residents who meet the above criteria, EBP are recommended when performing the following high-contact resident care activities: -Dressing; -Providing hygiene; -Bathing/showering; -Transferring; -Changing linens; -Changing briefs or assisting with toileting; -Indwelling medical devices care; -Chronic wound care; -Place EBP sign at entrance to the room for the resident who meets the criteria; -Staff will clean their hands before entering and when leaving the room; -Staff will wear gloves and a gown for High-Contact Resident Care Activities; -Do not wear the same gloves and gown for the care of more than one person; -If only one resident in the room requires EBP, place an EBP sign above the bed of the resident who meets the criteria as well as the entrance to the room. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/25, showed: -Cognitively intact; -Dependent on staff for toileting, positioning and transfers; -Indwelling urinary catheter; -Three Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcers present on admission. Review of the resident's care plan dated 5/8/25, showed: -Problem: Resident requires enhanced barrier precautions; -Goal: Resident will receive care from staff using EBP while maintaining a homelike environment, and will remain free from infections through next review; -Approaches: Enhanced barrier precautions will be utilized while providing direct care. (ex. wound dressing changes, showers/bathing, transfers, hygiene, linen changes, toileting assistance, during therapy, device care). Staff will don gown and gloves prior to entering room to perform care. EBP to be removed prior to leaving room. Review of the resident's June 2025 electronic Physician's Order Sheet (ePOS), showed: -An order for indwelling urinary catheter, assess and monitor and empty each shift; -An order to cleanse wound with wound cleanser and apply Medi honey (an ointment to aid in the healing of wounds) to wound bed daily and as needed; -No physician order for EBP. Observation on 6/4/25 at 10:37 A.M., showed an EBP sign on or by the resident's door. No PPE cart or equipment was visibly available for staff to use. Certified Nurse Aide (CNA) C was in the resident's room with CNA D, providing morning care to the resident. CNA C emptied the resident's catheter bag and provided perineal (cleaning of the groin and buttocks) care. CNA D assisted the resident with getting dressed. Both staff used a mechanical lift to transfer the resident from his/her bed to a wheelchair. Both staff wore gloves but neither staff wore a gown. During an interview on 6/4/25 at 10:30 A.M., CNA C and CNA D said they should have been wearing gowns while providing care to Resident #1. The facility did not provide additional PPE for residents on EBP. 2. Review of Resident #2's admission MDS, dated [DATE], showed: -Cognitively intact; -Has indwelling catheter; -Colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall for the elimination of feces); -Risk of pressure ulcers; -Three Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers, present on admission. Review of the resident's June 2025 ePOS, showed: -Dakin's Solution (sodium hypochlorite) solution; 0.125 %; (topical antiseptic used to treat and prevent infections from wounds); -Clean left gluteal (buttocks) region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily; -Clean right gluteal region with wound cleaner or normal saline. Lightly pack with Dakin's; -Clean gluteal cleft region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily; -Clean left ischium (lower portion of the hip bone) region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily; -Clean right ischium region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily; -Clean coccyx (tailbone) region with wound cleaner or normal saline. Lightly pack with Dakin's moistened gauze. Apply dry dressing and secure with tape. Change daily. -Indwelling Catheter: -Empty catheter bag every shift. Monitor for hematuria (blood in the urine), changes in color, consistency and odor every shift. Notify physician of changes; -Provide catheter care every shift; -Shower twice weekly on Wednesday and Saturday evening; -No physician order for EBP. Review of the resident's care plan dated 3/17/25, showed staff did not address the need for EBP. Observation and interview on 6/4/25 at 7:32 AM, showed Registered Nurse (RN) A and RN B entered the resident's room. There was no EBP signage on the door or wall adjacent to the resident's room. There was no visible PPE cart or PPE supplies observed. RN A assisted RN B in providing wound treatments to the resident. Both staff wore gloves but no gowns. RN A touched and moved the indwelling catheter when repositioning the resident. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Dependent on staff for positioning, transfers, toileting hygiene, and showers/baths; -Indwelling urinary catheter; -Colostomy; -One Stage IV pressure ulcer present on admission; -Wound infection; -Intravenously (IV, administered into a vein) medications while a resident. Review of the resident's care plan, dated 4/25/25, showed: -Problem: Resident requires Enhanced Barrier Precautions related to wounds and use of Foley catheter; -Goal: Resident will receive care from staff using EBP while maintaining a homelike environment; -Approach: Staff do not need to use EBP if they are not engaging in high contact resident care: giving medication, conversing with resident, answering call light. Staff to use EBP while providing the following care: Wound dressing changes, showers/bathing, transfers, providing hygiene, changing of linens, toileting assistance/changing of briefs, providing therapies, device care or use, receiving therapies. Staff will don gown and gloves prior to entering room to perform care. EBP to be removed prior to leaving room. Staff will wash hands or use hand sanitizer prior to entering room and when leaving room. Review of the resident's June 2025 ePOS, showed: -#20 French (size of catheter tubing) Foley catheter with 10 millimeters (ml) balloon, monthly using sterile technique once on Wednesday every four weeks; -Dakins Solution: Clean wound to right buttock with wound cleaner. Pack with moistened Dakins dressing and then dry dressing packed on top. Cover with bordered dressing and secure with tape. Change daily. -Enhanced Barrier Precautions: Special Instructions: EBP for wounds, ostomy and catheter. Observation on 6/4/25 at 7:05 AM, showed RN A and RN B entered the resident's room. There was EBP signage on the door or wall adjacent to the resident's room. There was no visible PPE cart or PPE supplies observed. RN A assisted RN B in providing wound treatments to the resident. Both staff wore gloves but no gowns. RN A touched and moved the indwelling catheter when repositioning the resident. 4. Review of Resident #5's care plan dated 5/19/25, showed staff did not address the resident's pressure ulcer or the need for EBP. Review of the resident's 5-day MDS, dated [DATE], showed: -Moderately impaired cognition; -Recent fracture; -Risk of pressure ulcers; -Antibiotics provided. Review of the resident's June 2025 ePOS, showed: -Left heel: Clean with wound cleaner, apply betadine (a topical antiseptic), wrap with gauze or apply border gauze. Change daily and as needed; -No orders for EBP. Observation and interview on 6/4/25 at 7:32 AM, showed RN A and RN B entered the resident's room. There was EBP signage on the door or wall adjacent to the resident's room. There was no visible PPE cart or PPE supplies. RN A assisted RN B in providing wound treatments to the resident. Both staff wore gloves but no gowns. RN A touched and moved the indwelling catheter when repositioning the resident. 5. During an interview on 6/4/25 at 8:30 A.M., RN A and RN B said they should have been wearing gowns while providing wound care. The facility did not supply enough PPE carts and supplies for residents requiring EBP. 6. During an interview on 6/4/25 at 2:51 P.M., the Assistant Director of Nursing (ADON) said there should be EBP signs on the resident doors who had wounds, open areas and catheters. Staff should wear PPE when providing care to residents on EBP. Staff did not need to wear PPE if they would not be in close contact with residents or would not be in the room more than 15 minutes. She expected staff to wear PPE appropriately. There should be an EBP sign on the doors and PPE equipment available for each room. At this time, the facility did not have enough PPE carts and/or PPE supplies. 7. During an interview on 6/4/25 at 2:59 P.M., the Regional Nurse Manager said she expected staff to wear PPE while providing care to residents on EBP. EBP signs should be posted on or near the resident's room. There should always be enough PPE to meet the needs of the residents requiring EBP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to treat four of 26 sample residents (R) 14, R27, R171, and R220) with dignity and respect by failing to assist R171 with clean socks, to assist R220 to obtain clothing to wear instead of the hospital gown, and staff standing while assisting two (R27 and R14) residents to eat their meal. These failures created an undignified manor of care for the four residents. Findings include: 1. Review of R171's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R171 was admitted [DATE] with diagnoses of dementia, schizoaffective disorder, bipolar disorder, borderline personality disorder, generalized anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R171 was severely cognitively impaired. On 11/11/24 at 11:30 AM, R171 was observed wearing yellow non-skid socks and no shoes. The socks were black, with dirt, from the toes to the arch of his foot. The resident propelled himself in his wheelchair using his feet. On 11/12/24 at 09:45 AM, R171 was observed wearing yellow non-skid socks which were black from the toes to the arch of the foot all around the sock. During an interview on 11/12/24 at 1:07 PM, R171 acknowledged that his socks were dirty. When asked if he had a clean pair, R171 stated, You have to ask the nurse. The resident did not know if he had asked for a clean pair. On 11/13/24 at 8:21 AM and 11/14/24 at 10:20AM, R171 was observed wearing yellow non-skid socks that remained black all around from the toes to the arch of his foot. During an interview on 11/14/24 at 1:30 PM, the certified nursing assistant (CNA15) stated I know I gave him a pair, I don't know what he did with them. When CNA15 was asked if staff assist the resident to change soiled socks, CNA15 did not answer. During an interview with the Administrator on 11/14/24 at 10:20 AM, she stated, R171 should have a clean pair of socks. 2. During the initial screening of R220 on 11/11/24 at 10:42 AM, she stated she did not have any clothes to wear and had been wearing a hospital gown since her admission to the facility. When asked if she had notified a staff member that she needed clothes, she said I didn't know who to ask but they can see I do not have any clothes. She said she did not have family members that could bring clothes for her to the nursing facility and that it was her choice to have clothes to wear instead of a hospital gown. With the permission of R220, inside of her closet were two items, a blue pair of shorts and a black t-shirt. The storage drawers were empty. Review of R220's electronic medical record (EMR), profile tab, face sheet revealed R220 was admitted [DATE] with diagnoses acute kidney failure, generalized muscle weakness, and obesity. Review of R220's EMR admission MDS with an ARD of 09/17/24 revealed a BIMS score of 14 of 15, which indicated R220 was cognitively intake. During an interview with CNA3 and Licensed Practical Nurse (LPN)2 on 11/13/24 at 11:32 AM, both stated they had not noticed R220 needed clothing. During an interview with the Administrator on 11/13/24 at 2:36 PM, she stated that she did not know of a resident in the facility that needed clothing and that the nursing staff would let her know. She stated the facility has an orphan room where discarded clothes are kept. She said if the discarded clothes would not fit a resident, then new clothes are purchased for the resident. She said she was not notified that R220 had no clothing since her admission two months ago. During an interview on 11/14/24 at 2:55 PM, the Administrator stated her expectation was for staff to notify her of residents in need of clothing and that it was unacceptable for a resident to stay in a hospital gown unless it is the choice of the resident. 3. Review of the R27's admission MDS with an ARD of 10/04/24 under the MDS tab of the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses of Non-Alzheimer's Dementia, and Macular Degeneration. The MDS indicated a BIMS score of 10 out of 15 indicating R27 was moderately cognitively impaired. Review of the R14's Significant Change MDS with an ARD of 08/26/24 under the MDS tab of the EMR revealed the resident was admitted to the facility on [DATE] and diagnoses of dysphagia and unspecified intellectual disabilities. The MDS indicated a BIMS score of three out of 15, indicating R14 was severely cognitively impaired. During an observation of meal service on 11/11/24 at 12:40PM to 12:45PM, CNA19 stood while feeding R27 his lunch meal. During an observation of meal service on 11/11/24 at 12:45 to 12:50 PM, CNA19 stood over R14 while feeding his lunch meal. During an interview on 11/11/24 at 01:15 AM, CNA19 stated that we are supposed to get a chair and sit when we assist a resident with their meal. During an interview on 11/11/24 at 01:15 AM, CNA15 stated I always stand, it's easier for me. During an interview on 11/11/24 at 01:45 AM, the Director of Nursing (DON) stated that staff should always sit and make eye contact with residents while assisting them with meals. They should never stand over them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide an alternative communication device for one resident (Resident (R) 35) of 26 sampled residents which failed to allow R35, who is non-verbal, a means to express himself. Findings include: Review of R35's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnoses of cerebral palsy, generalized anxiety disorder, mood disorder, conversion disorder with seizures or convulsions, dysphagia, and multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) located in the EMR under the RAI tab, with an assessment reference date (ARD) of 09/17/24 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R35 was not able to answer the questions. R35 was identified to be non-verbal. Review of the Care Plan located under the RAI tab in the EMR dated 09/13/24 did not identify how the resident would communicate his wants or needs. During an interview on 11/12/24 at 4:02 PM, the Administrator stated, He understands, he knows what you're saying, he can communicate. When asked if R35 had ever had a communication board or communication device, the Administrator stated, no. When asked, the Administrator stated, Well, he knows what you say. A communication board would be a good idea. During an interview on 11/14/24 at 10:11 AM, a certified nursing assistant (CNA19), who has worked with R35 since his admission to the facility, confirmed the resident does not have a communication board or device. On 11/14/24 at 02:17 PM, R35 was asked to answer a question using a thumbs up for yes or a thumbs down for no, or to shake his head up and down for yes or shake his head side to side for no. R35 was asked if he had ever had a communication board or a communication device to be able to communicate with staff and others. R35 shook his head back and forth in a no gesture. R35 was asked if a communication board or device would be helpful to him to communicate, R35 shook his head up and down in a yes gesture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide needed care in accordance with the resident's preferences for one of one resident (Resident (R)220) in the sample of 26 resident reviewed for skin care This failure had the potential to affect the physical, mental, and psychosocial health and well-being of the resident. Findings include: Review of R220's electronic medical record (EMR)Face sheet under the profile tab revealed R220 was admitted [DATE] with diagnosis acute kidney failure, generalized muscle weakness, and obesity. Review of R220's admission Minimum Data Set (MDS) in the EMR under the MDS tab with an assessment reference date (ARD) of 09/17/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R220 was cognitively Intact. Observation on 11/11/24 at 10:42 AM, revealed R220's feet and legs that appeared to be extremely dry with flaking skin onto the bedsheets. Interview with R220 at this time, she stated she would like to have something done for her feet and legs. She said she thought she had a prescription for some ointment, but no one ever puts it on her feet and legs. During subsequent observations of R220's feet and legs, on 11/12/24 at 11:00 AM and 11/13/24 at 2:45 PM, her feet and legs appeared to be extremely dry and scaling with dry skin flaking on the bedsheet. Review of the EMR Physician orders dated 11/13/24 indicated an order for white petrolatum gel be applied topically to bilateral feet and legs daily for 2 weeks. During an interview with Certified Nursing Assistant (CNA)3 and Licensed Practical Nurse (LPN)2 on 11/13/24 at 11:32 AM, LPN2 said R220 had been prescribed a cream to treat her dry feet and legs but said it had not been done on her current shift and did not know why the cream had not been used. CNA3 said she did not have the task on her daily assignment sheet to apply the cream to R220's legs and feet. During an interview on 11/14/24 at 2:55 PM, with the Director of Nursing (DON) and the Administrator, the DON stated her expectation of the nursing staff was to be more attentive to R220's dry scaling skin and to apply the special ointment as prescribed.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of three errors occurred out of 30 opportunities for error due to residents not receiving their medications on time for one resident (Residents (R)11) of six residents observed for medication administration. In addition, one of six residents (R41) received a medication that did not have a physician's order. The facility medication error rate was 6.67%. This failure had the potential to affect the accurate dosing of medication administered to the residents. Findings include: 1. During medication administration observation on 11/13/24 at 8:37AM, Licensed Practical Nurse (LPN)1, administered R1 Daily-Vite with folic acid tablet (MVI) one tablet. Review of R41's Physician Orders dated November 2024 in the electronic medical record (EMR) under the Orders tab indicated there was not a physician's order for the Daily Vite with folic acid medication. 2. During medication administration observation on 11/13/24 at 9:55AM, Certified Medical Technician(CMT) 2 administered R11's Buspar 15 milligram (mg) 1 tablet that was ordered for 7:30AM. Review of R11's Physician Orders in the EMR under the Orders tab revealed, Buspirone 15 milligram (mg) one tablet twice a day. Review of R11's Medication Administration Record (MAR) dated November 2024 indicated Buspirone 15 mg one tablet was to be administered at 7:30AM and 4:00PM. Interview on 11/14/24 at 1:00PM, LPN1 was asked what the parameters of time for medication administration was. LPN1 said one hour before to one hour after was acceptable. LPN1 said it would be a medication error if the medication was given outside of this parameter. LPN1 stated regarding the multi vitamin and the folic acid, LPN1 stated that the medication should not be given if it is not ordered. Interview on 11/14/24 at 1:15PM, CMT2 was asked what the parameters of time for medication administration are. CMT2 said one hour to one hour after was acceptable. Interview on 11/14/24 at 2:15PM, the Director of Nursing(DON) was asked what the parameters of time for medication administration are. The DON said one hour to one hour after was acceptable. The DON said medication administered outside of these parameters would be a medication error. When asked if a medication should be given if there isn't a physician order, the DON said, Absolutely not.

Based on observations, and interviews, the facility failed to ensure that the food residents received was at an appetizing temperature for one of three meals on one of four survey days. The deficient practice has the potential to affect all 69 residents who receive food from dietary. Findings include: Observation of food temperatures on the steam tabled revealed the regular diet pot roast was 174 Fahrenheit (F), the scalloped potatoes were 202 degrees F and the winter vegetables were 175 degrees F. The cart left the kitchen at 12:40 PM and arrived at the first floor at 12:42 PM. Lunch was scheduled to be served at 12:00 PM. Observation on 11/13/24 at 1:10PM of the test tray temperatures on the first floor kitchenette revealed using a facility thermometer pot roast 106 F. The pot roast tasted cool. Interview with the Dietary Manager (DM) at the time, he stated that the pot roast tasted cold to him. Interview with R11 at 1:15 PM on 11/13/24, after she had finished her meal, she stated the pot roast tasted cold. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 09/24/24 Interview with the DM on 11/13/24 at 1:20 PM stated there are no food temperature logs on the unit prior to the food service nor food temperature logs in the kitchen prior to the food leaving the kitchen and being transported to each of the two units. Interview with the Registered Dietician (RD) on 11/14/24 at 10:50 AM, she indicated the expectation is that food temperatures should be taken prior to the food leaving the kitchen and prior to service and a log of such events should be maintained. The facility policy was requested of the DM; however, no policy was provided prior to the survey team exiting the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three residents who expired and had money in their accounts (Residents #104, #107 and #106). In addition, the facility failed to provide notification when the resident's trust account reached $200 less than the Supplemental Security Income (SSI) resource for four residents (Resident #7, #101, #102, #105). The facility held funds for 51 residents. The census was 74. Review of the facility Resident's Rights Policy, undated, showed the following: -Notice of certain balances: The facility must notify each resident that received Medicaid benefits: -When the amount in the resident's account reaches $200 less than the SSI resource limit for one person; -That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI -Conveyance upon discharge, eviction, or death. Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. 1. Review of Resident #104's medical record, showed the following: -Expired on [DATE]; -Ending balance of $4771.87; -No TPL was completed. 2. Review of Resident #107's medical record, showed the following: -Expired on [DATE]; -Ending balance of $5833.00; -No TPL was completed. 3. Review of Resident #106's medical record, showed the following: -Expired on [DATE]; -Ending balance of $610.61 4. Review of the facility Resident Trust Fund Statements, dated [DATE] through [DATE], Statement dated [DATE], showed the following: -Resident #7, [DATE], ending balance $6407.28; -No documentation of Medicaid Resident Fund Notification. -Resident #101, [DATE], ending balance $6196.57; -No documentation of Medicaid Resident Fund Notification. -Resident #102, [DATE], ending balance $6576.08; -No documentation of Medicaid Resident Fund Notification. -Resident #105, [DATE], ending balance $10,357.35; -No documentation of Medicaid Resident Fund Notification. 5. During an interview on [DATE] at 12:14 P.M., the Administrator said TPL and Resident Fund notifications have not been completed. The Administrator said she was just learning these needed to be completed. The Administrator said the Business Office Manager (BOM) is responsible for these tasks, but he/she has only been here since [DATE]. The BOM is still working on various tasks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to maintain a clean, comfortable, and homelike environment for one of two floors, (the secured second floor) affecting the 30 residents of the second floor. Specifically, the facility failed to maintain an environment free of food splatters on the walls, missing ceiling tiles, functioning door handles, holes in bedroom walls, holes in bathroom walls, unclean surfaces of tables, bathroom tiles, and clean equipment for the ice container creating an unpleasant environment for the residents. Findings include: During an initial tour of the second floor secured unit on 11/11/24 from 10:45 AM to 12:45 PM, the following concerns were observed and discussed with the Administrator, Maintenance Director (MD), and the Housekeeping Supervisor on 11/14/24 beginning at 09:49 AM. The dining room: The four of four tables were marred, scarred, had peeling purple paint, and had uncleanable surfaces. The walls had spills that had run down and were dried. The ice chest was dirty on the outside. The ice chest cart had a heavy buildup of dirt, grime, and food spills. The ice scoop was placed next to the ice chest uncovered. The window tracks had a black substance in the tracks. The planter on top of a half wall had food particles and debris inside. The half wall was marred, dirty, and had dried drips down the side. Interview with certified nursing assistant (CNA15) who worked on the second floor secured unit stated, it's always been like this, the tables especially. room [ROOM NUMBER]: The window blinds were broken. There was a missing drawer in the wardrobe. There was no handle on the bathroom door. The inside of the handle mechanism was exposed and observed with dirt and brown matter on the metal. The bathroom could not be accessed from room [ROOM NUMBER]. room [ROOM NUMBER]: There was no privacy curtain for bed A. The bathroom door was marred. There was wall damage behind the toilet and sink. The bathroom tiles had been painted and appeared to be dripping. The wall tiles had not been cleaned of the damaged paint. room [ROOM NUMBER]: There was a gap around the air conditioning unit under the window. The gap allowed one to see outside which would allow for cold or hot air and pests/bugs to enter the room. There was wall damage in the bathroom. The drawer that was observed on 11/11/24 was pulled out. The latex glove stuck in a large circle of dried brown liquid remained in the drawer. The tiles in the bathroom had been painted, appeared to be dripping, and had not been cleaned. room [ROOM NUMBER]: The metal vent fan, located directly above the toilet, was falling out of the ceiling. Approximately five inches of the metal fan was exposed. The were ceiling tiles missing around the vent. The bathroom tiles had been painted, appeared to be dripping, and had not been cleaned. There was wall damage by the dresser and behind the headboard of the bed. room [ROOM NUMBER]: There was wall damage in the bathroom which measured 12 inches across by 3 feet high exposing the wall supports and pipes. The bathroom door was stuck, very difficult to open. There were ceiling tiles missing in the bathroom. room [ROOM NUMBER]: There was a heavy layer of dust and dirt on air conditioning unit, the windowsill and towel dispenser in the bathroom. The resident stated, they don't clean my room. room [ROOM NUMBER]: There were no bedside tables for either resident in the room. Bed A had 1/2 cup of juice on the floor next to the bed and a cup of water on the floor. There was damage behind the headboards of bed A and bed B which measured 12 inches across. room [ROOM NUMBER]: There were pieces of floor tiles missing around the front of the toilet. There was wall damage on the corner of the wall under the window, approximately two by three inches. The face of the air conditioning unit was coming off. CLEAN LINEN ROOM: There was no doorknob on the door. A hole was where the doorknob should have been. There were ceiling tiles missing, approximately 6 feet by 3 feet which exposed the duct work, wires, and pipes. The MD said he was unaware of the concern. room [ROOM NUMBER]: There were two missing ceiling tiles. room [ROOM NUMBER]: There was a large, two feet by one foot ceiling tile missing above the wardrobe which exposed the duct work. The window blinds were broken. There was wall damage near the bed, approximately six inches in length. The light above the bed flickered continuously. There was a 4 foot by 2 foot area of drywall that had been patched. The bottom section approximately 2 feet across was not patches and which exposed wires. Pieces of floor tiles in the bathroom were broken and missing. room [ROOM NUMBER]: There was wall damage in the bathroom between the sink and the toilet, approximately two feet by one foot. room [ROOM NUMBER]: There was wall damage in the room behind the bed, approximately twelve inches in length. There were two ceiling tiles missing in the bathroom. There were brown stains around the base of the toilet. Pieces of floor tiles were missing in the bathroom around the toilet. room [ROOM NUMBER]: The door handle into the room was difficult to use as it went around too far before unlatching the door. There was an approximate 6 inch hole in the wall behind the door. The air conditioning unit cover was coming off. The wall tiles in the bathroom had been painted, appeared to be dripping, and had not been cleaned. room [ROOM NUMBER]: There were three ceiling tiles missing in the bedroom. The air conditioning unit cover was coming off. room [ROOM NUMBER]: The room was not occupied. There was a pillow, without a pillowcase, which had brown matter all across the pillow. The pillow was on top of an unmade bed. The floor was dirty. The bathroom door was scarred and chipped. The bathroom wall had an approximate 3 ½ feet hole in the wall which exposed pipes and rubble. A 9 inch by 12 inch area of wall also exposed pipes. room [ROOM NUMBER]: The room was unoccupied. The window blinds were broken. There were broken ceiling tiles. There were holes in the wall behind the beds. The painted tiles, around the sink down to the floor, in the bathroom were peeling and not clean. During an interview on 11/14/24 at 10:59 AM, the Administrator said she was unaware of the conditions identified on the tour. The MD said he was unaware of the conditions identified. When asked what type of communication system was in place for staff to alert the MD of needed repairs, he said he did not have a system in place. The Administrator said the windows had already been identified that they need cleaning and fix. The Administrator was asked to show the plan including what was involved, how it was to be accomplished, and the time frame for correcting the concern. The Administrator provided no documentation prior to the exit on 11/14/24 at 7:00 PM. MO00244495

Based on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for seven staff members. A sample of 10 employees hired were reviewed. The facility hired at least 100 new employees since the last survey. The census was 74. Review of the facility's Abuse Prevention Program, dated 9/29/22, showed the following: -Procedures for Prevention -Pre-employment Screening of Potential Employees: This facility will not knowingly employ any individual convicted of resident abuse, neglect, or misappropriation of property. The facility will not knowingly employ any direct care staff convicted of any of the crimes listed in the State Healthcare Worker Background Check Act (unless waivered under the provision of the Act), or with findings of abuse listed on the State CNA Registry. The facility will not knowingly employ any licensed staff that have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Prior to a new employee starting a working schedule, this facility will: a. Initiate a reference check from previous employers in accordance with facility policy; b. Obtain a copy of the state license of any individual being hired for a position requiring professional license; c. Check the Missouri CNA Registry on any individual being hired for prior to reports of abuse, previous fingerprint check results, and the sex offender website links on the registry. 1. Review of Housekeeper (Hsk) A's employee file, showed the following: -Hire date: 10/1/22; -No CNA registry check performed. 2. Review of Activity Director B's employee file, showed the following: -Hire date: 7/18/23; -No CNA registry check performed. 3. Review of Hsk C's employee file, showed the following: -Hire date: 4/29/24; -No CNA registry check performed. 4. Review of Hsk D's employee file, showed the following: -Hire date: 7/17/24; -No CNA registry check performed. 5. Review of Dietary Aide (DA) E's employee file, showed the following: -Hire date: 8/25/24; -No CNA registry check performed. 6. Review of Maintenance Director F's employee file, showed the following: -Hire date: 9/12/24; -No CNA registry check performed. 7. Review of Medical Record G's employee file, showed the following: -Hire date: 10/9/24; -No CNA registry check performed. 8. During an interview on 11/20/24 at 1:11 P.M., the Administrator said the Business Office Manager (BOM), who is also in charge of Human Resources (HR), should have been checking the CNA registry. The administrator said she spoke with the BOM/HR and he/she said he/she was never trained to check the CNA registry for non nursing staff. The BOM/HR person is out sick.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that diets provided were prepared and distributed as prescribed by the residents' physician for seven residents (R12, R43, R35, R171, R50, R4 and R26 ) out of 26 residents in the sample. The deficient practice has the potential for residents to lose weight. Findings include: 1. Review of R12's Face sheet in the electronic medical record (EMR) under the profile tab revealed diagnoses of Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, cerebral infarction, type 2 diabetes without complications, abnormal weight loss and pressure ulcer, sacral region stage 2. Review of R12's physician orders in the EMR under the orders tab revealed an order for a pureed diet, power potatoes for lunch, cheesy eggs for breakfast, ice cream for snacks, health shakes at each meal, whole milk at breakfast and apple or cranberry juice for lunch and dinner. Observations on 11/11/24 at 12:30 PM; 11/12/24 at 8:30 AM; 11/12/24 at 12:45 PM and on 11/13/24 at 12:35 PM revealed the resident failed to receive a diet as prescribed by the physician which included power potatoes for lunch on 11/11/24, 11/12/24 and 11/13/24; cheesy eggs on 11/12/24 and health shakes on 11/11/24 and 11/12/24. Interview with the Dietary Manager (DM) on 11/13/24 at 1:30 PM revealed he did not prepare or serve cheesy eggs or power potatoes all week starting 11/11/24 through 11/13/24; health shakes on 11/11/24 and on 11/12/24. 2. Review of R43's EMR revealed under the profile tab diagnoses of traumatic subdural hematoma without loss of consciousness, dementia, mood disturbance, psychotic disturbance, Parkinsonism, post-traumatic stress disorder, anxiety disorder, depression, anxiety disorder and anorexia. Review of R43's physician orders under the orders: tab in the EMR revealed regular diet and health shakes three times a day or with each meal. Observations on 11/11/24 at 12:30 PM and 11/12/24 at breakfast at 8:30 AM revealed that R43 did not receive health shakes. The facility did not order the health shakes from the supplier until the problem was pointed to the facility at lunch on 11/12/24. Interview with the DM on 11/13/24 at 1:30 PM revealed he did not prepare health shakes for 11/11/24, 11/12/24, and 11/13/24. Interview with the Registered Dietician (RD) on 11/14/24 at 10:50 AM, the RD stated that all diets should be followed as prescribed by the physician. She was not aware that power potatoes, cheesy eggs and health shakes were not being provided. 3. Review of R35's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnoses that included cerebral palsy, generalized anxiety disorder, mood disorder, conversion disorder with seizures or convulsions, dysphagia, and multiple sclerosis. Review of the Physician orders located under the orders tab in the EMR revealed and order dated 06/12/24 for regular diet, mechanical soft. Special Instructions: finger foods, health shake for breakfast only, provide large portions at meals. 4. Review of R171's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnoses that included dementia, schizoaffective disorder, bipolar disorder, borderline personality disorder, major depressive disorder, generalized anxiety disorder, and unspecified severe protein-calorie malnutrition. Review of the 10/30/24 Physician orders located under the orders tab in the EMR revealed Regular diet, health shakes with meals. Special instructions: large portions for breakfast with cheesy eggs, power potatoes for lunch. 5. Review of R50's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE] with diagnoses that included Alzheimer's disease, schizophrenia, depression, and generalized anxiety disorder. Review of the Physician Orders dated 09/12/24 located in the EMR under the orders tab revealed Regular diet. Health Shakes with each meal TID [three times a day]. 6. Observations of the residents' meals during the survey from 11/11/24 - 11/14/24 revealed the following: No health shakes were provided to R35, R71 and R50 for breakfast, lunch, or dinner on 11/11/24, 11/12/24, and 11/13/24. Interview on 11/13/24 at 1:30PM, the DM confirmed that health shakes were not prepared for any of the residents' meals. No power potatoes were provided for R171 on 11/11/24 and 11/12/24 when potatoes were served. Interview with the Dietary Manager (DM) on 11/13/24 at 1:30 PM revealed he did not prepare or serve power potatoes all week starting 11/11/24 through 11/13/24. 7. Review of R4's EMR profile tab Face sheet revealed R4 was last admitted [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis, type 2 diabetes, iron deficiency anemia, and abnormal weight loss. Review of R4's EMR, physician orders under the orders tab revealed a diet order dated 04/22/24 for a regular diet with a Nepro shakes added to all three meals, potatoes three times each week, and large protein portions for all meals. Lunch observations on 11/11/24, 11/12/24 and 11/13/24, and breakfast observations on 11/13/24, R4 did not receive health shake. or large portions of protein for all meals. 8. Review of R26's EMR profile Face sheet revealed R26 was admitted [DATE] with diagnoses of abnormal weight loss, Vitamin D deficiency, hypertensive heat disease, anemia, and mild protein-calorie malnutrition Review of R26's EMR physician orders under the orders tab revealed a physician order dated 09/12/24 for a regular diet with a health shake added to all three meals, and with cheesy eggs and super cereal for breakfast and ice cream for lunch and supper. Lunch observations on 11/11/24, 11/12/24 , and 11/13/24, and breakfast observations on 11/13/24, revealed R26 did not receive a health shake or ice cream with any of his lunch meals, and no health shake, cheesy eggs, or super cereal for his breakfast meal. During an interview with the Administrator on 11/13/24 at 11:30 AM, she stated her expectation was for the DM to immediately begin serving special diets as ordered and to learn how to order health shakes as needed. The facility policy was requested from the DM, however, was not provided by the survey team's exit from the facility.

Based on interview and record review, the facility failed to follow their tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) policy when staff failed to complete a two step and the annual one step of the employee TB screening tests in a timely manner for a total of five employees. The census was 74. Review of the facility's Tuberculosis Policy, dated 2005, showed the following; -Tuberculosis (TB) Screening - Employees -It is the policy of this facility that all healthcare workers will undergo testing for tuberculosis upon hire. Initial testing will be completed using the two-step tuberculin skin test (TST) procedure. The first dose being administered within seven days after being employed and the second dose administered one to three weeks after the first test, if the first test is negative. 1. Review of Staff Member A's employee file, showed the following: -Hire date: 10/1/22; -No documentation of an annual one step. 2. Review of Staff Member B's employee file, showed the following: -Hire date: 7/18/23; -No documentation of an annual one step. 3. Review of Staff Member C's employee file, showed the following: -Hire date: 2/22/24; -No documentation of a two step. 4. Review of Staff Member D's employee file, showed the following: -Hire date: 3/7/24; -No documentation of a two step. 5. Review of Staff Member E's employee file, showed the following: -Hire date: 9/12/24; -No documentation of a two step. 6. During an interview on 11/20/24 at 1:17 P.M., the Administrator said after the Director of Nursing (DON) or the Assistant Director of Nursing (ADON), have administered the TB test, the Human Resource Manager (HRM) should follow up to ensure both steps are completed and the documentation is in the employee's file. The administrator said she would expect the TB policy to be followed. The DON and HRM are out sick today.

Based on observations and interviews, the facility failed to use the services of a registered nurse on duty at least eight hours daily. The RN passing medications on dates listed below was also serving as the Director of Nursing while the facility had an average daily occupancy of 68 residents. Findings include: Review of the resident census list provided by the administrator dated 11/12/24 revealed the occupancy was 69 residents in house, on 11/13/24 revealed 69 residents in house and on 11/14/24 revealed 68 residents in house. Observations on 11/12/24 at 10:15 AM, 11/13/24 at 2:30 PM, and 11/14/24 at 09:30 AM, the Director of Nursing (DON) was working as the charge nurse administering medications to residents while working in the capacity of the DON. According to the nurse schedule dated 11/01/24 through 11/14/24, provided by the Administrator, seven of fourteen days did not have RN coverage for eight consecutive hours a day, The following days did not have RN coverage at least eight consecutive hours a day on 11/01/24, 11/05/24. 11/06/24. 11/07/24, 11/08/24, 11/12/24, and 11/13/24. During an interview with the Administrator and the DON, on 11/14/24 at 5:26 PM, the DON stated that she had been working as the DON and as the charge nurse as needed because staffing has been an ongoing issue for several months. The Administrator stated she was not aware that the DON could not serve as the RN on duty while working as the DON.

Based on job description review and interview, the facility failed to ensure that the Dietary Manager (DM) met minimum qualifications when a Registered Dietician (RD) was not employed full time at the facility. The deficient practice has the potential to affect all 69 residents who receive food from dietary. Findings include: Interview with the Dietary Manager (DM) on 11/11/24 at 9:40 AM, revealed he stated that he is not certified as a DM. Interview with the RD on 11/14/24 at 10:50 AM, revealed that she was at the facility eight hours a day one day a month. She stated she was responsible for the clinical aspects of the facility and advised the facility through reports of sanitation and food service. The RD stated that she was aware that the DM was not certified. Interview with the Administrator on 11/12/24 at 11:30 AM revealed she was aware of the lack of training when he accepted the job. We thought we could finish the training prior to the survey. Review of the facility job description titled Job Description-Dietary Manager undated indicated the qualifications for the job on the last page include a certificate for dietary manager as a minimum qualification.

Based on review of menus, policy review, observations and interviews, the facility failed to ensure that menus were followed for all four days of the survey. The deficient practice has the potential to affect all 69 residents that receive food from dietary. Findings include: Observation of the first-floor food service on 11/13/24 at 12:40 PM revealed Dietary Aide (DA) 1 used a three ounces ladle to serve residents winter vegetables from the steam table. The menu/spreadsheet indicated that four ounces of vegetables. In addition, staff had no way to measure double portions of six ounces or single portions of three ounces of pot roast. Interview with DA1 at the time of the observation stated the cards provided do not have portion sizes or menus are not available. She stated that for the meat, I simply use my eyes and serving tongs to decide how much meat is to be provided. Observations of the first-floor food service on 11/13/24 at 12:40 PM revealed that DA1 served all nine mechanical soft diets whole pieces of pot roast, winter vegetables and scalloped potatoes. The menu indicated for these nine diets, mechanical soft to receive chopped meat, vegetables, and potatoes. The steamed winter blend vegetables made up of broccoli and cauliflower and scalloped potatoes were served not chopped. A dinner roll was indicated on the menu to be served to each resident however, no dinner rolls were served to any of the residents. Interview with the Dietary Manager (DM) on 11/13/24 at -11:45 AM, he stated he felt the items were soft enough and did not need to be chopped for that reason and verified he did not serve the dinner rolls at lunch on 11/13/24. The DM was asked for a policy and did not provide the policy prior to the survey team's exit from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, document review, policy review and interview, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards of practice including dishwasher sanitizing, cleaning, food storage and handling and processing food for serving. The deficient practice has the potential to affect all 69 residents receiving food from dietary. Findings include: Observation on 11/11/24 at 9:47 AM revealed the temperature gauge on the dishwasher was stuck at 105 degrees Fahrenheit (F). The dishwasher was a low temperature machine and relies on sanitizer to sanitize the dishes during the final rinse. The machine specifics located on the side of the machine via label indicate for machines using sanitizer solutions to sanitize dishes, wash, rinse and sanitize water shall be minimum 120 degrees F. The facility continued to wash and distribute dishes. Interview with the Dietary Manager (DM) at the time of the observation verified the temperature gauge problems. Observation on 11/11/24 at 9:50 AM revealed two ducted wall air vents near the steamer and window, had a heavy accumulation of dust and dirt to the point of hanging off the vent. In addition, the window at the steamer was severely cracked and damaged over four feet in length with large amounts of dust, and cobweb debris at the inside and outside of the window. One walk-in freezer with the door removed used as permanent storage was found on 11/11/24 at 9:55 AM to have two dirty mopheads on the floor, red tile floor turned black with dirt, used cups, cleaning solutions, gloves, bags and food debris on the floor. Interview with the DM at the time of the observation verified the findings and indicated he does not have a cleaning schedule for the kitchen, or any other area related to food service. On 11/11/24 at 10:05 AM, DA3 was observed loading dirty dishes and unloading clean dishes from the dishwasher without changing gloves. DA1 was observed on 11/12/24 at 9:45 AM to be loading dirty dishes and unloading clean dishes without changing the gloves. In all cases, the dishes were stacked and sent back into circulation at mealtime. Interview with the DM at the time of the dish machine observation, verified the process and stated Observation on 11/13/24 at 9:45AM, the dry storage area and back corridor of the kitchen have red tile floors that were black with dirt and grease. The dry storage area also had black floors with a 25-pound bag of Chinese breadcrumbs and a cardboard box of 192 English muffins on the floor. Observation on 11/13/24 at 9:50 AM revealed the Midea refrigerator with a six-pound container of [NAME] pears opened and uncovered. Interview with the DM at the time of the observation verified the open can was opened yesterday and the floors in the dry storage area have not been cleaned. Observation on 11/13/24 at 10:15 AM the microwave in the kitchen had a large amount of red food splashes inside at the top of the device. In addition, the device had no rotation plate to ensure food was cooked on all sides when microwaved. Interview with the DM at the time of the observation verified the condition of the microwave. Observation of the refrigerator on the first-floor kitchenette used by residents on 11/13/24 at 10:30 AM revealed four-by-four inch styro-foam containers with an unidentified molded food item appearing to be gray and black with fur. No date or label was noted on any container. three compartment styro-foam device contained smoke house fried chicken and mashed potatoes dated 09/23/24 and another container with chicken, mashed potatoes with gravy and green beans dated 11/03/24. In addition, a five-inch birthday cake was found in a bag with icing and a sale by date of 09/14/24. Finally, two mighty shakes were in the same refrigerator with no thaw dates. Interview with the Administrator on 11/13/24 at 10:55 AM verified all the contents. Observation on 11/13/24 from 11:05 AM to 12:45 PM, a large four-pound pre-cooked pot roast still packaged was observed on the counter at room temperature without refrigeration or cooling. Interview with the DM at the time of the observation indicated somebody forgot about the pot roast. Review of the facility' Registered Dietician (RD) report titled Consultant Dietician Report dated 10/16/24 submitted to the facility administration indicated multiple food items were noted to be uncovered and undated in the stainless-steel refrigerator. Walls throughout the facility need good cleaning. Review of the facility's policy titled Food Labeling, Date and Time dated January 2012 revealed the food item shall be labeled with the date and time of preparation. Review of the facility's policy titled Machine Ware Washing dated January 2012 revealed the dish machine washing temperature will be 120 F. and rinse temperature of 75-120 degrees F. No reference was made to sanitize rinsing. The policy also required logging temperatures for purposes of monitoring temperatures. There was no reference in the policy to changing gloves when using the dishwasher and working from dirty to stacking clean dishes.

Based on observations, review of policy and interview, the facility failed to ensure the area around the garbage dumpster area was free of trash on four of four days of the survey. The deficient practice has the potential to affect all 69 residents. Findings include: Observations on 11/11/24 at 10:00 AM revealed the exterior garbage dumpster area had two dumpsters and the area around the dumpster had one college size broken pink refrigerator, numerous plastic gloves, food debris, numerous small and large cups for medicine, numerous fast-food bags, 10 cardboard boxes in various conditions, bottles of over-the-counter medicine, splatters of garbage, paper towels, plastic bags. Observations on 11/12/24 at 8:00 AM, 10:20 AM, 5:00 PM, 11/13/24 at 7:45 AM and 5:00 PM and 11/14/24 at 8:00 AM and 7:00 PM, revealed one of the dumpsters was noted to have the lid open. Interview with the Administrator on 11/12/24 at 10:20 AM revealed that housekeeping and maintenance maintain the area by cleaning it once a week. She stated she has no documentation related to when the area was cleaned. The Administrator provided a policy that indicated that the maintenance department was responsible for ensuring the exterior garbage area was free of trash and the lids were kept closed.

Based on observations and interview, the facility failed to ensure that it maintained essential equipment in working condition. Specifically, the large walk-in refrigerator has been inoperable for over three months. The deficient practice has the potential to affect all 69 residents that receive food from dietary. Findings include: Observation on 11/11/24 at 9:35AM revealed a 15' foot deep by 10' foot wide walk-in refrigerator in dietary that was empty of refrigerated food items. Interview with the Dietary Manager at the time of the observation indicated the large walk-in refrigerator has not worked since July of 2024. Interview with the Administrator on 11/11/24 at 10:20 AM provided an estimate to replace the refrigerator compressor.

See the deficiency cited at Event K4Wl12. Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from significant medication error by not obtaining the resident's prescribed narcotic in a timely manner. The sample size was three. The census 67. Review of the facility's Medication Order Policy, undated, showed: -This facility shall use uniform guidelines for the ordering of medication; -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe; -Each medication order should be documented with the date, time and signature of the person receiving the order; -The order should be recorded on the physician order sheet, and the medication administration record (MAR); -Transcribe newly prescribed medication on the MAR or treatment record. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/13/24, showed: -Severe cognitive impairment; -Diagnoses included heart failure, renal failure, dementia and seizures; -On a scheduled pain medication regimen; -Indicators of pain or possible pain in the last five days, non-verbal sounds, crying, vocal complaints, facial expressions, or body posturing was not observed or documented; -Receiving hospice care while a resident. Review of the resident's care plan, in use at the time of survey, showed: Problem: -The resident is at risk for pain related to osteoarthritis (overuse or injury to the joints); Approach: -Assist with mobility and transfers; -Document and notify the provider of any changes; -Monitor pain characteristics every shift; -Monitor signs of non-verbal pain every shift; -Provide analgesics as ordered and monitor for effectiveness. Review of the resident's physician order sheets (POS), dated, 1/13/24 through 3/13/24, showed: -An order, dated 2/12/24, Hydrocodone-acetaminophen (narcotic pain reliever) 5/325 milligram (mg), give one tablet twice daily, stop date 3/9/24. Review of the resident's MAR, dated 2/1/24 through 2/29/24, showed: -An order, dated, 2/12/24, Hydrocodone-acetaminophen 5/325 mg, give one tablet, twice daily; -Hydrocodone-acetaminophen 5/325 mg was documented as Not administered, drug not available on: -2/13/24 at 9:00 A.M. and 5:00 P.M.; -2/14/24 at 9:00 A.M. and 5:00 P.M.; -2/15/24 at 9:00 A.M. and 5:00 P.M.; -2/16/24 at 9:00 A.M.; -2/17/24 at 9:00 A.M. and 5:00 P.M.; -2/18/24 at 9:00 A.M. and 5:00 P.M.; -2/21/24 at 9:00 A.M. and 5:00 P.M.; -2/22/24 at 5:00 P.M.; -2/23/24 at 9:00 A.M. and 5:00 P.M.; -2/24/24 at 5:00 P.M.; -2/15/24 at 5:00 P.M.; -2/26/24 at 9:00 A.M. and 5:00 P.M.; -2/27/24 at 9:00 A.M. and 5:00 P.M.; -2/28/24 at 5:00 P.M.; -2/29/24 at 9:00 A.M. and 5:00 P.M.; Review of the resident's MAR dated 3/1/24 through 3/13/24, showed: -An order, dated, 2/12/24, Hydrocodone-acetaminophen 5/325 mg, give one tablet twice daily; -Hydrocodone-acetaminophen 5/325 mg was documented as Not administered, drug not available on: -3/1/24 at 9:00 A.M. and 5:00 P.M.; -3/2/24 at 9:00 A.M. and 5:00 P.M.; -3/3/24 at 5:00 P.M.; -3/6/24 at 9:00 A.M. Review of the resident's progress notes dated 2/12/24 through 3/6/24, showed no documentation of communication with the hospice company, physician or pharmacy regarding the resident's Hydrocodone. Observation on 3/13/24 at approximately 9:30 A.M., showed the resident lay in bed with oxygen on and eyes closed. During an interview on 3/13/24 at 10:14 A.M., Licensed Practical Nurse (LPN) A said he/she is aware when the residents are getting near to running out of pain medications. The nurse is responsible to call the physician or make the appropriate appointments. He/She thought there was an emergency supply of narcotics in the Emergency Kit (E-kit) but did not have access and did not know what medications were in the E-kit. He/She was not aware of the Hydrocodone not being available for the resident because the resident had just been recently moved to his/her floor. During on interview on 3/13/24 at approximately 10:30 A.M., Certified Medication Technician (CMT) B said that he/she kept trying to reorder the resident's pain medication by sending an electronic message to the pharmacy. After a week or so, he/she noticed that the resident's Hydrocodone was still unavailable, and that is when he/she brought it to the attention of the Director of Nurses (DON). The resident was not having pain, so he/she wasn't overly concerned that the medication wasn't available. He/She later found out that the resident's pain medication script was sent to the resident's hospice pharmacy and not the facility's regular pharmacy. CMT B said the facility really Dropped the ball about obtaining the resident's pain medications. During an interview on 3/13/24 at 11:59 A.M., the DON said the resident's Hydrocodone was not delivered into the building until 3/6/24. She had taken a verbal order from the hospice nurse on 2/12/24 and thought the hospice nurse was taking care of the script by sending it to the hospice pharmacy. She did not know that the medication was not in the building until the CMT B told her about it. The medication was immediately sent over as soon as she found out that the script was not handled by the hospice nurse. Some nurses do have access to the E-kit and lately it has not been functioning properly. It is unacceptable for staff to document that the medication was not available for such a lengthy time. It is expected that the staff should not allow the resident to miss more than two doses before letting someone in management know or make the pharmacy aware. If staff was communicating with the pharmacy and the physician trying to trouble shoot in obtaining the medications, it is expected to be documented in the resident's progress notes. MO00232962 MO00232898

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from significant medication error by not obtaining the resident's prescribed narcotic in a timely manner. The sample size was three. The census 67. Review of the facility's Medication Order Policy, undated, showed: -This facility shall use uniform guidelines for the ordering of medication; -Medications should be administered only upon the signed order of a person lawfully authorized to prescribe; -Each medication order should be documented with the date, time and signature of the person receiving the order; -The order should be recorded on the physician order sheet, and the medication administration record (MAR); -Transcribe newly prescribed medication on the MAR or treatment record. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/13/24, showed: -Severe cognitive impairment; -Diagnoses included heart failure, renal failure, dementia and seizures; -On a scheduled pain medication regimen; -Indicators of pain or possible pain in the last five days, non-verbal sounds, crying, vocal complaints, facial expressions, or body posturing was not observed or documented; -Receiving hospice care while a resident. Review of the resident's care plan, in use at the time of survey, showed: Problem: -The resident is at risk for pain related to osteoarthritis (overuse or injury to the joints); Approach: -Assist with mobility and transfers; -Document and notify the provider of any changes; -Monitor pain characteristics every shift; -Monitor signs of non-verbal pain every shift; -Provide analgesics as ordered and monitor for effectiveness. Review of the resident's physician order sheets (POS), dated, 1/13/24 through 3/13/24, showed: -An order, dated 2/12/24, Hydrocodone-acetaminophen (narcotic pain reliever) 5/325 milligram (mg), give one tablet twice daily, stop date 3/9/24. Review of the resident's MAR, dated 2/1/24 through 2/29/24, showed: -An order, dated, 2/12/24, Hydrocodone-acetaminophen 5/325 mg, give one tablet, twice daily; -Hydrocodone-acetaminophen 5/325 mg was documented as Not administered, drug not available on: -2/13/24 at 9:00 A.M. and 5:00 P.M.; -2/14/24 at 9:00 A.M. and 5:00 P.M.; -2/15/24 at 9:00 A.M. and 5:00 P.M.; -2/16/24 at 9:00 A.M.; -2/17/24 at 9:00 A.M. and 5:00 P.M.; -2/18/24 at 9:00 A.M. and 5:00 P.M.; -2/21/24 at 9:00 A.M. and 5:00 P.M.; -2/22/24 at 5:00 P.M.; -2/23/24 at 9:00 A.M. and 5:00 P.M.; -2/24/24 at 5:00 P.M.; -2/15/24 at 5:00 P.M.; -2/26/24 at 9:00 A.M. and 5:00 P.M.; -2/27/24 at 9:00 A.M. and 5:00 P.M.; -2/28/24 at 5:00 P.M.; -2/29/24 at 9:00 A.M. and 5:00 P.M.; Review of the resident's MAR dated 3/1/24 through 3/13/24, showed: -An order, dated, 2/12/24, Hydrocodone-acetaminophen 5/325 mg, give one tablet twice daily; -Hydrocodone-acetaminophen 5/325 mg was documented as Not administered, drug not available on: -3/1/24 at 9:00 A.M. and 5:00 P.M.; -3/2/24 at 9:00 A.M. and 5:00 P.M.; -3/3/24 at 5:00 P.M.; -3/6/24 at 9:00 A.M. Review of the resident's progress notes dated 2/12/24 through 3/6/24, showed no documentation of communication with the hospice company, physician or pharmacy regarding the resident's Hydrocodone. Observation on 3/13/24 at approximately 9:30 A.M., showed the resident lay in bed with oxygen on and eyes closed. During an interview on 3/13/24 at 10:14 A.M., Licensed Practical Nurse (LPN) A said he/she is aware when the residents are getting near to running out of pain medications. The nurse is responsible to call the physician or make the appropriate appointments. He/She thought there was an emergency supply of narcotics in the Emergency Kit (E-kit) but did not have access and did not know what medications were in the E-kit. He/She was not aware of the Hydrocodone not being available for the resident because the resident had just been recently moved to his/her floor. During on interview on 3/13/24 at approximately 10:30 A.M., Certified Medication Technician (CMT) B said that he/she kept trying to reorder the resident's pain medication by sending an electronic message to the pharmacy. After a week or so, he/she noticed that the resident's Hydrocodone was still unavailable, and that is when he/she brought it to the attention of the Director of Nurses (DON). The resident was not having pain, so he/she wasn't overly concerned that the medication wasn't available. He/She later found out that the resident's pain medication script was sent to the resident's hospice pharmacy and not the facility's regular pharmacy. CMT B said the facility really Dropped the ball about obtaining the resident's pain medications. During an interview on 3/13/24 at 11:59 A.M., the DON said the resident's Hydrocodone was not delivered into the building until 3/6/24. She had taken a verbal order from the hospice nurse on 2/12/24 and thought the hospice nurse was taking care of the script by sending it to the hospice pharmacy. She did not know that the medication was not in the building until the CMT B told her about it. The medication was immediately sent over as soon as she found out that the script was not handled by the hospice nurse. Some nurses do have access to the E-kit and lately it has not been functioning properly. It is unacceptable for staff to document that the medication was not available for such a lengthy time. It is expected that the staff should not allow the resident to miss more than two doses before letting someone in management know or make the pharmacy aware. If staff was communicating with the pharmacy and the physician trying to trouble shoot in obtaining the medications, it is expected to be documented in the resident's progress notes. MO00232962 MO00232898

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, comfortable, homelike environment by failing address plumbing and roofing issues that led to bulging, brown and rust-colored ceiling tiles in three residents' rooms (Resident #10, Resident #11, and Resident #12) and in the 100 hall shower room, that one resident used daily (Resident #1). The facility also failed to complete timely repairs and improvements to the walls in the main entrance lobby hallway leading to the main elevator. The sample size was 12. The census was 66. Review of the facility's Routine Maintenance policy, revision date, 8/16/22, showed maintenance staff is responsible to ensure that preventative, routine, maintenance is completed in compliance with applicable life safety standards and needs of the facility. Preventive and routine maintenance shall be completed according to the weekly, monthly, quarterly, semi-annual, and annual maintenance round forms. Review of the facility's Resident's Rights policy, revised 8/31/23, showed the resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living; housekeeping and maintenance services necessary to maintain, a sanitary, orderly, and comfortable interior. 1. Review of Resident #10's quarterly minimum data set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/29/23, showed: -Cognitively intact; -Diagnoses included heart disease, diabetes, depression and psychotic (mental) disorder. Observation and interview on 2/7/24 at 10:05 A.M. and at approximately 12:00 P.M., showed in the resident's bathroom, a white ceiling tile bulging with a large brown, rust-colored stain. Above the resident's door leading to the hallway, there was another white ceiling tile with a large brown, rust-colored stain. The resident said he/she was told that the resident above him/her flooded the bathroom and it leaked into his/her ceiling. The resident said the bulging and stained ceiling tiles had been there for a couple of months. He/She had told several staff members over the last couple of months. He/She didn't like the ceiling tiles' appearance and worried that it may be fecal material or mold. He/She thought the pipes were probably old and needed repair. 2. Review of Resident #11's annual MDS, dated [DATE], showed: -Mild cognitive impairment; -Diagnoses included heart failure, wound infection, and diabetes. Observation and interview on 2/7/24 at 11:17 A.M. and at approximately 2:00 P.M., showed in the corner of the resident's room, above his/her bed, a white ceiling tile with a large brown, rust-colored stain. The resident said that the tile had been like that for a several weeks. The resident didn't like it and was worried it was mold. 3. Review of Resident #12's, annual MDS, dated , 10/10/23, showed: -Severe cognitive impairment; -Diagnoses included: Heart failure, diabetes, depression, and schizophrenia (a mental condition that affects the persons perception of reality). Observation and interview on 2/7/24 at 12:09 P.M., showed in the resident's room, above his/her closet and laundry basket, one white ceiling tile with large brown and rust-colored stains and one ceiling tile bent out of place and slightly hanging down. The resident did not know how long the stains had been there, and he/she didn't like it. He/She said it looked a mess. 4. Review of Resident #1's, admission MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's (undated) face sheet, showed diagnoses that included scoliosis (deformity of the spine) and frequent falls. Observation and interview on 2/7/24 at 9:20 A.M., showed in the 100 hall resident shower room, over the toilet, a white ceiling tile with large brown and rust-colored stains. The plastic panel that covered the ceiling light fixtures had brown and rust-colored stains. Resident #1 thought the shower room was disgusting with all the stains on the ceiling tiles and worried that one of the ceiling tiles would fall on someone. He/She used the shower daily. He/She worked in construction for years and knew that could potentially be a plumbing problem that needed to be fixed. It looked like a shower room that a prison would have. 5. Observation and interview on 2/7/24 at 8:05 A.M. and at 9:20 A.M., showed a main hallway on the bottom level that all visitors and residents travel through to exit and enter the facility, reach the main elevator, beauty shop, and physical therapy. The walls had mainly dark blue paint that did not cover the entire wall and large white squares where decorative wall hangings used to be hung. The wall had a clear dried film that flaked off in some areas. The film appeared to be coming from the top of the walls and had a dripping type of pattern. Multiple signs were posted that remodeling was in progress. Resident #1 said the lobby halls have looked like that for a couple of months and it looks like a messy construction zone. 6. During an interview on 2/8/24 at 2:28 P.M., the facility Maintenance Director said that the problem with the ceiling tiles on the first floor is that some of the second floor, cognitively impaired residents overflowed the toilets and sinks. He didn't think the brown stains were mold or fecal material and thought the stains where from the original cast iron plumbing that is rusting. The stains that occurred on the second-floor ceiling tiles were from the roof leaking, and a porous material was used previously to repair the leak. He changes out the ceiling tiles when he is aware that they are damaged. He was hired in August 2023 with plans for him to renovate and to repair the building with contracted help. The planned renovations and repairs included fixing the plumbing and roof. The walls in the main entrance hallway have been like that since he was hired. Plans, blueprints, and proposals have all been submitted to the corporate office and the owners of the facility. He has had meetings with corporate about the renovations and repairs, but he has not been given the approval to move forward. The appearance of the main hallway walls, the stained ceiling tiles and leaking pipes were not a home like environment for the residents. 7. During an interview on 2/8/24 at 4:28 P.M., the Administrator said she would expect the facility to look neat and clean and the residents be provided a safe and homelike environment. She would expect plumbing issues to be addressed, the roof to be repaired and overall general repairs to be made, which included finishing the bottom level hallway. The overall appearance of the main hallway walls had been like that since July 2023 when she was hired. MO00231038 MO00239149

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, staff failed to maintain resident dignity by speaking to and assisting one resident (Resident # 37) during mealtime in a disrespectful manner. Additionally, the facility failed to ensure one resident came to the dining room in clean and odor free clothing (Resident #61) and one resident wore proper undergarments to enhance his/her dignity (Resident #70). The census was 74. Review of the Resident Rights admission Packet, undated, showed: The facility shall care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/23, showed: -The resident is rarely or never understood; -No rejection of care or behaviors; -Required supervision with eating. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Behavioral symptoms; The resident has episodes of refusing and resisting care; -Approach: Redirect resident as needed; Return at a later time when the resident is resisting care; -Focus: Communication; The resident has a communication deficit; -Approach: Adjust tone when speaking to the resident as needed; Allow ample time for the resident to respond; Explain each procedure to resident prior to performance; Anticipate the resident's needs; face resident when speaking; Repeat statements to assure the resident understands; Speak slowly and clearly; Talk to the resident when providing care. Observation on 8/8/23 at 8:10 A.M., showed the resident in the dining room eating dry cereal out of a bowl with his/her hands. No silverware was provided. Physical Therapist (PT) G was standing over the resident, attempting to pry the resident's fingers off of the bowl and saying to the resident you are eating too quickly. Certified Nursing Assistant (CNA) H then came over to the dining room table and sat next to the resident. The resident was provided a second bowl of dry cereal with no milk. The resident continued to eat with his/her hands and lifted the bowl of cereal to his/her mouth. CNA H held the resident's right wrist and pried the resident's fingers off of the bowl. CNA H then said the resident was a real piece of work. During an interview on 8/10/23 at 10:25 A.M., CNA I said residents should not be spoken to in a disrespectful manner. Calling the resident a piece of work was disrespectful. The resident should have been re-approached when he/she refused to release the cereal bowl and staff should not force the resident by prying their fingers. During an interview on 8/10/23 at 12:42 P.M., the Administrator said the resident should never be called a piece of work and staff is expected to treat the residents with dignity and respect. Staff is expected to be gentle and re-approach when resistance from the resident occurs. An alternative method should have been utilized if the resident was not eating safely, such as a small cup. 2. Review of Resident #61's admission MDS, dated [DATE], showed: -Mild cognitive impairment; -Rejection of care occurred one to three days; -Required supervision from staff for dressing and hygiene; -Occasionally incontinent of bowel and bladder; -Diagnosis include psychotic (mental) disorder. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's care needs. Observation on 8/7/23 at 8:20 A.M., showed the resident walked into the second floor dining room using a walker. The resident wore a white t-shirt with an American flag on it. The back of the resident's t-shirt was urine-stained up to the resident's shoulders and a urine odor was present. Multiple residents and staff members were present in the dining room. During an interview on 8/8/23 at 7:15 A.M., the resident said he/she is forgetful and needs reminders about changing his/her clothing. He/She doesn't like and is embarrassed that he/she had on soiled clothing outside of his/her room. During an interview on 8/10/23 at 10:25 A.M., CNA I said the resident requires assistance with changing his/her brief and clothing. The resident should have been redirected to his/her room to get changed. 3. Review of Resident #70's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Required limited assistance with dressing; -Diagnoses of epilepsy, intellectual disabilities and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Review of the resident's care plan, dated 7/10/23, showed the following: -Problem: admitted to long term care (LTC). Requires a baseline care plan identifying care needs, risks, strengths, and goals within the first 48 hours; -Goal: Initial goal is to remain in LTC. Will have access to necessary services to promote adjustment to his/her new living environment and or post discharge from facility; -Approach: Require assist with all activities of daily living. Limited assistance with oral care; limited with bathing; limited, extensive with grooming; supervision with eating; limited with toileting; limited assistance with dressing; independent with mobility. Needs (support, assistance) to have his/her personal care needs met while supporting his/her strengths and personal goals. Observation on 8/7/23 at 11:45 A.M., showed the resident sat in the dining room on the second floor. Multiple residents and staff members were in dining room. The resident wore a white t-shirt made of thin material. His/Her chest was visible through the shirt and no bra was worn. Observation on 8/8/23 at 8:08 A.M., showed the resident walked in the hallway on the way to a meal. The resident wore a clean white t-shirt made of thin material. His/Her chest was visible through the shirt and no bra was worn. During an interview on 8/9/23 at 11:29 A.M., the resident said he/she wants to wear a bra but was told he/she does not have enough money for one. The resident said he/she talked to the Social Worker but the Social Worker must have forgotten. During an interview on 8/10/23 at 10:11 A.M., the Social Worker said she was aware the resident wanted a bra. The Social Worker said the resident spoke with her last Thursday about a bra purchase but that she was unable to purchase the resident a bra due to an absence from work. During an interview on 8/10/23 at 10:41 A.M., the Administrator said the Social Worker or the Activities Director are responsible for buying clothing for residents who are not able to go to the store. She said assuming the Activities Director was aware the resident was in need of a bra, they could have gone to the store in place of the Social Worker. The Administrator expected residents to be covered up and in appropriate clothing. MO00211648 MO00214827

Based on observation, interview and record review, the facility failed to provide reasonable accommodations of individual needs and preferences by failing to ensure Resident #57 had assistive devices while eating. The sample was 18. The census was 74. Review of Resident #57's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/23, showed the following: -Diagnoses of legal blindness, chronic kidney disease and hypertension; Cognition not listed; -Supervision/touch assistance needed when eating. Review of the resident's care plan, dated 2/7/23, showed the following: -Problem: resident is on a mechanical soft diet. He/She has special devices needed during meals: divided plate, dycem (a non slip material used under a resident's plate to avoid plate movement), and food in bowls; -Goal: Resident to follow diet as much as possible x 90 days; -Approach: Diet as ordered: mechanical soft. Resident prefers to eat meals in room/eat meals in dining room Observation on 8/8/23 at 7:53 A.M., showed the resident ate cereal with his/her hands. No staff assisted him/her. Observation on 8/8/23 at 8:20 A.M., showed the resident was given a regular plate with hot breakfast food. No dycem was at the resident's place setting. Observation on 8/8/23 at 8:27 A.M., showed the resident feeling around the space in front of him/her to find the breakfast plate. No staff assisted the resident. The resident did not eat his/her food. Observation on 8/10/23 at 8:20 A.M., showed the resident at the table. The resident's food was on a regular plate. No bowls or dycem were present at the resident's spot. The resident was not eating his/her food. No staff assisted the resident. Observation on 8/10/23 at 12:21 P.M., showed the resident's lunch tray was brought to the resident. The plate was a regular plate. No bowls or dycem were present at the resident's spot. During an interview on 8/10/23 at 12:45 P.M., the Director of Nursing (DON) said she asked the dietary department for a tri-plate for the resident and was told there were not enough plates for all the residents who needed them. The facility needs to order more plates and she expected the resident to be using a dycem, divided plate, and to have staff assistance. During an interview on 8/11/23 at 7:13 A.M. the Dietary Manager said a month ago, the facility had enough tri-plates for all the residents who need them but now they only have two for the entire facility. He ordered more and the plates are on the way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Inaccurate assessments occurred for two of three closed record sampled residents (Residents #73 and #74). The census was 74. 1. Review of Resident #73's discharge Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment, dated [DATE], showed: -The resident discharged [DATE]; -discharged to an acute care hospital. Review of the resident's electronic physician order sheet (ePOS), showed an order dated [DATE], for discharge to a different long term care facility with current medications. Review of the resident's progress notes, showed: -On [DATE] at 1:23 P.M., discharge order and has been accepted to a different long term care facility; -On [DATE] at 6:13 A.M., resident exited building to be transported to new facility. He/She was alert, oriented, able to make needs know; -On [DATE] at 10:39 A.M., nurse called and gave report to Director of Nursing (DON) for resident transferring to the new long term care facility. During an interview on [DATE] at 1:24 P.M., the DON said if the resident was discharged to a different facility she would expect it to be coded correctly in the discharge MDS. 2. Review of Resident #74's Medical Record, showed: -The resident admitted on [DATE] at 2:18 P.M. and was discharged to the hospital on [DATE] at 9:44 A.M.; -Medical Diagnoses included anemia (lack of oxygen-carrying iron in the blood), Alzheimer's Disease, Chronic Kidney Disease (CKD, decreased functioning of the kidneys), and Depression. Review of the resident's discharge MDS, completed on [DATE], showed: -discharged [DATE]; -Expired while residing at the facility. Review of the resident's progress notes, showed: -On [DATE] at 10:17 A.M., the resident had been sent to the hospital due to concerns about the resident's oxygenation status, and was sent out for evaluation at the hospital; -On [DATE] at 9:17 A.M., call from the resident's spouse to inform them the resident had expired at the hospital. During an interview on [DATE] at 1:24 P.M., the DON said if a resident was discharged to the hospital, she would expect the discharge MDS to be coded correctly to reflect that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure care provided met acceptable standards of nursing practice. This included medication administration incongruent with the medical record for one resident and nutritional tube feedings not provided as ordered for one resident (Residents #1 and #55). The facility census was 74. Review of the facility's Monitoring of Medication Administration policy, undated, showed: -To administer all medication safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis; -Read and follow any special instructions written on labels. 1. Review of Resident #1's electronic physician order sheet (ePOS), showed: -An order dated 11/20/17, for Melatonin (natural sleep supplement) 3 milligram (mg). One table per gastrostomy tube (g-tube, a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication) at bed time for sleep; -An order dated 2/07/23, for acetaminophen (Tylenol) 325 mg; 2 tablets by mouth special instructions: Per g-tube every 6 hours as needed for pain/elevated temperature; -An order dated 2/07/23, for Oxcarbazepine (controls seizure) 150 mg Otic (ear). Special instructions: Take ½ tablet (75 mg) per tube twice daily for mood; -An order dated 2/07/23, for gavilax (stool softener) 17 grams/dose oral. Special instructions, mix 1 capful in 8 ounces (oz) liquids and take per g-tube; -An order dated 2/07/23, for Buspirone (relieves anxiety) 10 mg oral. Two tablets per g-tube (20 mg) three times a day; -An order dated 2/07/23, for Liothyronine (regulates hormones) 5 micrograms (mcg) oral. 2 tablets every day (10 mcg) per g-tube; -An order dated 2/07/23, for venlafaxine (controls mood) 75 (mg) oral. Special instructions: One tablet per g-tube daily; -An order dated 3/16/23, for levothyroxine (controls mood) 75 mcg oral, give one tablet per g-tube daily, take on empty stomach at least 1 hour apart from food/drink and other medication; -An order dated 4/28/23, for risperidone (controls mood) 0.5 mg oral. Special instructions: One tablet per g-tube at bedtime. Observation on 8/8/23 at 8:00 A.M., 9:00 A.M., and 10:13 A.M., showed Certified Medicine Technician (CMT) E administered the resident's medications orally. During an Interview on 8/8/23 at 1:52 P.M., the Director of Nursing (DON) said medication should be administered as ordered. The resident takes meds orally but used to take them via g-tube and that should be changed. 2. Review of Resident #55's Medical Record, showed: -The resident was admitted on [DATE] at 2:01 P.M. and resided at the facility; -Medical diagnoses included stroke, abnormal weight loss, atrial fibrillation (an abnormal heart rhythm), tracheostomy (a surgical opening made at the trachea to facilitate breathing), and dysphagia (trouble swallowing food or fluids). Review of the resident's physician orders, showed an order dated 8/2/23 at 4:22 P.M. for Diebetisource (an enteral feeding formula providing extra caloric nutrition to a resident unable to eat by mouth) 60 milliliters (mL) per hour to be given through the resident's gastric tube during each shift with 30 minutes of bowel rest. Review of the resident's Nutritional Status Assessment, dated on 8/8/23 at 12:43 A.M. and completed by Licensed Practical Nurse (LPN) A, showed the resident's weight listed at 210 pounds (lbs.) and the resident's enteral feed, Diebetisource, to be running at 65 mL per hour. Review of the resident's weights while residing at the facility, showed the following measurements: -A weight of 150.6 lbs. on 5/30/23; -A weight of 148.6 lbs. on 6/15/23; -A weight of 146.6 lbs. on 6/30/23; -A weight of 155.2 lbs. on 7/4/23; -A weight of 147.2 lbs. on 7/12/23. Observation of the resident on 8/7/23 at 7:03 A.M., 8/8/23 at 11:03 A.M., and 8/9/23 at 3:07 P.M., showed the resident rested quietly in bed with enteral feed Diabetisource infused at 70 mL per hour. During interview on 8/11/23 at 7:21 A.M. LPN A said the facility's dietician sees residents at the facility every 1-2 months, and communicates orders to the Assistant Director of Nursing (ADON), who then communicates those updated orders to staff. When administering medications or any kind of feeding, staff are expected to review physician orders and administer them per those orders. Staff are expected to administer enteral feeds to residents per physician orders to promote weight gain or combat abnormal weight loss. 3. During interview on 8/11/23 at 9:03 A.M. the facility Administrator and DON said they would expect facility nursing staff to check physician orders prior to administering any medication, and would expect medications to be administered per physician orders. The DON said she would expect facility nursing staff to administer enteral feeds at the correct rate and accurately track resident weights in order to provide adequate nutritional supplementation to residents at risk for weight loss. MO00220430

**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 two residents with weight loss, one of which was significant (Residents #4 and #40). The facility also failed to appropriately monitor meal intake and develop and/or implement resident specific-interventions to address weight loss. The sample was 18. The census was 74. Review of the facility's Nutritional Assessments policy, revised January 2012, showed: -Policy: All residents who experience significant or undesirable weight loss shall be assessed for nutritional status and required intervention by the Registered, Licensed Dietitian (RDLD). A course of action increasing calories shall be implemented unless the weight loss is deemed desirable and necessary for medical status. If increasing calories are required, a request for supplementation shall be made by the RDLD to the physician through nursing. The order shall be for supplementation once daily, twice daily, or three times daily. Residents on supplementation shall be monitored for acceptance of the supplemental calories by Dietary/Nursing. Weights shall be reported to the RDLD for review and assessment; -Purpose: To provide an intervention for weight loss without increasing food volume. To ensure the facility weight control program effectively meets the desired outcome; -Procedure(s): -1. Resident shall be weighed and weights reported monthly to the RDLD. If significant weight loss is identified or low body weight is identified, a request for supplementation for once daily, twice daily, or three times daily shall be made by the consultant dietitian to the physician through the Director or Nursing (DON) or his/her designee; -2. Once the order is approved, the Dietary Manager shall communicate the request to the dietary staff through documentation on the tray card; -3. Dietary shall provide the increased calories according to physician order; -4. Residents shall be thoroughly assessed for progress monthly by the consultant dietician and adjustments to care made according to progress; -5. Residents progress shall be reviewed the with DON and Dietary Manager; -6. All progress shall be documented in the medical record. 1. Review of Resident #4's medical record showed: -Diagnoses included pressure ulcer to the left hip, abnormal weight loss, muscle weakness, depression, heart failure, and cerebral infarction (a blood clot in the brain affecting cognition); -Hospice Services for Cerebral infarction; -The following Care Areas noted on the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/17/23, showed cognitive loss, urinary incontinence, psychosocial well-being, falls, and required extensive assistance with eating. Review of the resident's weights From May 2023 to July 2023, showed: -On 5/3/23, he/she weighed 149 pounds (lbs.); -On 6/30/23 he/she weighed 142 lbs., a 4.6% weight loss; -On 7/14/23 he/she weighed 140 lbs., a 6% weight loss; -No August weights were noted in the record. Review of the resident's care plan, in use for the duration of the survey, showed: -Problem: the resident has heart failure and is at risk for respiratory distress, with a goal of relief from respiratory distress during the review date. Approaches included assessing for chest pain and shortness of breath, keeping the call light within reach, rest periods as needed, and cardiology and Registered Dietitian (RD) evaluations as needed; -Problem: the resident is receiving hospice services related to end stage disease processes, with a goal of relief of pain/symptoms within 30 minutes of the resident reporting it. Approaches included hospice Registered Nurse (RN) visits three times weekly, observe for verbal and nonverbal indicators of pain or discomfort, and reporting any changes to the hospice medical doctor (MD); -Problem: the resident has demonstrated self-isolation due to change in life circumstances, with a goal of increasing resident's social interaction through the review period. Approaches included enrolling the resident with counseling services; -Problem: the resident is at risk for hypo/hyperglycemia (low/high blood sugar due to the body's lack of insulin production) due to status as a diabetic, with a goal of maintaining blood sugar within normal parameters through the review period. Approaches included giving the resident meals as per the diet order, consult with the RD, monitoring accurate food/fluid intake, reporting to the physician when the resident has weight loss, and offering snacks when the resident does not consume his/her meal; -No care plan entry regarding the resident's significant, current weight loss. Review of the resident's progress note, dated 7/13/23 at 4:15 P.M., showed the facility RD documented the resident exhibited a significant weight loss of 10.4% over the last three months and a significant weight loss of 15.6% over the past 6 months. The RD's note included instructions to continue serving the resident health shakes three times daily, but offered no new dietary recommendations. Review of the resident's physician orders, showed a diet order, dated 7/14/23 at 2:10 P.M., for a regular diet with regular consistency liquids, a health shake three times daily with each meal, Super cereal (a fortified, supplemental breakfast cereal with additional calories and carbohydrates) with each breakfast and ice cream with each lunch and dinner. Review of the resident's electronic Medication Administration Record (eMAR) for the month of August up to the end of the survey, showed all supplements given three times daily as ordered. Observation of the lunch meal on 8/8/23 at 12:33 P.M., showed the resident seated at a table in the first floor dining room, he/she received feeding assistance from staff. The resident ate less than 25% of the meal, and showed little interest in eating. The resident was not served a health shake or ice cream with the meal as ordered. The dietary slip showed ice cream with lunch and dinner. Review of the resident's meal intake for 8/8/23 showed 51-75% of the lunch meal consumed. Observation of the lunch meal on 8/9/23 at 12:41 P.M., showed the resident seated at a table in the first floor dining room, he/she received feeding assistance from staff. The resident showed little interest in eating and ate 25% or less of the meal. The resident was not served a health shake or ice cream with the meal as ordered. The dietary slip showed ice cream with lunch and dinner. Review of the resident's meal intake for 8/9/23 showed 51-75% of the lunch meal consumed. Observation of the dinner meal on 8/9/23 at 5:41 P.M., showed the resident resting in bed with the dinner meal placed on his/her side table over the bed. The DON provided assistance to the resident with eating the meal of navy bean soup, a fruit cup, and a tuna sandwich. The resident appeared moderately interested in eating and consumed the entirety of the navy bean soup and fruit cup with staff assistance. The resident was not offered the tuna sandwich during the meal. No health shake or ice cream was given to the resident with this meal as ordered. The dietary slip showed ice cream with lunch and dinner. Review of the resident's meal intake for 8/9/23 showed 76-100% of the dinner meal consumed. Observation of the breakfast meal on 8/10/23 at 8:59 A.M., showed the resident seated at a table in the dining room, he/she received feeding assistance from staff. The meal consisted of sausage, eggs, oatmeal, a piece of toast, and a glass of orange juice. No super cereal was on the resident's tray, the resident was not offered a health shake with the meal as ordered. Staff minimally cued and assisted the resident with eating. Approximately 25% or less of the meal was consumed by the resident. The dietary slip showed super cereal with breakfast. Review of the resident's meal intake for 8/10/23 showed 76-100% of the breakfast meal consumed. Observation of the resident on 8/10/23 at 10:46 A.M., showed Certified Nurse Aide (CNA) L assisted the resident onto the floor's resident weight scale in his/her broda chair (a high-backed, wheeled chair providing extra support and comfort to a dependent resident). After subtracting the total weight of the chair, it was determined the resident's body weight was 135 lbs., indicating a 9.4% weight loss in the last three months. The resident appeared frail. Review of the resident's meal intakes, showed: -8/8/23: 75-100% of the breakfast meal consumed; -8/8/23: 51-75% of the lunch meal consumed; -8/8/23: 76-100% of the dinner meal consumed; -8/9/23: 76-100% of the breakfast meal consumed; -8/9/23: 51-75% of the lunch meal consumed; -8/9/23: 76-100% of the dinner meal consumed; -8/10/23: 76-100% of the breakfast meal consumed; -8/10/23: 1-25% of the lunch meal consumed; -8/10/23: 76-100% of the dinner meal consumed; -8/11/23 76-100% of the breakfast meal consumed; -8/11/23: 76-100% of the lunch meal consumed; -No intake recorded for the dinner meal on 8/11/23. During interview on 8/8/23 at 9:13 A.M., Licensed Practical Nurse (LPN) A said the resident had orders for a mechanical diet, but did not know what supplement orders the physician had ordered for the resident. LPN A said the resident did not look like he/she had lost any weight and was unsure if the resident had any documented weight loss. The resident required frequent cueing at meals as well as some mechanical assistance with eating. During an interview on 8/10/23 at 11:21 A.M., the facility's RD said he/she saw the resident last month, and had recommended health shakes three times daily with meals, with super cereal at breakfast and ice cream with lunch and dinner. The RD expected these recommendations to be followed and was unaware staff were not following these recommendations for the resident's nutritional supplementation. The RD expected to be notified of continued weight loss and was not aware the resident had continued to lose weight. Health shakes at the facility are delivered to the floors in bulk and he/she was told nursing staff hands them out. The RD questioned this practice, as he/she recommended to the facility that dietary staff serve shakes or supplements with meals and supplements on the floors should be labeled to indicate which residents should receive them and when. The RD communicates her recommendations to the Assistant Director of Nursing (ADON). During interview on 8/18/23 at 9:58 SW V, the Social Worker for Physician T's office, said Physician T was not notified of weight loss for either Resident #40 and expected to be notified of unplanned weight loss for any resident under his/her care at the facility. SW V said Physician T was unsure of Physician T's response as to whether Resident #40's weight loss was avoidable. 2. Review of Resident #40's medical record showed: -Diagnoses included hypertension (high blood pressure), hyperlipidemia (high cholesterol), hypokalemia (low potassium), anemia (blood disorder), Multiple Sclerosis (nervous system disease affecting the brain and spinal cord), anxiety, and depression; -No RD assessments; -No documentation of dietary preferences. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -Orders, dated 9/22/22, to monitor and record meal percentages and fluid intake for breakfast, lunch, and dinner; -An order, dated 9/27/22, for health shakes with meals, give 2 health shakes with meals at 8:00 A.M., 12:00 P.M., and 5:00 P.M.; -An order, dated 10/19/22, for regular diet, regular consistency, thin (regular) liquids. Special instructions: super cereal for breakfast, power potatoes (whipped potatoes fortified with extra calories and carbohydrates) for lunch, 2 health shakes with all meals, larger portions of meals. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Rejection of care behavior not exhibited; -Required extensive assistance of two (+) person physical assist for transfers; -Setup help required for eating; -Weight: 166 lbs. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Nutritional status. Resident is at risk for impaired nutrition and hydration related to multiple sclerosis. He/She is on a regular diet; -Goal: Resident will be nutritionally stable as evidenced by no significant weight changes through the next review; -Approaches included: Diet as ordered by provider. Dietary Manager to ask about likes and dislikes. Dietitian to evaluation chart as warranted and recommend nutritional needs to provider. Encourage resident to eat 100% of meals served. Encourage resident to drink fluids. Monitor appetite and record percentage of intake. Nutritional supplements/vitamins as ordered and monitor for side effects. Verbal cueing and/or staff assist to aid in self feeding as warranted. Review of the resident's weights, showed on 5/30/23, he/she weighed 177.2 lbs. Review of the resident's Nurse Practitioner (NP) note, dated 6/14/23, showed chief complaint of follow-up related to weight loss. Weight was stable. Weight was 177.2 lbs. Abnormal weight loss. Continue with power potatoes, super cereal, health shakes three times a day, and larger portions of meals. Review of the resident's weights, showed on 6/29/23, weighed 175.6 lbs. Review of the resident's weights, showed on 7/5/23, weighed 174.0 lbs. Review of the resident's NP note, dated 7/12/23, showed weight was 174 lbs. Weight was stable. Continue with power potatoes, super cereal, health shakes three times daily, and larger portions of meals. Review of the resident's tray cards, undated, showed: -Breakfast: Large portions. Preferences: 2 health shakes, super cereal, large portions; -Lunch: Large portions. Preferences: 2 health shakes, power potatoes, large portions; -Dinner: Large portions: preferences: 2 health shakes, large portions. Observation and interview on 8/7/23 at 9:17 A.M., showed the resident lay in bed, with a plate of food on his/her bedside table. A serving of oatmeal had been consumed. Two sausage links and a scoop of scrambled eggs were untouched. No large portions or health shake were with the resident's meal. The resident said the food served at the facility was terrible and he/she was not served enough food during meals. Staff do not offer him/her alternative options to eat. Review of the resident's meal intake for 8/7/23, showed staff documented the resident consumed 76-100% of his/her meal at breakfast. Review of the resident's eMAR, showed on 8/7/23, staff documented health shakes administered at 8:00 A.M., 12:00 P.M., and 5:00 P.M. Observation of breakfast on 8/8/23 showed: -At 8:34 A.M., Dietary Aide (DA) C prepared plates of food for hall trays in the kitchenette. He/She reviewed tray cards before placing food on each plate. Hall tray plates contained one piece of toast, one scoop of scrambled eggs, and two pieces of bacon or one scoop of ham; -At 8:49 A.M., CNA N delivered a cup of juice and a plate of food to the resident's room; -At 8:57 A.M., the resident was seated upright in bed, drinking a cup of juice held by his/her trembling left hand. A plate of food on the resident's bedside contained a piece of toast, a scoop of scrambled eggs, and two pieces of bacon. An unopened container of jelly was next to the plate. No large portions, super cereal, or health shake were served with the resident's meal. During an interview, the resident said he/she no longer has use of his/her right hand and now uses his/her left, non-dominant, hand to feed him/herself. He/She needs staff to set up his/her food. There was a container of jelly for his/her toast, but he/she cannot open it. Breakfast was the meal he/she looks forward to the most. He/She was never served anything, but scrambled eggs at breakfast and they are terrible. He/She would like something different, maybe an omelet. He/She was supposed to get cereal and health shakes, which he/she likes. He/She very seldom gets health shakes and would like to have some. It would help to have a health shake, because he/she doesn't care for the other food. Staff do not offer him/her health shakes and he/she could not remember the last time he/she got one. He/She had lost some weight. Review of the resident's meal intake for 8/8/23 showed no documentation of intake at breakfast. Observations of lunch on 8/8/23 showed: -At 12:56 P.M., the resident sat upright in bed, using his/her left hand to eat a piece of sweet potato pie from a bowl. The resident's plate of breakfast remained on the bedside table with the scrambled eggs untouched. A plate of lunch on the bedside table, contained a whole piece of chicken breast, a scoop of white rice, a scoop of mixed vegetables, and a piece of white bread. No large portions, power potatoes, or health shake were served with the resident's meal. During an interview, the resident said he/she had not received a health shake today. He/She was unsure how he/she would eat the chicken because he/she could not cut it; -At 1:08 P.M., CNA P entered the resident's room and asked if the resident was finished eating. He/She did not offer to cut up the resident's chicken and did not ask the resident if he/she wanted something else to eat; -At 1:10 P.M., CNA P exited the resident's room with the resident's dishes. The slice of pie and piece of bread consumed, and the chicken, rice, and vegetables were untouched. During an interview on 8/8/23 at 1:20 P.M., the resident said he/she ate a slice of pie for lunch. He/She was not given a health shake and would have liked one. Review of the resident's meal intake for 8/8/23 showed no documentation of intake at lunch. Review of the resident's eMAR, showed on 8/8/23, staff documented health shakes administered at 8:00 A.M., 12:00 P.M., and 5:00 P.M. Observations of dinner on 8/9/23, showed: -At 5:21 P.M., DA C prepared plates of food in the kitchenette for hall trays. He/She reviewed tray cards before placing food on each plate. Ten of 11 hall trays contained a tuna sandwich and a cup of bean soup; -At 5:24 P.M., CNA B and CNA M delivered the resident's meal tray that contained cheesecake, a tuna sandwich, and cup of beans to the resident's room. No beverages, large portions, or health shakes were served with the resident's meal; -At 5:57 P.M., CNA K entered the resident's room and got ice for the resident's roommate. He/She left the room and returned a minute later with a shake for the resident's roommate. He/She did not offer a beverage or shake to the resident and exited a minute later; -At 6:08 P.M., CNA B entered the resident's room and asked if he/she was finished with dinner. He/She did not ask if the resident wanted anything else to eat or anything to drink; -At 6:09 P.M., CNA B exited the resident's room with the resident's dishes. The cheesecake and sandwich were consumed, and the bowl of bean soup was untouched. Review of the resident's eMAR, showed on 8/9/23, staff documented health shakes administered at 8:00 A.M., 12:00 P.M., and 5:00 P.M. Observation on 8/10/23 at 7:34 A.M., showed CNA L zeroed out the facility's scale and weighed the resident in his/her wheelchair. The scale showed 223.6 lbs. During an interview, CNA L said he/she helps obtain resident weights on a regular basis. He/She has a log of wheelchair weights, which showed the resident's wheelchair weighs 56 lbs. After subtracting the wheelchair weight from the weight on the scale, the resident's current weight is 167.6 lbs. The resident weighed 174 lbs. last month. Review of the resident's weights, showed from 7/5/23 to 8/10/123, a weight loss of 4.02% in one month. During an interview on 8/9/23 at 10:36 A.M., CNA L said the resident does not like to be out of bed. When the resident was on his/her assignment, he/she makes sure the resident was out of bed and in the dining room for lunch, because the resident eats better that way. The resident needs to be around people and to get encouragement to eat. He/She likes sweets and sodas. During an interview on 8/10/23 at 9:32 A.M., CNA L said the resident had some confusion, but he/she knows what he/she wants and needs. He/She loves health shakes. He/She was supposed to get large portions and items like power potatoes, but doesn't. He/She required set up assistance for eating and can feed him/herself. He/She needs encouragement to eat. During an interview on 8/10/23 at 9:52 A.M., CNA Q said the resident is pretty with it, and knows what he/she wants and needs. He/She had muscle issues and needs some assistance from staff setting things up, but he/she can feed him/herself. He/She does not eat much, but likes snacks and sweets. Staff should be encouraging him/her to get out of bed for breakfast and lunch. During an interview on 8/11/23 at 7:19 A.M., LPN A said Resident #40 was alert and oriented, and does not like to be bothered. He/She can express his/her wants and needs and make his/her own decisions. He/She feeds him/herself when he/she wants to eat the food, but often, he/she isn't touching the food. The LPN expected staff to encourage the resident to eat and offer alternatives. He/She had a good rapport with certain staff who can get him/her to eat. During interview on 8/18/23 at 9:58 SW V, the Social Worker for Physician T's office, said Physician T was not aware the facility kitchen staff did not have standard recipes for power potatoes or super cereal. Physician T was not notified of weight loss for Resident #4 and expected to be notified of unplanned weight loss for any resident under his/her care at the facility. SW V said Physician T would consider Resident #4's weight loss avoidable. 3. During an interview on 8/10/23 at 9:32 A.M., CNA L said dietary staff sets up resident trays and they bring health shakes to the floor. Nursing staff were responsible for checking trays to make sure residents have what they are supposed to get on their tray card, including health shakes. If a resident does not like what was served that day or doesn't eat their food, staff should offer substitutes and encourage the resident to eat. Nursing staff were responsible for charting how much a resident eats at each meal, and the charting should be accurately documented. 4. During an interview on 8/10/23 at 9:52 A.M., CNA Q said dietary serves meals from the kitchenette on the floor. During meal service, CNAs go to the kitchenette counter, where the resident's tray will have been prepared by dietary. The CNA checks the tray card to make sure everything is on the tray that should be. Dietary staff bring health shakes to the floor for CNAs to pass during meals. If a resident does not like the food served, they will drink the health shakes. Staff should offer alternatives and encourage residents to eat. He/She does not know what super cereal is. He/She has never seen power potatoes. Super cereal and power potatoes might be something eaten by residents on mechanically-altered diets. After a meal, CNAs should chart how much the resident has eaten. Staff should chart nutritional intake accurately. Residents who eat meals in their rooms should be provided with beverages and the food items they need. Staff should ensure meals are set up and items needed are within reach before leaving the room. 5. During an interview on 8/10/23 at 10:10 A.M., Certified Medication Technician (CMT) O said the staff responsible for ensuring residents receive health shakes would depend on who were working. If the CMT was not busy, they will pass the health shakes. If the CMT was busy, they have the CNA pass the health shakes. If a resident refuses their health shake, staff should try to offer it again later. If the resident continues to refuse or if the health shake was unavailable, it should be noted as such on the eMAR. Whether or not a resident receives their health shake should be accurately documented on the eMAR. 6. During an interview on 8/11/23 at 7:19 A.M., LPN A said a RD sees residents in the facility every one to two months. The RD's recommendations are communicated to the ADON, who communicates the recommendations to the rest of staff. LPN A expected residents to receive diets as ordered, including supplemental food items. The CMT or CNA was responsible for providing residents with health shakes. The CMT was supposed to verify the resident received the items on their tray cards and that the resident received their health shake before documenting it as administered on the eMAR. Health shakes are provided to address weight loss and to promote adequate nutritional status. If staff observe a resident had not eaten their meal, he/she expected staff to offer the resident an alternative and report it to the nurse. Staff should document the resident's nutritional intake at each meal. Documentation of meal intake should accurately represent what percentage of a meal was eaten. Staff track nutritional intake to address weight loss. 7. During an interview on 8/10/23 at 12:56 P.M., DA C said at meal time, dietary staff bring health shakes to the floor and nursing staff hands them out. Tray cards show staff exactly what to serve each resident. He/She had never made power potatoes, but thinks they are potatoes from a bag with thickener added to give them the power they need. Super cereal was hot cereal with something added to it, like bananas. Large portions means the resident gets double everything. There are two residents who receive double portions on the first floor, neither of which were Residents #4 or #40. 8. During an interview on 8/11/203 at 1:18 P.M., the Culinary Services Director said tray cards are generated based on the orders received from nursing. He expected dietary staff to follow each resident's tray card to ensure they are provided with the items they are supposed to receive. Super cereal has extra calories from brown sugar, butter, or fruit. Power potatoes have extra calories from cheese, sour cream, or chicken. He expected dietary staff to make super cereal and power potatoes daily. This week, power potatoes were made for the first time today. He made up the recipe for today's power potatoes. The facility did not have recipes for power potatoes or super cereal. When a resident had orders to receive large portions, he expected dietary staff provide the resident with two portions of the protein, and double portions of the starch and vegetables. 9. During an interview on 8/11/23 at 8:17 A.M., the Administrator said power potatoes and super cereal should have extra calories, and are provided to help address weight loss. She expected dietary staff to have recipes for power potatoes and super cereal for consistency and to ensure additional nutrition is provided. She expected diet orders to be followed, including the provision of supplemental food items, such as power potatoes and health shakes. 10. During an interview on 8/11/23 at 9:03 A.M., the ADON, DON and Administrator said dietary and nursing staff are responsible for ensuring residents receive supplemental food items as ordered by the physician and RD, and as indicated on the resident's tray card. Dietary staff brings the supplemental food items to the floor and nursing staff ensures the items are on the resident's meal tray. The purpose of supplemental food items is to address weight loss. Nursing staff are responsible for ensuring residents receive health shakes. The CMT should confirm the health shake was provided to the resident before indicating it as administered on the eMAR. If a resident does not eat the food provided to them, staff should make an attempt to assist the resident with eating, find out why the resident is not eating, and/or offer an alternative. CNAs should track meal intake and document the percentage of food accurately. The facility employs a RD who sees residents monthly for weight loss and other nutritional concerns. Issues with new and ongoing weight loss should be addressed with the facility's RD. A resident's care plan should indicate interventions to address nutritional status and weight loss. All of nursing has access to update the resident's care plan. 11. During interview on 8/18/23 at 9:58 SW V, the Social Worker for Physician T's office, said Physician T expected residents who are ordered supplements for each meal to receive them as ordered, and expected residents who are ordered super cereal, power potatoes, or double portions to receive them as ordered. Physician T was not aware the facility kitchen staff did not have standard recipes for power potatoes or super cereal. Physician T expected to be notified if residents are refusing supplements, and expected staff to offer alternatives if a resident does not like a particular menu item. MO00210692

Based on observation, interview and record review, the facility failed to establish a system of records of receipt for all controlled drugs in sufficient detail to enable an accurate reconciliation for one out of one medication room reviewed. The census was 74. Review of the facility's Controlled Substance policy, revised July 2014, showed: -Controlled substance must be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, must count the controlled substances together; both individuals must sign the designated narcotic record; -Controlled substances must be stored in the mediation room in a locked container or in a mediation cart in a locked box, separate from containers for any non-controlled medications. Observation and interview on 8/8/23 at 9:07 A.M., in the second floor locked medication room, showed 59 vials of lorazepam (a medication to treat anxiety) 2 milligrams (mg) per milliliter (ml) located in an unlocked refrigerator. The packaging on the medication bags that the lorazepam was being stored showed 60 vials of lorazepam delivered to the facility on 7/10/23. The Director of Nursing (DON) said the controlled substances are logged into the computer electronically and that paper narcotic books are not used. The DON verified that the 60 vials of lorazepam was not entered electronically into the controlled system log. She was not aware that the lorazepam was in the unlocked refrigerator and it is expected for the nurse that received the medication add the narcotics in the electronic system. The Medication Administration Record (MAR) for the resident that the lorazepam was ordered for was reviewed with the DON and the resident did not receive any doses of lorazepam. The DON was not sure where the missing vial of the Lorazepam could be because it is expected that the staff document on the MAR when a medication is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications were re-evaluated after 14 days for two residents (Resident #50 and Resident #61). The sample size was 18. The census was 74. Review of the facility's Psychotropic Medication Use policy, revised December 2018, showed: -Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record. 1. Review of Resident #50's Quarterly Minimum Data set (MDS, a federally mandated assessment instrument completed by facility staff), dated 8/1/23, showed: -Cognitively intact; -No behaviors; -Rejection of care one to three days; -Diagnoses included schizophrenia (a mental condition involving a breakdown in the relation between thought emotion and behavior, leading to faulty perception) and anxiety. Review of the resident's care plan, in use at the time of survey, showed: Focus: Behaviors: The resident exhibits elopement behaviors; Approach: Approach the resident in a calm manner; calmly re-direct the resident; monitor any significant changes in behavior; psych consult as needed, monitor wander guard (an electronic monitoring device) function. Review of the resident's physician order sheets (POS), showed an order, dated 7/6/23, for lorazepam (medication to treat anxiety) 2 milligrams (mg) intramuscular (IM) every six hours PRN with no stop date. Review of the resident's Medication Administration Record (MAR), dated 7/1/23 through 7/31/23, showed the lorazepam 2 mg IM PRN was not administered. Review of the resident's MAR, dated 8/1/23 through 8/11/23, showed the lorazepam 2 mg IM PRN was not administered. Review of the resident's psychiatric progress notes, dated 7/26/23, did not show documentation that the lorazepam should be extended past the 14 days. 2. Review of Resident # 61's admission MDS, dated [DATE], showed: -Cognitively impaired; -Verbal behaviors occurred one to three days; -Rejection of care occurred one to three days; -Diagnoses included psychotic (mental) disorder. Review of the resident's care plan, in use during the survey, showed it did not reflect any of the resident care needs. Review of the resident's POS, showed an order dated 7/18/23, for lorazepam 2 mg IM every six hours PRN with no stop date. Review of the resident's MAR, dated 7/1/23 through 7/31/23, showed the lorazepam 2 mg IM PRN was not administered. Review of the resident's MAR, dated 8/1/23 through 8/11/23, showed the lorazepam 2 mg IM PRN was not administered. Review of the resident's psychiatric progress notes, dated 7/26/23, did not show documentation that the lorazepam should be extended past the 14 days. 3. During an interview on 8/8/23 at 9:07 A.M. and 8/10/23 at approximately 12:00 P.M., the Director of Nursing (DON) said it is expected for the lorazepam to have been renewed if it was indicated for use past the 14 days. MO00215981

Based on observation, interview and record review, the facility failed to administer medications with a less than five percent medication error rate. Out of 25 opportunities for error, two errors occurred, resulting in an 8% medication error rate (Resident #1). The sample size was 25. The census was 74. Review of the facility's undated Monitoring of Medication Administration policy, showed: -Based on the facility medication administration policy designated nursing staff to administer all medication safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms, and help in diagnosis; -Review the resident's Medication Administration Record (MAR). Read each order entirely; -If there is any discrepancy between the MAR and the label, check physician orders before administering medication; -If the label is wrong it is the responsibility of the nurse to apply a Direction Change sticker to the medication label; -If the medication is discontinued or outdated, removed medication for proper disposal. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/30/23, showed: -Diagnoses included anxiety, depression, and psychotic disorder; -Cognitively Intact. Review of the resident's electronic physician order sheet (ePOS), showed: -An order dated 2/7/23, for Gavilax (miralax) 17 grams once a day, scheduled administration time 9:00 A.M.; -An order dated 4/23/23, for Risperidone 0.5 milligram (mg) one tablet twice a day, scheduled administration time 9:00 A.M. and 9:00 P.M. During a medication administration observation on 8/8/23 at 8:00 A.M., 9:00 A.M., and at 10:00 A.M., Certified Medicine Technician (CMT) E administered the resident's scheduled 8:00 A.M., 9:00 A.M., and 10:00 A.M., medications. CMT E said the resident's Risperidone was not available. CMT E failed to administer the resident's ordered Miralax. During an interview on 8/8/23 at 1:52 P.M., the Director of Nursing said medications should be administered as ordered. When medications are out, staff should call the pharmacy. Medication should be ordered before they run out. MO00215149 MO00216686

Based on observation, interview, and record review, the facility failed to maintain and follow recipes to ensure adequate nutritive value of fortified foods (super cereal and power potatoes) used to assist residents in maintaining acceptable nutritional status (Residents #40 and #4). The census was 74. 1. Review of Resident #40's medical record, showed diagnoses included high blood pressure, high cholesterol, low potassium, anemia (blood disorder), multiple sclerosis (nervous system disease affecting the brain and spinal cord), anxiety, and depression. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 10/19/22, for regular diet. Special instructions included super cereal for breakfast and power potatoes for lunch. Review of the resident's nurse practitioner note, dated 6/14/23, showed chief complaint of follow-up related to weight loss. Weight is stable. Weight is 177.2 lbs. Abnormal weight loss. Continue with power potatoes, super cereal, health shakes three times a day, and larger portions of meals. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Nutritional status. Resident is at risk for impaired nutrition and hydration related to multiple sclerosis. He/She is on a regular diet; -Goal: Resident will be nutritionally stable as evidenced by no significant weight changes through the next review; -Approaches included: Diet as ordered by provider. Nutritional supplements/vitamins as ordered and monitor for side effects; -The care plan failed to identify the resident's physician order for fortified foods during meals. Review of the resident's tray cards, undated, showed: -Breakfast preferences included super cereal; -Lunch preferences included power potatoes. Observations of breakfast on 8/8/23, showed: -At 8:34 A.M., Dietary Aide (DA) C prepared plates of food for hall trays. He/She reviewed tray cards before placing food on each plate. Hall tray plates contained one piece of toast, one scoop of scrambled eggs, and two pieces of bacon or one scoop of ham; -At 8:49 A.M., Certified Nurse Aide (CNA) N delivered a plate of food to the resident's room. The plate consisted of a piece of toast, a scoop of scrambled eggs, and two pieces of bacon; -No super cereal was served. Observation of lunch on 8/8/23 at 12:56 P.M., showed the resident sat upright in bed, using his/her left hand to eat a piece of sweet potato pie from a bowl. A plate of lunch on the bedside table contained a whole piece of chicken breast, a scoop of white rice, a scoop of mixed vegetables, and a piece of white bread. No power potatoes were served. Observation of lunch on 8/9/23 at 12:28 P.M., showed the resident was served meatloaf, mashed potatoes and green beans. During an interview on 8/10/23 at 9:32 A.M., CNA L said the resident is supposed to get items like power potatoes, but doesn't. 2. Review of Resident #4's medical record, showed diagnoses included abnormal weight loss, diabetes, high potassium, high cholesterol, high blood pressure, heart disease, stroke, and muscle wasting and atrophy. Review of the resident's ePOS, showed an order, dated 7/14/23, for regular diet. Special instructions included super cereal with breakfast. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Nutritional status. Resident is at risk for hypo/hyperglycemia related to diabetes; -Goal: Will maintain blood sugar within parameters ordered per physician for 90 days; -Approaches included: Diet per order; -No documentation regarding a physician order for fortified foods. Review of the resident's tray cards, undated, showed super cereal at breakfast. Observation of breakfast on 8/8/23 at 8:27 A.M., showed a regular plate of pureed scrambled eggs and pureed ham served to the resident in the dining room. No super cereal was served. 3. Observations of breakfast on 8/8/23, showed DA C prepared plates of food in the first floor kitchenette. Scrambled eggs, toast, bacon, and diced ham were served from the warming table. No super cereal was prepared or served. Observations of lunch on 8/8/23 at 12:56 P.M., showed residents served chicken, white rice, and mixed vegetables. No super cereal prepared or served. 4. During an interview on 8/10/23 at 9:52 A.M., CNA Q said he/she does not know what super cereal is. He/She has never seen power potatoes. Super cereal and power potatoes might be something eaten by residents on mechanically-altered diets. 5. During an interview on 8/10/23 at 12:56 P.M., DA C said he/she has never made power potatoes, but thinks they are potatoes from a bag with thickener added to give them the power they need. Super cereal is hot cereal with something added to it, like bananas. 6. During an interview on 8/11/203 at 1:18 P.M., the Culinary Services Director said tray cards are generated based on the orders received from nursing. He expected dietary staff to follow each resident's tray card to ensure they are provided with the items they are supposed to receive. Super cereal has extra calories from brown sugar, butter, or fruit. Power potatoes have extra calories from cheese, sour cream, or chicken. He would expect dietary staff to make super cereal and power potatoes daily. This week, power potatoes were made for the first time today. He made up the recipe for today's power potatoes. The facility does not have recipes for power potatoes or super cereal. 7. During an interview on 8/11/23 at 8:17 AM, the Administrator said she expected the facility to have recipes for fortified foods, such as power potatoes and super cereal. Power potatoes and super cereal should have extra calories, like butter. There should be recipes for these items so dietary staff has uniform expectations to follow in order to ensure adequate nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure arrangements were made for pain management services outside of the facility for two residents prescribed narcotic pain medication (Residents #16 and #126). The sample was 18. The census was 74. 1. Review of Resident #16's medical record, showed diagnoses included pain in left knee and anxiety. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 5/12/23, for tramadol (pain medication) 50 milligrams (mg), three times a day as needed (PRN). Review of the resident's June 2023 electronic Medication Administration Record (eMAR), showed; -Tramadol administered 46 times; -No tramadol documented as administered after 6/24/23. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/28/23, showed: -Cognitively intact; -On a scheduled pain medication regimen; -Diagnoses included osteoarthritis. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Pain: Resident is at risk for increased complaints of pain due to (blank); -Goal: Resident will be able to express relieve or acceptable reduction of pain and discomfort by next review date; -Approaches included: Provide pain medication PRN. Review of the resident's July 2023 eMAR, showed no tramadol documented as administered. Review of the resident's August 2023 eMAR, showed: -On 8/5/23, reported pain level of 5; -On 8/6/23, reported pain level of 4; -On 8/7/23, reported pain level of 4; -No tramadol or other pain medication documented as administered. Review of the resident's progress note, dated 8/8/23, showed the Assistant Director of Nurses (ADON) documented the resident's order for tramadol was discontinued. Will reschedule follow-up appointment with physician for pain management. Transportation did not show yesterday on 8/7/23. Will reschedule appointment. Review of the resident's ePOS, showed the order for tramadol discontinued 8/8/23. Observation and interview on 8/10/23 at 8:06 A.M., showed Certified Medication Technician (CMT) O searched the medication cart and said there was no tramadol for the resident. During an interview on 8/7/23 at 8:58 A.M., the resident reported he/she has chronic pain. He/She reported leg pain last night and asked for pain medication, but did not receive it. During an interview on 8/10/23 at 7:55 A.M., the resident said he/she sees a pain management doctor outside of the facility for his/her tramadol. Transportation did not show up this week for his/her pain management appointment. It is a hassle getting to his/her pain management appointments and he/she has missed a pain management appointment before due to transportation not showing. 2. Review of Resident #126's medical record, showed: -admission date 8/3/23; -Diagnoses included chronic pain due to trauma, other intervertebral disc degeneration of lumbar region-degenerative disc disease, and anxiety; -An order dated 8/4/23, for oxycodone (narcotic pain medication) 10 mg, one tablet every six hours PRN. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident admitted to facility for long-term care; -Goal: Initial goal to discharge to community. Resident will have access to necessary services to promote adjustment to new living environment and/or post-discharge from facility; -Approaches included: Resident is alert and cognitively intact. Resident requires assistance with medication management. During an interview on 8/9/23 at 10:42 A.M., the resident said he/she has chronic pain all over due to being involved in a car accident. He/She receives oxycodone 10 mg every six hours and the facility is running low on his/her medication. He/She only has a couple days of oxycodone left and is worried. He/She is not sure if his medication will be refilled. Observation and interview on 8/10/23 at 8:00 A.M., showed Licensed Practical Nurse (LPN) A pulled the resident's blister card of oxycodone from the medication cart. Review of the blister card of oxycodone, showed a 28 count card of 10 mg tablets filled on 8/3/23, to be administered every six hours PRN, with 8 tablets remaining. LPN A said the resident takes his/her oxycodone every six hours exactly. During an interview on 8/10/23 at 10:26 A.M., the resident said he/she was worried the facility will run out of his/her pain medication. On 8/11/23, the resident said he/she is really worried about running out of his/her oxycodone. He/She is in chronic pain and cannot be without the pain medication. He/She takes the medication every six hours and only has five pills left. 3. During an interview on 8/10/23 at 8:00 A.M., LPN said Physician T, the facility's medical director, does not deal with narcotic pain medication. All narcotic pain medications must be overseen by the pain management physician outside of the facility, Physician U. After a resident sees Physician U, they return to the facility with a card showing their next appointment. The nurse gives the appointment card to the Social Services Director (SSD), who sets up the transportation. Once the SSD schedules transportation, she puts notification of the transportation in the binder at the nurse's station. The SSD is supposed to schedule Resident #126's pain management appointment and transportation because Physician U said they did not have any appointments available. The SSD should have scheduled transportation for Resident #16's missed pain management appointment. 4. During an interview on 8/10/23 at 10:34 A.M., the SSD said she sets up transportation for appointments outside of the facility. Nursing gives her the request for transportation, she sets it up, and then puts confirmation of the transportation in the binder at the nurse's station. If a ride is missed through Medicaid transportation, transportation could be set up through private pay. On 8/7/23, Resident #16 missed his/her appointment for Physician U. The SSD has not set up a new appointment or transportation yet. She was out of the facility this week, but was working from home. Resident #126 was admitted on [DATE] and came to the facility with a script for oxycodone, but no medication. He/She has to be seen by Physician U, but the earliest appointment Physician U has available is 8/21/23. Another physician filled a 30-day script for Resident #126's oxycodone, but the medication will run out before the appointment with Physician U. 5. During an interview on 8/11/23 at 6:43 A.M., the ADON said the facility's medical director, Physician T, will not write scripts for narcotic pain medication. The nurse practitioner who works with the facility cannot write scripts for narcotic pain medications. Any resident who receives a narcotic pain medication must be seen by a pain management physician outside of the facility. Resident #16 has chronic pain for which he/she requires tramadol. He/She usually gets two tramadol a day. Tramadol is probably not documented as administered in July or August 2023 because the facility did not have it. The resident is seen by the pain management physician, Physician U, every 60 days. It has been so long since his/her script was written, it cannot be filled and he/she needs to see Physician U to obtain a new order. Resident #126 is a new admission to the facility. He/She has a limited amount of oxycodone and needs to be seen by Physician U for a new script. He/She takes the medication every six hours as prescribed and will run out of the medication soon. It is unknown what will happen when he/she runs out of his/her pain medication. After a resident is seen by Physician U, documentation of their next scheduled appointment goes to the SSD. The SSD sets up transportation for the appointment and puts documentation of the scheduled transportation in the binder at the nurse's station so nursing staff can have the resident ready on the day of their appointment. On 8/7/23, transportation did not come to the facility to take Resident #16 to his/her pain management appointment. This has happened before. The ADON discontinued the resident's order for tramadol because the medication cannot be administered until a new script is issued. On 8/7/23, the ADON asked the SSD to set up another appointment and transportation for Resident #16, as well as an appointment and transportation for Resident #126. The ADON would have expected these arrangements to have been made in a timely manner. 6. During an interview on 8/11/23 at 7:01 A.M., the SSD said she scheduled appointments for Residents #16 and #126 to see Physician U on 8/21/23. When she was made aware of Resident #126's need to be seen by pain management on 8/3/23, she did not schedule an appointment at that time because she was more focused on getting the resident's oxycodone filled. 7. During an interview on 8/11/23 at 9:03 A.M., the ADON, Director of Nurses (DON) and Administrator said they would expect transportation arrangements for appointments outside of the facility to be made in a timely manner, as soon as staff become aware that an appointment is needed. The SSD is responsible for setting up transportation. There have been ongoing issues with transportation through Medicaid not showing up for appointments. Knowing this has been an issue, it would be expected for the SSD to explore other options to ensure residents make it to appointments outside of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medical records were accurately documented in accordance with acceptable professional standards of practice when staff failed to document skin assessments for one resident with a blister on his/her left heel (Resident #5). Staff documented nutritional supplements as administered for two residents (Residents #40 and #4) when the supplements were not provided, and staff failed to accurately document meal intake in accordance with physician orders. The sample was 18. The census was 74. Review of the facility's Charting policy, revised February 2012, showed: -Policy: It is the policy of the company that all services provided to the residents, or any changes in the resident's condition, shall be recorded in the resident's medical record; -Procedures included: All observations, medications given, services performed, etc., must be recorded in the resident's chart. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/11/23, showed: -Diagnoses of diabetes, depression and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)); -Severe cognitive impairment. Review of the resident's electronic medical record (EMR), showed the following: -Progress note created on 6/20/23 at 10:42 A.M. showed the resident readmitted from the hospital, skin warm and dry to the touch, fluid filled blister to left heel. Review of the resident's skin assessments, showed the following: -6/25/23 at 6:39 A.M., incomplete assessment with questions left blank. No skin issues documented; -7/15/23 at 4:43 A.M., incomplete assessment with questions left blank. No skin issues documented. Review of the resident's Wound Management report, showed the following: -Wound report created on 7/24/23 at 7:59 P.M. showed the heel wound measured, length: 3 centimeters (cm), Width 4.5 cm, Wound healing is documented as stable; -Wound report created on 7/30/23 at 7:59 P.M. showed the heal wound measured, length: 3 cm, width: 1 cm, depth: 0.1 cm, wound healing is documented as improving. During an interview on 8/10/23 at 12:46 P.M., the Director of Nurses (DON) said she expected for resident assessments to be completed and accurate. She expected skin assessments for the resident to be completed and not left blank. 2. Review of Resident #40's medical record, showed diagnoses included high blood pressure, high cholesterol, low potassium, anemia (blood disorder), multiple sclerosis (MS, nervous system disease affecting the brain and spinal cord), anxiety and depression. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -Orders, dated 9/22/22, to monitor and record meal percentages and fluid intake for breakfast, lunch and dinner; -An order, dated 9/27/22, for health shakes with meals, give 2 health shakes with meals at 8:00 A.M., 12:00 P.M., and 5:00 P.M. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Rejection of care behavior not exhibited; -Required extensive assistance of two (+) person physical assist for transfers; -Required setup help for eating. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Nutritional status. Resident is at risk for impaired nutrition and hydration related to multiple sclerosis. He/She is on a regular diet; -Goal: Resident will be nutritionally stable as evidenced by no significant weight changes through the next review; -Approaches included: Monitor appetite and record percentage of intake. Nutritional supplements/vitamins as ordered and monitor for side effects. Observation on 8/7/23 at 9:17 A.M., showed the resident lay in bed, with a plate of food on his/her bedside table. A serving of oatmeal consumed. Two sausage links and a scoop of scrambled eggs untouched. No health shake was with the resident's meal. Review of the resident's meal intake for 8/7/23, showed staff documented the resident consumed 76-100% of his/her meal at breakfast. Review of the resident's electronic medication administration record (eMAR), showed on 8/7/23, staff documented a health shake was administered at 8:00 A.M. Observation of breakfast and lunch on 8/8/23, showed: -At 8:57 A.M., the resident sat upright in bed, with a plate of food on the bedside table containing a piece of toast, a scoop of scrambled eggs, and two pieces of bacon. No health shakes were with the resident's meal. During an interview, the resident said he/she is supposed to get health shakes, which he/she likes. He/She very seldom gets health shakes and would like to have some. Staff do not offer him/her health shakes and he/she could not remember the last time he/she got one; -At 12:56 P.M., the resident sat upright in bed. His/Her plate of breakfast remained on the bedside table with scrambled eggs untouched. A plate of lunch on the bedside table, contained a whole piece of chicken breast, a scoop of white rice, a scoop of mixed vegetables, and a piece of white bread. No health shake was with the resident's meal. During an interview, the resident said he/she has not received a health shake today; -At 1:10 P.M., Certified Nurse Aide (CNA) P exited the resident's room with the resident's dishes. The chicken, rice, and vegetables were untouched. During an interview on 8/8/23 at 1:20 P.M., the resident said he/she was not given a health shake today and would have liked one. Review of the resident's meal intake for 8/8/23, showed no documentation of meal intake at breakfast or lunch. Review of the resident's eMAR, showed on 8/8/23, staff documented health shakes administered at 8:00 A.M., 12:00 P.M., and 5:00 P.M. Observations of dinner on 8/9/23, showed: -At 5:24 P.M., CNA B and CNA M delivered a bowl and plate of food to the resident's room; -Continuous observation of dinner, showed no health shake delivered to the resident's room; -At 6:08 P.M., CNA B entered the resident's room and asked if he/she was finished with dinner. He/She left the room with the resident's dishes a minute later. Review of the resident's eMAR, showed on 8/9/23, showed staff documented health shakes administered at 8:00 A.M., 12:00 P.M., and 5:00 P.M. During an interview on 8/10/23 at 7:40 A.M., the resident said no one brought him/her a health shake the previous day. During an interview on 8/10/23 at 9:32 A.M., CNA L said the resident has some confusion, but he/she knows what he/she wants and needs. He/She loves health shakes. He/She is supposed to get them at each meal. CNAs are responsible for making sure residents get their health shakes. 3. Review of Resident #4's EMR, showed: -Diagnoses included pressure ulcer to the left hip, abnormal weight loss, muscle weakness, depression, heart failure, hospice services, and cerebral infarction (a blood clot in the brain affecting cognition). Review of the resident's ePOS, showed a diet order dated 7/14/23 at 2:10 P.M. for a regular diet with regular consistency liquids, and specifications to provide the resident with a health shake three times daily with each meal. The order also stated the resident should receive super cereal with each breakfast and ice cream with each lunch and dinner. Observation of the lunch meal on 8/8/23 at 12:33 P.M., showed the resident sat at a table in the first floor dining room, receiving feeding assistance from staff. The resident was not served a health shake with the meal. Observation of the lunch meal on 8/9/23 at 12:41 P.M. showed the resident sat at a table in the first floor dining room, receiving feeding assistance from staff. The resident was not served a health shake with the meal. Observation of the lunch meal on 8/9/23 at 5:41 P.M. showed the resident resting in bed with the dinner meal placed on his/her side table over the bed. The DON provided assistance to the resident with eating the meal of navy bean soup, a fruit cup, and a tuna sandwich. No health shake was given to the resident with this meal. Observation of the breakfast meal on 8/10/23 at 8:59 A.M. showed the resident sat at a table in the dining room, receiving feeding assistance from staff. No super cereal was served on the resident's tray, and the resident was not offered a health shake with the meal. Review of the resident's eMAR for the month of August up to the end of the survey, showed all supplements given three times daily as ordered. 4. During an interview on 8/10/23 at 10:10 A.M., Certified Medication Technician (CMT) O said the CMT or CNA is responsible for passing health shakes. If the health shake is not administered due to being unavailable or resident refusal, it should be noted as such on the resident's eMAR. It would not be appropriate to document a health shake as received when it was not. 5. During an interview on 8/11/23 at 7:19 A.M., Licensed Practical Nurse (LPN) A said CMTs or CNAs are responsible for ensuring residents get their health shakes. If a resident does not receive their health shake, it should be accurately documented on the eMAR. 6. During an interview on 8/11/23 at 9:03 A.M., the Assistant Director of Nurses (ADON), DON, and Administrator said nursing staff is responsible for providing residents with health shakes as ordered. The CMT should confirm the health shake was provided to the resident before indicating it as administered on the eMAR. Documentation in the resident's clinical record should be completed accurately.

Based on interview and record review, the facility failed to distribute interest (money paid regularly to depositors of money at a financial institution a particular rate) for residents who allowed the facility to manage their resident funds during the months of August 2022 through October 2022. In addition, the facility failed to ensure residents who held funds below $50.00 in the interest bearing bank account were credited interest earned on the account. (Residents #62, #16, #426, #28, #41, #276, #52, #427, #428, #9, #2, #26, #50, #429, #430 and #27). The census was 74. Review of the facility's Resident Trust Fund (RTF) policy, revised 2/2020, showed: -The Business Office Manager has the primary responsibility for ensuring that residents' funds are appropriate and legitimate; -Interest is to be posted once a month to resident accounts with an account balance of $50.00 or greater. 1. Review of the RTF bank statements for August 2022, September 2022 and October 2022, showed 0.00% interest credited to the RTF interest-bearing bank account. During an interview on 8/9/23 at 4:07 P.M., the Business Office Manager (BOM) said interest should be dispersed every month. She did not know why the interest was not credited to the RTF account. She did not know if the residents had been reimbursed for the missing interest credits. 2. Review of the RTF interest-bearing bank statements for January 2023 through July 2023, showed: -January 2023: Residents #62, #426, #28, #41, #429, #430 and #27 had RTF balances less than $50.00 and did not receive an interest credit; -February 2023: Residents #62, #426, #28, #41 and #427 with RTF had RTF balances less than $50.00 and did not receive an interest credit; -March 2023: Residents #62, #26, #429, #426, #41, #28, #276, #427 and #50 had RTF balances less than $50.00 and did not receive an interest credit; -April 2023: Residents #62, #429, #426, #41, #28, #276, #427, #50, #2 and #9 had RTF balances less than $50.00 and did not receive an interest credit; -May 2023: Residents #62, #429, #426, #41, #28, #276, #427, #50, #428 and #9 had RTF balances less than $50.00 and did not receive an interest credit; -June 2023: Residents #62, #16, #426, #41, #28, #276, #427, #50, #428, #9 and 52 had RTF balances less than $50.00 and did not receive an interest credit; -July 2023: Residents #62, #16, #426, #41, #28, #276 and 52 had RTF balances less than $50.00 and did not receive an interest credit. During an interview on 8/9/23 at 4:07 P.M. the BOM said the program the facility used to manage the RTF account automatically distributed interest credits only to accounts more than $50.00. She did not know if she could change the program to give credit to all residents with funds in the interest bearing account. During an interview on 8/10/23 at 12:12 P.M., the Administrator said all residents should receive monthly interest if their money is in the RTF interest bearing account.

Based on interview and record review, the facility failed to ensure general accounting principles were followed for an accurate accounting of all monies, by failing to research outstanding checks. This affected residents whose funds were managed by the facility. The census was 74. 1. Review of the facility provided September 2022 Check Listing Report dated 9/30/22, showed the following outstanding checks that had not cleared the bank as of 8/8/23. Check Number Date Amount 1043 08/17/2020 $3,250.11 1137 01/27/2021 $0.65 1311 08/04/2021 $3,483.10 1318 08/10/2021 $12.00 1389 11/08/2021 $136.00 1420 12/14/2021 $0.80 Review of the facility October 2022 Bank Reconciliation on 8/9/23, showed the checks written in 2020 and 2021 were not listed under the reconciled checks. During an interview on 08/09/23 at 4:07 P.M., the Business Office Manager (BOM) said he/she had not followed up on any of the old outstanding checks and did not know if there was a process in place. During an interview on 08/10/23 at 12:12 P.M., the Regional Business Office Manager (RBOM) said the facility went under new ownership last year. The outstanding checks were in the old Resident Trust Fund (RTF) bank account. The account was closed on 10/01/22 and all monies were moved into the new account. Resident money was left in the old RTF account for the checks that had not yet cleared. The RBOM no longer had access to the old RTF account, and did not know if the checks ever cleared. 2. Review of the facility provided RTF Bank Reconciliations from March 2023 through July 2023 on 8/9/23, showed check #1061 dated 01/31/23 in the amount of $5,700.00, that had not cleared from the RTF bank account as of 7/31/23. During an interview on 08/09/23 at 4:07 P.M., the BOM said he/she was responsible for managing the RTF account and noticed the $5,700.00 outstanding check had not cleared. The BOM also said he/she was not aware of any process to address outstanding checks and had not contacted anyone regarding the outstanding check. During an interview on 08/10/23 at 12:12 P.M., the RBOM said outstanding checks carry over month to month and had no expiration date. If a check was outstanding after 90 days, he/she would call to see what the status of the outstanding check was and then reissue a new check if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to reasonable access to the use of a telephone in a place where calls could be made without being overheard. The facility additionally failed to provide reasonable access to send and receive mail on the weekends. The facility census was 74. Review of the Resident's Handbook, undated, showed: A telephone for private calls is available for resident use 24 hours a day and each resident room is equipped for a telephone. Review of the Resident's admission Packet, undated, showed: A resident has the right to have a reasonable access to the private use of a phone. 1. Observation and interview on 8/8/23 at 7:25 A.M., showed, on the second floor, two white telephones in an unlocked room on a desk. One telephone was unplugged and one telephone was connected to a phone jack and did not have a dial tone. Certified Medicine Technician (CMT) J verified the phones in the room were designated for resident use only. Observation of the 100 hall phone room on 8/8/23 at 12:08 P.M. showed a room approximately 6 feet wide by 12 feet long with a cabineted countertop and contained two corded phones plugged into a phone line outlet at the wall. Neither phone emitted a dial tone when picked up. Calls placed out from the phones did not connect to known working phone numbers. Observation and interview of the 100 hall phone room on 8/9/23 at 10:58 A.M. showed a room approximately 6 feet wide by 12 feet long with a cabineted countertop, and contained two corded phones plugged into a phone line outlet at the wall. Neither phone emitted a dial tone when picked up. Calls placed out from the phones did not connect to known working phone numbers. Licensed Practical Nurse (LPN) A said the phones had not worked for at least a month. Residents had been asked to make outgoing calls from the phones at the nurses' station. 2. Review of Resident #61's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/23, showed: -Cognitively impaired; -Independent with transfers, walking in room and hall; -Diagnosis included anemia, high blood pressure, and psychotic (mental) disorder. During an interview on 8/8/23 at 7:15 A.M., the resident said the phone that residents are to use on the second floor did not work. It had not worked for about one month. He/She needed to speak with his/her family member. He/She didn't always know when his/her family member were coming to visit and it created anxiety. The resident was not allowed to use the nurses' station phone because he/she was told by staff it was for business only. 3. Review of Resident #24's quarterly MDS, dated [DATE], showed; -Cognitively intact; -Diagnoses included dementia, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and depression. Observation on 8/9/23 at 5:39 P.M., showed the resident approached the first floor nurses' station and asked Certified Nurse Aide (CNA) B to use the phone. CNA B told the resident to wait and walked down the hall. The resident walked to the side of the nurses' station and looked behind the counter. At 5:40 P.M., the Director of Nurses (DON) approached the resident and said he/she could not be behind the nurses' station. The DON moved the phone from behind the nurses' station to the counter. The resident made a phone call at the nurses' station. During the resident's phone call, CNA B, CNA K, and another resident walked by, within earshot of the resident. During an interview on 8/9/23 at 5:42 P.M., the resident said there used to be a phone they could use privately in the room around the corner from the nurses' station, but the phone did not work anymore. The phone had not worked for about a month. Now residents had to ask permission to use the phone at the nurses' station. It was not private and residents could not speak freely. 4. During an interview on 8/9/23 at 2:00 P.M. resident council members said the phones available to make private phone calls were broken. During an interview on 8/10/23 at 9:32 A.M., CNA L said the phone for residents to use on the first floor was in a room next to the nurses' station, but was broken. Residents now needed to make their phone calls at the nurses' station. During an interview on 8/10/23 at 10:25 A.M., CNA I said the phone on the second floor for resident use had been broken for about a month. CNA I had let residents use his/her own personal cell phone to make calls. During an interview on 8/10/23 at 12:42 P.M. the Director of Operations and the Administrator said the phones for resident use had been out of service for about a month. The facility had been working with the utilities company to get a land line, but had not been successful. The facility was expected to provide a phone for the residents to use in private. 6. During an interview on 8/9/23 at 2:00 P.M. resident council members said the facility did not always hand mail out on the weekend because the front office was closed. During an interview on 8/11/23 at 8:02 A.M. the Administrator said the Activities Director was responsible to hand out mail to residents on week days. On the weekends, it was the nurses' responsibility to hand mail out to residents. During an interview on 8/11/23 at 8:12 A.M. LPN A said he/she worked the weekend shift. He/She said it was not the responsibility of nursing staff to deliver mail to residents on the weekend. LPN A was unsure if he/she had ever witnessed mail being delivered to residents on the weekend.

Based on observation, interview and record review, the facility failed to ensure they provided residents a homelike environment by failing to maintain clean shower rooms on the 200 and 100 halls, out of three shower rooms observed. The resident sample was 18. The census was 74. 1. Review of the facility's House Keeping Duties list, showed the following: -One housekeeper per floor (1st and 2nd), pull all trash in all rooms and bathrooms, wipe bedside tables off, wipe furniture if needed, clean all bathrooms in rooms, clean all bathrooms in the hallways, clean shower rooms, clean dining rooms (sweep and mop) only, sweep and mop all rooms, pull trash in the serving areas, wipe doors front and back along with door knobs, wipe coffee and soda stains off walls, wipe food off walls, dust picture frames, put bags at the bottom of each trash can, clean mirrors in each room, pick up wet floor signs before leaving. 2. Observation of the 200 hall resident shower room on 8/7/23 at 5:18 A.M., showed the toilet full of urine and stool, and brown matter smeared on the walls next to the toilet and on the toilet seat. A trash can overflowed with food trash. Observation of the 200 hall resident shower room on 8/8/23 at 7:26 A.M., showed floors dirty with a brown substance on it, used towels and resident clothing on the ground, a trash can overflowed with trash, toilet paper on the ground, and brown substance on the wall next to the toilet. Wall tiles next to the door were missing, and the shower curtain had brown stains on it. 3. Observation of the 100 hall resident shower room on 8/8/23 at 8:09 A.M., showed the shower stall full of wheelchairs, shower chairs, a shower bed, a side table, a mattress, and a trash bag; with no room available for staff to utilize the shower stall to bathe residents. A large amount of stool was unflushed in the toilet. Observation of the 100 hall resident shower room on 8/9/23 at 11:09 A.M., showed the shower stall full of wheelchairs, shower chairs, a shower bed, a side table, a mattress, and a trash bag, with no room available for staff to utilize the shower stall to bathe residents. A large amount of stool was unflushed in the toilet. 4. Review of Resident #60's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/2/23, showed the resident cognitively intact. During an observation and interview on 8/8/23 at 8:00 A.M., the resident walked down the 200 hall with wet hair. The resident said He/She had just taken a shower and the shower room was gross and needed to be cleaned. 5. During an interview on 8/11/23 at 8:15 A.M. Housekeeper W said that He/She works mainly on the 1st floor and that they clean the shower room every day. Staff try to clean the shower room twice a day but their hours were cut. Housekeeper W would expect for shower rooms to be clean and maintained for resident usage. 6. During an interview on 8/11/23 at 8:22 A.M., Housekeeper X said that he/she cleans the shower rooms once a day and then tries to go check the trash can. Staff try to go back and re-clean the shower room if it gets dirty but they have many other cleaning duties so most of the time they can only go back once or twice during a shift. 7. During an interview on 8/11/23 at 9:27 A.M. the Director of Nursing said she would expect shower rooms to be clean and maintained for resident use. MO00210692 MO00215981

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents for four of 18 sampled residents (Residents #4, #61,#70, and #277). The census was 74. 1. Review of Resident #4's Medical Record, showed: -Medical diagnoses included: Pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) to the left hip, abnormal weight loss, muscle weakness, depression, heart failure, and cerebral infarction (a blood clot in the brain affecting cognition); -The following care areas were noted on the quarterly Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 7/17/23: Cognitive loss, urinary incontinence, psychosocial wellbeing, and falls; -A readmission weight of 149 pounds (lbs) on 5/3/23; -A diet order placed on 7/14/23 at 2:10 P.M., for a regular diet with regular consistency liquids, and specifications to provide the resident with a health shake (supplemental nutrition) three times daily with each meal. Review of the resident's care plan, in use for the duration of the survey, showed: -Problem: the resident received hospice services related to end stage disease processes; -Goal: relief of pain/symptoms within 30 minutes of the resident reporting it; -Approaches included hospice Registered Nurse (RN) visits three times weekly, observe for verbal and nonverbal indicators of pain or discomfort and report any changes to the hospice MD; -Problem: the resident had demonstrated self-isolation due to change in life circumstances; -Goal: increase resident's social interaction through the review period; -Approaches included enrolling the resident in local counseling services; -Problem: the resident was at risk for hypoglycemia (too little sugar in the bloodstream)/hyperglycemia (too much sugar in the bloodstream) due to status as a diabetic; -Goal: maintain blood sugar within normal parameters through the review period; -Approaches included giving the resident meals as per the diet order, consult with the registered dietician, monitor accurate food/fluid intake, report to the physician when the resident had weight loss, and offer snacks when the resident did not consume his/her meal; -The care plan did not address the resident had significant, current weight loss. Observation of the resident on 8/10/23 at 10:46 A.M., showed Certified Nurse Aide (CNA) L assisted the resident in his/her broda chair (a high-backed, wheeled chair providing extra support and comfort to a dependent resident) onto the floor's resident weight scale. After subtracting the total weight of the chair, it was determined the resident's body weight was 135 lbs., indicating a 9.4% weight loss in the last three months. During interview on 8/8/23 at 9:13 A.M. Licensed Practical Nurse (LPN) A stated the resident had orders for a mechanical diet (texture-modified food for individuals with difficulty chewing and swallowing), but did not know what supplement orders the physician had ordered for the resident. LPN A stated the resident did not look like he/she had lost any weight, and was unsure if the resident had any documented weight loss. During interview on 8/10/23 at 11:21 A.M. the facility Dietician said she saw the resident last month, and had recommended health shakes three times daily with meals, with supercereal (high calorie oatmeal) at breakfast and ice cream with lunch and dinner as the resident had exhibited weight loss since last being seen. The facility Dietician communicated each of her recommendations for each resident to the facility Assistant Director of Nursing (ADON), who in turn was responsible for communicating these recommendations to staff. The Dietician stated she expected these recommendations to be followed. She was unaware staff were not following these recommendations for the resident's nutritional supplementation. The Dietician expected to be notified of continued weight loss, and was not aware the resident had continued to lose weight. She said health shakes at the facility were delivered to the floors in bulk and was told nursing staff handed them out. The Dietician questioned this practice. She recommended to the facility dietary staff served shakes or supplements with meals and supplements on the floors should be labeled to indicate which residents should receive them and when. During interview on 8/11/23 at 9:03 A.M. the facility Administrator and facility Director of Nursing(DON) said they would expect a resident to have a care plan entry regarding abnormal or significant weight loss if the resident had experienced any. The DON said the purpose of including these concerns on the care plan is to communicate to staff how best to care for each resident individually. 2. Review of Resident # 61's admission MDS, dated [DATE], showed: -Cognitively impaired; -Independent with transfers, walking in room and hall; -Required staff supervision for toileting and hygiene with one person physical assist; -Used a walker; -Occasionally incontinent of bowel and bladder; -Diagnoses included anemia, high blood pressure, and psychotic (mental) disorder. Review of the resident's care plan, in use during the survey, did not reflect any of the resident's care needs. During an interview on 8/8/23 at 7:15 A.M., the resident said he/she was always incontinent and required reminders from staff about bathing and changing his/her clothing. He/She was independent with walking and uses a walker. 3. Review of Resident #70's admission MDS dated [DATE], showed: - admission date of 6/23/23; - Diagnoses of epilepsy, intellectual disabilities, and bipolar disorder; - Severe cognitive impairment. Review of the resident's care plan, dated 7/10/23, showed the following: -Problem: admitted to long term care (LTC). Required a baseline care plan identifying care needs, risks, strengths, and goals within the first 48 hours; -Goal: Initial goal is to remain in LTC. Will have access to necessary services to promote adjustment to his/her new living environment and or post discharge from facility; -Approach: Required assist with all activities of daily living (ADLs, self-care). Limited assistance with oral care; limited with bathing; limited, extensive with grooming; supervision with eating; limited with toileting; limited assistance with dressing; independent with mobility. Needs (support, assistance) to have his/her personal care needs met while supporting his/her strengths and personal goals; - The care plan did not address the resident refusing hygiene assistance or having behaviors related to refusal of hygiene assistance. During an observation on 8/7/23 at 11:45 A.M. the resident sat in the dining room on the second floor. The resident's hair was observed to be stringy and matted. Observation on 8/8/23 at 8:08 A.M. showed the resident in the hallway on the way to a meal. The resident's hair was observed to be stringy and matted. During an interview on 8/9/23 at 10:27 A.M. the resident said nothing could be done with his/her hair. It would have to be cut off to fix it. The resident said he/she wanted his/her hair unmated. During an observation on 8/10/23 at 7:33 A.M. the resident was observed outside the shower room. The resident's hair had been cut and was short. The resident's hair appeared to no longer be matted. During an observation on 8/10/23 at 8:35 A.M. the resident was observed with a staff member. The resident was happy and smiled when his/her haircut was brought up. The staff member told the resident that he/she glowed and looked like a whole new person. During an interview on 8/10/23 at 10:11 A.M. The social worker said she was aware of the resident's matted hair. The resident had admitted to the facility with matted hair from a different facility. The social worker said the resident's family member had tried to de-matt the resident's hair but was unsuccessful. During an interview on 8/10/23 at 10:41 A.M. the Administrator said the resident's family member had tried to de-matt the resident's hair but was unsuccessful. She said facility staff had also tried to de-matt the resident's hair but the resident resisted because it hurt his/her head. During an interview on 8/11/23 at 12:32 A.M. the DON said anything related to the resident should be on the resident care plan. Nursing staff should attempt to redirect residents who refuse hygiene assistance. Staff have tried to help the resident with his/her hair but the resident refused. The DON said that she tried helping the resident de-matt his/her hair during a smoke break and the resident got angry and tried to burn her with a cigarette. The DON said the incident was not documented or care planned. 4. Review of Resident #277's Medical Record, showed: -The resident was admitted to the facility on [DATE] and discharged from the facility on 2/25/23.; -Medical diagnoses included malignant neoplasm (cancer) of the right breast, secondary malignant neoplasm of the liver and bile duct and secondary malignant neoplasm of the bone; -Care Areas noted on the resident's admission MDS, dated [DATE], showed: falls, urinary incontinence and indwelling catheter (a tube inserted into the bladder to aid in voiding urine), ADL (activities of daily living) function loss, and cognitive loss/dementia; -The resident had a code status of Do Not Resuscitate (DNR, a medical order written by a doctor for facility staff to not provide life saving interventions); -The resident was admitted to the facility enrolled in hospice services. Review of the resident's care plan, in use for the duration of his/her admission to the facility, showed: -Problem: the resident has an advanced directive that should be honored; -Goal: Honor the resident's advanced directive (legal document that provides medical instruction when incapacitated ) wishes; -Approaches included ensuring the advanced directive was completed accurately, ensure staff were educated on the advanced directive, and notifying the resident's legal representative of any changes; -The care plan did not address the resident's care needs or enrollment into hospice. 5. During interview on 8/11/23 at 9:03 A.M. the Administrator and DON said after admission to the facility a resident should have a baseline care plan completed within 48 hours. The baseline care plan should include resident-specific needs, code status, and any special services the resident receives, including hospice services. The DON said the purpose of including these concerns on the care plan was to communicate to staff how best to care for each resident individually.

**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) received personal care and showers in accordance with their needs and preferences (Residents #61, #40, #21 and #70). The sample was 18. The census was 74. Review of the facility's Bathing a Resident policy, revised July 2014, showed: -Policy: It is the policy of the company that residents will receive a shower/bath will be scheduled regularly and as needed (PRN); -Procedures included: -Check with the nurse to determine if special precautions need to be taken while showering or bathing the resident, e.g., cast, dressing, isolation precautions, toenails can be trimmed; -Assist the resident in showering/bathing if necessary; -Wash from head to feet, shampoo hair (if necessary), then wash perineal area; -Apply deodorant and lotion. If hair has been shampooed and will be dried in the resident's room, then towel dry hair and wrap in towel. Provide nail care if necessary. Cut toenails, if applicable and ordered by physician; -Document the date of the shower and any abnormalities on the bath/shower completion form. 1. Review of Resident #61's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/23, showed: -Cognitively impaired; -Independent with transfers, walking in room and hall; -Requires staff supervision for toileting and hygiene with one person physical assist; -Uses a walker; -Occasionally incontinent of bowel and bladder; -Diagnoses included anemia (low blood cells in blood), high blood pressure and psychotic (mental) disorder. Review of the resident's care plan, in use during the survey, showed it did not reflect any of the resident care needs. Observation and interview on 8/7/23 at 9:10 A.M., showed the resident lay in bed, with an extremely strong odor of urine noted. The resident's bed spread, bed sheet and multiple incontinent pads located under the resident were saturated with urine. A pile of approximately three urine stained sheets and incontinent pads were near the resident's doorway on the floor. The resident said the soiled linens had been there for several days. The resident didn't know what to do with them. A room deodorizer was sitting on the resident's bedside table. When the surveyor exited the room and closed the door per the resident's request, Certified Nurses Aide (CNA) R was walking past the resident's room and said that urine smell is strong. CNA R did not go into the resident's room. Observation and interview on 8/8/23 at 7:15 A.M., showed the resident lay in bed, with an extremely strong odor of urine noted. The resident's sheets had a yellow ring and two incontinent pads located under the resident were saturated with urine. A pile of approximately three urine stained sheets and incontinent pads sat near the resident's doorway on the floor. A white t-shirt with an American flag with urine stains was draped over the empty bed next to the resident. The resident said he/she is always incontinent and requires some assistance with his/her hygiene. During an interview on 8/9/23 at approximately 2:30 P.M., the resident said he/she had a special implanted device located in his/her back that controlled his/her urine. He/She believes the pump is broken or the batteries are dead because the urine goes out quickly and he/she has no bladder control. He/She has an appointment coming up to see his/her urologist (a kidney and bladder specialist). The resident's family member was visiting the resident and verified the resident had the device placed about three years ago. He/She takes the resident's clothing home to wash the resident's clothing that is soaked with urine. The family member has to use a special deodorizing laundry soap to kill the smell. Observation on 8/10/23 at 8:32 A.M., showed the resident lay in bed with his/her eyes closed. A strong odor of urine was noted. The resident's bed sheet and bed pads were saturated with urine. Observation on 8/11/23 at 7:01 A.M., showed the resident lay in bed with his/her eyes closed. A strong odor of urine was noted. The resident's bed had a yellow ring on the bed sheet underneath him/her. During an interview on 8/10/23 at 8:50 A.M., CNA F said the resident is not incontinent and is independent with his/her hygiene. CNA F looks at the care plan for the resident's care needs. During an interview on 8/10/23 at 10:25 A.M. CNA I said the resident is incontinent of urine and requires assistance with hygiene. The resident is forgetful and needs reminders. During an interview on 8/10/23 at approximately 12:00 P.M., the Director of Nursing (DON) said the resident is incontinent and staff is expected to help him/her with his/her hygiene and incontinent needs. 2. Review of Resident #40's medical record, showed: -Diagnoses included high blood pressure, multiple sclerosis (MS, nervous system disease affecting the brain and spinal cord), anxiety and depression; -A physician order, dated 9/26/22, to shower twice a week, Tuesdays and Fridays. Special instructions: Shower at least twice weekly per resident's preference. Once a day, Tuesday and Friday evenings. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Rejection of care behavior not exhibited; -Required extensive assistance of two (+) person physical assist for bed mobility and transfers; -Required extensive assistance of one person physical assist for dressing and personal hygiene; -Total dependence of one person physical assist for bathing; -Lower extremity impairment on both sides. Review of the resident's care plan, in use at the time of survey, showed: -Problem: ADL functional status/rehabilitation potential. Resident needs extensive assistance for ADLs related to cognitive impairment; -Goal: Resident will be able to maintain present level of functioning through next review date as evidenced by: blank; -Approaches included: Assist as needed with ADLs; -Problem: Cognitive loss/dementia. Resident is cognitively impaired; -Goal: Resident will have all needs anticipated and met by staff; -Interventions included: Anticipate all needs for resident. Provide total care; -The care plan failed to identify the resident's needs and preferences related to bathing/showers. Review of the resident's shower sheets. dated June 2023 through August 2023, showed: -In June 2023, five showers documented. The resident missed four scheduled showers; -In July 2023, seven showers documented; -On 8/1/23, shower sheet completed with type of bathing, shower or bed bath, not indicated. No documentation of issues related to the resident's skin, hair or nails. Observation on 8/7/23 at 9:17 A.M., showed the resident on his/her back in bed, dressed in a white hospital gown. The resident's shoulder-length hair was slicked back behind his/her head and was oily in appearance. Facial hair stubble less than 0.25 inches was present along his/her cheeks and chin. The fingernails on his/her right hand long, had a brown-red substance underneath his/her right thumbnail and pinky nail, which were approximately 0.25 inches long. During an interview, the resident said he/she cannot stand and needs staff to assist him/her with bathing. He/She could not remember the last time he/she had a shower. He/She was last shaved several weeks ago. Observations on 8/8/23 at 8:47 A.M. and 12:56 P.M., showed the resident on his/her back in bed, dressed in a white hospital gown. Several chunks of a tan substance were on the top of his/her hospital gown. His/Her shoulder-length hair was oily and slicked back behind his/her head. Facial hair stubble less than 0.25 inches was present along his/her cheeks and chin. The fingernails on his/her right hand long, had a brown-red substance underneath his/her right thumbnail and pinky nail, which were approximately 0.25 inches long. During an interview, the resident said the tan substance on his/her hospital gown was from dinner last night. At 12:56 P.M., the resident remained in the same soiled hospital gown with oily hair, facial hair stubble, and long fingernails with a substance underneath. Observation on 8/9/23 at 5:13 P.M., showed the resident on his/her back in bed. His/Her hair was cut to approximately 4 inches long. The resident's hair was oily and slicked back behind his/her head. During an interview, the resident said he/she had not received a shower. Observation on 8/10/23 at 7:34 A.M., showed the resident sat in his/her wheelchair with oily hair slicked behind his/her head. Chunks of yellow skin throughout the resident's hair were on the back of his/her head. During an interview on 8/10/23 at 9:32 A.M., CNA L said the resident has some confusion, but knows what he/she wants and needs. He/She does not like to get out of bed because he/she has pain. Today, CNA L saw the resident had dandruff and his/her hair was matted. He/She could tell the resident has not had a shower in some time. The resident is supposed to receive his/her showers during the evening shift. He/She requires total assistance from staff with personal care. The facility has a shower bed they can use for the resident's showers. During an interview on 8/11/23 at 7:19 A.M., Licensed Practical Nurse (LPN) A said the resident is alert and oriented. He/She can express his/her wants and needs and make his/her own decisions, but doesn't like to be bothered. The resident requires total assistance from staff with personal care. He/She hates to be out of bed and hates being in a chair. 3. Review of Resident #21's medical record, showed: -Diagnoses included high blood pressure, stroke, hemiplegia (paralysis to one side of the body) following stroke affecting left non-dominant side, contracture (stiffening of muscles) to left hand, muscle wasting and atrophy, generalized muscle weakness, abnormal posture and depression; -A physician order, dated 9/26/22, to shower twice a week, Wednesdays and Saturdays. Special instructions: Shower at least twice weekly per resident preference. Once a day on Wednesday and Saturday evenings. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Rejection of care behavior not exhibited; -Required extensive assistance of two (+) person physical assist for bed mobility and transfers; -Required extensive assistance of one person physical assist for dressing and personal hygiene; -Total dependence of one person physical assist for bathing; -Upper and lower extremity impairment on one side. Review of the resident's care plan, in use at the time of survey, showed: -Problem: ADL functional status/rehabilitation potential. Resident is totally dependent on nursing for all aspects of care related to stroke; -Goal: Resident will be kept well groomed, free of odors, and clean and dry by next review date; -Approaches included: Observe skin condition with daily care. Provide daily care for resident; -The care plan failed to identify the resident's needs and preferences related to bathing/showers. Review of the resident's shower sheets, dated June 2023 and July 2023, showed: -In June 2023, four showers documented. The resident missed four scheduled showers; -In July 2023, four showers documented. The resident missed four scheduled showers. Observations on 8/7/23 at 5:36 A.M. and 9:23 A.M., showed the resident on his/her back in bed with a brief on and no clothing, with a sheet covering the left side of his/her body. The skin on his/her right leg was dry and flaky. The resident's hair was wiry and disheveled, and measured approximately four inches long. Facial hair. approximately 0.25 inches long, was present on the resident's cheeks and chin. During an interview on 8/7/23 at 9:23 A.M., the resident said he/she has not been getting showers. Observation on 8/8/23 at 12:19 P.M., showed the resident on his/her back in bed, his/her hair was wiry and disheveled, and measured approximately four inches long. His/Her facial hair was approximately 0.25 inches long on the resident's cheeks and chin. Review of the resident's shower sheet, dated 8/8/23, showed: -Type bathing, shower or bed bath, not indicated; -No dryness indicated; -Does the resident need his/her toenails cut: blank. Observation on 8/9/23 at 10:29 A.M., showed the resident on his/her back in bed with his/her hair disheveled and facial hair measured approximately 0.25 inches long. He/She wore pants, leaving the bottom half of his/her dry, flaky shins exposed. The resident's right big toenail was jagged. Observation on 8/9/23 at 5:12 P.M., showed the resident on his/her back in bed, dressed in a hospital gown. The resident's face and head were shaved. A sheet covered the left side of the resident's body, leaving the right side exposed. The resident's right leg was dry and flaky. His/Her big toenail was jagged. [NAME] matter was underneath the resident's fingernails, approximately 0.5 inches long, on his/her right hand. During an interview, the resident said he/she usually gets bed baths and not showers. Today was the first day he/she received a shower in the past three weeks. He/She would prefer to take showers more often. He/She needs staff to assist him/her with this because he/she can't reach to do it him/herself. During an interview on 8/10/23 at 9:32 A.M., CNA L said the resident has some memory issues, but knows what he/she wants and needs. He/She likes to be clean and does not refuse personal care. He/She is paralyzed on one side and requires total assistance from staff with personal care. He/She is scheduled for showers on the evening shift. During an interview on 8/11/23 at 7:19 A.M., LPN A said the resident is alert and oriented and requires total assistance from staff with personal care due to being paralyzed on one side. 4. Review of Resident #70's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses of epilepsy, intellectual disabilities and bipolar disorder. Review of the resident's care plan, dated 7/10/23, showed the following: -Problem: admitted to long term care (LTC). Requires a baseline care plan identifying care needs, risks, strengths, and goals within the first 48 hours; -Goal: Initial goal is to remain in LTC. Will have access to necessary services to promote adjustment to his/her new living environment and or post discharge from facility; -Approach: Require assist with all activities of daily living. Limited, assistance with oral care; limited with bathing; limited, extensive with grooming; supervision with eating; limited with toileting; limited assistance with dressing; independent with mobility. Needs (support, assistance) to have his/her personal care needs met while supporting his/her strengths and personal goals. Observation on 8/7/23 at 11:45 A.M., showed the resident sat in the dining room on the second floor. The resident's hair was observed to be stringy and matted. Observation on 8/8/23 at 8:08 A.M., showed the resident's hair was stringy and matted. During an interview on 8/9/23 at 10:27 A.M., the resident said nothing can be done with his/her hair and that it will have to be cut off to fix it. The resident wanted his/her hair unmatted. During an observation and interview on 8/10/23 at 8:35 A.M., a staff member told the resident that they were glowing and a whole new person. The resident was smiling and his/her hair was cut and not matted. During an interview on 8/10/23 at 10:41 A.M., the Administrator said the resident's family member had tried to de matt the resident's hair but was unsuccessful. 5. During an interview on 8/10/23 at 9:32 A.M., CNA L said staff should follow the shower schedule documented in the resident's record. During a shower, staff should provide hair, skin and nail care. They should put lotion on dry, flaky skin. Staff are required to fill out shower sheets when they complete a shower and document any issues they observe. If a resident refuses their shower, CNAs should report it to the nurse. If the resident continues to refuse, staff document the refusal on a shower sheet and have the resident sign it. Once completed, shower sheets go in the binder at the nurse's station for the nurse. 6. During an interview on 8/10/23 at 9:52 A.M., CNA Q said CNAs follow the shower schedule on the staffing assignment sheets. Nursing staff fill out shower sheets for every shower completed, and they should mark any new skin issues and what care was provided during the shower. Bed baths do not count as showers. During a shower, staff should wash the resident's hair and put lotion on the resident's skin if it is dry. The DON lets CNAs know when it is time to cut a resident's nails. General nail care should be provided during showers, such as cleaning underneath the residents' fingernails. 7. During an interview on 8/11/23 at 7:19 A.M., LPN A said he/she expected nursing staff to follow the shower schedule. Completed showers should be documented on shower sheets, which are reviewed by the nurse. Shower sheets should be completed accurately. When providing a shower, he/she expected staff to wash the resident's hair, clean and trim their nails, and put lotion on the resident's dry skin. If a resident refuses a shower, he/she expected staff to ask the resident more than once. They should try involving another employee with whom the resident might have a good rapport. If the resident continues to refuse, staff should notify the nurse and have the resident sign a shower sheet. If a resident prefers bed baths, he/she expected staff to provide the resident with a thorough bed bath that addresses everything in a shower. A resident receiving a bed bath should be cleaned up just as well as they would be in a shower. If appropriate personal care was provided, brown substances should not be noted underneath a resident's fingernails. A resident's ADL requirements and bathing preferences should be documented on their care plan. 8. During an interview on 8/11/23 at 9:03 A.M., the Assistant Director of Nurses (ADON), DON, and Administrator said they expected residents to receive showers twice a week. It is expected that nursing staff follow the shower schedule. During a shower, staff should wash a resident's hair, clean and trim their nails, and apply lotion to their skin. Once a shower is completed, staff should document it in the resident's medical record and complete a shower sheet. If a resident does not want a shower during their scheduled time, staff should offer other options, such as a different time. If a resident refuses to shower, staff should notify the nurse so they can try to encourage the resident. If the resident continues to refuse, it should be documented on the shower sheet. Shower sheets are reviewed by the nurse and then should added to the resident's medical record. Residents #40 and #21 require total assistance from staff with personal care. They do not want to get on the shower beds used in the shower room. Staff could provide them with nail care and thorough bed baths in their rooms. It is expected for staff to provide the same level of cleanliness during a bed bath as in a shower. If a resident does not want their hair washed, the facility has non-rinse shampoo caps that can be used instead. A resident's specific ADL needs and preferences should be indicated on their care plan. All of nursing has access to update resident care plans. MO00210692 MO00214219 MO00216027

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement an ongoing resident centered activity program that incorporates the residents' interests and maintains and/or improves residents' physical, mental and psychosocial well-being for three residents (Resident #61, Resident #5 and Resident #63). The sample was 18. The census was 74. Review of the facility's undated Activity Program policy, showed: -An ongoing program of activities is designed to meet the needs of each resident; -The activity program is designed to encourage restoration to self-care and maintenance of normal activity which is geared to the individual resident's needs; -Activities are scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the program; -The activity program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident and includes, at a minimum: -Social activities; -Indoor and outdoor activities; -Activities away from the facility; -Religious programs; -Creative activities; -Intellectual and educational activities; -Exercise activities; -Individualized activities; -In-room activities; -Community activities; -Scheduled activities are posted on the resident bulletin board; -The individualized and group activities should reflect the schedules, choice and rights of the residents; -The activities are offered when they are convenient to the residents, including holidays and weekends; -Reflect the cultural and religious interests of the residents; -Appeal to both men and women as well as all age groups of residents in the facility; -Residents are encouraged, but not forced, to participate in scheduled activities; -Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. Review of the facility's second floor activities calendar, dated August, 2023, showed: -Sundays: -2:00 P.M., Ice cream and Movie; -6:00 P.M., Quiet Music and [NAME] Down; -Mondays: -10:30 A.M., Coloring and Music; -1:30 P.M., Movie and Snack; -6:00 P.M., Quiet Music and [NAME] Down; -Tuesdays: -10:30 A.M., Dance Party; -2:00 P.M., Coloring and Music; -6:00 P.M., Quiet Music and [NAME] Down; -Wednesdays: -10:30 A.M., Fancy Nails; -1:30 P.M., Movie and popcorn; -6:00 P.M., Quiet Music and [NAME] Down; -Thursdays: -10:30 A.M., Arts and Crafts; -2:00 P.M., Movie and Snack; -6:00 P.M., Quiet Music and [NAME] Down; -Fridays: -10:30 A.M., Dance Party; -2:00 P.M., Happy Hour; -Saturdays: -9:00 A.M., Quiet Music and Morning Motivation; -2:00 P.M., Movie and Snack; -6:00 P.M., Quiet Music and [NAME] Down. 1. Review of Resident #61's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/23, showed: -Cognition moderately impaired; -Interview for activities assessment: -How important is it to do things with groups of people?: Very important; -How important is it to you to do your favorite activities?: Very important; -How important is it to you to participate in religious activities?: Very important. Review of the resident's care plan, in use at the time of survey, showed activities was not addressed. Review of the resident's face sheet, showed his/her diagnosis included psychotic (mental) disorder with hallucinations and major depressive disorder. During observation and interview on 8/7/23 at 9:10 A.M., the resident said he/she does not really know when the activities are because staff members have not been reminding him/her. He/She would participate in everything if he/she could. He/She really wants some type of church service offered. The resident had an activity calendar posted in his/her room, dated July, 2023. During observation and interview on 8/9/23 at 2:30 P.M., the resident requested the surveyor take him/her to the movie and popcorn that was being offered. The resident was not sure how he/she heard about the activity because he/she did not have an updated calendar in his/her room. The resident walked to the second floor nurses' station and there was no movie playing or popcorn offered on the second floor. The resident requested Certified Nursing Assistant (CNA) F bring him/her to where the movie was being shown. The resident was brought to the first floor along with his/her family member by CNA F. The first floor large TV was on in the dining area. The Activities Director (AD) prepared the popcorn and said she was not sure what movie was on and it looked like a regular TV show was playing. The AD said she did not know how to work the DVD player to show the movies. 2. Review of Resident #5's annual MDS, dated [DATE], showed: -Moderately impaired cogitation; -Interview for activities assessment: -How important is it to you to keep up with the news?: Somewhat important; -How important is it to do thing with groups of people?: Somewhat important; -How important is it to you to do your favorite activities?: Somewhat important; -How important is it to you to go outside and get fresh air when the weather is good?: Very important. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is self-directed in choosing preferred activities; -Approach: Doing things with groups of people; Explain time, place and nature of the activity as needed; Invite the resident to daily activity of choice as tolerated; Reading books, newspapers or magazines; Keeping up with the news; Spending time outdoors and outside the facility; Offer activity materials to actively pursue diversified activities and remain occupied in and out of room as tolerated; Listening to music; Offer religious services of choice; Participate in favorite activities. Review of the resident's face sheet, showed his/her diagnoses included mild dementia, schizophrenia disorder (a mental condition that is a breakdown between thoughts, emotions and behavior, leading to faulty perceptions), stroke and failure to thrive. During an interview on 8/9/23 at 1:18 P.M., the resident said he/she had not been participating in many of the activities because he/she either does not know what they are or he/she is not interested. He/She thinks coloring is insulting and child-like. He/She has no idea what quiet music and winding down is. He/She has not seen a dance party. 3. Review of Resident #63's admission MDS, dated [DATE], showed: -Cognitively intact; -Interview for activities assessment: -How important is it to you to keep up with the news?: Somewhat important; -How important is it to do thing with groups of people?: Somewhat important; -How important is it to you to do your favorite activities?: Somewhat important; -How important is it to you to go outside and get fresh air when the weather is good?: Very important. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is self-directed is choosing preferred activities; -Approach: Explain time, place and nature of the activity as needed; Invite the resident to daily activity of choice as tolerated; Offer activity materials to actively pursue diversified activities and remain occupied in and out of room as tolerated; Offer religious services of choice; Provide monthly activity calendar in room; Respect residents right to choose to attend activity or not. Review of the resident's face sheet, showed his/her diagnoses included major depressive disorder. During observation and interview on 8/8/23 at 10:40 A.M., the resident said he/she requires staff to assist him/her to the activities. He/ She has not really liked any of the activities except for Bingo and the staff have to take him/her down to the first floor for it because he/she needs assistance with his/her wheelchair. The resident's posted activity calendar in his/her room was dated July, 2023. 4. During an interview on 8/8/23 at approximately 11:00 A.M., the Nurse Practitioner (NP) said it is very important for the activities to meet the interests of the residents, especially if they have mental disorders or conditions. It gives them something to look forward to. 5. During an interview on 8/10/23 at 10:10 A.M., the AD said she thought the activities had a lot of the same stuff offered. She has only been the AD for about three to four weeks. There are no religious services offered. 6. During an interview on 8/10/23 at 12:42 P.M., the Administrator said activities are expected to be resident centered.

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional. The census was 74. Review of the facility's undated Activities Program Staffing policy, showed: -The activity program is staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident; -The activity program is under the direct supervision of a qualified professional who: - Is a qualified therapeutic specialist or an activities professional who is licensed or registered, if applicable, by the state in which the person is practicing; -Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; -Or has two years' experience in a social or recreational program within the last five years; -Or is a qualified occupational therapist or occupation therapy assistant; -Or has completed a training course approved by the state. During an interview on 8/9/23 at 2:30 P.M., the Activities Director (AD) said she was the daytime receptionist until the facility eliminated that position about three to four weeks ago. She has had no training, experience, or any type of certification. She has had no input into the activities calendar and thinks that someone from corporate developed the current activities calendar. She did not know how to work the DVD player to play the movies and really did not know what some of the other activities consisted of because she did not receive any training. The AD has not been approached about any type of training since she took the position. During an interview on 8/11/23 at 12:42 P.M., the Administrator said the AD did not have type of certification or qualifications and was recently placed in the position three to four weeks ago. The facility is expected to have a qualified AD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an ongoing restorative nursing program (RNP) to ensure residents maintained their functional ability to the greatest extent possible (Residents #40, #16, #31, #35 and #57). The facility identified 20 residents as qualified for restorative therapy (RT) services. The census was 74. Review of the facility's Restorative Nursing policy, revised July 2014, showed: -Policy: It is the policy of the company to provide restorative nursing which promotes the resident's ability to live as independently and safely as possible. Restorative nursing focuses on achieving and maintaining the optimum level of physical, mental, and psychological function of the resident; -Procedure included: -Restorative nursing services are provided by Restorative Nursing Assistants, Certified Nursing Assistants (CNAs) and other staff trained in restorative techniques; -Restorative nursing is under nursing supervision; -Every resident who receives restorative nursing has a care plan with individualized, measurable goals and interventions; -Restorative treatments are recorded on the Restorative Nursing Participation Daily Record; -The treatment is listed on the Restorative Nursing Participation Daily Record in specific language to include the component and distance/number of repetitions. Example: Active range of motion (AROM) to bilateral upper extremities x 10 reps/5 x per week; -The Restorative Nursing Assistant documents the resident's progress on the Restorative Nursing Participation Daily Record; -The Restorative Nurse documents the resident's progress and indicates if the current plan should continue or if the resident should be referred back to therapy for a screen/evaluation. 1. Review of the Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/28/23, showed: -Moderate cognitive impairment; -Rejection of care behavior not exhibited; -Required extensive assistance of two (+) person physical assist for bed mobility and transfers; -Required extensive assistance of one person physical assist for locomotion, dressing and personal hygiene; -Required set up help for eating; -Total dependence of one person physical assist required for bathing; -Lower extremity impairment on both sides; -Diagnoses included high blood pressure, multiple sclerosis (MS, nervous system disease affecting the brain and spinal cord), anxiety and depression; -Physical therapy (PT) started 4/5/23. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident is at risk for contracture (stiffening of muscles) related to decreased mobility secondary to MS; -Goal: Resident will not develop any contractures by next review date; -Approaches included: AROM with daily care as tolerated to upper and lower extremities. Encourage resident to participate in daily range of motion (ROM) exercises; -Problem: Activities of daily living (ADLs) functional status/rehabilitation potential. Resident needs extensive assist for ADLs related to cognitive impairment; -Goal: Resident will be able to maintain present level of functioning through next review as evidenced by: (blank); -Approaches included: AROM/passive range of motion (PROM) with care as tolerance. PT as needed; -No documentation regarding a restorative program recommendation from PT. Review of the resident's physical therapy (PT) Discharge summary, dated [DATE], showed: -Diagnoses of MS and generalized muscle weakness; -Discharge reason: Highest practical level achieved; -Prognosis to maintain current level of function (CLOF) = good with consistent staff follow-through; -Discharge recommendations included: Restorative aide (RA) program in place; -Restorative program established/trained = other restorative program (omnicycle x 15 minutes at level 2 resistance). Review of the resident's electronic Physician Order Sheet (ePOS), reviewed 8/7/23, showed no orders for RT. Observation on 8/7/23 at 9:17 A.M., showed the resident on his/her back in bed with hands trembling. During an interview, the resident said he/she used to receive therapy but does not anymore. He/She can't stand and needs staff to assist him/her with bathing and walking. Observation on 8/8/23 at 8:57 A.M., showed the resident on his/her back in bed with hands trembling. During an interview, the resident said he/she has not received therapy in a while. He/She used to be right handed but now his/her hand is numb and he/she has to use his/her left hand for everything. Review of the resident's ePOS, reviewed 8/9/23 at 1:55 P.M., showed: -An order, dated 8/8/23, for RT program for bed mobility 6-7 times a week, every shift; -An order, dated 8/8/23, for RT program for dressing 6-7 times a week, every shift; -An order, dated 8/8/23, for RT program for transfers 6-7 times a week, every shift. Review of the facility's restorative nursing category report, run date 8/9/23, showed: -Date range: 8/7/23 through 8/9/23; -On 8/8/23 evening shift, resident received restorative nursing minutes for bed mobility, transfers, and dressing and/or grooming; -No additional restorative documented on other days or shifts. Review of the resident's electronic medical record (EMR), showed no other documentation of RT provided 5/29/23 through 8/8/23. During an interview on 8/9/23 at 2:34 P.M., the resident said he/she did not receive therapy or any assistance with his/her range of motion yesterday. He/She has not received therapy in months. He/She would like to get some therapy of whatever he/she can get. His/Her hands are numb and tingly, and he/she cannot use his/her right hand. He/She relies on staff to transfer him/her. He/She would like to get stronger. During an interview on 8/10/23 at 9:32 A.M., CNA L said the resident has some confusion, but he/she knows what he/she wants and needs. He/She doesn't like to be out of bed due to complaints that his/her back, bottom, and hands hurt. RT would be good for the resident to prevent muscle loss. The facility does not have a restorative program at this time. It has been months since they facility had a RA. 2. Review of Resident #16's occupational therapy (OT) Discharge summary, dated [DATE], showed: -Diagnoses of difficulty walking and generalized muscle weakness; -Discharge reason: Highest practical level achieved; -Prognosis to maintain current level of function (CLOF) = good with consistent staff follow-through; -Discharge recommendations included: Plan to establish RNP as indicated to maintain current strength and mobility; -Restorative program established/trained = Restorative ROM program. ROM program established/trained: Establish RNP as indicated to maintain current strength and mobility. Review of the resident's ePOS, showed an order, dated 11/10/23, to discharge from skilled OT at this time. Establish RNP as indicated in order to maintain current mobility and strength, once a day. Review of the resident's quarterly MDS, dated [DATE], showed: -Rejection of care behavior not exhibited; -Supervision of one person physical assist required for personal hygiene; -Required one person physical assist for bathing; -RNP received 0 days. Review of the resident's care plan, in use at the time of survey, showed: -Problem: ADL functional status/rehabilitation potential. Resident is independent with ADLs; -Goal: Resident will be able to maintain present level of functioning through next review as evidenced by: (blank); -Approaches included: OT/PT as needed. -No documentation regarding a restorative program recommendation from OT. Review of the facility's restorative nursing category report, run date 8/9/23, showed: -Date range: 8/7/23 through 8/9/23; -On 8/8/23 day shift, resident received restorative nursing minutes for dressing and/or grooming; -No additional restorative documented on other days. Review of the resident's EMR, showed no other documentation of RT provided 11/10/22 through 8/8/23. 3. Review of Resident #31's PT Discharge summary, dated [DATE], showed: -Diagnoses of fracture of right humerus (upper arm bone), generalized muscle weakness, and unsteadiness on feet; -Discharge reason: Highest practical level achieved; -Prognosis to maintain CLOF = excellent; -Discharge recommendations included: RA program in place; -Restorative program established/trained: Restorative ambulation program, restorative ROM program. Ambulation program established/trained; Walking along the hallway with 2 wheeled walker. ROM program established/trained: omnicycle with level 2 resistance x 15 minutes. Review of the resident's quarterly MDS, dated [DATE], showed: -Rejection of care behavior not exhibited; -Required supervision of one person physical assist for dressing and eating; -RNP received 0 days. Review of the resident's care plan, in use at the time of survey, showed: -Problem: ADL functional status/rehabilitation potential. Resident needs extensive assistance for ADLs related to cognitive deficit; -Goal: Resident will be able to maintain present level of functioning through next review as evidenced by: (blank); -Approaches included: AROM/PROM with care as tolerance. OT/PT as needed; -No documentation regarding a restorative program recommendation from PT. Review of the resident's ePOS, reviewed 8/8/23, showed no order for RT. Review of the facility's restorative nursing category report, run date 8/9/23, showed: -Date range: 8/7/23 through 8/9/23; -On 8/8/23 day and evening shift, resident received restorative nursing minutes for dressing and/or grooming and eating and/or swallowing; -No additional restorative documented on other days. Review of the resident's EMR, showed no other documentation of RT provided 5/29/23 through 8/8/23. 4. Review of Resident #35's quarterly MDS, dated [DATE], showed: -Rejection of care behavior not exhibited; -Required extensive assistance of one person physical assist for bed mobility, locomotion, and dressing; -Required extensive assistance of two (+) physical assist for transfers and toileting; -Total dependence of one person physical assist for personal hygiene; -Diagnoses included dementia; -RNP received 0 days. Review of the resident's care plan, in use at the time of survey, showed: -Problem: ADL functional status/rehabilitation potential. Resident is totally dependent on nursing for all aspects of care related to dementia; -Goal: Resident will be kept well groomed, free of odors and clean and dry by next review date; -Approaches included: AROM/PROM with care as tolerated. OT/PT screen as needed. -No documentation regarding a restorative program recommendation from PT. Review of the resident's PT Discharge summary, dated [DATE], showed: -Diagnoses included arthritis and generalized muscle weakness; -Reason for discharge: Highest practical level achieved; -Prognosis to maintain CLOF = good with consistent staff follow-through; -Discharge recommendations included RA program in place; -Restorative program established/trained = other restorative program (omnicycle x 15 minutes for bilateral lower extremities at level 1 to 2 resistance). Review of the resident's ePOS, reviewed 8/7/23, showed no order for RT. Review of the facility's restorative nursing category report, run date 8/9/23, showed: -Date range: 8/7/23 through 8/9/23; -On 8/8/23 day and night shift, resident received restorative nursing minutes for bed mobility, transfers, and dressing and/or grooming; -No additional restorative documented on other days. Review of the resident's EMR, showed no other documentation of RT provided 6/26/23 through 8/8/23. 5. Review of Resident #57's annual MDS, dated [DATE], showed: -Rejection of care behavior not exhibited; -Required extensive assistance of one person physical assist for bed mobility, transfers, walking, locomotion, toilet use, dressing, eating and personal hygiene; -Diagnoses included dementia and seizures. Review of the resident's care plan, in use at the time of survey, showed: -Problem: ADL functional status/rehabilitation potential. Resident is totally dependent on nursing for all aspects of care related to dementia; -Goal: Resident will be kept well groomed, free of odors and clean and dry by next review date; -Approaches included: AROM/PROM with care as tolerated. OT/PT screen as needed; -No documentation regarding a restorative program recommendation from PT. Review of the resident's PT Discharge summary, dated [DATE], showed: -Diagnoses included generalized muscle weakness and other abnormalities of gait and mobility; -Reason for discharge: Highest practical level achieved; -Prognosis to maintain CLOF = good with consistent staff follow-through; -Discharge recommendations included RA program in place; -Restorative program established/trained = Restorative ambulation program, other restorative program (omnicycle at level 1 resistance x 15 minutes); -Ambulation program established/trained: walking with hand held assistance and cues for directions. Review of the facility's restorative nursing category report, run date 8/9/23, showed: -Date range: 8/7/23 through 8/9/23; -On 8/8/23 day and night shifts, resident received restorative nursing minutes for bed mobility, transfers, walking, and dressing and/or grooming; -No additional restorative documented on other days. Review of the resident's EMR, showed no other documentation of RT provided 7/10/23 through 8/8/23. 6. During an interview on 8/10/23 at 9:52 A.M., CNA Q said the therapy department is responsible for doing restorative with residents. 7. During an interview on 8/11/23 at 7:19 A.M., Licensed Practical Nurse (LPN) A said when a resident is discharged from therapy, they are picked up by restorative to help the resident maintain their ADLs. The facility had a RA a few weeks ago, but not anymore. He/She does not know who oversees the RNP. 8. During an interview on 8/10/23 at 11:34 A.M., the Therapy Director said the therapy department makes the recommendations for some residents to receive RT. Therapy creates the restorative plan and gives it to the Director of Nurses (DON). It is up to the DON to implement the restorative program, not the therapy department. The facility used to have a RA, but they haven't had one for a few weeks. The point of restorative is to keep residents going, to help them maintain their current level of functioning and prevent them from further deteriorating. She expected recommendations for RT to be implemented within 30 days. 9. During an interview on 8/11/23 at 9:03 A.M., the Assistant Director of Nurses (ADON), DON, and Administrator said the DON oversees the restorative program. Therapy creates restorative plans given to nursing. The facility has not had a RA since October 2022. In October 2022, the facility changed EMR providers, which resulted in the restorative tracking function being turned off in the EMR. The restorative charting function was turned back on this week, a few days ago. There is no documentation to show restorative was done between October 2022 and this week. The restorative program started again a couple days ago. CNAs and Certified Medication Technicians (CMTs) are now responsible for doing restorative. When a resident is discharged from therapy with orders for RT, it is expected the resident is provided with RT right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper gait belt usage and the care planning of gait belt usage to ensure resident safety for two of 18 sampled residents (Residents #57 and #35) and failed to complete a smoking assessment and supervision for one sampled resident (Resident #126). The census was 74. 1. Review of the facility's Gait Belt Use policy, revised July 2014, showed the following: -Policy: It is the policy that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident or the employee; -Procedure: -Explain to the resident what is about to happen. The gait belt is placed around the resident's waist; -Fasten the gait belt snuggly, but not too tight. Be careful of tubes, wounds, or incisions; -When transferring the resident, use good body mechanics, bend knees, not back, reach under the resident's arms and hold the gait belt behind his/her back. Assist the resident to stand and complete the transfer. Request the assistance from a coworker if necessary; -When walking the resident, apply the gait belt, assist the resident to a standing position. Position yourself to the right or left of the resident (on the affected side if appropriate). Then, walk with the resident, placing your closest hand on the gait belt behind his/her back and holding his/her hand in your other hand. Walk slightly behind the resident so that if he/she starts to fall, you can pull the resident close to your body to support him/her to prevent the fall or slide the resident down your leg to ease him/her to the floor; -Staff will be given a copy of the gait belt policy and sign it during orientation. 2. Review of Resident #57's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 7/7/23, showed the following: -Diagnoses of legal blindness, chronic kidney disease, and high blood pressure; -Cognition not listed; -Extensive assistance needed when walking. Review of the resident's care plan, dated 2/7/23, showed no mention of gait belt usage when transferring or walking with the resident. During an observation on 8/7/23 at 8:44 A.M., Certified Nursing Assistant (CNA) R was observed to assist the resident down the hallway towards the dining room. The resident's arm extended straight in front of him/her as CNA R held onto the resident's hand. The resident's gait appeared unsteady. No gait belt was used. During an observation on 8/10/23 at 7:41 A.M., CNA F guided the resident into the dining room and held his/her right arm with one hand and one arm around the resident's back. The resident's gait at the time appeared unsteady. CNA F wore a gait belt around his/her neck. No gait belt was used. During an interview on 8/10/23 at 7:47 A.M., CNA F said staff use their gait belt to transfer the resident out of bed. He/She would have to look in the resident's chart to see if they were required to use a gait belt while walking. During an interview on 8/10/23 at 12:42 A.M., the Director of Nursing (DON) said that she would expect for staff to walk with the resident side by side in a gentle manner. Gait belt usage should be care planned for each resident. 3. Review of the Resident #35's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Transfers: Requires extensive assist with two persons; -Bed mobility: Requires extensive assist with one person; -Diagnoses include dementia. Review of the residents care plan, in use at the time of survey, showed: -Focus: Activities of Daily Living (ADL) functional status; the resident is dependent on nursing for all aspects of care related to dementia; -Approach: Ensure proper body alignment while in bed or chair; provide daily care for the resident; turn and reposition the resident while in bed or chair for comfort; -The resident's transfer status was not addressed on the care plan. Review of the resident's transfer assessment, dated 6/15/23, showed staff to use a gait belt and two persons for all transfers. Observation on 8/7/23 at 8:30 A.M., showed CNA R provided care to the resident and then positioned the resident's legs to the side of the bed. He/She then assisted the resident to an upright sitting position onto the side of the bed. CNA R positioned the resident's wheelchair next to the bed and lifted the resident under his/her arms off of the bed and encouraged the resident to stand. The resident was unable to straighten his/her legs and his/her knees remained bent. CNA R transferred the resident into his/her wheelchair by holding the resident under his/her arms. A gait belt was not used. During an interview on 8/10/23 at 7:50 A.M., CNA F said that the resident should be transferred with two persons and a gait belt. 4. During an interview on 8/9/23 at 10:30 A.M., the Rehab Director said gait belts are expected to be used for all residents that require assistance from staff. 5. During an interview on 8/10/23 at approximately 12:00 P.M. and 8/11/23 at 9:07 A.M., the DON said a gait belt is expected to be used when staff assist the residents. The purpose of a gait belt is for resident safety. 6. Review of the facility's Smoking policy, revised October 2017, showed: -Purpose: To assure that all residents are safe while smoking. To assure that all residents that do not smoke are not offended by or exposed to second hand smoke; -Procedure included: -Any resident that expresses an interest to smoke will be assessed at the time of admission and least quarterly or with any significant change to determine the level of assistance and supervision that will be needed to ensure the resident's safety; -Based on the assessment findings the resident's plan of care will be revised to reflect the level of assistance, supervision (note any concerns such as difficulty holding or lighting cigarette or burn holes in clothing), and assistive devices that will be needed by the resident to enable the resident's safety; -Smoking materials, including electronic cigarettes must be secured at the nurse's station when not in use, unless otherwise specified; -Residents who are determined by the care plan team to be able to smoke without supervision may smoke at will in the designated smoking area. Smoking materials will be returned to the nurse's station and will not be kept in the resident's room, unless a secured area of mechanism is available in the resident's room; -All residents that are not deemed capable to smoke unsupervised, will be given the opportunity to smoke with supervision at the designated facility smoking times. All smoking supplies for residents that require supervision will be kept at the nurse's station when not in use. Review of Resident #126's medical record, showed: -admission date 8/3/23; -Diagnoses included heart disease, chronic obstructive pulmonary disease (COPD, lung disease), anxiety, and depression. Review of the resident's electronic medical record (EMR), reviewed 8/7/23, showed no smoking assessments. Review of the resident's care plan, reviewed 8/7/23, showed no documentation regarding smoking. Observations on 8/7/23 at 8:44 A.M. 8/8/23 at 12:28 P.M., and 8/9/23 at 9:45 A.M., showed the resident sat in a wheelchair in the interior courtyard of the facility's first floor. The resident smoked a cigarette with no staff present. During an interview on 8/9/23 at 10:42 A.M., the resident said he/she was new to the facility. He/She can smoke outside by him/herself whenever he/she wants. He/She can keep his/her cigarettes and lighter with him/her. Observation on 8/9/23 at 2:28 P.M., showed the resident propelled in him/herself in a wheelchair outside to the interior courtyard. He/She removed cigarettes and a lighter from his/her pocket, lit the cigarette, and smoked it with no staff present. Review of the resident's EMR, reviewed 8/11/23, showed no smoking assessments. Review of the resident's care plan, reviewed 8/11/23, showed: -Problem: Resident admitted to facility for long-term care; -Approaches included: Resident is independent of all activities of daily living (ADLs) OR overall, requires supervision with oral care and bathing, independent with grooming, supervision with eating, and independent with toileting, dressing, and mobility. Resident is alert and cognitively intact. Resident requires orientation to surroundings, reminders, and assistance with medication management, meal times, therapy, ADLs, and recreational activities until acclimated; -The care plan failed to identify the resident's needs and preferences related to smoking. During an interview on 8/11/23 at 7:19 A.M., Licensed Practical Nurse (LPN) A said nurses are responsible for completing smoking assessments upon a resident's admission and quarterly. The purpose of completing the smoking assessment is to ensure safety for the resident and others. Some residents have been assessed to be able to smoke independently, without staff supervision. All residents are supposed to return their cigarettes and lighter to staff and these items are locked up at the nurse's station. Resident #126 is a smoker and was admitted to the facility on [DATE]. LPN A has seen the resident smoke independently and he/she seems to be safe. His/Her care plan should be updated to reflect smoking, and his/her smoking assessment should have been completed by now, but the EMR triggers some assessments late. Nurses rely on triggers from the EMR to prompt them when it is time to complete an assessment. During an interview on 8/11/23 at 9:03 A.M., the Assistant Director of Nursing (ADON), DON, and Administrator said residents should be assessed for smoking upon admission and on a quarterly basis. Some residents are able to smoke unsupervised, based on their smoking assessment. Cigarettes and lighters are supposed to be locked up and stored in activities or at the nurse's station. If a resident is assessed as able to smoke independently, the resident has to get their cigarettes and lighter from staff, go smoke, then return the items to staff. Resident #126's smoking assessment should have been completed by now. Smoking assessments are completed to ensure resident safety.

Based on observation, interview and record review the facility failed to ensure the Director of Nursing (DON) did not serve as charge nurse when the facility's average daily census was greater than 60 residents. The facility census was 74. Review of the facility's resident census for the duration of the survey and licensure process, showed a daily census of 72 residents at the facility. Observation of the lunch meal on 8/9/23 at 5:41 P.M. showed a resident rested in bed with the dinner meal placed on his/her side table over the bed. The facility DON provided assistance to the resident with eating the meal of navy bean soup, a fruit cup, and a tuna sandwich. During interview on 8/11/23 at 9:03 A.M., the facility administrator and DON estimated the average daily census at the facility is around 70 residents. When asked how many days this week the DON was needed to work the floor in order to provide adequate staffing levels for resident care, the DON responded all of them. The DON said she typically works the 7:00 A.M. to 3:00 P.M. shift once or twice a week as the charge nurse and three to four days per week on the evening shift to provide enough staffing to give adequate resident care. The facility Assistant DON has been completing at least some of the DON-specific tasks to accommodate this schedule. MO00220430 MO00216027

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. These practices affected one out of three medication carts and one out of one medication room reviewed. The census was 74. 1. Review of the facility's Medication Labels policy, undated, showed: -Labels are permanently affixed to the outside of the prescription container; -Each prescription medication label or package includes: -The resident's name; -Specific directions for use, including route of administration; -Medication name; -Strength of medication; -Prescribers name; -Date dispensed; -Quantity of medication; -Beyond use (or expiration) date of medication on the package. Review of the facility's Controlled Substance policy, revised July/2014, showed: -Controlled substances must be stored in the mediation room in a locked container or in a mediation care in a locked box, separate from containers for any non-controlled medications. 2. Review of the manufacturer's instructions for Advair inhaler (a medication used to treat lung disease), showed: Once opened may be used up to 30 days after removal from the foil pouch. Review of the manufacturer's instructions for Breo Ellipta inhaler (a medication used to treat lung disease), showed: Once opened may be used up to 30 days after removal from the foil pouch. Review of the manufacturer's instructions for albuterol sulfate (a medication to treat lung disease), showed: Once opened may be used up to 12 months. Review of the manufacturer's instructions for Combivent-Respimat (a medication used to treat lung disease), showed: May be used three months after first actuation (inhaling medication). Observation on 8/8/23 at 8:40 A.M., of the second floor Certified Medicine Technician (CMT) medication cart, showed: -Combivent-Respimat 20/100 micrograms (mcg) inhaler with no resident name or open date; -One Advair 500/50 mcg inhaler with no open date; -One Breo-Ellipta 100/25 mcg inhaler with no open date; -One albuterol sulfate 90 mcg with on open date. During an interview on 8/8/23 at 8:45 A.M., CMT J said the Combivent-Respimat did not have a name on it because everyone that works the cart knows it is for that particular resident and is in a slot with the resident's name. CMT J did not know that inhalers had to be labeled with the open date. During an interview on 8/8/23 at 9:00 A.M., the Director of Nurses (DON) said that the inhalers are expected to be labeled with the resident's name and open date. 3. Observation and interview on 8/8/23 at 9:07 A.M., of the second floor locked medication room, showed 59 vials of lorazepam (a medication to treat anxiety) 2 milligrams (mg) per milliliter (ml) were located in an unlocked refrigerator. The DON was not aware that the Lorazepam was in the unlocked refrigerator and it is expected to be in a locked refrigerator. 4. Review of a sign on 8/8/23 at 9:07 A.M., located on the unlocked refrigerator in a plastic sleeve, showed: -January, 2023 temperatures and February, 2023 temperatures documented as completed; -No further temperature logs available or provided upon request. During an interview on 8/8/23 at 9:07 A.M., the DON said that the night shift is expected to check the temperatures daily and place the temperatures on the log.

Based on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. The census was 74. Review of the facility assessment, dated 5/22/23, showed the staffing plan included one contracted RD and one director of food/nutrition services. During an interview on 8/10/23 at 1:18 P.M., the Culinary Services Director said he worked as a cook in the facility for two years and has been employed in his current position for five months. He has a food certification. He was unable to specify the area of certification or provide a copy of the certification. The facility has a RD consultant with corporate who does not work with the facility full-time. During an interview on 8/11/23 at 7:40 A.M., the Administrator said the facility has a consultant RD who does not work for the facility on a full-time basis. The Culinary Service Director's certification and education information was requested. During an interview on 8/11/23 at 8:00 A.M., the Administrator said the Culinary Services Director is not certified. She would expect the facility to have a director of food/nutrition services with the appropriate certification. She has signed up the Culinary Services Director for a certification course.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to have a system for monitoring proper functioning of the dish machine to ensure proper sanitation. The facility failed to ensure foods were stored at the appropriate temperatures to prevent foodborne illness. The facility failed to ensure foods were prepared and distributed under sanitary conditions when dietary staff failed to exhibit appropriate hand hygiene while serving food and to have facial hair properly covered during food preparation. The facility failed to appropriately store and handle dishware, and to store bulk dry goods and canned goods in a manner to protect from cross contamination. These deficient practices had the potential to affect all residents who ate at the facility. The census was 74. 1. Observation on 8/8/23 at 9:51 A.M., showed Dietary Aide (DA) D placed a bin of dirty dishes into the dish machine. The external temperature gauge on the dish machine showed 100 degrees Fahrenheit (F) during the first cycle. The external temperature gauge showed 120 degrees F during the second cycle. During an interview, DA D said he/she is one of the kitchen's dishwashers and runs dishes through the dish machine throughout his/her shift. The dish machine washes on the first cycle and rinses on the second cycle. He/She does not check the dish machine's temperature or chemicals. Observation on 8/10/23 at 1:07 P.M., showed DA D started the dish machine. The external temperature gauge showed 100 degrees F during the first cycle. During an interview on 8/8/23 at 10:04 A.M., the Culinary Service Director said dietary staff do not use the three-vat sink to wash dishes. All dishes are washed in the dish machine. Review of the operational requirements sticker on the exterior of the kitchen's dish machine, showed: -Wash temperature: 120 degrees F minimum; -Rinse temperature: 120 degrees F minimum; -Required: 60 parts per million (PPM) available chlorine rinse. Observation and interview on 8/10/23 at 1:11 P.M., showed a tube of PPM test strips on top of the dish machine's auto-drain compartment. During an interview, the Culinary Service Director said he had never tested the dish machine before. He did not have a manual for the dish machine. He left the dish machine area and returned with hydrogen (pH) paper test strips. He started the dish machine and dipped a pH strip into the dish machine's water reservoir. The strip turned a shade of light green and the Culinary Service Director said he was not sure what it meant. The Culinary Service Director removed a test strip from the container on top of the dish machine's auto-drain compartment. He dipped the test strip into the dish machine's water reservoir. The test strip turned grey. He compared the test strip to the guide on the test strip container, which showed 50 ppm. 2. Observation on 8/7/23 at 7:17 A.M., showed a refrigerator next to the deep fryer in the kitchen. The refrigerator's external digital thermometer showed 56 degrees F. Observation on 8/8/23 at 9:45 A.M., showed a refrigerator next to the deep fryer in the kitchen. The refrigerator contained an open container of heavy whipping cream, a container of coffee creamer, and several open bulk containers of condiments, including mayonnaise, ranch dressing, and various salad dressings. The refrigerator's external digital thermometer showed 50 degrees F. Observations of the kitchen on 8/9/23, showed: -At 4:49 P.M., a calibrated thermometer placed inside the refrigerator next to the deep fryer; -The refrigerator contained a large metal pan of potato salad, a wrapped bundle of lunch meat, a wrapped bundle of sliced cheese, a sandwich, and several open bulk containers of condiments, including mayonnaise, ranch dressing and various salad dressings; -At 4:51 P.M., the calibrated thermometer was removed and showed 53.6 degrees F; -The refrigerator's external digital thermometer showed 55 degrees F. Observation on 8/10/23 at 7:12 A.M., showed a refrigerator next to the deep fryer in the kitchen. The refrigerator contained an open container of heavy cream, a large metal pan of potato salad, a bin of white rice, and several open bulk containers of condiments, including mayonnaise, ranch dressing, and various salad dressings. The refrigerator's external digital thermometer showed 53 degrees F. Review of the temperature log posted on the refrigerator door, reviewed 8/10/23 at 7:14 A.M., showed: -On 8/1/23, 8/3/23, and 8/4/23, documented temperature of 45 degrees F; -On 8/7/23, documented temperature of 49 degrees F; -On 8/8/23, documented temperature of 46 degrees F; -On 8/9/23 and 8/10/23, no temperature documented; -All temperatures documented with the Culinary Service Director's initials. 3. Observation on 8/8/23 at 7:29 A.M., showed the Culinary Services Director with a face mask over his nose and mouth. Facial hair uncovered, approximately 0.25 inches (in.) long, were present on his cheeks and jawline, as he washed chicken and wrapped it in plastic. Observation on 8/8/23 at 9:25 A.M., showed the Culinary Services Director with a face mask over his nose and mouth. His facial hair was uncovered, approximately 0.25 in. long, and present on his cheeks and jawline, as he handled 80 chicken breasts to be served at lunch. Observation on 8/9/23 at 4:50 P.M., showed the Culinary Services Director with a face mask over his nose and mouth. His facial hair was uncovered, approximately 0.25 in. long, and present on his cheeks and jawline, as he used plastic wrap to cover a bin of chicken. Observation on 8/10/23 at 7:17 A.M., showed the Culinary Services Director with a face mask over his nose and mouth. His facial hair was uncovered, approximately 0.25 in. long, and present on his cheeks and jawline, as he handled bread to be served at breakfast. Observation on 8/10/23 from 8:15 A.M. to 8:26 A.M., showed the Culinary Services Director with a face mask over his nose and mouth. His facial hair was uncovered, approximately 0.25 in. long, and present on his cheeks and jawline, as he prepared trays of food in the second floor kitchenette for 18 residents. 4. Observations on 8/8/23, showed: -At 7:51 A.M., DA C with ungloved hands, removed stacks of wet plates, approximately 40 total, from the dish line and placed them on a rolling wire cart; -At 7:58 A.M., DA C with ungloved hands, used the sink's water nozzle to rinse dirty pans. He/She placed the pans in the dish machine and turned the machine on. He/She removed a stack of wet plates from the dish line and placed them on a rolling wire cart; -At 8:00 A.M., DA C entered the walk-in cooler and exited within the minute; -At 8:00 A.M., DA C with ungloved hands, picked up a stack of plates and added them to a rolling wire cart; -At 8:04 A.M., DA C with ungloved hands, picked up a green bucket, rinsed it out with the nozzle at the sink, and left it on the sink's counter; -At 8:06 A.M., DA C with ungloved hands, picked up a stack of napkins and placed them on the rolling wire cart. He/She touched his/her right ear and covered hair with his/her right hand; -At 8:07 A.M., DA C with ungloved hands, brought rags out from the cleaning supply room. He/She brought the green bucket from the sink to the three-vat sink and filled two green buckets with cleaning solution; -At 8:08 A.M., DA C with ungloved hands, grabbed a handful of gloves and placed them on top of the rolling wire cart; -At 8:11 A.M., DA C with ungloved hands, placed the green buckets on top of the rolling wire carts and pushed one of the carts out of the kitchen, down the hall, and onto the elevator; -At 8:14 A.M., DA C entered the first floor kitchenette with the wire rolling cart. He/She did not wash his/her hands before putting on gloves from the top of the rolling wire cart; -From 8:18 A.M. to 8:25 A.M., DA C sorted through tray cards with his/her right hand and placed a card on a tray with a wet plate. While holding trays with his/her left hand, he/she used his/her right hand to pick up pieces of toast and bacon to place on trays. Approximately 12 trays went out to residents in the dining room; -At 8:26 A.M., DA C wiped his/her pants with his/her right hand; -From 8:28 A.M. to 8:40 A.M., DA C sorted through tray cards with his/her right hand and placed a card on a tray with a wet plate. While holding trays with his/her left hand, he/she used his/her right hand to pick up pieces of toast and bacon to place on trays. Approximately 6 trays went to residents in the dining room and 12 trays were placed on the warming cart for residents who receive hall trays. Observation on 8/8/23 at 10:09 A.M., showed DA S removed a stack of bowls from the clean area of the dish line, leaning the stack of bowls against his/her shirt, and placed them on a shelf. DA S removed a second stack of bowls from the clean area of the dish line, leaning the stack of bowls against his/her shirt. He/She placed his/her chin in the top bowl as he/she carried the stack across the kitchen. DA S picked up three small stacks of bowls at the clean area of the dish line, placing his/her thumb in the top bowl of each stack, and carried the stack of bowls to the dish storage area. 5. Observation on 8/8/23 at 10:14 A.M., showed two stacks of approximately 32 bowls total, stacked right side up on the wire shelving in the dish storage area. The bowls were wet. Observation on 8/10/23 at 7:18 A.M., showed stacks of plate covers, stacked right side up, on the wire shelving unit in the dish storage area. The top plate cover of each stack contained crumbs and debris, with orange liquid pooled at the bottom of one plate cover. 6. Observation of the kitchen's dry storage area on 8/8/23 at 7:39 A.M., showed two dented 50 ounce (oz.) cans of chicken noodle soup stored in the front row of the soup, among all other canned goods. Observations of the kitchen's dry storage area on 8/8/23 at 7:39 A.M. and 8/10/23 at 7:24 A.M., showed two dented 50 oz. cans of chicken noodle soup stored in the front row of the soup, and a 99 oz. can of shredded sauerkraut in the front row, among all of the other canned goods. 7. Observation on 8/7/23 at 7:15 A.M., showed scoops in the bulk flour bin and bulk oat bin, with handles resting on the food products. Observation on 8/9/23 at 4:46 P.M., showed a scoop in the bulk flour bin. The lid of the bulk sugar bin was off with a fly inside the bin. 8. During an interview on 8/10/23 at 1:18 P.M., the Culinary Service Director said he has been in his position with the facility for five months. He takes the refrigerator temperatures first thing in the morning, when it has been closed all night. Refrigerator temperatures should be at 41 degrees F for food preservation. Dietary staff's hair and facial hair should be completely covered in food preparation areas at all times to prevent contamination. The facility does not have beard guards to cover facial hair. He expected dietary staff to wash their hands before putting on gloves to handle food. Tray cards are not considered to be sanitary. Dietary staff should wash their hands and change their gloves when moving from dirty to clean. Dishes should be stacked inverted so water and debris do not get inside the dishes. Dented cans should be thrown away and should not be stocked with the rest of canned goods. Dented cans should not be used due to potential contamination. He expected bulk storage bins to be covered with scoops stored separately to prevent cross contamination. 9. During an interview on 8/11/23 at 7:40 A.M., the Administrator said she expected dietary staff to have a system for monitoring proper functioning of the dish machine. She expected refrigerators used for food storage to be maintained at less than 41 degrees F. If dietary staff observe a refrigerator's temperature is out of range, it should be reported to the Administrator or Maintenance. She expected dietary staff to ensure all hair, including facial hair, is covered throughout food preparation areas. She expected staff to practice hand hygiene in between touching clean and dirty objects/surfaces. She expected staff to store dishes in a manner that prevents bacterial growth and cross contamination. She expected dietary staff to dispose of dented cans or store them separately from the rest of the canned goods.

Based on interview and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff member was verbally discourteous to one resident (Resident #6). The sample size was 13. The census was 78. Review of the facility's policy entitled, Resident's Rights, undated, showed the following: -Residents have a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. This facility shall protect and promote the rights of each resident which shall include the following rights: -A resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion, as well as having his/her property misappropriated. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/12/22, showed: -Cognitively intact; -No behaviors noted; -Diagnoses included anxiety, depression, chronic obstructive pulmonary disease (COPD, lung disease that blocks airflow) and osteoarthritis (chronic degeneration of the joint cartilage). Review of the resident's care plan, revision date of 2/7/23, showed the following: -Problem: The resident presents with independence when making decisions; -Interventions included allow the resident ample time to understand and respond to conversation, provide opportunities for resident to make decisions; -Problem: the resident exhibits problems as seen by verbally abusive language toward staff, often accuses staff of things that are not true when unable to receive medications; -Interventions included: encourage the resident to vent feelings, fears, frustrations as needed. Review of the resident's physician order sheet, showed the following: -An order dated 2/7/23, for Trazodone (anti-depressant) 150 milligrams (mg), give at bedtime, 8:00 P.M. for insomnia. Review of the resident's progress notes, dated 2/12/23 at 7:52 A.M., showed Licensed Practical Nurse (LPN) A wrote the resident was having a hissy fit during the 4:00 P.M. medication pass by saying he/she needed his/her night medications. The resident started early evening trying to manipulate the staff into giving his/her medication that he/she should not have. The resident tried to confuse staff into thinking that they were wrong, knowing staff was not. The resident then pretended that he/she couldn't breathe and he/she could get the medication, he/she would feel better. The resident then threatened staff saying he/she was going to call the Administrator and his/her family. The LPN educated the resident regarding the medication, saying it would make the resident drowsy and would cause a problem if the resident did not stay in bed because the resident did not have stable balance. The resident thinks he/she can threaten staff into getting his/her way. During an interview on 2/28/23 at 9:21 A.M., the resident said the following: -Some staff are nicer than others; -The night nurse was rude, yelled and screamed at him/her; -One time, the night nurse put the resident in his/her wheelchair, tipped it back and spun the resident around and around in circles, laughing at the resident when he/she pleaded with the nurse to stop; -He/She reported it to the Administrator but nothing happened to the nurse that the resident knew of. During an interview on 2/28/23 at 1:10 P.M., the Administrator said the following: -The resident and LPN A did not get along; -The resident had reported to her previously that LPN A would speak harshly to the resident, speaks abruptly to him/her, and was too direct, all of which upset the resident; -The Administrator spoke to LPN A about the resident's complaint and the LPN said the resident must have misunderstood him/her. Going forward, LPN A would make sure he/she would be more cautious in his/her speech. During an interview on 3/10/23 at 12:47 P.M., LPN A said the following: -The resident always wanted his/her medication early; -He/She educated the resident saying he/she would get too drowsy after taking the medication if the resident took it at 5:00 P.M.; -If he/she gave the resident the medication early, the resident would refuse to stay in his/her wheelchair or bed and would then fall; -He/She would not deliberately speak rudely to residents; -He/She could see how his/her tone could be interpreted as rude by the residents as the LPN had a stern, direct manner. Review of facility's investigation, dated 2/28/23, time unknown, showed the following: -The Social Worker conducted interviews with all residents on the first floor, asking the following questions: -Have you ever had any of the aides treat you badly or rough?; Have you ever had any of the aides speak to you badly?; -Have any of the nurses treated you badly or rough?; -Have you ever heard the aides or the nurses treating another resident badly or rough?; -One resident voiced a concern regarding LPN A. Resident #6 alleged that he/she was out in the hall talking with other residents when LPN A came bouncing out of nowhere and grabbed his/her wheelchair and lifted the front wheel off the ground and began spinning him/her in circles. The resident kept asking him/her to stop and put him/her down and he/she kept doing it. He/She then put the resident in his/her room and the resident asked him/her why he/she did that and he/she never answered the resident. The resident didn't remember when this happened or who else was around when it happened; -Additional questions were asked of residents on the floor and none reported witnessing any such incident; -During an interview on 3/2/23, time unknown, LPN A regarding the allegations, the employee denied ever spinning resident around in the wheelchair. He/She admitted the resident got upset with him/her often because the resident requested to take his/her medication sooner than it was prescribed. LPN A reported the resident called him/her mean sometimes because of this. LPN A reported that they bicker with each other a lot; -Based on the conclusion of the investigation, the facility gave LPN A disciplinary action for being discourteous to residents in a manner that can be perceived as unprofessional or mean tone. MO00214694 MO00214677

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision and assistance for one resident (Resident #1) who utilized a wheelchair, was totally dependent on two or more staff for bed mobility and transfers, and had impaired range of motion on both sides of the upper and lower extremities. On 2/26/23, the resident was found with swelling to his/her face on the left side after receiving care from Certified Nursing Assistant (CNA) B. The facility also failed to ensure care was provided to residents in a manner that helped promote quality of life by not supervising or evaluating the care given by CNA B, which resulted in complaints of rough treatment from six sampled residents (Resident #5, #7, #8, #10, #12 and #13). The sample size was 13. The census was 78. Review of the facility's Accident and Supervision policy, undated, showed the following: -The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents; -The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents; - All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident; - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. 1. Review of Resident #1's care plan, dated 12/9/22, showed the following: -Problem: The resident is totally dependent on nursing for all aspects of care related to multiple sclerosis (MS, disease affecting brain, spinal cord and nervous system), use Hoyer lift (mechanical lift) for all transfers and must have two staff members at all times; -Interventions included ensure proper body alignment when in bed or chair; -There was no documentation regarding refusal of care or behaviors. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/14/22, showed: -admitted on [DATE]; -Severe cognitive deficiencies; -Required extensive assistance of two or more people for bed mobility, transfers and dressing; -Required extensive assistance of one person for personal hygiene; -Toilet use was shown as an activity that did not occur; -Impairment on both upper and lower body; -Wheelchair for mobility; -Diagnoses included kidney failure, neurogenic bladder (lacks bladder control due to brain, spinal cord or nerve problem), dementia, paraplegia (paralysis of the legs and lower body), MS, depression and psychotic disorder (mental disorder characterized by a disconnection from reality). Review of the resident's physician order sheets, showed an order dated 1/17/23, for Eliqius (blood thinner) 5 milligrams (mg), give 5 mg twice a day for thrombosis (blood clots). Review of the resident's medication administration record (MAR), dated February 2023, showed the facility administered Eliquis 5 mg twice a day as ordered. Review of the resident's side rail screening, dated 2/20/23, showed the resident requested side rails to provide and allow independence in bed mobility. Two side rails will be raised as an enabler to promote independence. Review of the resident's progress notes, showed the following: -On 2/27/23 at 1:01 A.M., the resident was noted to have a large swelling to the left side of his/her face. No discoloration, or redness noted. When asked the resident how long he/she had that, he/she said two days. The writer couldn't recall seeing any swelling the previous day. The resident complained of pain. Upon examination of the resident's mouth, it appeared he/she had an extra-large cavity in a tooth that was swollen and discolored. As needed (PRN) medication was given for comfort. Resident will see the Nurse Practitioner (NP) tomorrow morning; -On 2/27/23 at 8:27 A.M., the resident had swelling and bruising relating to abscess to left side of his/her face and under his/ her left eye. No limited range of motion to area, pain to area which the resident received pain medication, notified in house NP and Assistant Director of Nursing (ADON); -On 2/27/23 at 9:42 A.M., the NP assessed the resident and found he/she had swelling and bruising with associated pain to the left side of his/her face. The resident stated his/her face has been swollen and in pain since yesterday; -On 2/27/23 at 10:29 A.M., the NP gave orders to send the resident out to the hospital for evaluation and treatment. Review of the hospital records, dated 2/27/23, showed the following: -At 11:41 A.M., the physical exam showed the resident had left sided facial bruising and swelling, poor dentition (poor, or missing teeth), no gingival fluctuance (pus at the gums) or swelling; -The medical decision making, showed the resident had left sided facial swelling, bruising and poor dentition, no gingival fluctuance. The computerized tomography (CT, a series of x-ray images taken from different angles) of the soft tissue in the resident' face showed no evidence of abscess (pocket of pus in a tooth caused by infection), a hematoma (bruise) was present and with no facial fracture. During an interview on 2/28/23 at 1:10 P.M., the Administrator said the following: -She expected staff to report any new skin conditions immediately to the nurse so they could assess the resident's condition; -She expected staff to immediately contact the administrative team if there was suspected abuse; -They were not aware there was a suspicion of abuse until this morning when the hospital called and gave report on the resident's condition. They thought the resident's swelling was due to an infection in one of his/her teeth; -She expected staff to treat all residents with respect and give care in a gentle way; -She expected staff to notify her if there was an accident which may have caused injury; -She started the investigation into the incident regarding the resident's bruised and swollen face immediately upon getting the hospital report; -She was not sure if the resident was coming back to the facility. Review of the facility's investigation, dated 2/28/23, showed the following: -The resident had varying mentation throughout the day but usually alert and orientated to self and place. He/She had assist rails on his/her bed that are approximately 5 inches wide to allow the resident to assist with holding self over during hygiene. He/She was transferred via Hoyer lift (mechanical lift); -Statements and interviews were gathered from all staff that had worked with the resident for the previous 48 hours. No one had noticed any swelling or bruising. No one reports seeing any possible abuse, rough handling, or issues with transfers with the resident; -Statement and interview with NP on 2/28/23 found that she had questioned the resident also about the injury when she was assessing the resident on 2/27/23. She reports that the resident denied being hit by anything, anyone or falling to cause the injury. The NP reports the facial swelling appeared to be from a dental issue at the time; -Statements and interviews were completed on all residents residing on the floor where the resident resided. Eight residents voiced concerns about CNA B rough handing with care. They reported asking him/her to slow down or be gentler but he/she did not comply. No one reported being hit or struck by CNA B, but handled roughly; -Licensed Practical Nurse (LPN) A testified he/she saw the resident on two occasions previous to CNA B giving the resident direct care. The resident did not have evidence of any swelling or bruising until after CNA B gave care to the resident; -At the conclusion of the facility's investigation, they determined based on statements from staff and residents it was plausible that the bruising and swelling happened when the resident was receiving incontinence care from CNA B. Multiple checks on the resident prior to that care revealed no swelling or bruising. One possibility is that, with the assist rails to the bed at the approximate level of resident's shoulder, his/her face bumped into the rail when the CNA rolled the resident onto his/ her left side unassisted. Because multiple residents reported that CNA B did things quickly, was not gentle, and was sometimes rough with residents, CNA B was terminated. During an interview on 3/10/23 at 8:33 A.M., CNA B said the following: -He/She came on shift on 2/26/23 at approximately 3:30 P.M., and immediately started rounds on his/her assigned residents; -He/She did rounds on the residents by him/herself and did not receive report from the off-going staff; -When CNA B entered the resident's room during his/her initial rounds, he/she noticed the resident needed incontinence care and had a light swelling located on the resident's jaw on the left side of his/her face; -CNA B immediately told LPN A; -LPN A came and assessed the resident, looked into the resident's mouth and said the swelling was caused by an abscessed tooth; -CNA B asked the resident if something happened to cause the swelling and the resident said he/she did not know and was not in any pain; -After LPN A assessed the resident, CNA B performed perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks) for the resident without help from another staff member; -The resident was totally dependent on one to two staff for bed mobility and could not hold him/herself by utilizing the positioning bars on his/her bed; -There were 1/4 size positioning bars attached on each side of the resident's bed, located at approximately upper arm level. The resident was not able to pull him/herself up using the rails; -CNA B used a draw sheet (a long sheet under a resident's buttocks which acts as leverage when pulling a resident to their side); -CNA B knew he/she should have had help from another CNA to position the resident, as the resident was difficult to move and could not pull him/herself up with the side rails. There was no one available to help CNA B; -CNA B put a pillow between the positioning bar and the resident's head/face for protection; -He/She had never received reports that he/she was too rough with the residents from the administrative team; -Residents would complain to him/her that he/she was too rough, too fast while giving care. They also asked that he/she explain what he/she was going to do next before performing the task; -He/She would apologize to the residents and explain it was not his/her intent to act roughly or disrespectfully; -CNA B admitted he/she might move too fast when providing direct care but it was not intentional; -CNA B knew residents had a right to refuse care and to be treated with dignity and respect. During an interview on 3/10/23 at 12:47 P.M., LPN A said the following: -He/She was the nurse assigned to the resident's floor on 2/26/23; -His/Her assignment started at approximately 5:00 P.M.; -He/She answered the resident's call light shortly after his/her arrival to the unit. The resident wanted his/her medications early. There were no visible marks to the resident's face at that time; -The resident pressed the call light again, during dinner time at approximately 5:30 P.M. and asked for incontinence care. LPN A told the resident they were in the middle of passing hall trays but will send CNA B to the room for assistance; -LPN A saw the resident again at approximately 7:30 P.M., as a foul odor of bowel movement was emitting from outside the resident's room. The resident informed him/her that he/she still need incontinence care; -LPN A approached CNA B to tell him/her again to go and provide care to the resident. CNA B was perturbed at LPN A after their conversation; -CNA B provided incontinence care to the resident and at approximately between 8:45 P.M. and 9:15 P.M. and went to LPN A to report the resident had swelling to his/her left face and jaw; -LPN A assessed the resident immediately and saw the swelling on the resident's left lower cheek and jaw. He/She described it looked as if the resident had pocketed his/her food between his/her gum and cheek; -LPN A used a flashlight to peer into the resident's mouth and the tooth near the swelling had a cavity, though the resident's norm was bad teeth; -LPN A assumed the resident had an abscessed tooth and gave the resident Tylenol for pain as ordered; -CNA B told LPN A the swelling was there before he/she provided incontinence care; -LPN A had not seen any swelling to the resident's face until after CNA B provided care; -LPN A monitored the resident's condition throughout the shift and noticed the resident's cheek, jaw, and under the eye, on the left side of his/her face, had developed a bruise and increased swelling; -LPN A reported the assessment to the Director of Nursing (DON) and the visiting NP; -The NP assessed the resident, agreed it could be an abscessed tooth and gave orders to send the resident out to the hospital for evaluation. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included neurogenic bladder, MS and depression. Review of the facility investigation, dated 2/28/23, unknown time, showed during an interview the resident said the following: -He/She had issues with CNA B being rough and he/she hurt after the CNA took care of him/her. 3. Review of Resident #7's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included diabetes mellitus, fracture, stroke, hemiplegia (paralysis on one side of the body), seizures and depression. Review of the facility investigation, dated 2/28/23, unknown time, showed during an interview the resident said the following: -CNA B was very rough with him/her and was verbally aggressive also. 4. Review of Resident #8's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included kidney failure, diabetes mellitus, stroke, hemiplegia and depression. Review of the facility investigation, dated 2/28/23, unknown time, showed during an interview the resident said the following: -CNA B was very rough during care and pulled on the resident's arm. 5. Review of Resident #10's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included diabetes mellitus, anxiety and depression, Review of the facility investigation, dated 2/28/23, unknown time, showed during an interview the resident said the following: -He/She was Resident #1's roommate and witnessed CNA B be very rough with him/her. CNA B would yank on Resident #1. 6, Review of Resident #12's quarterly MDS, dated [DATE], showed: -Able to make self-understood and able to understand others; -Short term and long term memory intact; -Independent of making decisions on daily tasks of life; -Diagnoses included heart failure, kidney disease, diabetes mellitus and chronic obstructive pulmonary disease (COPD, lung disease that blocks airflow). Review of the facility investigation, dated 2/28/23, unknown time, showed during an interview the resident said the following: -CNA B was very rough when giving care to him/her. 7. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included septicemia (an infection of the blood), diabetes mellitus and bipolar disease (psychiatric illness characterized by both manic and depressive episodes, and manic ones only). Review of the facility investigation, dated 2/28/23, unknown time, showed during an interview the resident said the following: -CNA B had been rough and verbally aggressive with him/her. 8. Review of CNA B's last performance evaluation, showed it was dated 7/20/21. 9. Review of an email sent by the Administrator on 3/22/23 at 11:40 A.M., showed the facility had some changes in the nursing office about the time of CNA B's next scheduled evaluation and she believed it got missed. MO00214694 MO00214677

Based on interview and record review, the facility failed to follow their policy and report an allegation of resident abuse to the Department of Health and Senior Services (DHSS) as required, within a two-hour time frame, for one of three sampled residents (Resident #1). The census was 81. Review of the facility's abuse, neglect and exploitation policy, reviewed on 10/8/20, showed the following: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law; -Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or; Not later than 24 hours if the events that cause the allegations do not involve abuse or do not result in serious bodily injury. Review of the Resident #1's medical record, showed the following: -Diagnoses included stroke, head injury, traumatic subdural hemorrhage (a serious condition where blood collects between the skull and the surface of the brain due to a severe brain injury) with loss of consciousness, gastrostomy tube (g-tube, a tube inserted through the wall of the abdomen directly into the stomach for nutrition, hydration and medications) and seizures; -A note, dated 11/11/22 at 8:00 P.M., showed the resident was admitted to the facility, spoke English but was very confused. He/She was not able to make all his/her needs known and be correct due to confusion; -A skin assessment, dated 11/18/22 at 6:56 P.M., showed no skin abnormalities were present; -A note, dated 11/21/22 at 1:37 A.M., showed the resident pulled out his/her g-tube. The physician was called and new orders were given to send the resident to the hospital in the morning; -A note, dated 11/21/22 at 8:55 A.M., showed the resident left the facility to go to the hospital; -A note, dated 11/21/22 at 4:15 P.M., showed the resident returned to the facility from the hospital with his/her g-tube replaced; -There was no documentation regarding the resident making an allegation of abuse against the facility. During an interview on 11/22/22 at 10:43 A.M., the resident said the following: -He/she was in a room, sitting in his/her wheelchair, when a staff member (provided a specific name), put his/her arms around the resident's chest and picked him/her up out of his/her wheelchair. The action caused the resident's whole body and back to crack and was painful; -The staff member also twisted the resident's neck, made it crack, and called the resident bad names; -The event happened about a month ago; -He/she told a staff member and the staff member got upset. He/she could not remember who he/she reported to or when; -The same thing happened yesterday when staff followed the resident to the train station and yelled at the resident again. He/she could not name or describe the staff members. During an interview on 11/22/22 at 11:39 A.M., the social worker (SW) said the following: -She received a call at approximately 1:45 P.M. on 11/21/22 from the hospital nurse, who said the resident made allegations that staff was abusing him/her at the facility; -She was not sure who was responsible for reporting abuse allegations to DHSS; she thought it was the Director of Nursing (DON); -The facility policy was to report allegation of abuse within two hours. During an interview on 11/22/22 at 11:26 A.M., the administrator said the following: -The hospital called the facility on 11/21/22, spoke to the facility SW and told her the resident had made allegations that facility staff had choked him/her; -She thought that if the hospital was really concerned about the validity of the abuse allegation, they would not have returned the resident to the facility; -She did not report the allegation to DHSS as required because the hospital staff said they were calling DHSS to report the allegation of abuse. During an interview on 11/22/22 at 12:02 P.M., the DON said the following: -She did not find out about the resident making an allegation of abuse until this morning at morning meeting; -She did not report the abuse allegation to DHSS because the hospital said they were reporting the facility to DHSS; -The facility policy was to report allegations of abuse within two hours, if the resident was in the facility when the allegations were made. During an interview on 11/28/22 at 12:51 P.M., the administrator said the following: -She expected staff to follow policies and procedures; -Both she and the DON acted as the Abuse Coordinator and were responsible to report abuse allegations to DHSS within the required time-frames. MO00210218

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately take steps to begin an immediate full, documented investigation of an allegation of abuse and to protect all residents during the investigation when a resident alleged staff members had abused him/her both physically and verbally (Resident #1). The sample size was three. The census was 81. Review of the facility's abuse, neglect and exploitation policy, reviewed on 10/8/20, showed the following: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish; -The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written; -An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation or reports of abuse, neglect or exploitation occur; -Written procedures for investigations include: Identifying staff responsible for investigation; Investigation different types of alleged violations; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witness, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause; Providing complete and thorough documentation of the investigation; -The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and the integrity of the investigation; Examining the alleged victim for any signs of injury, including a physical exam or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Review of Resident #1's medical record, showed the following: -Diagnoses included stroke, head injury, traumatic subdural hemorrhage (a serious condition where blood collects between the skull and the surface of the brain due to a severe brain injury) with loss of consciousness, gastrostomy tube (g-tube, a tube inserted through the wall of the abdomen directly into the stomach for nutrition, hydration and medications) and seizures; -A note, dated 11/11/22, at 8:00 P.M., showed the resident was admitted to the facility, spoke English but was very confused. He/she was not able to make all his/her needs known and be correct due to confusion; -A skin assessment, dated 11/18/22 at 6:56 P.M., showed no skin abnormalities were present; -A note, dated 11/21/22 at 1:37 A.M., showed the resident pulled out his/her g-tube. The physician was called and new orders were given to send the resident to the hospital in the morning; -A note, dated 11/21/22 at 8:55 A.M., showed the resident left the facility to go to the hospital; -A note, dated 11/21/22 at 4:15 P.M., showed the resident returned to the facility from the hospital with his/her g-tube replaced; -No baseline care plan or care plan found; -No documentation regarding the resident making an allegation of abuse; -No documentation of a skin assessment on 11/21/22 or 11/22/22. Review of the facility's incident/accident report, dated 11/22/22, showed no documentation of an incident regarding the resident. During an interview on 11/22/22 at 10:19 A.M., Certified Medication Technician (CMT) A said the following; -He/she did not know of any recent allegations of abuse on the floor where the resident resided; -He/she worked on the floor where the resident resided today and yesterday; -He/she expected the facility to investigate allegations of abuse and to suspend the alleged perpetrator until the investigation was completed. During an interview on 11/22/22 at 10:28 A.M., Certified Nursing Assistant (CNA) B said the following: -He/she did not know of any recent allegations of abuse on the floor where the resident resided; -He/she worked on the floor where the resident resided today and yesterday; -He/she was not assigned to care for the resident yesterday but did assist another CNA to help get the resident into his/her wheelchair; -He/she did not see any abuse occur to the resident; -He/she expected the facility to investigate allegations of abuse and to suspend the alleged perpetrator until the investigation was completed. During an interview on 11/22/22 at 10:36 A.M., CNA C said the following: -He/she did not know of any recent allegations of abuse on the floor where the resident resided; -He/she worked on the floor where the resident resided today and yesterday; -He/she was assigned to assist the resident today and yesterday; -He/she did not witness any abuse occur to the resident and the resident did not report any abuse occurred to him/her; -He/she expected the facility to investigate allegations of abuse and to suspend the alleged perpetrator until the investigation was completed; -He/she loved working with the resident and had no problems working with the resident; -The resident was often confused, was alert to self and sometimes to place. During an interview on 11/22/22 at 10:43 A.M., the resident said the following: -He/she was in a room, sitting in his/her wheelchair, when a staff member (provided a name), put his/her arms around the resident's chest and picked him/her up out of his/her wheelchair. The action caused the resident's whole body and back to crack and was painful; -The staff member also twisted the resident's neck, made it crack, and called the resident bad names; -The event happened about a month ago; -He/she told a staff member and the staff member got upset. He/she could not remember who he/she reported to or when; -The same thing happened yesterday when staff followed the resident to the train station and yelled at the resident again. He/she could not name or describe the staff members. During an interview on 11/22/22 at 11:39 A.M., the social worker (SW) said the following: -She received a call at approximately 1:45 P.M. on 11/21/22 from the hospital nurse who said the resident made allegations that staff was abusing him/her at the facility; -The resident said two staff members, (by name), and described one of them had long, frizzy, brown hair; -The facility did not have a staff member by these names; -The resident's Power of Attorney (POA) was at the facility and said the resident was often confused when the SW reported the resident's allegation of abuse; -The resident's POA was not concerned about the allegation, just said OK and left the facility; -The SW interviewed the resident this morning before the surveyor came to the facility. The resident said facility staff hurt him/her by cracking his/her bones during care. The resident said the name of the alleged perpetrator, which sounded similar to CNA C's name, but CNA C had very short, almost shaved blonde hair; -CNA B has long, brown hair but was not assigned to care for the resident; -She stopped the investigation after the surveyor arrived because she did not want to interfere with the surveyor's investigation; -Investigations of abuse normally consisted of interviewing all residents to ask if they had any complaints of care or felt threatened by staff, to inform the family, and inform the administrator and Director of Nursing (DON); -She informed the administrator and the Assistant Director of Nursing (ADON) yesterday of the abuse allegation before the resident arrived back to the facility; -She documented investigations after they were complete in resident's progress notes. During an interview on 11/22/22 at 11:26 A.M., the administrator said the following: -The hospital called the facility on 11/21/22, spoke to the facility SW and told her the resident had made allegations that facility staff had choked him/her; -She thought if the hospital was really concerned about the validity of the abuse allegation, they would not have returned the resident to the facility; -She expected staff to fill out an incident report in residents' electronic medical report when there was an allegation of abuse; -She was not sure why the resident was not listed on the facility's incident/accident report; -The incident/accident report was generated by the electronic medical record system which would compile all the individual incident/accident reports created by nursing. During an interview on 11/22/22 at 12:02 P.M., the DON said the following: -She did not find out about the resident making an allegation of abuse until this morning at morning meeting; -She was not working on 11/21/22; -She expected the SW to start the investigation once the abuse allegations were made by interviewing the residents and staff; -The resident reported two staff members choked him/her but the DON did not recognize the names belonging to any facility staff; -She expected staff to immediately start an investigation when there was an allegation of abuse; -The staff should first remove the resident to safety, send an alleged perpetrator home pending investigation, get statements (from the resident, residents on the hall, and staff) and assessments (skin, pain, vitals, etc.) of the resident, and also notify family and physician; -She expected staff to document the investigation in the resident's medical record in both progress notes and in an incident report for continuity of care; -She expected the nurses to start the investigation if the ADON or DON were not in building; -She expected Nurse D to start an investigation by getting statements from residents and staff and by completing head to toe assessments on the resident when the resident arrived back from the hospital on [DATE]. During an interview on 11/22/22 at 12:30 P.M., CNA B said the following: -He/she was not interviewed by Nurse D yesterday; -He/she worked with the resident yesterday but the resident was already up and dressed when he/she arrived to his/her assignment; -The resident was sent to the hospital shortly after breakfast; -He/she has had long, brown hair for the past few days, before that he/she had long, brown hair that he/she wore in a bun or a ponytail; -The resident sometimes complained staff rolled him/her too much during care but did not complain of pain; -He/she would explain to the resident that staff had to roll him/her in order to provide care and the resident was not upset; -The resident was often confused, asking for people who were not there, but was easily redirected. The resident was a sweetheart. During an interview on 11/22/22 at 1:14 P.M., the ADON said the following: -She worked on 11/21/22 and was assigned as charge nurse on the resident's floor today; -The administrator told her about the resident's allegation of abuse yesterday while the resident was at the hospital; -She thought the resident made the allegation of abuse about hospital staff until the morning meeting, when she found out the resident made the abuse allegations against the facility; -She was not told to start an investigation; -The offgoing nurse did not tell the ADON the resident made an allegation of abuse; -She expected the offgoing nurse to know about the allegation of abuse for continuity of care; -She expected staff to immediately start an investigation when hearing an allegation of abuse by getting the resident safe, send the alleged perpetrator home pending investigation, get statements from residents and staff, and complete head to toe assessments on the resident; -She expected staff to document the investigation in the progress notes and on an investigation report so other staff was aware of what occurred and what needed completed. During an interview on 11/22/22 at 1:30 P.M., the Nurse Practitioner (NP) said she was not aware of the resident's abuse allegations until that morning. During an interview on 11/22/22 at 1:56 P.M., CNA C said the following: -He/she did a skin assessment with the DON earlier today while the surveyor was in the building; -The ADON informed him/her of the resident's abuse allegations after the surveyor was in the building. During an interview on 11/22/22 at 2:00 P.M., CNA B said he/she was not informed the resident made an allegation of abuse. He/she was not asked to give a statement by other staff members. During an interview on 11/22/22 at 2:08 P.M., CMT A said the following: -He/she was not informed the resident made an allegation of abuse; -He/she was not asked to give a statement by other staff members; -He/she expected to know about an allegation of abuse so he/she could ensure the resident felt safe during care; -He/she would watch for any changes in the resident's behavior and would care for the resident with another staff member. During an interview on 11/22/22 at 3:56 P.M., the DON said the following: -She expected staff to start an investigation as soon as abuse allegations were made; -She expected staff to interview residents, staff who worked with the resident, notify the family and the physician, and complete a head to toe assessment on the resident; -She expected staff to document the investigation in the resident's progress notes and to create an incident report so all would know for continuity of care and to maintain an accurate record; -She expected Nurse D and the ADON to start the investigation of abuse on 11/21/22 because both staff members were made aware of the resident's allegation of abuse before the resident came back from the hospital; -She expected the off-going staff to report the abuse allegation to the oncoming staff so the oncoming staff could change care if needed, perhaps care in pairs; -She expected the care plan to get updated with new interventions after the investigation was completed; -She expected the SW to document the conversation she had with the hospital staff, including the notification of the resident's family member, in the resident's medical record. During an interview on 11/28/22 at 12:51 P.M., the administrator said the following: -She expected staff to follow policies and procedures; -She expected completion of investigations within 24 hours of the first notification of an allegation; -She expected the investigation of the resident's abuse allegation to be completed by mid-afternoon on 11/22/22; -There were many staff members who had long, brown hair. During an interview on 11/28/22 at 1:20 P.M., the DON said the following: -She started the investigation after the surveyor came to the facility on [DATE]; -She interviewed staff while the surveyor was at the facility. MO00210218

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure two dependent residents (Residents #53 and #72) had their call lights within reach to allow them to call when they required staff assistance. The facility census was 99. 1. Review of Resident #72's most recent Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/14/20, showed the following staff assessment: -Understands others; -Usually understood; -Dependence on staff assistance for completion of his/her activities of daily living (ADLs). Review of the resident's comprehensive care plan for the area of ADL functional status, not dated, showed the resident needs assistance from one staff member. Review of the resident's care card showed the following: -Staff are directed to assist x 1 with all ADLs; -The resident self-propels in a wheelchair; -The resident is at risk for falls; -The resident is incontinent of bowel and bladder. Observation on 3/2/20 at 4:56 P.M. showed the resident sat in his/her wheelchair with his/her head slumped down to his/her chest, next to his/her bed. The resident said he/she would like to go to bed. The resident sat facing a bedside table and the wall behind it. The resident was not within reach of his/her call light that was wedged between the bedside table and the top drawer. The resident pointed to the call light, and the surveyor handed the call light to the resident. Observations on 3/3/20 at 1:32 P.M. showed the activities director wheeled the resident in his/her wheelchair from the dining room to his/her room. The resident's call light sat on the resident's bed, but not within reach of the resident. At 2:03 P.M., the resident remained seated in his/her wheelchair facing his/her bedside table and wall. The call light remained out of the resident's reach. The resident said he/she wanted to go to bed. At 3:20 P.M. and 4:46 P.M., the resident remained in the wheelchair at his/her bedside, with his/her head slumped down, and out of reach of his/her call light. Observation on 3/4/20 at 9:36 A.M., showed the resident sat in his/her wheelchair next to his/her bed, with his/her head slumped down to his/her chest. The resident said can I go to bed now? It's always like this. The resident sat out of reach of his/her call light that was wedged in his/her bedside cabinet drawer and not within reach of the resident. During an interview on 3/5/20 at 2:28 P.M., certified nurse aide (CNA) G said the resident is alert and oriented most of the time. The resident requires one staff for assistance with his/her ADLs and is able to voice his/her needs. During an interview on 3/6/20 at 11:27 A.M., CNA H said the resident is able to make his/her needs known and requires one staff assistance to use the toilet and with other ADLs. The resident does use his/her call light and will alert staff when he/she needs to have a bowel movement. 2. Review of Resident #53's most recent MDS, dated [DATE], showed the following staff assessment: -The resident had moderately impaired cognitive skills for daily decision making; -Required staff assistance for completion of his/her ADLs. Review of the resident's comprehensive care plan showed staff noted the resident had a history of falls. The plan directed staff to: -Keep the resident's call light and water in reach; -Answer the call light promptly; -Remind the resident to ask for assistance; reorient the resident to the call light if necessary. Observation on 3/3/20 at 1:50 P.M., showed the resident sat in his/her wheelchair at the bedside. His/her call light was clipped to his/her bed on the right side of the resident, but he/she could not reach the call light. The resident said he/she has use of his/her right hand, but it doesn't extend out as normal. Observation on 3/4/20 at 9:31 A.M., showed the resident sat in his/her wheelchair next to his/her bed. The resident's call light was clipped to the resident's bed on his/her right side and behind his/her chair, out of reach. The resident asked the surveyor for his/her call light, so he/she could call for help. Observation on 3/5/20 at 9:06 A.M., showed the resident sat in his/her wheelchair next to his/her bed. The resident's call light was attached to the room dividing curtain behind the resident, and not in his/her reach. During an interview on 3/6/20 at 3:08 P.M., CNA J said the resident can make his/her needs known. The resident will use his/her call light or yell at people walking by his/her room to get assistance. The resident requires total care, except he/she feeds him/herself. During an interview on 3/6/20 at 4:14 P.M., CNA I said call lights should be in reach for all residents whether they are able to use the call light or not. During an interview on 3/6/20 at 5:30 P.M., the administrator and Director of Nurses (DON) said call lights should be in reach of all residents, regardless of if a resident uses the call light or not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to ensure one resident's (Resident #77) physician's orders for his/her code status matched the resident's advance directive wishes and failed to ensure two residents' (Residents #65 and #307) current physician's orders listed the resident's code status. The facility census was 99. 1. Review of Resident #65's code status form in front of the medical record, dated [DATE], showed the resident wished to be a full code. Review of the resident's physician's order sheet (POS) dated [DATE]-[DATE] showed no code status listed on the resident's current physician's orders. 2. Review of Resident #77's Code Status Form in his/her medical record showed it is his/her choice to be a Full Code (Cardio Pulmonary Resuscitation (CPR) would be performed if the resident's heart and/or breathing stopped). Review of the POS, dated [DATE] - [DATE], showed the resident did not have an order for code status. 3. Review of Resident #307's Code Status Form in front of the medical record, dated [DATE], showed the resident's responsible party wished for the resident to have a code status of Do Not Resuscitate (DNR)/Do Not Intubate (No CODE). Review of the resident's physician's order sheet dated [DATE]-[DATE] showed an order for a full code status. Review of the resident's face sheet, dated [DATE], showed the resident was a full code. During an interview on [DATE] at 5:30 P.M., the administrator and director of nursing (DON) said residents' code status should be listed on the resident's face sheet and physician's orders sheet. During an interview on [DATE] at 5:30 P.M., the administrator said if the resident or resident's responsible party indicated on the Code Status Form that the resident be a DNR, Social Services should follow up with the physician about changing their code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to revise, review and/or update the comprehensive care plan for three residents (Residents #31, #44, and #46). Review of the facility's undated Comprehensive Care Plan Development policy and procedure, showed it is the policy of the facility to complete a comprehensive care plan for each resident requiring a Minimum Data Set (MDS) assessment and care area assessment (CAA) completion. 1) The care plan is based on the CAA process, which is required for Omnibus Budget Reconciliation Act (OBRA)-required comprehensive assessments. 2) After completing the MDS and CAA portions of the comprehensive assessment, the interdisciplinary team must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's strengths, problems, and needs. 3) A new care plan does not need to be developed after each annual assessment or significant change assessment, but the MDS and CAAs should be assessed for the need to modify or revise the current care plan. 4) The facility should also evaluate the appropriateness of the care plan after each quarterly assessment and modify the care plan on an ongoing basis, if appropriate. 1. Review of Resident #46's most recent Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/11/19, showed the following staff assessment of the resident: -Independent in cognitive skills for daily decision making; -Dependent on staff for completion of all his/her activities of daily living (ADLs); -One Stage IV pressure ulcer; no other pressure ulcers; -An unplanned weight loss. Review of the resident's plan of care showed the following: -The resident's wound care company's printed progress notes dated 2/7/20 and 2/24/20; -A resident's wound care company's exit interview forms dated 9/30/19 and 12/2/19, that show a summary of each resident in the facility that the company visited on that date (including this resident), and a description of those residents' wounds; -MDS Care Area Assessment (CAA) Summary sheets dated 12/11/19 and 2/13/20; -A care plan for unplanned weight gain, dated 3/23/17, that directed staff in interventions to assist the resident in weight loss; -A care plan that address a planned weight loss, dated 1/21/19, that directed staff in interventions to assist the resident to not lose additional weight; -A care plan for unplanned weight loss, dated 2/20, that shows, My diet is (blank) and I have been placed on the following supplements: (blank); the plan directs staff in interventions to assist the resident to not lose additional weight; -Six different care plans that addressed pressure ulcers, some of which were noted to have healed. One dated 10/1/16 showed a pressure ulcer on the resident's right proximal posterior heel, with notation on 5/8/18 that the resident has no pressure ulcers at that time, and one dated 4/21/17 showed a pressure ulcer on the resident's left heel, with notation on 5/8/18 that the resident had no pressure ulcers. These plans were still part of the comprehensive care plan. All six of the plans addressed the same interventions for staff, except for one written in note that the resident refuses to lay down and wants to smoke. -One plan, undated, that addressed pressure ulcers on the right and left hip. Due to no date, it was not possible to show when the resident had the pressure ulcers and if staff should still be directed on the plan. -Eight pages of a care plan completed in a different format, some pages dated and others not, that appear to be the resident's initial plan of care created upon admission on [DATE]. One plan, dated 3/9/16, directed staff in the resident's ADL needs, which included assistance for completion of the resident's ADLs, to hand the resident one item at a time, and to cue and allow resident to do as much for self as is safely able to do. Review of the resident's Care Card, which directs care staff use to provide care, showed staff were directed that the resident is total care, and his/her left arm is paralyzed. 2. Review of Resident #44's most recent MDS, dated [DATE], showed the following staff assessment: -Independent in cognitive skills for daily decision making; -No behavioral issues or rejection of care. Review of the resident's plan of care showed the following: -MDS CAA Summary sheets dated 12/13/19 and 2/28/20; -A plan dated 11/29/19, which noted the resident had behavioral disturbances including physically and verbally inappropriate and refuses care as evidenced by exposing him/herself to staff members of the opposite sex, refuses showers and curses at staff. The plan did not show the resident refused taking his/her medications when they are ordered to be given. The plan showed the resident would receive his/her medications as ordered by his/her attending physician and will be monitored for potential side effects as well as efficacy. Review of the resident's nurse's notes showed the following: -On 10/3/19, 11-7 shift, resident evening medications still at bedside; encourage to take all medications per order; -On 10/4/19, 11-7 shift, medication left at bedside; -On 10/6/19, 11-7 shift, medication still on bedside table; encourage to take all medications; -On 10/8/19, 11-7 shift, resident has evening medications still at the bedside; encourage to take all meds; -On 10/10/19, shift not specified, medication left on bedside table; -On 10/11/19, shift not specified, medication left on bedside table; encourage to take all meds daily; -On 10/12/19, shift not specified, evening meds left on bedside table; -On 11/25/19, shift not specified, medication left on bedside table, resident encouraged to take his meds; very noncompliant with his/her medication; Observation on 3/4/20 at 9:46 A.M., showed the resident sat in a wheelchair in his/her room. A medicine cup containing multiple medications sat on the resident's bedside table. The resident said he/she had just finished dressing and would take his/her pills in a bit. The resident said staff brought the medications in during breakfast, and he/she just hadn't taken them yet. Observation on 3/5/20 at 9:35 A.M., showed the resident lay asleep in his/her bed. A medicine cup with multiple medications sat on the bedside table beside the resident. Staff were not present. 3. Review of Resident #31's most recent MDS, dated [DATE], showed the following staff assessment: -Moderately impaired cognitive skills for daily decision making; -Independent for completion of his/her ADLs; -Had two falls with no injury, one fall with an injury (not major) and one fall with a major injury (bone fracture, joint dislocation, closed head injury with altered consciousness, or subdural hematoma). Review of the resident's plan of care showed the following: -A CAA Summary dated 10/2/19; -Two different care plans for smoking; one dated 1/16/18 that showed the resident was assessed to be able to smoke with assistance only; one dated 2/4/19 that showed the resident was assessed to be able to smoke independently. -A page that appeared to be a copy of a sign, dated for the resident's admission date of 10/24/17, directing staff to not let the resident leave the building with anyone. -Six pages of the resident's referral for services at the facility in 10/17, his/her intensive treatment plan dated 10/2/17, and a behavior contract dated 5/4/18. -Two different care plans for falls, one dated 9/22/19 and one dated 2/20. The plans direct staff on the same interventions; -A plan of care to address falls, dated 2/20, with staff notes that the resident has many complaints of falls when he/she is with his/her family. The resident has been seen putting him/herself on the floor; -A plan of care for falls in a different format than the other fall plans, with updates dated 5/14/19 and 12/26/19. The 12/26/19 note showed the resident has a soft cast for three weeks on his/her right hand. This notation did not state that the resident fell in the shower room, nor any additional interventions to prevent a future fall while the resident showers him/herself. During an interview on 3/4/20 at 2:00 P.M., the resident said he/she broke her wrist with a fall in the bathroom while taking a shower. During an interview on 3/6/20 at 11:47 A.M., Licensed Practical Nurse (LPN) M said the resident fell in the shower room a while back; the LPN sent the resident out to the hospital due to a wrist injury. The LPN said staff only set up the resident's shower, and the resident is able to complete his/her shower his/her own. Review of a nurse's note dated 12/18/19 showed an x-ray was performed due to the resident falling in the bathroom. The resident was sent to the emergency department and returned on 12/19/19 with a orthopedic soft cast. During an interview on 3/5/20 at 10:38 A.M., LPN N said the charge nurse can update the care plans in the care plan book if they need to, but he/she would usually notify the Quality Assurance (QA) nurse or the administrator if changes needed to be made. The LPN does not know when the care plans are reviewed, who reviews them, if the care plans are signed and dated when they are reviewed. During an interview on 3/5/20 at 5:00 P.M., the QA nurse and the administrator said there is no documentation such as a sign in sheet to show when the care plans are reviewed and who reviewed them. The administrator said he/she is responsible for completing the care plans and keeping them updated, but it is very hard to keep up with in addition to his/her duties as an administrator. During an interview on 3/6/20 at 5:30 P.M., the administrator said she completes residents' care plans. She said the care plan should be an overall picture of the residents' needs. She thought adding residents' wound assessments and additional paperwork to the care plans helped to explain everything about the resident and their needs. Old care plan interventions were kept in the care plan to show all interventions that had been implemented. The administrator said ideally, a care plan should be updated after each fall, but right now, she has only been adding the number of falls a resident had in the month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide adequate and appropriate perineal cleansing for two dependent residents (Residents #23 and #46) and failed to ensure good grooming for one resident's (Resident #72) fingernails. The facility census was 99. 1. Review of Resident #23's most recent MDS, dated [DATE], showed the following staff assessment: - Required extensive assistance from staff for dressing, toileting and personal hygiene; - Always incontinent of bladder; - Frequently incontinent of bowel; - Diagnosed with a urinary tract infection (UTI). Review of the resident's care plan, with multiple dates, showed the following: - The resident was at risk for pressure ulcers. Staff were directed to manage moisture (skin and incontinence management); - The resident was reluctant to perform personal hygiene without assistance. Staff were directed to assist as needed. Observation on 3/3/20 at 9:50 A.M., showed certified nurse aide (CNA) B provided care for the resident while the resident was in bed. The resident was incontinent of urine. CNA B used a wet washcloth to wipe the resident's lower back and buttocks and then wiped the perineal area from back to front. CNA B used a second wet wash cloth and again wiped the resident's lower back and buttocks and then wiped the perineal area from back to front. CNA B then used a towel to first dry the resident's lower back and buttocks and then the perineal area, wiping from back to front. During an interview on 3/6/20 at 5:30 P.M., the director of nurses (DON) said she expected staff to wipe from front to back when cleansing a resident's perineal area. 2. Review of Resident #46's most recent Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/11/19, showed the following staff assessment: -Dependent on staff for completion of his/her activities of daily living (ADLs), including toileting and personal hygiene; -Incontinent of bowel; -Had a urinary catheter; -Had one Stage IV pressure ulcer. Review of the resident's plan of care showed the following: -An undated plan which directed staff on the management of his/her suprapubic catheter; the plan had one written in update dated 6/15/17 which stated the resident's suprapubic catheter was patent; -A plan for activities which showed a written intervention dated 4/1/19 stating the resident is total care and needs assistance. Observation on 3/3/20 at 10:36 A.M., showed CNA G and CNA H provided care for the resident while in bed. CNA G used washcloths perineal cleansing spray for cleaning the resident's perineal area, but did moisten the washcloths before he/she sprayed the cleanser onto the cloth. CNA G wiped the resident's front while the resident lay on his/her back, by wiping down between the resident's legs without spreading the resident's legs. The CNA observed the cloth after wiping and with the last swipe, still showed brown smears. The CNAs turned the resident to his/her side, which showed the pad beneath the resident was wet with urine and smears of feces. The resident said he/she does have some urine leakage at times. CNA G wiped the resident's bottom with the dry cloth and perineal spray. The CNA cleansed the resident's right buttock and hip around his/her wound bandages, but did not cleanse the left buttock and hip. During an interview on 3/6/20 at 3:55 P.M., CNA I said the resident requires total care by staff. The resident has a suprapubic catheter, but dribbles some urine. The CNA said when cleaning a resident's perineal area, it is important to thoroughly clean all areas soiled with feces or urine. 3. Review of Resident #72's most recent MDS, dated [DATE], showed the following staff assessment of the resident: -Dependent on staff for his/her activities of daily living; -Incontinent of bowel and bladder. Review of the resident's plan of care for ADL functions, not dated, showed staff noted the following: -The resident is capable of performing partial hygiene and grooming without assistance; -The resident is reluctant to perform personal hygiene without assistance; -The resident requires assistance from one staff member for ADL completion. Observation on 3/2/20 at 4:56 P.M., showed the resident sat in his/her wheelchair. The resident's nails were long and exhibited brown debris beneath the length of the nails. Continued observations on 3/3/20 at 3:20 P.M. and on 3/4/20 at 9:36 A.M., showed the resident's fingernails remained with thick brown debris under the nails, which extended approximately one-quarter inch long, and the resident's hands and nails exhibited a foul, sour odor. Staff did not assist the resident to clean his/her nails until 3/5/20 at 9:08 A.M. During an interview on 3/6/20 at 11:27 A.M., CNA H said staff are directed to cleans residents' fingernails during showers and as needed to maintain good hygiene. During an interview on 3/6/20 at 5:30 P.M., the administrator and DON said when providing perineal cleansing, staff are expected to clean all areas soiled or wet. When using perineal cleansing spray, staff should moisten the washcloth prior to cleaning to avoid abrading the skin with a dry cloth. Staff are also expected to clean residents' fingernails during each shower and as needed in between. The activities staff also provide nail care as an activity.

Based on observation and record review, facility staff failed to implement new interventions for one resident (Resident #66) after he/she resident had multiple falls. In addition, staff failed to follow the facility policy for falls. The facility census was 99. Review of the facility's Tracking Record for Improving Patient Safety (TRIPS), undated, showed the following: - It is the policy of this facility that a TRIPS form is completed on every resident experiencing a fall; - After evaluating and treating the resident immediately, the nurse should investigate the circumstances of the falls and look at all possible causes. All licensed nurses will be trained in the immediate fall response; - The Falls Nurse Coordinator will use the data recorded on the TRIPS form to identify trends related to types of falls. Such details include location, time and activity; - The nurse is still required to complete a narrative nurses note. 1. Review of Resident #66's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/14/20, showed staff assessed the resident as follows: - Moderately cognitively impaired; - Required limited assistance from staff for transfers, walking, dressing, toileting and personal hygiene; - Had two or more falls without injury since reentry. Review of the resident's care plan, documented as reviewed on 12/4/19, showed staff documented the resident had fallen due to an unsteady gait, dementia and weakness. Review showed staff documented the resident was very unsteady, had a stroke and used a cane. Review showed staff were directed to do the following: - Keep the call light and water within reach; - Answer my call light promptly; - Remind me to ask for assistance. Reorient me to the call light if necessary; - Ask me if I need to use the bathroom every two hours; - Encourage me to change positions slowly; - Keep my bed in the lowest position; - Assist me with all transfers; - Frequently reorient me to my surroundings as needed; - Visually check me at least every two hours; - Provide me a calm and quiet environment with reassurances; - Keep a small night light in my room; - Eliminate potential hazards, such as uneven surfaces, debris or water on the floor; - Put appropriate, nonskid footwear on me; - Ensure I am using assistive equipment appropriately if used; - Keep my assistive device within reach; - Ensure my assistive devices are appropriate to me; - Attend to me during activities of daily living; - Increase staff assistance and surveillance of me; - Evaluate me medically for causes contributing to my fall, such as postural hypotension, medication interaction, etc; - Address my pain issues if appropriate; - Evaluate me for skilled therapy services or restorative services if appropriate; - Provide me fluids and snacks as appropriate; - Allow me to rise naturally; - Staff to assist with toileting. Review of the nurses' notes showed staff documented the resident fell on the following dates: 12/14/19, 12/30/19, 1/30/20, 2/7/20, 2/22/20, 2/23/20 and one documented fall was undated and occurred at 3:10 A.M Review of the resident's chart showed the only TRIPS form that staff completed was for the fall on 1/30/20. Review showed staff did not complete a TRIPS form, as directed by facility policy, for the falls on 12/14/19, 12/30/19, 2/7/20, 2/22/20, 2/23/20 and the one documented fall which was undated and occurred at 3:10 A.M Review of the resident's care plan showed staff did not implement any new fall interventions after the resident began to have falls on 12/14/19. During an interview on 3/6/20 at 5:30 P.M., the Administrator said every time a resident falls the nurse is supposed to complete a TRIPS form. The administrator said ideally, a care plan should be updated after each fall, but right now, she has only been adding the number of falls a resident had in the month. MO00166169

Based on observation, interview and record review, facility staff failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (Resident #241), when they did not evaluate the resident's usual patterns of behavior, did not document changes in the resident's behavior, did not document they informed the physician about changes in a resident's behavior, and did not implement individualized non-pharmacological interventions to address the resident's behavioral symptoms. The facility census was 99. Review of the facility's Behavior Management Policy, undated, showed the following: - It is the policy of this facility to identify behavioral symptoms using appropriate screening tools, manage behavioral symptoms appropriately and comply with regulatory requirements related to the use of medications to manage behavioral changes. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort or express thoughts that cannot be articulated; - Behavioral or Psychological Symptoms of Dementia (BPSD) describes behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause. Current guidelines recommend the use of non-pharmacological interventions for BPSD; - As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and care givers, reviews of medical record and general observations the following: A. The resident's usual patterns of cognition, mood and behavior; B. The resident's usual method of communicating things like pain, hunger, thirst or other physical discomforts; C. The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers; - The nursing staff will identify, document and inform the physician about specific details regarding changes in an individual's mental status, behavior and cognition including: A. Onset, duration, intensity and frequency of behavioral symptoms; B. Any precipitating or relevant factors or environmental triggers; and C. Appearance and alertness of the resident and related observations; - New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others; - The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition; - The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly; - Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs and strives to understand, prevent or relieve the resident's distress or loss of abilities; - Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes as well as the potential situation and environment reason for the behavior. The care plan will include, at a minimum: - A. A description of behavioral symptoms including frequency, intensity, duration, outcomes, location, environment and precipitating factors or situations; - B. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; - C. The rationale for the interventions and approaches; - D. Specific and measurable goals for targeted behaviors; and - E. How the staff will monitor for effectiveness of the interventions; - Non-pharmacological approaches will be utilized to the extent possible to avoid or reduce the use of psychotropic medications to manage behavioral symptoms. 1. Review of Resident #241's Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/17/20, showed staff assessed the resident as follows: - Severely cognitively impaired; - Had delusions; - Independent with bed mobility, transfers, and toilet use; - Required staff supervision for dressing and eating. Review of the resident's care plan, dated 2/3/20, showed staff documented the following: - The resident had cognitive loss related to dementia; - Alzheimer's, paranoid aggression, falls, agitated, pacing, chews nails, thinks spouse is cheating, tearful, diabetic, behaviors, hypertension; - Review showed no specific behavior symptoms were documented and no individualized non-pharmacological interventions to prevent behavior symptoms. Review of the resident's nurses' notes showed staff documented the following: - 2/8/20 - The resident attempted to pick up a chair and throw it out the window. The resident stated that he/she wants out and is not supposed to be here. The psychiatrist was called and a new order was given to send the resident to the hospital for evaluation and treatment; - 2/17/20 - The resident returned to the facility from the hospital. - Review showed the last nurse's note documented for the resident was on 2/17/20. Review of the resident's Behavior Management Monthly Summary, dated February 2020, showed staff documented the resident was sent to hospital for behavior, no PRN (as needed) medications were used, a new intervention of sent out was added and this was successful in redirecting adverse behaviors. Staff document the resident is not currently seeing a psychiatrist and is not exhibiting any adverse reactions or side effect to any medications. Observation on 3/2/20 at 1:18 P.M., showed the resident walked quickly down the hallway while frequently looking behind himself/herself and crying. The resident briefly stopped in the dining room for approximately 30 seconds as residents ate lunch and staff assisted them. The resident had difficulty expressing what was wrong, but was able to state the man is coming to get me. He had the cord thing and I saw him and now he's trying to get me. The resident began to walk out of the dining room and down the hallway as he/she continued to cry and frequently looked behind himself/herself. Observation on 3/3/20 at 10:20 A.M., showed the resident in the hallway wringing his/her hands. The resident cried and quickly walked down the hallway. The resident said I need something to drink. I hope they don't get mad at me. I hope they are nice. Do you think they will get mad at me? The resident went into the dining room, sat in a chair, folded his/her arms and placed his/her head face down on his/her folded arms as he/she sobbed. Two staff were in the dining room, but did not address the resident until the state surveyor told them the resident was thirsty. Observation on 3/3/20 at 1:23 P.M., showed Resident #241 was not crying and assisted a resident as he/she pushed the resident's wheelchair down the hallway. An unidentified staff person told Resident #241 You can't be doing that, you can't push them. Resident #241 walked away from the wheelchair and out of the dining room. The resident began to cry and quickly walked down the hallway. During an interview on 3/3/20 at 3:45 P.M., the pharmacist said the resident seems very weepy today. She said the resident was not like that last month when she saw the resident. Observation on 3/3/20 at 5:35 P.M., showed the resident walked quickly down the hallway while crying. Observations on on 3/4/20, showed the following: - At 10:15 A.M., the resident walked quickly down the hallway while crying. The Corporate Nurse sat at the nurses' station. When the Corporate Nurse saw the resident, he/she got up from the nurses' station and tried to talk to the resident. The Corporate Nurse then asked a certified nurse aide (CNA) to do an activity with the resident; - At 10:25 A.M., the resident ran down the hallway crying. There was not a staff person with the resident. The Corporate Nurse again got up from the nurses' station and began walking down the hallway with the resident trying to calm him/her down. The resident began to walk down the hallway beside the Corporate Nurse instead of running; - At 10:29 P.M., the Corporate Nurse returned to the desk and told licensed practical nurse (LPN) A that the resident needed to be one on one right now; - At 10:35 P.M., the Corporate Nurse told LPN A to call the psychiatrist and tell him the resident has had all the medication they can have and the resident is still severely agitated; - At 10:40 A.M., LPN A placed a phone call and left a voice message for the physician to call him/her back about the resident. Continued observation at 10:41 showed LPN A continued to sit at the desk. A CNA was walking past the nurses' station holding the resident's hand as the resident cried. LPN A told the CNA to bring the resident closer to the nurses' station. LPN A went into the medication room and brought out a vial and a syringe. LPN A drew up medication from the vial and gave the resident an injection in the left upper arm as the resident put his/her head on the CNA's chest and sobbed. During an interview on 3/4/20 at 1:45 P.M., LPN A said the following: -When a resident's behavior reaches a level that he/she has to address it, then he/she calls the physician and documents this in a nurse's note. If they contact a physician this should be documented in a nurse's note along with what the physician's response is. Observation on 3/5/20 at 8:35 A.M., showed the resident walked quickly down the hallway while wringing his/her hands and crying. Observation at 8:49 A.M., showed the resident continued to walk quickly down the hallway while wringing his/her hands and crying. The resident said They are after me as she sobbed. Observation on 3/5/20 at 8:56 A.M., showed the resident was walking past the nurses' station while crying and LPN A asked the resident to come closer to the nurses' station. LPN A drew up a medication from a vial with a syringe and needle and gave the resident an injection in the right arm. The resident then walked off alone and sobbing. Review of the resident's chart on 3/6/20 at 9:45 A.M., showed the Nurse Practitioner wrote an order dated 3/5/20 for Haldol 5 mg daily as needed. Review showed the order did not clarify if the medication was to be given by mouth or injection. Review showed there was not an order for Haldol written on 3/4/20. During an interview on 3/6/20 at 9:53 A.M., LPN E said he/she could not find an order written for Haldol prior to 3/5/20. During an interview on 3/6/20 at 10:30 A.M., LPN A said the following: - The injection he/she gave the resident on 3/4 and 3/5/20 was Haldol; - He/she is unsure why there was not an order for PRN Haldol in the resident's chart prior to the one the Nurse Practitioner wrote on 3/5/20, because he/she wrote the order on 3/4/20. The psychiatrist gave him/her a telephone order for Haldol on 3/4/20 within two hours after he/she left the physician a voice message about the resident. He/she obtained the Haldol from the emergency medication kit. The resident had to have the Haldol, because he/she was walking the floors crying hysterically; - He/she does not think he/she has ever charted anything about the resident's behavior symptoms. The resident's spouse calls about 20 times a day, so there is not time to sit down and write a long nurse's note about the resident. During an interview on 3/6/20 at 5:30 P.M., the Administrator said if a resident has an increase in behavior symptoms then staff should contact the physician and document this in a nurse's note along with any new orders received from the physician and what interventions they tried to address the increase in behavior symptoms before they called they physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure one resident (Resident #16) was not given psychotropic medication unless necessary, when they started the resident on Seroquel (an antipsychotic), after the hospital directed this medication be discontinued, increased the dose of this medication from 12.5 mg to 50 mg without any indications to do so, and did not address a pharmacist's recommendation to clarify the dose of the Seroquel. Additionally, the facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines for one resident (Resident #78). The facility census was 99. Review of the facility's Antipsychotic Medication Use Policy, dated 2015, showed the facility will attempt to taper psychotropic medication use in at least two separate quarters with at least one month between attempts, unless clinically contraindicated, during the first year. This will occur for both residents who are admitted from the community or transferred from a hospital and who are already receiving psychotropic medications that have been initiated by the facility. 1. Review of the Resident #16's Minimum Data Sets (MDSs), a federally mandated assessment tool, dated 2/13/18, 5/30/18, 8/7/18, 11/9/18, 2/12/19 and 5/15/19, showed staff assessed the resident did not receive an antipsychotic medication. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: - Severe cognitive impairment; - Did not have hallucinations, delusions, behavioral symptoms, rejection of care or wandering; - Totally dependent on staff for locomotion, dressing and hygiene; - Required extensive assistance from staff for transfers and toileting; - Required limited assistance from staff for eating; - Always incontinent of bowel and bladder; - Diagnosed with non-Alzheimer's dementia; - Did not receive an antipsychotic in the past seven days. Review of the resident's Physician Order Sheet (POS), dated 10/1/19 through 10/31/19 for prior to the resident's hospitalization, showed the resident did not have orders for an antipsychotic medication. Review of a nurses note, dated 10/11/19, showed staff documented the resident was involved in a resident to resident altercation, was sent to the hospital and admitted to the ICU for a frontal lobe contusion. Review of the discharge paperwork from the hospital showed the following: - A discharge summary, signed on 10/15/19 at 4:12 P.M., that directed the resident was to continue taking Seroquel 12.5 mg by mouth at bedtime; - A discharge summary, signed on 10/15/19 at 4:29 P.M., that directed the resident was to discontinue taking Seroquel; - A Post Acute Care Handoff from the hospital, printed 10/15/19 at 6:17 P.M., that directed the resident was to discontinue Seroquel 12.5 mg by mouth daily at bedtime. Review of the FDA website shows Seroquel has a black box warning (appears on the label of a prescription medication to alert consumers and healthcare providers about safety concerns, such as serious side effects or life-threatening risk; is the most serious medication warning required by the U.S. Food and Drug Administration) which states that there is an increased risk for mortality in elderly patients with dementia when this medication is given. Review of the resident's POS, dated 10/15/19 through 10/31/19, showed the following: - Staff documented an order for Seroquel 0.5 mg to be given by mouth at bedtime; - Staff documented they verified the hospital discharge orders with the residents attending physician at the facility. Review of the resident's MAR, dated October 2019, showed staff wrote an order, dated 10/15/19, for Seroquel 0.5 mg to be given by mouth at bedtime. Staff documented they gave this medication 13 out of the remaining 17 days of October. Review of a Medication Regimen Review found in the resident's chart, dated 10/17/19, showed the pharmacist documented a potential clinically significant medication issue was found. The pharmacist documented Hospital discharge summary has Seroquel 12.5 mg HS and POS has 50 mg HS. Please clarify dose. Review showed there was a spot on the form titled Facility Response and it was blank. Review of the resident's POS, dated 11/1/19 through 11/30/19, showed an order for for Seroquel 50 mg to be given at bedtime. Review of the resident's MAR, dated November 2019, showed an order for Seroquel 50 mg to be given by mouth at bedtime. Staff documented they gave this medication 29 out of 31 days for this month. Review of the resident's POS, dated 12/1/19 through 12/31/19, showed an order for for Seroquel 50 mg to be given at bedtime. Review of the resident's MAR, dated December 2019, showed an order for Seroquel 50 mg to be given by mouth at bedtime. Staff documented they gave this medication 25 out of 31 days for this month. Review of the resident's POS, dated 1/1/20 through 1/31/20, showed an order for for Seroquel 50 mg to be given at bedtime. Review of the resident's MAR, dated January 2020, showed an order for Seroquel 50 mg to be given by mouth at bedtime. Staff documented they gave this medication 31 out of 31 days for this month. Review of the resident's POS, dated 2/1/20 through 2/29/20, showed an order for for Seroquel 50 mg to be given at bedtime. Review of the resident's MAR, dated February 2020, showed an order for Seroquel 50 mg to be given by mouth at bedtime. Staff documented they gave this medication 29 out of 29 days for this month. Review of the resident's POS, dated 3/1/20 through 3/31/20, showed an order for for Seroquel 50 mg to be given at bedtime. Review on 3/5/19 at 10:30 A.M. of the resident's MAR, dated March 2020,showed an order for Seroquel 50 mg to be given by mouth at bedtime. Staff documented they gave this medication 3/1 through 3/5/20. Review of the resident's nurses' notes from 10/15/19 through 3/5/20, showed there was not any documentation of hallucinations, delusions, behavior symptoms, rejecting care or wandering. In addition, review showed no notes documented about the Medication Regimen Review from the pharmacist, dated 10/17/19, asking for clarification of the Seroquel dose. Observation on 3/2/20 at 11:45 A.M., showed the resident lay in bed quietly with his/her eyes closed. Observation on 3/4/20 at 11:23 A.M., showed the resident lay in bed quietly with the comforter over his/her head. Observation on 3/4/20 at 8:45 A.M., showed CNA B assisted the resident to walk from the dining room to his/her room. Certified Nurse Aide (CNA) B provided care to the resident and assisted the resident to lay down in bed. The resident lay in bed quietly with his/her eyes closed. During an interview on 3/5/20 at 10:50 A.M., CNA B said the resident naps all the time, but does come out of his/her room for activities and eats good. During an interview on 3/5/20 at 1:55 P.M., the quality assurance (QA) nurse said the former assistant direction of nurses (ADON) left about a month ago, but before she left she was in charge of the follow through with the pharmacy recommendations. The director of nurses (DON) is in charge of this now. During an interview on 3/5/20 at 2:00 P.M., the Corporate Nurse said the pharmacy gives their recommendations to the ADON and the ADON communicates the recommendation to the physician. Usually, they require these recommendations be addressed within three days. The former ADON had promised she had taken care of the pharmacy recommendations. Upon review though, they found she had not been following up on the pharmacy reviews in January and February. The DON was then delegated to take over the pharmacy recommendations task, but she didn't and she left about a week ago. Observation on 3/5/20 at 3:07 P.M., showed the resident lay in bed quietly with his/her eyes closed. Observation on 3/6/20 at 10:07 A.M., showed the resident lay in bed quietly with his/her eyes closed. During an interview on 3/6/20 at 10:00 A.M., the resident's attending physician said he did not recall if staff contacted him about the resident's antipsychotic medication. During an interview on 3/6/20 at 5:30 P.M., the administrator said when a resident comes to them from a hospital, the nurse verifies the discharge hospital medication list with the resident's physician at the facility and then writes the ordered medications on the MAR. If a nurse has a question about a medication then they should contact the resident's physician. The DON and ADON review orders for new admissions and readmissions the morning after the resident enters the facility. 2. Review of Resident 78's quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 1/9/20, showed staff assessed the resident as follows: -Severe cognitive impairment; -Total physical dependence of one person for toileting, personal hygiene, dressing, and bathing; -Extensive physical assistance of one person for eating; -Limited physical assistance of one person for bed mobility, transfers, walking, and locomotion; -Always incontinent of bowel and bladder; -Diagnoses of multiple sclerosis, seizure disorder, dementia, cerebral palsy, and depression; -No signs/symptoms of pain; -One non-injury fall since prior assessment; -No pressure ulcers; -During the seven day look back period took seven days of antipsychotic, antianxiety, and antidepressant medications, with last attempted gradual dose reduction (GDR) on 2/1/19. Review of the resident's Physician Order's Sheet (POS), dated 3/1/20 - 3/31/20, showed orders for the following psychotropic medications; -Lorazepam 0.5 milligrams (mg) by mouth two times daily; -Effexor 37.5 mg by mouth daily; -Seroquel 25 mg by mouth three times daily. Review of the resident's progress notes on 3/5/20, showed the pharmacist reviewed the resident's medications on 2/1/19 and made recommendation to reduce the Lorazepam from 0.5 mg two times daily and to reduce the Effexor from 75 mg to 37.5 mg. A GDR recommendation for Seroquel was not located in the resident's record. During an interview on 3/5/20 at 10:30 A.M., the administrator said he/she expected a GDR to be recommended by the pharmacist and evaluated by the physician as directed by CMS. The administrator contacted the pharmacist and he/she said recommendations for a Seroquel GDR had been made but the physician had not followed through. He/She does not know where those recommendation forms are. The administrator was unable to find them in the DON's office or in medical records.

Based on observation, interview and record review, facility staff failed to ensure they administered medications with an error rate of less than five percent. Facility staff made two errors of a total of 32 medications passed, yielding an error rate of 6.25%. The facility census was 99. 1. Review of Resident #18's physician's order sheet (POS) dated 3/1/20-3/31/20, showed a physician's order for Meloxicam (a non-steroidal anti-inflammatory medication used to treat arthritis) tablet, give one by mouth twice daily with food. Review of potential side effects of Meloxicam include upset stomach, nausea, vomiting, heartburn, diarrhea constipation, and serious gastrointestinal effects including bleeding, ulceration and perforation of the stomach or intestines. Observation on 3/3/20 at 5:07 P.M., showed Certified Medication Technician (CMT) K administered to the resident, his/her Meloxicam tablet in the resident's room without any food. Review of the facility's dining times showed dinner was served starting at 5:30 P.M. During an interview on 3/6/20 at 5:30 P.M., the administrator and Director of Nurses (DON) said if a medication is ordered to be given with food, then the medication should be given with food or a snack. 2. Review of Resident #47's POS showed a physician's order for Advair 250-50 Diskus (an inhaler used to treat asthma and chronic bronchitis), inhale 1 puff orally twice daily, rinse mouth after use. Observation on 3/5/20 at 9:00 A.M. showed CMT L administered the resident's morning medications. The CMT asked the resident if he/she had his/her inhaler, to which the resident said that he/she did. The CMT did not watch the resident use his/her inhaler. Review of the resident's medication administration record for 9:00 A.M., showed CMT L documented he/she administered the resident's inhaler to the resident. During an interview on 3/6/20 at 9:54 A.M., the resident showed this surveyor his/her Advair Diskus inhaler in a drawer in his/her room. The resident said he/she uses the inhaler twice daily, without staff supervision. The resident also showed this surveyor an albuterol inhaler (an inhaler used to relax muscles in the airway and increase air flow to the lungs) that he/she uses as needed. During an interview on 3/6/20 at 5:30 P.M., the administrator and DON said a resident should not have medication left at the bedside unless they have a physician's order stating it is okay and the other parameters of self-administration of medications is met.

Based on observation and interview, facility staff failed to label and store medications in an appropriate manner when they failed to date insulin and multi-use vials on the date the vials were opened, failed to ensure medication carts were free of loose pills, and failed to discard expired medications. The facility census was 99. 1. Observation on 3/5/20 at 10:17 A.M., of the medication room on the first floor of the facility showed the following: In an upper storage cabinet: -A 100 count box of bisacodyl suppositories (laxative) with an expiration date of 9/19; -A four ounce bottle of Ultra tuss cough suppressant expectorant with an expiration date of 9/19; -A 100 count box of mucus relief guaifenesin (reduces chest congestion) 400 mg, with an expiration date of 12/19; -A one-half ounce bottle of ear drops earwax removal aide with an expiration date of 10/19; -A 16 ounce bottle of iron supplement elixir ferrous sulfate 220 mg with an expiration date of 1/20. In a medication refrigerator: -A bottle of Brisk lemonade stored in the freezer portion of the refrigerator; -An opened vial of influenza vaccine with no date written on the bottle or box to show when it was opened; -Nine bisacodyl suppositories with an expiration date of 9/19; -An opened vial of Aplisol (tuberculin 10 test) in a bag, with no date written on the bottle or bag to show when it was opened; -A one-half milliliter vial of pneumovax 23 (vaccine to protect against pneumococcal disease), ordered for a specific resident who no longer resides in the facility, dated 11/19/18. 2. Observation on 3/5/20 at 1:30 P.M., of the first floor Certified Medication (CMT) medication cart showed the following in the top drawer of the cart: -A 100 count floor stock bottle of acidophilus with pectin (probiotic), with an expiration date of 1/20; -Twelve loose tablets, varied in size and color; -An opened vial of novolog insulin ordered for Resident #19, with no date written to show what date it was opened; -An opened vial of humalog insulin ordered for Resident #293 with no date written to show what date it was opened; -An opened vial of sterile water for injection with no date written to show what date it was opened. 3. Observation on 3/5/20 at 1:50 P.M. of the second floor CMT medication cart showed the following: In the top drawer: -A floor stock 100 count bottle of bisacodyl 5 mg, with an expiration date of 2/20; -A bottle of folic acid (a type of B vitamin) 400 micrograms, with an expiration date of 7/19; -Two loose tablets, of different size and color; -A medication cup with three pills, not labeled with the content of the cup nor the name of the resident to which they belonged; In the bottom drawer: -A 90 count floor stock bottle of fiber laxative calcium polycarbophil 625 milligrams (mg), with an expiration date of 9/19; -A bottle of fish oil, 500 mg, with an expiration date of 10/19; -A 16 ounce bottle of liquid pain relief acetaminophen 160 mg/5 ml, with an expiration date of 12/18; -A 16 ounce bottle of ultra tuss expectorant, with an expiration date of 10/19. During an interview on 3/6/20 at 5:30 P.M., the administrator and director of nurses said staff are expected to write the date on medication vials when they are opened, so they can be discarded within the recommended time frame. The CMT or nurse using a medication cart or medication room should routinely check for expired medications and discard them as needed.

Based on observation and interview, facility staff failed to adequately clean and disinfect multi-use blood glucose meters between resident use and failed to clean vials of insulin prior to removing insulin for injection for one resident (Resident #19). The facility census was 99. 1. Observation on 3/3/20 at 4:57 P.M., showed Certified Medication Technician (CMT) K obtained the multi-use blood glucose meter from a container in the top drawer of the CMT medication cart. The CMT did not clean the machine before he/she used the machine to check Resident #19's fingerstick blood glucose level. After obtaining the blood glucose result, the CMT placed the blood glucose meter back into the top drawer of the medication cart without cleaning the meter. The CMT then obtained the resident's Levimir insulin and the resident's Novolog insulin bottles from a container in the top drawer of the medication cart which held multiple other residents' insulin bottles, and drew up the doses of insulin without first cleaning the tops of the vials. Observation on 3/5/20 at 4:10 P.M., showed CMT D obtained the multi-use blood glucose meter from the container in the top drawer of the medication cart. The CMT did not clean the machine before he/she used the machine to check Resident #19's fingerstick blood glucose level. After obtaining the blood glucose result, the CMT took a single packaged alcohol wipe and swiped the wipe around the blood glucose meter for approximately five seconds, then placed the meter back into the medication cart. Review of the manufacturer's instructions for cleaning and disinfecting the type of blood glucose meter used, showed the following: -To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions; -The (brand name) blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed; -An Environmental Protection Agency (EPA) registered disinfectant product may be used to clean and disinfect the blood glucose meter. A list of manufacturers/brands were listed. The list provided did not include an alcohol wipe to be an effective disinfecting agent for the blood glucose meter; -The guidelines for cleaning and disinfecting the meter included wiping the entire surface of the meter using the towelette at least three times vertically and three times horizontally to clean blood and other body fluids from the meter. During an interview on 3/6/20 at 5:30 P.M., the administrator and Director of Nurses said the facility's blood glucose meters should be cleaned in between residents, with the special cleaner the facility has in stock and that facility staff had been inserviced to use. An alcohol wipe is not an appropriate cleanser to use to disinfect the meters. Staff are expected to clean medication vials with an alcohol wipe before inserting the needle when preparing for an injection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to maintain and follow policies and procedures for immunization of residents against pneumococcal disease as required. The facility staff failed to provide and document provision of pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine for six residents (Residents #1, #6, #8, #21, #77, and #88). The facility also failed to assess and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of pneumococcal vaccine as indicated by the Centers for Disease Control (CDC) guidelines. The facility census was 99. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Timing for Adults dated 11/30/15 showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23); -One dose of PCV 13 was recommended for adults 65 years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults 65 years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV 23 and no doses of PCV13 administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions. Review of the Center for Disease Control (CDC) website, last updated 12/6/17, showed the CDC recommendations for healthcare providers directs providers to: -There are two types of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccine (PCV13 or Prevnar13®) Pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax23®) -CDC recommends pneumococcal vaccination for all adults 65 years or older. In certain situations, other children and adults should also receive pneumococcal vaccines. Below is more information about which pneumococcal vaccines CDC recommends by age group and medical condition (where applicable). *For Adults 19 through 64 Years: -CDC recommends pneumococcal vaccination for adults 19 through [AGE] years old who have certain medical conditions or who smoke. *For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccines: Cerebrospinal fluid leaks Cochlear implant(s) CDC recommends you: Give 1 dose of PCV13 and 1 dose of PPSV23. Administer PCV13 first, then give the PPSV23 dose at least 8 weeks later. *For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccines: Sickle cell disease or other hemoglobinopathies Congenital or acquired asplenia Congenital or acquired immunodeficiency HIV infection Chronic renal failure or nephrotic syndrome Leukemia or lymphoma Hodgkin's disease Generalized malignancy Iatrogenic immunosuppression (diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and radiation therapy) Solid organ transplantation Multiple myeloma CDC recommends you: Give 1 dose of PCV13 and 2 doses of PPSV23. Administer PCV13 first, then give the first PPSV23 dose at least 8 weeks later. Give the second dose of PPSV23 at least 5 years after the first. *For anyone who smokes and has not previously received the recommended pneumococcal vaccine CDC recommends you: Give 1 dose of PPSV23. *For anyone with any of the conditions listed below who has not previously received the recommended pneumococcal vaccine: Alcoholism Chronic heart disease Chronic liver disease Chronic lung disease Diabetes mellitus CDC recommends you: Give 1 dose of PPSV23. *Adults 65 Years or Older CDC recommends pneumococcal vaccination for all adults 65 years or older: Give 1 dose of PCV13 to all adults 65 years or older who have not previously received a dose. Give 1 dose of PPSV23 to all adults 65 years or older at least 1 year after any prior PCV13 dose and at least 5 years after any prior PPSV23 dose. Adults who received one or two doses of PPSV23 before age [AGE] should receive one final dose of the vaccine at age [AGE] or older. Review of the facility's undated Pneumococcal Vaccine policy, showed all residents will be offered the option to receive a pneumococcal vaccination every five years unless medically contraindicated. This vaccination may be offered at any time during the year. It will be the responsibility of the DON/designee to ensure completion. Review of the policy showed it has not been updated to reflect the current CDC guidelines for the pneumococcal vaccine. Procedure: Each resident will be offered a pneumococcal vaccination at the time of admission to the facility annually thereafter, each time the vaccination is refused, unless due to a medical contraindication. 1) Each resident of his/her legal representative will receive education regarding the benefits and potential side effects of the pneumococcal immunization each time it is offered. 2) Each resident's medical record shall include documentation that education was provided to the resident or his/her legal representative. 3) Each resident or his/her legal representative will be required to return an authorization form, allowing the facility to administer the pneumococcal immunization which shall also include a signature certifying reception of educational material. 4) Each resident's medical record shall contain a physician's order permitting the immunization to be given every 5 years unless medically contraindicated or refused. 5) The pneumococcal immunization will be provided to each resident providing written authorization at time of admission and every five years thereafter as permissible unless medically contraindicated. 6) Each resident's medical record shall contain documentation verifying that the pneumococcal immunization was administered, refused, or not given related to a medical contradiction tracking sheet and/or nurses notes. 7) If the facility is unable to obtain verification at the time of admission from the resident or his/her legal representative that a pneumococcal vaccination has been administered in the last five years, the resident will receive the immunization at the time of admission. 8) The DON/designee will ensure that the MDS Coordinator is kept informed of each resident's status regarding the pneumococcal immunization for accurate documentation on the MDS. Review of the physician order sheets (POS), showed each resident had an order which says: Per CDC, Administer Prevnar (PCV13) times one dose upon admission, Pneumovax (PPSV23) times one dose one year after PVC13 administration to residents who have not already received it unless contraindicated, 1. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment, dated 11/8/19, showed the staff documented that the resident's pneumococcal vaccination was up to date. Review of the resident's paper chart showed staff did not document pneumococcal vaccine history, provision of pneumococcal vaccine education, and pneumococcal consent/refusal form. Review showed staff did not offer the pneumonia vaccination as directed by the CDC. The Resident Immunization Record, showed no documentation showing PCV13 or PPSV23 vaccine had been given. The facility staff were unable to produce documents showing the pneumonia vaccines had been offered and refused. 2. Review of Resident #6's quarterly MDS, a federally mandated assessment, dated 12/4/19, showed the staff documented that the resident refused the pneumococcal vaccination. Review of the resident's paper chart showed staff did not document pneumococcal vaccine history, provision of pneumococcal vaccine education, and pneumococcal consent/refusal form. Review showed staff did not offer the pneumonia vaccination as directed by the CDC. The Resident Immunization Record, showed documentation the Pneumovax vaccine was refused on 11/1/17. There was no documentation showing PCV13 or PPSV23 vaccine had been offered, given, of refused since 11/1/17. The facility staff were unable to produce documents showing the pneumonia vaccines had been offered and refused. 3. Review of Resident #8's quarterly MDS, a federally mandated assessment, dated 12/5/19, showed the staff documented that the resident's pneumococcal vaccine is up to date. Review of the resident's paper chart showed staff did not document pneumococcal vaccine history, provision of pneumococcal vaccine education, and pneumococcal consent/refusal form. Review showed staff did not offer the pneumonia vaccination as directed by the CDC. The Resident Immunization Record, showed documentation the Pneumovax vaccine was given at Mercy hospital on 2/15/17. There was no documentation showing PCV13 or PPSV23 vaccine had been offered, given, of refused since 2/15/17. The facility staff were unable to produce documents showing the pneumonia vaccines had been offered and refused. 4. Review of Resident #21's quarterly MDS, a federally mandated assessment, dated 12/3/19, showed the staff documented that the resident's pneumococcal vaccine is up to date. Review of the resident's paper chart showed staff did not document pneumococcal vaccine history, provision of pneumococcal vaccine education, and pneumococcal consent/refusal form. Review showed staff did not offer the pneumonia vaccination as directed by the CDC. The Resident Immunization Record, showed documentation the Pneumovax vaccine was given on 11/2/17. There was no documentation to show if PCV13 or PPSV23 vaccine was given or if all pneumonia vaccines had been offered, given, of refused since 11/2/17. The facility staff were unable to produce documents showing the pneumonia vaccines had been offered and refused. 5. Review of Resident #77's admission MDS, a federally mandated assessment, dated 1/3/20, showed the staff documented that the resident's pneumococcal vaccine is up to date. Review of the resident's paper chart showed staff did not document pneumococcal vaccine history, provision of pneumococcal vaccine education, and pneumococcal consent/refusal form. Review showed staff did not offer the pneumonia vaccination as directed by the CDC. The Resident Immunization Record, showed documentation the Pneumovax vaccine was given, per hospital record, on 9/24/18. There was no documentation to show if PCV13 or PPSV23 vaccine was given or if all pneumonia vaccines had been offered, given, of refused. The facility staff were unable to produce documents showing the pneumonia vaccines had been offered and refused. 6. Review of Resident #88's Annual MDS, dated [DATE], showed the staff documented the resident's pneumococcal vaccination was up to date. Review of the resident's chart showed an Authorization for Pneumococcal Vaccination form, dated 6/16/17, where staff documented they received permission to administer the pneumococcal vaccination from the resident's responsible party via the telephone. Review of the resident's chart showed a Resident Immunization Record where staff documented under the Pneumovax Vaccine Administration Record that the resident received this vaccination on 12/1/17. Review showed staff did not document if the PCV13 was received. During an interview on 3/6/20 at 10:30 A.M., the Administrator said the facility tries to offer Prevnar 13 and PPSV23 and should follow the CDC recommendations. There has been a change in the Director of Nursing and the records for the pneumonia vaccines could not be located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to complete a baseline care plan within 48 hours of admission and failed to document the baseline care plan was reviewed with the resident or responsible party for two residents (Residents #77, #241) out of 24 sampled residents. The facility census was 99. The administrator said the facility does not have a policy directing staff on completion of the baseline care plan. 1. Review of Resident #77's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/3/20, showed staff assessed the resident as follows: -admission date of 1/3/20; -Moderate cognitive impairment; -Total physical dependence of one staff for transfers, dressing, toileting, personal hygiene, and bathing; -Extensive physical assistance of one staff for locomotion; -Limited physical assistance of one staff for eating; -Limited range of motion of the upper extremity on one side; -Always incontinent of bladder, frequently incontinent of bowel; -Occasional complaint of pain rated at a 4 in a scale of 0-10; -At increased risk for pressure ulcer with two Stage II ulcers and one Stage III ulcer; -During the seven day look back, took seven days of antidepressants and two days of antibiotics. Review of the resident's undated Interim/Baseline Care Plan, showed staff documented the following: -The resident uses a bedpan, urinal, assist for bladder; -The resident uses a bedpan and assist for bowel; -Regular diet. Further review of the resident's 48 hour baseline care plan, showed staff did not complete all areas of the baseline care plan, did not document problem start dates, initial goals based on admission orders, or obtain signatures that the resident or resident representative reviewed and received a copy of the baseline care plan and physician orders. Review showed the 48 hour baseline care plan was not dated, so it is unknown if it was completed in the required 48 hours. 2. Review of Resident #241's MDS, dated [DATE], showed staff assessed the resident as follows: -admitted [DATE]; -Moderate cognitive impairment; -Extensive physical assistance of one person for bathing; -Limited physical assistance of one person for transfers, walking, locomotion, dressing and personal hygiene; -Supervision and set up help for eating; -Supervision for toileting; -Always continent of bowel and bladder; -Occasional pain at a 4 on a 0-10 scale; -History of two non-injury falls; -No pressure ulcers. Review of the resident's undated Interim care plan, showed facility staff documented the following: -Bladder-commode; -Bowel-commode; -Regular diet. Further review of the resident's 48 hour baseline care plan, showed staff did not complete all areas of the baseline care plan, did not document problem start dates, initial goals based on admission orders, or obtain signatures that the resident or resident representative reviewed and received a copy of the baseline care plan and physician orders. Review showed the 48 hour baseline care plan was not dated, so it is unknown if it was completed in the required 48 hours. During an interview on 3/5/20 at 5:00 P.M., the administrator said a baseline care plan should be totally completed for a new admission. The administrator said he/she is responsible for completing the care plans, including the baseline care plan. The administrator did not have an alternate plan if a resident was admitted on the weekend. He/She said the charge nurse could complete the baseline care plan to provide direction to staff for the resident's care. The administrator did not have documentation to show the resident or responsible party received a copy of the care plan.

Based on observation, interview and record review, facility staff failed to ensure they observed three residents (Residents #19, #28 and #44) take their medications, failed to ensure two residents (Residents #28 and #47) did not have inhalers left at their bedsides, and failed to apply the appropriate treatment to one resident's (Resident #53) pressure ulcer. The facility census was 99. 1. Observation on 3/3/20 at 4:48 P.M., showed Certified Medication Technician (CMT) K administered to Resident #28, the following medications: -Docusate sodium (laxative) 100 milligrams (mg); -Eliquis (anticoagulant) 100 mg tablet; -Tamsulosin (treats symptoms of enlarged prostate) 0.4 mg capsule. The CMT handed the resident a cup of the three medications, then left the resident's room and did not observe the resident take the medications. 2. Observation on 3/3/20 at 5:05 P.M., showed CMT K prepared medications for Resident #19 in the hallway outside the resident's room. The CMT popped Metformin 1000 mg, one tablet into a cup and handed the cup to Resident #18 (Resident #19's spouse), and allowed Resident #18 to bring the cup of medication to Resident #19 who sat inside his/her room. The CMT did not observe that the resident received and took the medication. 3. Review of Resident #47's physician's orders sheet (POS), dated 3/1/20-3/31/20, showed a physician's order for Advair 250-50 Diskus (an inhaler used to treat asthma and chronic bronchitis), inhale 1 puff orally twice daily, rinse mouth after use. The (POS) showed no order to allow the resident to self-administer his/her inhaler or any other medications. Observation on 3/5/20 at 9:00 A.M., showed CMT L administered the resident's morning medications. The CMT asked the resident if he/she had his/her inhaler, to which the resident said that he/she did. The CMT did not watch the resident use his/her inhaler. During an observation and interview on 3/6/20 at 9:54 A.M., the resident showed this surveyor his/her Advair Diskus inhaler in a drawer in his/her room. The resident said he/she uses the inhaler twice daily, without staff supervision. The resident also showed this surveyor an Albuterol inhaler (an inhaler used to relax muscles in the airway and increase air flow to the lungs) that the resident said he/she used as needed. 4. Review of Resident #28's POS, dated 3/1/20-3/31/20, showed a physician's order for Advair 250-50 Diskus, inhale one puff orally twice daily, rinse mouth after use. The (POS) showed no order to allow the resident to self-administer his/her inhaler or any other medications. During an observation and interview on 3/2/20 at 12:06 P.M., the resident sat in his/her recliner in his/her room. The resident's Advair Diskus inhaler sat on a chair next to the resident. The resident said staff leave the inhaler for him/her to use in his/her room. The resident said he/she uses the inhaler twice a day. 5. Review of Resident #44's POS, dated 3/1/20-3/31/20, showed physician's orders for the following morning medications: -Aspirin 81 mg, one daily; -Nephro-Vite tablet (vitamin), one daily; -Sevelemar tab (used to control phosphorus levels in patients on dialysis) 800 mg, three tablets, three times daily with meals; -Senna Lax (laxative) 8.6 mg, one daily; -Verapamil capsule (treats high blood pressure) 360 mg, one daily; -Vitamin B-1 100 mg (thiamin), one daily. Review of the resident's nurse's notes showed the following: -On 10/3/19, 11-7 shift, resident evening medications still at bedside; encourage to take all medications per order; -On 10/4/19, 11-7 shift, medication left at bedside; -On 10/6/19, 11-7 shift, medication still on bedside table; encourage to take all medications; -On 10/8/19, 11-7 shift, resident has evening medications still at the bedside; encourage to take all meds; -On 10/10/19, shift not specified, medication left on bedside table; -On 10/11/19, shift not specified, medication left on bedside table; encourage to take all meds daily; -On 10/12/19, shift not specified, evening meds left on bedside table; -On 11/25/19, shift not specified, medication left on bedside table, resident encouraged to take his/her meds; very noncompliant with his/her medication. Observation on 3/4/20 at 9:46 A.M., showed the resident sat in a wheelchair in his/her room. A medicine cup containing multiple medications sat on the resident's bedside table. The resident said he/she had just finished dressing and would take his/her pills in a bit. The resident said staff brought the medications in during breakfast, and he/she just hadn't taken them yet. Observation on 3/5/20 at 9:35 A.M., showed the resident lay asleep in his/her bed. A medicine cup with multiple medications sat on the bedside table beside the resident. Staff were not present. 6. Review of Resident #53's most recent Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/2/20, showed the resident had one Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) pressure ulcer. Review of the resident's most recent plan of care addressing pressure ulcers, dated 12/9, showed the plan directed staff to refer the resident to a wound specialist. The plan did not direct staff to ensure appropriate treatment per the residents' physician's orders. Review of an assessment by the resident's consultant wound care company dated 3/2/20 showed the following: -The visit was a follow-up for a Stage III pressure ulcer (Full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling) to the right foot; the resident has a contracture to the ankle; site is currently treated with skin prep; -The wound was covered in 100% eschar intact scab, measuring 0.2 centimeters(cm) x 0.2 cm; -The onset date was 11/29/19; -The wound care company's plan included to continue skin prep for one more week. Review of the resident's current POS, dated 3/1/20-3/31/20, showed a physician's order for skin prep every shift for seven days for the resident's right anterior foot wound. Observation on 3/3/20 at 10:27 A.M., showed the director of nurses (DON) provided treatment to the wound on the resident's right foot. The DON said the physician ordered treatment was skin prep. The DON showed the surveyor a packet of skin protectant ointment, and opened and applied the skin protectant ointment to the wound in a thick layer. The DON did not wear gloves to apply the treatment, and did not apply the correct wound treatment per physician's orders. During an interview on 3/6/20 at 5:30 P.M., the administrator and DON said when giving medications, staff are expected to stay with the resident to ensure the resident takes the medications. It is not appropriate for staff to give a medication and not observe the resident take the medication. A resident should not have medication left at the bedside unless they have a physician's order stating it is okay and the other parameters of self-administration of medications are met. The DON said she is aware Resident #44 will not take his/her morning medications until he/she gets up out of bed later in the morning. The medications should not be left unattended at the resident's bedside. Staff are also expected to follow physician's orders for wound treatment.

Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. The facility census was 99. 1. Review of the Facility Assessment, dated June 2019, showed it did not address the DON serving as a charge nurse. Review of the facility's Daily Assignments schedule, dated 3/1/20 - 3/6/20, showed the DON was assigned to work as a charge nurse on the day shift on Monday, 3/2/20, and on on Tuesday 3/3/20. During an interview, the DON said he/she had been employed at the facility for two weeks. The DON said, in addition to occasionally working as the charge nurse for a shift, the DON covers the floor when a nurse must leave early in the morning or come in late in the evening. During an interview., the administrator said the DON often works on the floor as a charge nurse, including on 3/2/20 and 3/3/20. He/She was not aware the DON could not work as a charge nurse if the facility had 60 or more residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the call light bulbs illuminated in the hallway for resident rooms and resident bathrooms when the call light button was activated. This practice potentially affected all residents in the facility. The facility census was 99 residents. 1. Observations with the Maintenance supervisor on 3/06/20, showed: -At 8:56 A.M., room [ROOM NUMBER], the call light to the hallway was burnt out. -At 10:29 AM., the call light bulb on the ground level and used by residents when in activities had been disabled and was not in working condition. During an interview on 3/06/20 at 10:29 A.M., the maintenance director said he did not know about these, because he had not been told by the staff there was a problem.