Based on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation, for one resident (Resident #48). The sample was 13. The census was 46. Review of the facility's Discharge Summary and Plan policy, reviewed 2/21, showed: -The discharge plan, instructions and summary provides a recapitulation or summary of the resident's stay; -Discharge planning will begin upon admission to the facility; -Admitting nurse will document the resident, family/caregiver stated reason for admission and the resident, family/caregiver plan for discharge; -Case Manager or Minimum Data Set (MDS, a federally mandated assessment completed by facility staff) nurse will make post discharge follow up calls and complete the discharge post discharge, follow up phone call assessment in the resident record. Review of Resident #48's admission Record, showed: -admission date of 4/23/25; -Diagnoses included chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung), congestive heart failure (CHF, a condition where the heart cannot pump blood effectively), pulmonary edema (PE, a condition caused by too much fluid in the lungs), respiratory failure (a condition that makes it difficult to breathe on your own), and stage IV chronic kidney disease. Review of the resident's Census List, showed: -On 4/23/25 at 10:06 A.M., Status: Active, Action Code: Actual admission; -On 4/23/25 at 5:30 P.M., Status: Stop Billing, Action Code: discharge date . Review of the resident's health records, showed: -No physician orders for discharge; -No documentation in progress notes of resident's discharge or if resident left against medical advice (AMA); -No signed against medical advice (AMA); -No discharge summary report; -No post discharge documentation. During an interview on 5/14/25 at 2:51 P.M., the Director of Nursing (DON) said the resident came to the facility and left right away. She was notified the resident wanted to change his/her physician. She was not in the facility at that time and needed time to review the resident's records and start the process of changing physician and getting orders. She was notified by staff the resident left the facility with family just few hours after admission. The discharge process was not completed. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she expected staff to complete the resident's discharge process and documentation.

Based on observation, interview and record review, the facility failed to assess one resident for the use of a belt restraint (Resident #44). The resident had a belt restraint on his/her wheelchair. The facility failed to assess the resident for its use, obtain a physician's order and document the use in the resident's care plan. In addition, the facility failed to ensure staff accurately documented medications, treatments, pain assessments, and behavior monitoring for two residents (Residents #19 and #6). The sample size was 13. The census was 46. Review of the facility's Restraints policy, dated 9/2/29, showed: -Policy Statement: Restraints are devices that prevent or restrict certain actions and/or behaviors and are not easily removed. There are Federal Regulations that govern the use of restraints on residents in long-term care facilities. Restraint usage can increase the scope and severity of injury. It is the goal of the facility to be restraint free in accordance with clinical best practices; -Policy: In order to provide the best possible care to residents, both physically and emotionally and comply with federal requirements governing same, facility shall restrict the use of restraints, both chemically and physically. Restraints shall only be used in the facility when they are required to temporarily treat a life-threatening situation or to treat the resident's medical condition. In non-life threatening situations, restraints will be used only after assessment, physician order, explanation to resident and or legally authorized representative, when the benefits outweigh the risks and the resident and his/her legally authorized representative does not refuse; -Procedure: -All residents, their legally authorized representative, and responsible parties shall be given a copy of the Use of Restraints/Informed Consent for the Use form; -Physician orders for restraints will be obtained by nursing staff, always ensuring the least restrictive device is used. Orders will be time framed and include the medical reason for use; -Restraint usage will be reviewed on admission, quarterly and annually and with any significant change. Restraint usage will be care planned and the reason for the use of the restraint will be discussed with the resident and/or responsible party; -Restraints will be monitored at least every 30 minutes and released every two hours unless contraindicated. 1. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/26/25, showed: -No information regarding cognition; -No behaviors; -Used a manual wheelchair; -Dependent on staff for all mobility and personal hygiene; -Diagnoses included fractures, hemiplegia (muscle weakness or partial paralysis on one side of the body) and depression; -Restraints not used. Review of the resident's care plan, in use during the time of the investigation, updated 3/3/25 and viewed on 5/12/25 at 5:14 P.M., showed no information regarding the use of a restraint or wheelchair belt. Review of the resident's May 2025 Physician's Order Sheet (POS), viewed 5/12/25 at 5:10 P.M., showed no order for the use of a restraint or wheelchair belt. Review of the resident's Assessment forms, viewed 5/13/25 at 10:50 A.M., showed no assessment for the use of a restraint. Observation on 5/13/25 at 8:30 A.M., showed the resident lay in bed on his/her back. The resident's wheelchair was next to his/her bed, with a belt sitting on the seat of the wheelchair. Observation on 5/14/25 at 10:21 A.M., showed the resident in the dining room participating in activities. He/She sat in his/her wheelchair with a black belt wrapped loosely around his/her waist. Observation and interview on 5/14/25 at 12:26 P.M., showed the resident sat in the dining room in his/her wheelchair. The belt was loosely wrapped around the resident's waist. The resident's boy/girlfriend was present and said they had a hard time tightening the belt. The resident said he/she used the belt to keep from falling and knew how to release the belt, if needed. He/She said the belt was necessary to prevent falling out of the wheelchair. During an interview on 5/14/25 at 10:42 A.M., Certified Nursing Assistant (CNA) A said he/she was familiar with the resident. He/She thought the belt was built into the wheelchair. The resident used the belt to prevent falling from the wheelchair. During an interview on 5/14/25 at 12:33 P.M., CNA C said the resident used the belt restraint to keep from falling out of the wheelchair. During an interview on 5/14/25 at 12:41 P.M., Licensed Practical Nurse (LPN) D said he/she was familiar with the resident and was not aware of the resident using a belt restraint. If there was a belt restraint used, there should be a physician's order for its use. During an interview on 5/14/25 at 12:49 P.M., LPN E said he/she was familiar with the resident and never noticed a belt on the resident's wheelchair. If the resident used a belt restraint, it was to keep him/her from falling out of the wheelchair. The resident has involuntary movements and may need it to prevent falls from the wheelchair. During an interview on 5/14/25 at 2:53 P.M., the Director of Nursing (DON) said they did not have anyone at the facility using a restraint or a wheelchair belt. When asked about the resident, the DON said she was not aware the resident had a belt restraint on his/her wheelchair. If there was a belt on the wheelchair, there should be a physician's order, an initial assessment should be done, along with quarterly assessments and during changes in condition. It should be documented on the care plan and the resident should be assessed every two hours to ensure he/she could release the belt. During an interview on 5/15/25 at 12:19 P.M., the Administrator and DON said they initially did not know the resident had the belt on his/her wheelchair. When it was discovered, they immediately obtained a physician's order, entered it onto the care plan and assessed the resident. The resident should have been assessed prior to wearing the belt restraint. 2. Review of Resident 19's medical record, showed: -Intact Cognition; -Diagnoses included diabetes mellitus (DM, metabolic disease), hyperlipidemia (high cholesterol), stroke, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), and epilepsy (seizure disorder). Review of the resident's Nurse Medication Administration Record (NMAR), dated 4/1/25 to 4/30/25, showed: -An order to check blood glucose before meals. If blood glucose is less than 50 or greater than 500 please call doctor right away. If blood sugar is less than 100 at bedtime, take a snack (one carbohydrate and one protein) with meals related to type 2 diabetes mellitus with unspecified complication; -An order to monitor every shift for opioid usage side effects: Blue or purple skin, fingernails, or lips. Unresponsive to voice or touch. Loss of consciousness. Pinpoint sized pupils. Bradycardia (slow heart rate) or hypotension (low blood pressure). Slow, shallow, irregular or stopped breathing. Pale, clammy, cool skin. Extreme sleepiness or lethargy. Breathing difficulty with choking sounds, gasping, gurgling or snoring noise. Limp, lifeless body movement. Every shift for opioid usage. Review of the resident's POS, showed no physician orders for checking the blood glucose levels or for monitoring opioid usage. 3. Review of the Charting and Documentation Policy, dated February 2021, showed: -Policy: -Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations; -Be concise, accurate, and complete and use objective terms. Document only the facts. Use only approved abbreviations and symbols; -Chart as often as necessary and as need arises; -Charting Errors: -Do not erase/delete any error. Erasures or deletions of any type may must not be made in the medical record -Draw a single line through the error and write the correction above the error, and initial the change. Do not use white out; -Do not leave blank lines. Draw a single line through a blank line. Review of Resident's #19 medical record, showed: -Intact Cognition; -Diagnoses included diabetes mellitus, hyperlipidemia (high cholesterol), stroke, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and epilepsy (seizure disorder). Review of the resident's POS, dated 5/13/25, showed: -An order dated 4/26/24, for Amlodipine Besylate Tablet 10 milligram (mg) tablet, give 1 tablet by mouth one time a day for hypertension; -An order dated 1/23/25, for Furosemide Tablet 20 mg tablet, give 1 tablet by mouth one time a day for congestive heart failure; -An order dated 6/12/24, for Ginger Oral Capsule 500 mg, give 1 capsule by mouth one time a day for supplement; -An order dated 3/4/25, for Keppra Tablet 500 mg, give 500 mg by mouth every 12 hours related to convulsion disorder with seizures or convulsions; -An order dated 2/14/25, for Lipitor Oral tablet 40 mg, give 1 tablet by mouth at bedtime related to diabetes mellitus with unspecified complications; -An order dated 7/23/23, for Clonidine HCI Oral Tablet 0.1 mg, give 1 tablet by mouth three times a day for hypertension; -An order dated 3/15/25, track and document hours of sleep each shift related to melatonin use. Every evening and night shift related to insomnia; -An order dated 2/19/25, for Nystatin powder, apply to breast, right flank, axilla topically every shift for redness/irritation; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -An order dated 8/6/24, for Lisinopril Oral Tablet 10 mg, give 10 mg by mouth one time a day for hypertension related to cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery; -An order dated 12/27/21, for Melatonin tablet 3 mg, give 3 mg by mouth at bedtime for insomnia; -An order dated 3/15/23, for Saccharomyces Boulardii oral capsule 250 mg, give 1 capsule by mouth one time a day for diarrhea; -An order dated 12/13/17, for Acetaminophen Oral Tablet 325 mg, give 2 tablets by mouth two times a day for mild pain . Do not exceed 4000 mg in 24 hours; -An order dated 1/2/25, for Kasaglar Kwikpen subcutaneous solution pen-injector 100 unit/ml (insulin glargine). Inject 14 units subcutaneously at bedtime related to type 2 diabetes mellitus with unspecified complications; -An order dated 7/10/23, for Glipizide Oral Tablet 10 mg, give one tablet by mouth in the morning related to type 2 diabetes mellitus with unspecified complications; -An order dated 8/3/23, for Tramadol HCI tablet 50 mg, give 1 tablet by mouth two times a day for osteoarthritis. Review of the resident's Medication Administration Record (MAR), dated 4/1/25 to 4/30/25, showed: -An order dated 4/26/24, for Amlodipine Besylate Tablet 10 mg tablet, give 1 tablet by mouth one time a day for hypertension; -Documentation showed one out of 30 opportunities left blank; -An order dated 1/23/25, for Furosemide Tablet 20 mg tablet, give 1 tablet by mouth one time a day for congestive heart failure; -Documentation showed one out of 30 opportunities left bank; -An order dated 6/12/24, for Ginger Oral Capsule 500 mg, give 1 capsule by mouth one time a day for supplement; -Documentation showed one out of 30 opportunities left blank; -An order dated 2/14/25, for Lipitor Oral Tablet 40 mg, give 1 tablet by mouth at bedtime related to diabetes mellitus with unspecified complications; -Documentation showed two out of 30 opportunities left blank; -An order dated 3/4/25, for Keppra tablet 500 mg, give 500 mg by mouth every 12 hours related to convulsion disorder with seizures or convulsions; -Documentation showed six out of 60 opportunities left blank; -An order dated 7/23/23, for Clonidine HCI oral tablet 0.1 mg, give 1 tablet by mouth three times a day for hypertension; -Documentation showed four out of 90 opportunities left blank; -An order dated 8/6/24, for Lisinopril Oral Tablet 10 mg, give 10 mg by mouth one time a day for hypertension related to cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery; -Documentation showed one out of 30 opportunities left blank; -An order dated 12/27/21, for Melatonin tablet 3 mg, give 3 mg by mouth at bed; -Documentation showed one out of 30 opportunities left blank; -An order dated 12/13/17, for Acetaminophen Oral Tablet 325 mg, give 2 tablets by mouth two times a day for mild pain. Do not exceed 4000 mg in 24 hours; -Documentation showed three out of 60 opportunities left blank; -An order dated 1/2/25, for Kasaglar Kwikpen subcutaneous solution pen-injector 100 unit/ml. Inject 14 units subcutaneously at bedtime related to type 2 diabetes mellitus with unspecified complications; -Documentation showed one out of 30 opportunities left blank; -An order dated 7/10/23, for Glipizide oral tablet 10 mg, give one tablet by mouth in the morning related to type 2 diabetes mellitus with unspecified complications; -Documentation showed one out of 30 opportunities left blank; -An order dated 8/3/23, for Tramadol HCI tablet 50 mg, give 1 tablet by mouth two times a day for osteoarthritis; -Documentation showed one out of 30 opportunities left blank; Review of the Treatment Administration Record (TAR), dated 4/1/25 to 4/30/25, showed: -An order dated 3/15/25, track and document hours of sleep each shift related to melatonin use. Every evening and night shift related to insomnia; -Documentation showed three out of 60 opportunities left blank; -An order dated 2/19/25, for nystatin powder, apply to breast, right flank, axilla topically every shift for redness/irritation; -Documentation showed two out of 90 opportunities left blank; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -Documentation showed two out of 90 opportunities left blank; Review of the resident's MAR, dated 5/1/25 to 5/31/25, showed: -An order dated 8/3/23, for tramadol HCI tablet 50 mg, give 1 tablet by mouth two times a day for osteoarthritis; -Documentation showed one out of 12 opportunities left blank; Review of the resident's TAR, dated 5/1/25 to 5/31/25, showed: -An order dated 3/15/25, track and document hours of sleep each shift related to melatonin use. Every evening and night shift related to insomnia; -Documentation showed one out of 24 opportunities left blank; -An order dated 2/19/25, for Nystatin powder, apply to breast, right flank, axilla topically every shift for redness/irritation; -Documentation showed two out of 36 opportunities left blank; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -Documentation showed one out of 36 opportunities left blank; 4. Review of Resident #6's medical record, showed the following: -Severely impaired cognition; -Diagnoses included atrial fibrillation (a-fib, irregular heart rhythm), heart failure, diabetes mellitus, hypertension, hyperlipidemia (high cholesterol), dementia, osteoporosis, depression, chronic obstruction pulmonary disease (COPD, lung disease) and respiratory disease. Review of the resident's POS, dated 5/13/25 showed: -An order dated 8/6/23, for Anticoagulant medication. Monitor for discolored urine, black tarry stools, sudden severe headache, a&v1, diarrhea, muscle and joint pain, lethargy, bruising, sudden changes in mental status and/or signs or symptoms (s/s), shortness of breath (SOB), and nose bleeds; -An order dated 6/3/24, for Antidepressant medication. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior; -An order dated 6/3/24, for antipsychotic medication. Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling, Extrapyramidal symptoms (EPS) symptoms, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -An order dated 4/19/25, to validate function every shift related to dementia in other diseases classified elsewhere, unspecified severity with agitation; -An order dated 4/5/22, for Amlodipine Besylate Tablet 10 mg tablet, give 1 tablet by mouth one time a day related to hypertension; -An order dated 4/5/22, for Aspirin 81 tablet delayed release, give 1 tablet by mouth one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris; atherosclerotic of aorta; -An order dated 8/5/24, for Bisacodyl oral tablet delayed release 5 mg tablet, give 1 tablet by mouth in the evening for constipation; -An order dated 9/11/24, for Famotidine Oral Tablet 20 mg Tablet, give 1 tablet by mouth one time a day for gastroesophageal reflux disease (GERD, acid reflux); -An order dated 8/5/24, for Miralax Oral Packet 17 mg, give 1 packet by mouth one time a day for constipation; -An order dated 4/7/22, for Sertraline HCI Tablet 25 mg, give 25 mg one time a day for depression related to major depressive disorder; -An order dated 9/17/24, for Vitamin C Oral Tablet, give 1 tablet by mouth one time a day for GERD; -An order dated 9/27/23, for Acetaminophen Oral Tablet 500 mg, give 1000 mg by mouth two times a day for pain per Hospice; -An order dated 4/5/22, for Carvedilol Tablet 6.25 mg, give 25 mg one tablet two times a day related to atherosclerotic heart disease of native coronary artery without angina pectoris; hypertension; -An order dated 11/15/22, for Quetiapine Fumarate Oral Tablet 50 mg, (give 1 tablet by mouth two times a day for psychosis, verbal/physical aggression related to dementia in other diseases classified elsewhere unspecified severity, with agitation; -An order dated 1/7/25, for Med Pass Supplement three times a day for dietary supplement, give 120 milliliters (ML); Review of the resident's MAR, dated 4/1/25 to 4/30/25, showed: -An order dated 4/5/22, for Amlodipine Besylate Tablet 10 mg tablet, give 1 tablet by mouth one time a day related to hypertension; -Documentation showed one out of 30 opportunities left blank; -An order dated 4/5/22, for Aspirin 81 tablet delayed release, give 1 tablet by mouth one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris; atherosclerotic of aorta; -Documentation showed one out of 30 opportunities left blank; -An order dated 8/5/24, for Bisacodyl oral tablet delayed release 5 mg tablet, give 1 tablet by mouth in the evening for constipation; -Documentation showed one two of 30 opportunities left blank; -An order dated 9/11/24, for Famotidine Oral Tablet 20 mg tablet, give 1 tablet by mouth one time a day for GERD; -Documentation showed one out of 30 opportunities left blank; -An order dated 8/5/24, for Miralax Oral Packet 17 mg, give 1 packet by mouth one time a day for constipation; -Documentation showed one out of 30 opportunities left blank; -An order dated 4/7/22, for Sertraline HCI Tablet 25 mg, give 25 mg one time a day for depression related to major depressive disorder; -Documentation showed one out of 30 opportunities left blank; -An order dated 9/17/24, for Vitamin C Oral Tablet, give 1 tablet by mouth one time a day for GERD; -Documentation showed one out of 30 opportunities left blank; -An order dated 9/27/23, for Acetaminophen Oral Tablet 500 mg, give 1000 mg by mouth two times a day for pain per Hospice; -Documentation showed two out of 60 opportunities left blank; -An order dated 4/5/22, for Carvedilol Tablet 6.25 mg, give 25 mg one tablet two times a day related to Atherosclerotic heart disease of native coronary artery without angina pectoris; hypertension; -Documentation showed three out of 60 opportunities left blank; -An order dated 11/15/22, for Quetiapine Fumarate Oral Tablet 50 mg, give 1 tablet by mouth two times a day for psychosis, verbal/physical aggression related to dementia in other diseases classified elsewhere unspecified severity, with agitation; -Documentation showed three out of 60 opportunities left blank; -An order dated 1/7/25, for Med Pass Supplement three times a day for dietary supplement, give 120 milliliters (ML); -Documentation showed four out of 90 opportunities left blank. Review of the resident's TAR, dated 4/1/25 to 4/30/25, showed: -An order dated 8/6/23, for Anticoagulant medication. Monitor for discolored urine, black tarry stools, sudden severe headache, diarrhea, muscle and joint pain, lethargy, bruising, sudden changes in mental status and/or s/s, SOB and nose bleeds; -Documentation showed two out of 90 opportunities left blank; -An order dated 6/3/24, for antidepressant medication. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior; -Documentation showed two out of 90 opportunities left blank; -An order dated 6/3/24, for antipsychotic medication. Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling, EPS symptoms, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue; -Documentation showed two out of 90 opportunities left blank; -An order dated 8/6/23, for Black Box Warning: Monitor for adverse cardiovascular effects, infections (especially respiratory), falls, blood nose and lipid elevations, abnormal involuntary movements, cerebrovascular adverse events, sedation, and death every shift for psychotic features related to dementia in other diseases classified elsewhere with behavioral disturbances; -Documentation showed two out of 90 opportunities left blank; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -Documentation showed two out of 90 opportunities left blank. Review of the resident's TAR, dated 5/1/25 to 5/31/25, showed: -An order dated 8/6/23, for Anticoagulant medication. Monitor for discolored urine, black tarry stools, sudden severe headache, diarrhea, muscle and joint pain, lethargy, bruising, sudden changes in mental status and/or s/s, SOB and nose bleeds; -Documentation showed two out of 36 opportunities left blank; -An order dated 6/3/24, for antidepressant medication. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior; -Documentation showed two out of 36 opportunities left blank; - -An order dated 6/3/24, for antipsychotic medication. Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling, EPS symptoms, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue; -Documentation showed two out of 36 opportunities left blank; -An order dated 8/6/23, for Black Box Warning: Monitor for adverse cardiovascular effects, infections (especially respiratory), falls, blood nose and lipid elevations, abnormal involuntary movements, cerebrovascular adverse events, sedation, and death every shift for psychotic features related to dementia in other diseases classified elsewhere with behavioral disturbances; -Documentation showed two out of 36 opportunities left blank; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -Documentation showed two out of 36 opportunities left blank; -An order dated 4/19/25, to validate function every shift related to dementia in other diseases classified elsewhere, unspecified severity with agitation; -Documentation showed two out of 36 opportunities left blank; 5. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she expected residents' records to be accurate and complete. There should not be any holes on the MARs and/or TARs.

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice when staff failed to transcribe a new order, resulting in the treatment not administered for one resident (Resident #24). The sample was 13. The census was 46. Review of the facility's Medical Provider Orders policy, dated reviewed/revised 4/17/22, showed: -If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy; -When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; -Validate the new order in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR); Review of the facility's Medication Orders policy, dated effective 6/1/18, showed: -Orders sent with the resident from an office visit, the nurse on duty at the time the order is received enters it on the physician order sheet telephone order sheet/electronic medical record depending on facility protocol and notes the order as follows: Noted time, date, nurse signature; -If the order is from a prescriber other than the attending physician, the order is verified with the current attending physician; -Written Transfer Orders (sent with a resident by a hospital or other health care facility): -Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission; -If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature; -The nurse who transcribes the orders to the physician order sheet electronic medical record and MAR documents on the admission form the date, the time and by whom the orders were noted. Review of the facility's Charting and Documentation policy, dated reviewed 2/21, showed: -Documentation pertaining to residents' leave of absence (i.e., trips to physician's office, treatments, home, emergency room, or another therapeutic leave) should include: -Date and time resident left the facility. -Reason for resident leaving the facility. -Date and time resident returned. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/25, showed: -Short term memory problem; -Long term memory ok; -Dependent (helper does all the effort. Resident does none of the effort to complete the activity) for grooming, dressing and bathing; -Diagnoses included coronary artery disease (CAD, arteries that supply blood to the heart muscle become narrowed or blocked), high blood pressure, renal insufficiency (kidneys unable to function properly), obstructive uropathy (normal flow of urine through the urinary tract is blocked or hindered), stroke and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors); -Had an indwelling catheter (a sterile tube inserted into the bladder to drain urine); -Always incontinent of bowel and bladder; -Moisture Associated Skin Damage (MASD, skin's barrier is compromised due to prolonged exposure to moisture and its contents); -Had applications of ointments/medications other than to feet. Review of the care plan, in use at the time of survey, showed: -Focus: The resident has bladder incontinence; -Interventions included: check the resident every two hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes; has catheter; Review of the progress notes dated 4/8/25 through 4/9/25, showed: -On 4/8/25 at 3:40 P.M., showed, resident complained of penile pain. Registered Nurse (RN) assessed area. Catheter was displaced and area bleeding. RN informed the doctor and removed the catheter. The doctor ordered Keflex (antibiotic) three times a day for 10 days. He/She also ordered Lotrimin topically until healed. RN replaced catheter. Referral to urologist order completed and sent to appropriate staff to schedule; -On 4/8/25 at 4:10 P.M., per family request resident was sent to the hospital emergency room (ER) via emergency medical service (EMS) to evaluate penis tear from catheter; -On 4/9/25 at 5:41 A.M., resident returned to facility via ambulance and two emergency medical technicians (EMTs) from hospital due to penis injury. Arrived at 2:15 A.M. with new order for Nystatin to affected area twice daily. Review of the After Visit Summary from the ER, dated 4/8/25, showed: -Reason for visit: penis injury; -Diagnosis: inflammation of penis; -Instructions: patient's penis must be properly cleaned with soap and water twice daily, clean thoroughly prior to applying prescribed Nystatin cream; -Your medications have changed: start taking Nystatin (myostatin, antifungal) 100,000 unit/gram cream, apply to affected area two times daily. Review of the Treatment Administration Record (TAR), dated 4/9/25 through 4/23/25, showed: -A physician order for Nystatin-Triamcinolone Cream (combination medication containing an antifungal and corticosteroid) 100000-0.1 unit/gram-%, apply topically two times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry and apply cream to coccyx and scrotal area. Do not cover; -A.M.: on 4/9 through 4/23, administered; -P.M.: on 4/9 through 4/13, administered, 4/14 was blank, on 4/15 a 7 (sleeping) was documented, on 4/16 through 4/23, administered; -A physician order for Triad hydrophilic wound dress external paste, apply to coccyx and scrotal area topically three times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry then apply a liberal amount of cream to coccyx and scrotal area. Do not apply any dressing to area; -A.M. and Noon: on 4/9 through 4/23, administered; -P.M.: on 4/9 through 4/13, administered, 4/14 was blank, on 4/15 a 7 (sleeping) was documented, on 4/16 through 4/23, administered. Review of the progress notes, dated 4/9/25 through 4/23/25., showed no documentation of the order for Nystatin from 4/9/25 was verified with the resident's physician and there was no documentation showing the physician wished to continue the Nystatin/Triamcinolone cream. Review of the progress notes, showed no documentation the resident went to the ER and returned to the facility. There was no documentation new treatment orders were verified with the physician or documentation showing the physician did not want to change the treatment. Review of the After Visit Summary from the ER, dated 4/23/25, showed: -Reason for visit: urinary catheter problems; -Diagnosis: inflammation of the penis; -Instructions: we discussed case with the urologist who is recommending Nystatin cream, local wound care, barrier creams as needed given the catheter is flowing appropriately; -Changes to your medication list: -Nystatin 100,000 unit/gram cream. Apply to affected area two times daily. What changes, another medication with the same name was added, make sure you understand how and when to take each; -Nystatin 100,000 unit/gram powder (Nystop, antifungal), apply to affected area twice daily. You were already taking a medication with the same name and this prescription was added. Make sure you understand how and when to take each; -This list has two medications that are the same as other medications prescribed for you. Read directions carefully and ask your doctor or other care provider to review them with you. Review of the TAR, dated 4/23/25 through 4/30/25, showed: -A physician order for Nystatin-Triamcinolone Cream 100000-0.1 unit/gram-%, apply topically two times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. pat dry and apply cream to coccyx and scrotal area. Do not cover; -A.M. and P.M., documented as administered; -A physician order for Triad hydrophilic wound dress external paste, apply to coccyx and scrotal area topically three times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry then apply a liberal amount of cream to coccyx and scrotal area. Do not apply any dressing to area; -A.M., Noon and P.M., documented as administered. Review of the progress notes, showed: -On 4/27/25 at 6:59 A.M., continues antibiotic monitoring related to torn skin surrounding urethra and catheter placement. Resident complained of positional discomfort this shift. Area remains swollen; -On 4/28/25 at 4:03 A.M., continues antibiotic monitoring related to torn skin surrounding urethra and catheter placement. Area remains swollen. Review of the TAR, dated 5/1/25 through 5/12/25, showed: -A physician order for Nystatin-Triamcinolone Cream 100000-0.1 unit/gram-%, apply topically two times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry and apply cream to coccyx and scrotal area. Do not cover; -A.M., administered; -P.M. on 5/1 and 5/2, administered, 5/3 was blank, 5/4 through 5/11, administered; -A physician order for Triad hydrophilic wound dress external paste, apply to coccyx and scrotal area topically three times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry then apply a liberal amount of cream to coccyx and scrotal area. Do not apply any dressing to area; -A.M., Noon, administered; -P.M. on 5/1 and 5/2, administered, on 5/3 blank, 5/4 through 5/11, administered. Observation and interview on 5/12/25 at 10:18 A.M., showed the resident lay in bed. The resident said he went to the hospital recently for an infection in his penis. The facility did not provide his treatment, and he had to go back a few weeks later. He did not feel like his catheter was set right because sometimes urine runs down his penis and he gets liquid in his brief and sometimes he has pain. Review of the order summary report, dated 5/12/25, showed: -Nystatin-Triamcinolone Cream 100,000-0.1 unit/gram-1%, apply topically two times a day for dermatitis. Cleanse coccyx (tailbone) and scrotal area with wound cleanser. Pat dry and apply cream to coccyx and scrotal area. Do not cover. Start date was 9/30/24; -Triad hydrophilic wound dressing external paste (wound dressing) apply to coccyx and scrotal area with wound cleanser. Pat dry then apply a liberal amount of cream to coccyx and scrotal area. Do not apply any dressing to area, start date was 10/28/24. Observation and interview on 5/14/25 at 2:00 P.M., showed Registered Nurse (RN) H assisted the resident to roll onto his side and cleaned his buttocks/coccyx with wound cleanser and applied Nystatin/Triamcinolone cream, then applied Triad paste to the same area. Then, the nurse assisted the resident to roll back on his back. The shaft of the penis just below the tip of the penis was red and inflamed. The nurse described the area as excoriated and said the resident did not have a treatment ordered and he/she would need to call the doctor. The resident said it hurt a little RN H cleaned the area and left it open to air. Once the nurse returned to the desk, he/she checked the order in the computer and expanded the treatment orders out and said the creams should be applied to both the coccyx and the scrotal area and he/she would go back and apply the creams to the scrotal area. During an interview on 5/14/25 at 2:00 P.M., RN H said when a resident goes out for a doctor's appointment/hospital, it should be documented in the progress notes when the resident left and when they returned. When the resident returned from the appointment/hospital, he/she would take a picture of the paperwork and send it to the doctor to review. The nurse on duty was responsible for verifying and entering the orders into the computer. If a physician did not want to change an order, that should be documented in the progress notes. During an interview on 5/14/25 at 2:51 P.M. and on 5/15/25 at 2:19 P.M., the Director of Nursing (DON) said when a resident leaves the building and when they return, it should be documented. Agency staff do not always document. When the resident returned, the nurse who was on duty was responsible for verifying the orders with the physician and entering the orders into the computer. Staff should also document if the physician did not want to change the order. On 4/8/25, the DON saw the resident before he went to the hospital and said the skin tear looked like the catheter was pulled and his skin looked like erosion from the catheter being in place for a while. On 4/23/25, the DON did not know if the resident went to the hospital or if he went out for a follow up appointment. She did not know if he returned with any new orders or not. Nystatin/Triamcinolone cream and Nystatin cream and Nystatin powder are not the same medication, this would be a medication error. The staff may have assumed they were the same medication. The DON said she would verify the order with the physician. The DON expected staff to verify the orders with the physician when they return to the facility, and document it. If the admitting nurse was unable to complete the task, the nurse should pass it on to the next shift or let the DON know. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she expected staff to follow the facility's policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures in resident rooms on the 100 hall and in the unlocked and accessible staff break room, between 105 degrees Fahrenheit (F) and 120 degrees F. This affected five sampled resident rooms, which included Resident #5. The temperatures at the sinks measured as high as 143 F. The sample size was 13. The census was 46. 1. Observations on 5/12/25 of the unlocked accessible employee break room handwashing sink, showed: -At 10:35 A.M., the water measured 137.8 F.; -At 11:50 A.M., the water measured 143 F.; -At 2:20 P.M., the water measured 139.0 F. Review of the facility's temperature logs, showed no documentation of temperatures for the employee break room. 2. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/17/25, showed: -Severe cognitive impairment; -Uses a manual wheelchair; -Diagnoses included dementia. Observations on 5/12/25 of the resident's room handwashing sink, showed: -At approximately 10:07 A.M., the water measured at 130.0 F; -At 10:40 A.M., the water measured 124.2 F.; -At 12:10 P.M. and 12:20 P.M., the water measured 130.0 F. Observations on 5/13/25 at 8:25 A.M., 5/14/25 at 10:39 A.M. and at 12:25 P.M., showed the resident wandered in his/her wheelchair throughout the facility. 3. Observation on 5/12/25 at 11:50 A.M., of resident room [ROOM NUMBER]'s handwashing sink, showed the water temperature measured 130.0 degrees F. 4. Observation on 5/12/25 at 12:15 P.M. of resident's room [ROOM NUMBER]'s handwashing sink, showed the water temperature measured 130.0 degrees F. 5. Observation on 5/12/25 of resident's room [ROOM NUMBER]'s handwashing sink, showed: -At approximately 10:08 P.M., the water temperature measured 130.0 degrees F; -At 12:20 P.M., the water temperature measured 130.0 degrees F. 6. Observation on 5/12/25 at approximately 10:09 A.M., of resident's room [ROOM NUMBER]'s handwashing sink, showed the water temperature measured 130.0 degrees F. 7. Observation of the boiler room, on 5/12/25 at 11:55 A.M., showed: -One large tank on the left side of the room. The temperature at the tank showed 120 F.; -Two smaller water tanks on the right side of the room. The temperature on both tanks read 130 F.; -Piping ran from the tanks to a mixing valve. The temperature on the mixing valve read 130 F. During an interview on 5/12/25 at 12:00 P.M. and at 2:20 P.M., the Maintenance Director said the larger tank supplied water to the laundry and staff break room. The two smaller tanks supplied water to the resident rooms. He took water temps about two times a week in a different resident room or shower room and documented them in a log. He used a digital thermometer but did not know it needed to be calibrated. He knew the temperatures needed to be between 105 F and 120 F. He knew the water was hot in the staff break room but thought it was okay since it was not a resident use room. Temperatures in the break room could run 145 F., but it needed to be hot for the laundry. The temperatures could run warmer on the 100 hall but if he found one that was too high, he would adjust the mixing valve to adjust it. They did not have a policy for water temperatures but followed the state guidelines. 8. During an interview on 5/12/25 at 3:15 P.M., the Administrator said she knew water temperatures needed to be between 105 degrees F and 120 degrees F but thought this was only in resident use areas. They had a sign on the staff break room door stating the room was for staff only. She did not know the temperatures were too high on the 100 hall.

Based on interview and record review, the facility failed to follow their policy when staff failed to ensure one resident's dialysis (a procedure that cleanses the blood of its impurities) communication logs were completed for all appointments (Resident #42). The facility identified one resident who received dialysis services. The sample was 13. The census was 46. Review of the facility's Dialysis Communication policy, dated 2/21, showed: -Director of Nursing (DON) or designee will contact dialysis unit to establish the communication, explain the facility will be sending a communication form that will facilitate the sharing of resident information surrounding dialysis; -A dialysis communication form will be used to send information to and from the facility to the dialysis center and back; -The nurse in charge of the care of the resident on the days of scheduled dialysis shall initiate the dialysis communication form and will ensure the form is sent with the resident; -Upon return of the resident from the dialysis center, the nurse in charge of the resident will review the communication form and will obtain necessary post dialysis information; -If there are any questions regarding the completion of the form or needs of the resident, the nurse will call the dialysis center for a telephone report of any significant information needed; -The nurse will complete post dialysis information on the dialysis communication form; -Completed form will be scanned into the electronic health record. Review of Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/5/25, showed: -Short and long-term memory was ok; -Make decisions regarding task of daily life: severely impaired, never/rarely made decisions; -Received dialysis while a resident; -Diagnoses included end stage renal disease (ESRD, chronic irreversible kidney failure). Review of the care plan, in use at the time of survey, showed: -Focus: the resident needs hemodialysis treatment related to renal failure; -Goal: The resident will have no signs symptoms of complications from dialysis through the review date; The resident will have immediate intervention should any signs/symptoms of complications from dialysis occur through the review date; -Interventions included: dialysis access-left arm arteriovenous fistula (AVF, abnormal connection between an artery and vein) used for access. History of left forearm AVF-thrombosis (a blood clot within the AVF) 1/13/25; -Encourage resident to go for scheduled dialysis appointments. Resident receives dialysis on Monday (M)-Wednesday (W)-Friday (F); -Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and blood pressure immediately. -Review communication form or flow sheet after treatment & implement new orders or recommendations. Review of the order summary sheet, dated 5/12/25, showed a physician order for dialysis every M-W-F; Review of the dialysis communication forms, dated 4/1/25 through 5/12/25, showed: -On 4/2 and 4/4/25, the post dialysis facility information was blank; -There were no other dialysis communication forms in the medical record. During an interview on 5/14/25 at 12:50 P.M., Registered Nurse (RN) D said a pre-dialysis assessment should be completed before a resident went out for dialysis. The assessment included checking the access site, vital signs and weight. There used to be a pop up in the computer for the assessment, currently he/she documents under the vital signs tab. Review of the vital signs tabs, dated 4/1/25 through 5/11/25, showed: -On 4/2, 4/4, 4/7, 4/9, 4/11, 4/16, 4/25, 4/28, 4/28, 5/1, 5/2, 5/5, 5/7 and on 5/9/25, there were no pre-dialysis., temperatures, respirations and blood pressures documented. During an interview on 5/14/25 at 1:40 P.M. and 5/15/25 at 12:19 P.M., the Administrator said the facility communicates all the time with the dialysis center and they will call the facility if there are any changes. The nurse should check the resident's weight and vital signs pre and post dialysis. This information is documented on the dialysis communication form. The assessments have been completed sporadically because the agency staff do not always do it. Once they are completed, they are uploaded into the computer. The Administrator expected the charge nurse to complete the dialysis communication form and to follow the facility's policy and procedures.

Based on observation, interview and record review, the facility failed to ensure on-going resident centered therapeutic activities were provided to residents in the evenings and on weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure that 1 on 1 activities were done more than one time a week. This deficient practice had the potential to affect all residents in the facility. The census was 46. 1. Review of the facility's May 2025 activity calendar, showed: -Monday through Friday, no activities offered after 2:00 P.M.; -Saturdays: 5/3/25, Self Directed Activities, 10:00 A.M., Bingo with volunteer and 3:30, House of Prayer Music Visit. 5/17/25 and 5/31/25 included bingo with volunteer at 10:00 A.M. All other Saturdays were Self Directed Activities, which included coloring, word puzzles, card and board games; -Sundays: Self-Directed activities, which include coloring and word puzzles, card and board games. 2. Review of the 1 on 1 list, provided by the facility, showed 14 residents receiving 1 on 1 activities. 3. During a group interview on 5/13/25 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. All six residents said the facility did not offer activities on the weekend. There is no one there to do activities on the weekend and throughout the week, none are offered after 4:00 P.M. There is a volunteer who came to the facility every other Saturday who did bingo with them. No activities were offered on Sundays. They wanted evening and weekend activities. 4. During an interview on 5/14/25 at 12:33 P.M., Certified Nursing Assistant (CNA) B said he/she sometimes worked the weekends and there was usually no activities for residents during the weekend. He/She saw someone doing bingo one Saturday but had not seen the person in awhile. The Activity Director (AD) left games and coloring books for the residents to use them while she was off on the weekends. Weekend activities were self-directed. 5. During an interview on 5/14/25 at 12:34 P.M., CNA C said there was no activity program on the weekend. Activities were self-directed. The AD left books and games for the residents. 6. During an interview on 5/14/25 at 12:49 P.M., Licensed Practical Nurse (LPN) E said there were no activities during the weekend. Activities were self-directed on the weekends. He/She saw someone assist with bingo on a Saturday, but could not recall how often they came. 7. During an interview on 5/14/25 at 3:13 P.M., the Activity Director (AD) said she had been at the facility since October, 2024. She was responsible for all the activities. She did not have an assistant. Activities after 4:00 P.M. were kind of iffy because when activities were done after 4:00 P.M., it would be a movie, but from what she heard, the residents didn't really come down for the movie. This would consist of maybe five people at the most. This was the only activity after 4:00 P.M., because she was not there after 4:00 P.M. because she lives about 40 minutes away, so sometimes she might be at the facility, but not for an activity. At those times, she might catch up on 1 on 1's or do computer work. Every other weekend, they have a volunteer who came to the facility at 10:00 A.M. and do bingo with the residents. He/She also would bring a friend sometimes who would do chair yoga with the residents. This is done just every other Saturday. Every first Sunday of the month, a music group who sings religious songs and hymns comes to the facility. The AD thought the residents deserved more but felt bad because she could not come on the weekends. It would be nice if she had help. If she had help, they could give the residents more of what they need regarding activities. She felt the residents should get activities after 4:00 P.M., but they do have plenty of self-directed activities. All of their board games are kept in the library because that is open space, so all their self-directed activities are easy access for them. They are either outside her office or in the library. The papers are updated every month. They have coloring papers, word games, board games, cards, etc. For residents who cannot do self-directed activities, she would see them and do 1 on 1's with them but that is only 1 time a week. They deserve more than that. 8. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she was not aware activities were not going on after 4:00 P.M. during the week and/or on the weekends. She said this was not true. They had activities on the weekends. It was not every Saturday and Sunday. A volunteer comes every other Saturday. The volunteer did not come in just for an hour. He/She would bring a yoga instructor with him/her and he/she would do chair yoga with the residents. The Administrator expected for activities for 1 on 1's to be done more than once a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy and ensure side rails were assessed as necessary on a quarterly and annual basis for six of 13 sampled residents(Residents #44, #5, #24, #9, #14 and #28). The census was 46. Review of the facility's Side Rails policy, dated 10/17/23, showed: -Policy: Assess resident side rail restraint needs on admission, annually and with any significant change in order to ensure the resident's highest practicable physical and psychosocial well-being. Review quarterly; -Procedure: -Nursing staff will assess need for side rails at time of admission, annually and with any significant change and place in the chart, reviewing quarterly; -Side rails will be evaluated quarterly and reduced/eliminated as possible. 1. Review of Resident #44's Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. A half length and quarter length rail was indicated. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/26/25, showed: -admitted [DATE]; -Short and long-term memory problem; -No behaviors; -Upper and lower extremities: Impairment on one side; -Dependent on staff for mobility and transfers; -Diagnoses included fractures, hemiplegia (muscle weakness or paralysis on one side) and depression. Review of the resident's care plan, revised 3/3/25, showed: -Focus: The resident has actual/potential for falls. Gait/balance problems and paralysis; -Goal: The resident will be free of minor injury through review date; -Interventions: Enabler bar to assist with safe transfers. Review of the resident's May 2025 active physician's order, showed an order, dated 12/1/23, for bed rails. Quarter length related to impaired mobility and diagnoses of hemiplegia, unspecified affecting left nondominant side. Review of the resident's electronic medical record (EMR), viewed 5/13/25 at 10:50 A.M., showed no side rail assessment. Observation on 5/13/25 at 8:30 A.M., showed the resident lay on his/her back. Quarter length side rails were raised on both sides. The resident said he/she used the rails to help with positioning. Observation on 5/14/25 at 8:26 A.M., showed the resident lay in bed on his/her back. Side rails were raised on both sides. During an interview on 5/14/25 at 10:42 A.M., Certified Nursing Assistant (CNA) A said he/she was familiar with the resident and he/she used the side rails to assist with turning and positioning. 2. Review of Resident #5's EMR, showed a Device/Restraint Evaluation, dated 10/18/22. Resident uses a grab bar. Review of the resident's Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. Review of the resident's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Rarely understood; -Dependent on staff for mobility and transfers; -Diagnoses included heart disease and dementia; -Bed rails not used. Review of the resident's care plan, revised 3/10/25, showed: -Focus: The resident has limited physical mobility; -Goal: The resident will maintain current level of mobility; -Intervention: Left and right quarter length assist rails for bed mobility. Review of the resident's May 2025 active physician's order, showed an order, dated 10/20/23: Resident has side rails, quarter length related to impaired mobility and diagnosis of abnormal posture and weakness. Observation on 5/12/25 at approximately 10:07 A.M., showed the resident sat in his/her wheelchair next to his/her bed. The resident's bed had raised quarter length side rails on both sides. The resident could not say what the side rails were used for. During an interview on 5/14/25 at 10:42 A.M., Certified Nursing Assistant (CNA) A said he/she was familiar with the resident and he/she used the side rails to assist with turning and positioning. 3. Review of Resident #24's quarterly MDS, dated [DATE], showed: -Short term memory problem; -Long term memory ok; -Had functional limitation of range of motion in both upper extremities. -Was dependent (helper does all the effort. Resident does none of the effort to complete the activity) for rolling left to right, to change positions from lying to sitting on the side of the bed and to go from sitting to standing; -Diagnoses included: coronary artery disease (CAD, arteries that supply blood to the heart muscle become narrowed or blocked), high blood pressure, renal insufficiency (kidneys unable to function properly), obstructive uropathy (normal flow of urine through the urinary tract is blocked or hindered), stroke and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the care plan, in use at the time of survey, showed: -Focus: resident has an Activities of Daily Living (ADL, grooming, dressing, bathing) self-care performance deficit; -Goal: will maintain current level of function in through the next review; -Interventions included: bed mobility, the resident can roll over in bed with use of the enabler rails. Review of the order summary report, dated 5/12/25, showed a physician order for bed side rails (1/4) related to impaired mobility and diagnoses of muscle weakness. Review of the device/restraint evaluation form, dated 10/18/22, showed resident used side rails. Observation and interview on 5/5/25 at 10:24 A.M., showed the resident lay in bed with U shaped side rails up on both sides. The resident said he/she used them to help him/her to stand up. Observation on 5/14/25 at 2:00 P.M., showed the resident lay in bed. Registered Nurse (RN) H assisted the resident to roll from his/her back onto his/her left side. The resident grabbed the side rail to help roll over. 4. Review of Resident #9's annual MDS, dated [DATE], showed: -re-admission date of 10/18/18; -Cognitively intact; -Uses wheelchair for mobility; -Diagnoses included stroke, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hemiplegia or hemiparesis (neurological conditions that cause weakness or paralysis on one side of the body). Review of the resident's physician orders, dated 10/20/23, showed an order for quarter bed side rails related to mobility and diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Review of the resident's medical record, showed no side rails assessment. Observation on 5/12/22 at 10:38 A.M., showed the resident had side rails on both sides of his/her bed. The side rails were down and the resident was not in bed. During an interview on 5/14/25 at 9:34 A.M., the resident said he/she used the side rails for positioning. 5. Review of Resident #14's significant change MDS, dated [DATE], showed: -re-admission date of 4/7/25; -Moderately impaired cognitive skills for daily decision making; -Uses wheelchair for mobility; -Diagnoses included heart failure, diabetes, hip fracture and malnutrition. Review of the resident's physician orders, dated 4/8/25, showed an order for left and right quarter rail enabler bars to aide in bed positioning and transfers. Observation on 5/14/22 at 10:22 A.M., showed the resident had side rails on both sides of his/her bed. The side rails were down and the resident was not in bed. During an interview on 5/14/25 at 12:50 P.M., LPN E said he/she did not know why the resident had side rails on the bed, but he/she was able to use the rails, and he/she thought they were beneficial for the resident with turning and positioning. 6. Review of Resident #28's significant change MDS, dated [DATE], showed: -re-admission date of 2/25/25; -Moderately impaired cognitive skills for daily decision making; -Impairment on one side of upper extremity; -Impairment on both sides of lower extremities; -Uses wheelchair for mobility; -Diagnoses included hip fracture, dementia, malnutrition, anxiety and depression. Review of the resident's physician orders, dated 10/20/23, showed an order of quarter bed side rails related to impaired mobility and diagnoses of unspecified injury at C4 level of cervical spinal cord, sequela (a condition which is the consequence of a previous disease or injury) and generalized muscle weakness. Review of the resident's medical record, showed no side rails assessment. Observation on 5/12/22 at 11:04 A.M., showed the resident's bed had one quarter side rail, to the resident's right side. The side rail was raised, while the resident sat in the wheelchair at bedside. During an interview on 5/14/25 at 11:00 A.M. the resident said he/she needed the side rail to get out of bed. During an interview on 5/14/25 at 12:33 P.M., CNA C said the resident's side rails were used for positioning and mobility. The resident used the right side rail only for mobility. He/She used it for standing or getting out of bed with one assist. 7. During an interview on 5/14/25 at 12:41 P.M., RN D said side rails were used for turning, positioning and safety. He/She had not assessed anyone for the use of side rails and was not sure who was responsible for assessing the use of side rails. During an interview on 5/14/25 at 12:49 P.M., LPN E said side rails were used for positioning and to prevent falls. Nursing did not assess for the use of side rails. He/She never assessed a resident for the use of side rails. If and when residents needed a side rail, he/she would let the Administrator or MDS nurse know. During an interview on 5/15/25 at 9:26 A.M., the MDS Coordinator said she was only responsible for the residents' care plans and MDS. During an interview on 5/14/25 at 2:53 P.M., the Director of Nursing (DON) said positioning devices are used by therapy and the U-rails are used for positioning. Therapy will assess residents upon admission, annually and with a change in condition. The nurses should report the change in condition and document it in the progress note. When asked to clarify, the DON said therapy would assess, then the nurses would be responsible for quarterly and annual assessments. She did not specify if the nurses or therapy had done side rail assessments. During an interview on 5/14/25 at 3:43 P.M., the Director of Rehab said therapy could be responsible for side rail assessments going forward, then nursing would be responsible for assessing the use of side rails quarterly, annually and as needed. He/She was not sure who assessed for side rails currently, but therapy had not done any assessments recently. During an interview on 5/15/25 at 12:19 P.M., the Administrator and DON said side rails should be assessed quarterly, annually and with a change in condition.

Based on interview and record review, the facility failed to provide and offer nourishing snacks at bedtime. This affected all residents who ate at the facility. The census was 46. Review of the dietary records, showed mealtimes scheduled for the following: -Breakfast meal at 7:30 A.M.; -Lunch meal at 12:15 P.M.; -Dinner meal at 5:30 P.M. During a group interview on 5/13/25 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. The residents said the staff just started passing out snacks. They pass the snacks out during the day, but not after dinner. This started within the last week or two. During an interview on 5/14/25 at 12:33 P.M., Certified Nursing Assistant (CNA) B said he/she worked the evening shift and snacks were not passed out in the evening. Activities would pass out snacks after lunch. During an interview on 5/14/25 at 12:34 P.M., CNA C said residents did not receive snacks in the evening. During an interview on 5/14/25 at 12:41 P.M., Registered Nurse (RN) D said residents did not receive evening snacks very often. During an interview on 5/14/25 at 12:49 P.M., Licensed Practical Nurse (LPN) E said bedtime or evening snacks were not provided to the residents. The Minimum Data Set (MDS) Nurse often brought snacks with his/her own money and passed them out at night. During an interview on 5/14/25 at 1:15 P.M., the Dietary Manager said he normally left the facility around 5:00 P.M. He would send snacks to the nurse's station. Often when he returned the next day, the snacks were still in the same spot where he left them. He did not believe staff passed out the snacks. During an interview on 5/15/25 at 12:19 P.M., the Administrator said it was her expectation that snacks were to be given to the residents after dinner. Snacks were out at the nurse's station.

Based on observation and interview, the facility failed ensure the ice machine had an air gap to prevent backflow from the drain pipe into the ice machine, potentially contaminating the contents of the ice machine. The census was 46. Observations on 5/12/25 at 9:53 A.M., 5/13/25 at approximately 8:30 A.M. and 5/14/25 at 8:07 A.M., 10:22 A.M. and 11:32 A.M., showed the ice machine located in the kitchen. The ice machine drain tubing extended down from the ice machine with the lower end of the drain tubing directly in the drain pipe. During an interview on 5/14/25 at 11:50 A.M., the Dietary Manager said he was not aware if there was an air gap from the drain tubing and drain pipe of the ice machine. When shown the tubing and drain, he said he would have to ask the Maintenance Director. During an interview on 5/14/25 at 11:53 A.M., the Maintenance Director said there was no air gap. The facility purchased the new ice machine around December 2024 and he had not yet created the air gap. The ice machine should have an air gap to prevent any backflow from the drainage pipe entering into the ice machine. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she would expect the ice machine to have an air gap.

**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 two 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) (Residents #14 and #20). In addition, staff failed to cleanse the shared blood sugar machine (Accu-check) with approved cleansing products between each resident use. Additionally, the facility failed to ensure newly hired employees were provided a two-step Mantoux Purified Protein Derivative (PPD, used to test for tuberculosis (TB, a serious infectious disease caused by bacteria that often affects the lungs) infection) tuberculin skin test for three employees who had no documentation showing they received their first or the second step TB test (Employees A, E and F), two employees who received their first step after their hire date and had no documentation of receiving the second step (Employee C and D) and one employee who had no documentation of receiving the second step (Employee B) out of 10 employees sampled. The census was 46. Review of the facility's EBP policy, reviewed/revised 12/12/23, showed: -Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves; -An order for EBP will be obtained for residents with any of the following: -Wounds (e.g., chronic wounds such as pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction), diabetic foot ulcers (an open wound or sore on the foot that occurs in people with diabetes), unhealed surgical wounds, and chronic venous stasis ulcers (ulcers caused by decrease in blood circulation)); -Indwelling medical devices (e.g., urinary catheters) even if the resident is not known to be infected or colonized with a MDRO; -Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray; -High contact resident care activities include: -Device care or use: urinary catheters: -Wound care: any skin opening requiring a dressing. Review of the facility's Glucometer (device used to measure blood sugar) Testing & Infection Control policy, dated 10/19/23, showed: -Policy: to standardize the treatment of Diabetes Mellitus (DM) through proper blood glucose (sugar) testing while maintaining proper infection control; -Procedure: A licensed nurse will: -Disinfect Accu-Check machines with germicidal (solution that kills or inactivates microorganisms, including bacteria, viruses, and fungi) disposable wipe between each resident. Wipe all contact surfaces, wrap wipe around machine to maintain 2-5-minute wet contact time. (By rotating machines between residents, the required 2-5 minutes will be achieved); -Set up equipment on clean surface (may use paper towel)-Accu-Check machine, test strip, alcohol wipe, disposable lancet, etc.; -Obtain Accu-Check; -Disinfect machine, remove gloves and wash hands. Review of the facility's Tuberculosis Infection Control policy, dated 6/24, showed: -The Infection Preventionist (IP) is responsible for oversite of the facility's TB program and reports activities to the facility's Quality Assurance and Assessment (QAA) committee; -TB infection: Residents and staff are tested for latent TB infections and screened for TB disease, if infected with TB; -Staff with a positive test are referred to occupational health care provider for evaluation. Review of the CDC guidance for Clinical Testing Guidance for TB: TST (TB skin test), dated 1/31/25, showed: -Background: The TB skin test is a test used to determine if a person is infected with TB bacteria. In this test, a standardized solution made with PPD, which is derived from tuberculin, is injected under the skin; -Determining an approach: -Two-step testing is a strategy used to reduce the likelihood that a boosted reaction will be misinterpreted as a recent infection if the person must be tested again. Two-step testing should be used for the initial (baseline) skin testing of persons who will be retested periodically. If the TB skin test is used for baseline testing of U.S. health care personnel, use two-step testing; -If the first TB skin test result is negative, a second TB skin test should be done one to three weeks later. Review of the ltc.health.mo.gov website, undated, showed, All new Long-Term Care facility employees who work 10 or more hours per week are required to obtain a Mantoux PPD (TB test) two-step tuberculin test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. It is the responsibility of each facility to maintain a documentation of each employee's tuberculin status. 1. Review of Resident #14's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/11/25, showed: -Moderately impaired cognitive skills for daily decision making; -Diagnoses included heart failure, diabetes, hip fracture, and malnutrition; -Risk of pressure ulcers; -Infection of the foot, diabetic ulcer, surgical wounds. Review of the resident's electronic Physician's Order Sheet (ePOS), showed: -On 4/8/25, Specialized Wound Care Management evaluation and treatment and treatment as indicated one time only related to osteomyelitis (infection of the bone), sepsis, Type II diabetes mellitus with diabetic peripheral angiopathy without gangrene (blood vessels in the legs or arms become narrowed or blocked, reducing blood flow without causing open wounds) for 12 months; -On 5/10/25, cleanse medial left toe with Vashe (wound solution) and apply betadine (antiseptic), cleanse with Vashe and apply skin prep to lateral left foot, cleanse with Vashe and apply Santyl (wound debriding ointment) to left heel wound bed and cover with Aquacel foam dressing every day and as needed, every dayshift for wound care; -No physician order for EBP. Observation and interview on 5/14/25 at 9:37 A.M., showed no EBP sign on or the by resident's door. Licensed Practical Nurse (LPN) E was in the resident's room with Nurse Practitioner (NP) F, providing wound treatments to the resident. NP F said they were just finishing up the resident's treatment. He/She then applied a foam dressing to the resident's left heel. LPN E and the NP F wore gloves. Neither wore gowns. 2. Review of Resident #20's admission MDS, dated [DATE], showed: -Cognitively intact; -Has indwelling catheter; -Diagnoses included abnormal or irregular heartbeat, high blood pressure, septicemia (blood poisoning), urinary tract infection (UTI), seizure disorder, malnutrition and respiratory failure; -Risk of pressure ulcers; -Has one or more unhealed pressure ulcers at Stage I or higher. Review of the resident's ePOS, dated 4/14/25, showed: -Cleanse lateral right foot with wound cleanser or NS (normal saline), apply zinc oxide to wound border and foam daily or dry dressing daily and PRN (as needed) every day shift every three days for wound treatment; -Cleanse right and left gluteus (buttock) with wound cleanser or NS and apply foam or dry dressing every three days or as needed every day shift every three days for wound treatment; -Cleanse right heel with wound cleanser or NS paint with thin layer of betadine and leave OTA (open to air) every day shift for wound treatment; -EBP related presence of indwelling catheter; -Indwelling catheter 16 French (Fr) 10 milliliter (ml) balloon. Observation and interview on 5/12/25 at 1:20 PM, showed Certified Nurse Assistant (CNA) A entered the resident's room. He/She said the PPE supplies on the wall were for the staff to use as needed when providing care to any residents. He/She did not specify the resident was on EBP. Observation on 5/14/25 at 10:27 A.M., showed no EBP sign on or by the resident's door. There were PPE supplies on the wall in the hallway, by the resident's door. Registered Nurse (RN) D assisted NP F in providing wound treatment. Both staff wore gloves but no gowns. RN D touched and moved the indwelling catheter when repositioning the resident. During an interview on 5/14/25 at 2:51 P.M., the Director of Nursing (DON) said there should be PPE on the residents' doors who had wounds, open areas and catheters. Staff should wear PPE when providing care to residents on EBP. Staff do not need to wear PPE if they will not be in close contact with residents or will not be in the room more than 15 minutes. PPE was to be worn when providing resident care. She expected staff to wear PPE appropriately. There should be an EBP sign on the door, but they were currently not utilizing signs. EBP residents' information were only located at the nurse's station. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she expected staff to wear PPE while providing care to residents on EBP. 3. Observation on 5/13/25 at 7:50 A.M., showed LPN E cleaned the blood sugar machine with an alcohol pad and placed the blood sugar machine on a barrier. LPN E performed the blood sugar test and cleaned the blood sugar machine with alcohol and wrapped the blood sugar machine with a paper towel. Observation on 5/13/25 at 8:05 A.M., showed LPN E used the same blood sugar machine to perform a blood sugar test on another resident. Then, he/she used an alcohol pad and cleaned the blood sugar machine and wrapped it in a paper towel. During an interview on 5/14/25 at 2:51 P.M., the DON said the blood sugar machines should be cleaned in between use with alcohol wipes. Observation and interview on 5/15/25 at 9:16 A.M., showed no germicidal disposable wipes in nurse medication cart 1. The cart contained the residents' insulin medications and blood sugar machines. LPN E said he/she used alcohol wipes to clean the blood sugar machines in between uses. Nurse medication cart 2 contained two tubs of germicidal disposable wipes, and a tub of bleach wipes. LPN G said he/she used germicidal disposable wipes for disinfecting the blood sugar machines and hard surfaces and used the bleach wipes for biohazard cleaning. During an interview on 5/15/25 at 12:19 P.M., the DON said staff may need to use multiple alcohol pads to clean the blood sugar machines. The Administrator expected the staff to follow their policy in cleaning the blood sugar machines. 4. Review of Employee A's employee file, showed: -Date of hire: 3/21/25; -No documentation the first or second step TB test was administered. Review of Employee E's employee file, showed: -Date of hire: 3/18/25; -No documentation the first or second step TB test was administered. Review of Employee F's employee file, showed: -Date of hire: 4/3/25; There was no documentation showing the first or second step TB test was administered. Review of Employee C's employee file, showed: -Date of hire: 6/24/25; -The first step was administered on 7/16/24 and read on 7/18/24; -No documentation the second step TB test was administered. Review of Employee D's employee file, showed: -Date of hire: 9/25/24; -The first step was administered on 12/3/24 and read on 12/6/24; -No documentation the second step TB test was administered. Review of Employee B's employee file, showed: -Date of hire: 11/14/24; -The first step was administered on 11/20/24 and read on 11/22/24; -No documentation the second step TB test was administered. During an interview on 5/14/25 at 1:40 P.M., the Administrator said employees should have a TB test completed upon hire, and at least one test should be completed prior to starting. Any nurse could administer/read the TB test. The DON should track the TB test administrations to ensure the second steps were completed. The Administrator expected all employees to have their TB tests completed.

Based on interview and record review, the facility failed to follow their antibiotic stewardship policy by failing to collect data regarding residents' antibiotic treatments and reviewing and documenting that data on the facility approved antibiotic surveillance tracking form. This deficient practice had the potential to affect all residents receiving antibiotics. The census was 46. Review of the facility's Antibiotic Use Stewardship policy, dated 9/2/18, showed: -Policy Statement: To develop on going best practices to improve antibiotic use; -Policy: Antibiotic prescribing will be monitored & tracked monthly utilizing best practice standards developed by the Centers for Disease Control and Prevention (CDC) and other professionals; -Procedure: -Director of Nursing (DON)/designee will track dose, duration & indication of antibiotics prescribed monthly; -Ensure availability of preferred drugs in emergency inventory ; -Have Pharmacy Consultant review antibiotic usage & culture results monthly & make recommendations to DON for timely follow through; -Have Laboratory provide antibiogram (Antibiotic sensitivity testing or antibiotic susceptibility testing) routinely; -DON, Medical Director & Laboratory will collaborate on best practices of microbiology testing; -Use of antibiotic time out will be implemented by DON; -Report findings at Quality Assessment and Performance Improvement (QAPI) meetings. During an interview on 5/13/25 at 10:28 A.M., the DON said she was still working on the antibiotic stewardship information. She said the Minimum Data Set (MDS, a federally mandated assessment completed by facility staff) Coordinator had the antibiotic stewardship and surveillance. During an interview on 5/14/25 at 11:40 A.M., the MDS Coordinator said she was not responsible for the antibiotic stewardship or surveillance. In the past the Assistant Director of Nursing (ADON) or the DON completed this. During an interview on 5/14/25 at 11:45 A.M., the DON said she did not have the antibiotic stewardship or surveillance, but she could see what she could pull together because she had the reports and the MDS Coordinator had some information written down. Observation and interview on 5/14/25 at 2:51 P.M., showed the DON provided two sheets of paper which were labeled Infection Control/Antibiotic Surveillance Log. One sheet was for March 2025 and the other was for April 2025. Each sheet contained columns, and each column had the residents' information who were on antibiotics, such as their names, room numbers, infection sites, date of lab and pathogen, antibiotic ordered, antibiotic susceptible, if they were facility acquired, precautions, date treated, if they met the criteria, and date resolved. The DON said she had just completed those two sheets based on the MDS Coordinator's records. There were no records prior to March 2025. During an interview on 5/15/25 at 9:26 A.M., the MDS Coordinator said she had never done antibiotic tracking. She was only responsible for the residents' care plans and MDS. During an interview on 5/15/25 at 10:08 A.M., the DON said she was starting the antibiotic surveillance log sheet for May 2025. She said there were two or three residents on antibiotics; however, she was unable to provide names when requested. There was not an antibiotics tracking system prior to the survey. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she would expect the facility to follow their antibiotic stewardship policy. The DON said moving forward she would make sure the antibiotic stewardship was completed per their policy.

Based on interview, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Control Preventionist (ICP) for the facility's infection prevention control program. The census was 46. During the entrance conference on 5/12/25 at 9:14 A.M., the Administrator said the facility did not have an ICP. During an interview on 5/14/25 at 2:51 P.M., the Director of Nursing (DON) said the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Coordinator was in the process of getting her ICP certification. The DON just started her ICP classes for certification as well. During an interview 5/15/25 at 12:19 P.M., the Administrator said she expected the facility to have a certified ICP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete an inspection of bed frames, mattresses and side rails as part of a regular maintenance program to identify areas of possible entrapment for six residents (Residents #44, #5, #24, #9, #14 and #28) of 13 sampled residents with side rails. The census was 46. Review of the facility's Side Rails policy, dated 10/17/23, showed: -Policy: Assess resident side rail restraint needs on admission, annually and with any significant change in order to ensure the resident's highest practicable physical and psychosocial well-being. Review quarterly; -Procedure: -Side rails will be evaluated quarterly and reduced/eliminated as possible. 1. Review of Resident #44's hand written Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. A half length and quarter length rail was indicated. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/26/25, showed: -Short and long-term memory problem; -No behaviors; -Upper and lower extremities: Impairment on one side; -Dependent on staff for mobility and transfers; -Diagnoses included fractures, hemiplegia (muscle weakness or paralysis on one side and depression. Review of the resident's May 2025 active physician's order, showed an order, dated 12/1/23, for bed rails. Quarter length related to impaired mobility and diagnoses of hemiplegia, unspecified affecting left nondominant side. Review of the resident's electronic medical record, viewed 5/13/25 at 10:50 A.M., showed no maintenance assessment for the use of side rails. Observation on 5/13/25 at 8:30 A.M., showed the resident lay on his/her back. Quarter length side rails were raised on both sides. The resident said he/she used the rails to help with positioning. 2. Review of Resident #5's electronic medical record, showed a Device/Restraint Evaluation, dated 10/18/22. Resident uses a grab bar. Review of the resident's hand written Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. Review of the resident's quarterly MDS, dated [DATE], showed: -Rarely understood; -Dependent on staff for mobility and transfers; -Diagnoses included heart disease and dementia; -Bed rails not used. Review of the resident's May 2025 active physician's order, showed an order, dated 10/20/23: Resident has side rails, quarter length related to impaired mobility and diagnoses of abnormal posture and weakness. Observation on 5/12/25 at approximately 10:07 A.M., showed the resident sat in his/her wheelchair next to his/her bed. The resident's bed had raised quarter length side rails on both sides. The resident could not say what the side rails were used for. Review of the resident's electronic medical record, viewed 5/14/25 at 1:00 P.M., showed no maintenance assessment for the use of side rails. 3. Review of Resident #24's quarterly MDS, dated [DATE], showed: -Short term memory problem; -Long term memory ok; -Had functional limitation of range of motion in both upper extremities. -Was dependent (helper does all the effort. Resident does none of the effort to complete the activity) for rolling left to right, to change positions from lying to sitting on the side of the bed and to go from sitting to standing; -Diagnoses included: coronary artery disease (CAD, arteries that supply blood to the heart muscle become narrowed or blocked), high blood pressure, renal insufficiency (kidneys unable to function properly), obstructive uropathy (normal flow of urine through the urinary tract is blocked or hindered), stroke and Parkinson disease. Review of the care plan in use at the time of survey, showed: -Focus: resident has an Activities of Daily Living (ADL, grooming, dressing, bathing) self-care performance deficit; -Goal: will maintain current level of function in through the next review; -Interventions included: bed mobility, the resident can roll over in bed with use of the enabler rails. Review of the medical record, showed: -A physician order for bed side rails (1/4) related to impaired mobility and diagnoses of muscle weakness; -No documentation of maintenance inspection for possible areas of entrapment. Observation and interview on 5/5/25 at 10:24 A.M., the resident lay in bed with the top U shaped side rails up on both sides . The resident said he/she used them to help him/her to stand up. Observation on 5/14/25 at 2:00 P.M., the resident lay in bed. Registered Nurse (RN) H was assisting the resident to roll from his/her back onto his/her left side. The resident grabbed the side rail to help roll over. 4. Review of Resident #9's annual MDS, dated [DATE], showed: -re-admission date of 10/18/18; -Cognitively intact; -Uses wheelchair for mobility; -Diagnoses included stroke, Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hemiplegia or hemiparesis (neurological conditions that cause weakness or paralysis on one side of the body). Review of the resident's ePOS, dated 10/20/23, showed an order for ¼ bed side rails related to mobility & diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Review of the resident's medical record, showed no side rails assessment. Observation on 5/12/22 at 10:38 A.M., the resident had side rails on both sides of his/her bed. During an interview on 5/14/25 at 9:34 A.M., the resident said he/she used the side rails for positioning. 5. Review of Resident #14's significant change MDS, dated [DATE], showed: -re-admission date of 4/7/25; -Moderately impaired cognitive skills for daily decision making; -Uses wheelchair for mobility; -Diagnoses included heart failure, diabetes, hip fracture and malnutrition. Review of the resident's ePOS, dated 4/8/25, showed an order for left and right ¼ rail enabler bars to aide in bed positioning and transfers. Observation on 5/14/22 at 10:22 A.M., showed the resident had side rails on both sides of his/her bed. During an interview on 5/14/25 at 12:50 P.M., LPN E said he/she did not know why the resident had side rails in bed, but he/she was able to use the rails, and he/she thinks they were beneficial for the resident with turning and positioning. 6. Review of Resident #28's significant change MDS, dated [DATE], showed: -re-admission date of 2/25/25; -Moderately impaired cognitive skills for daily decision making; -Impairment on one side of upper extremity; -Impairment on both sides of lower extremities; -Uses wheelchair for mobility; -Diagnoses included hip fracture, dementia, malnutrition, anxiety and depression. Review of the resident's ePOS, dated 10/20/23, showed an order for ¼ bed side rails related to impaired mobility and diagnosis of unspecified injury at C4 level of cervical spinal cord, sequela (a condition which is the consequence of a previous disease or injury) and generalized muscle weakness. Review of the resident's medical record, showed no side rails assessment. Observation on 5/12/22 at 11:04 A.M., showed the resident's bed had one ¼ side rail, to the resident's right side. The side rail was raised up, while the resident was up sitting in the wheelchair at bedside. During an interview on 5/14/25 at 11:00 A.M. the resident said he/she needed the side rail to get out of bed. During an interview on 5/14/25 at 12:33 P.M., Certified Nurse's Aide C said the residents' side rails were use for positioning and mobility. Resident #28 used right side rail only for mobility. He/She used it for standing up or getting out of bed with one assist. 7. During an interview on 5/15/25 at 9:21 A.M., the Maintenance Director said he was responsible for completing routine inspections of bed rails, but had not done it in about a year. During an interview on 5/15/25 at 12:19 P.M., the Administrator and DON said side rails should be assessed quarterly, annually and with a change in condition. The administrator would expect maintenance to also assess for entrapments and document the assessments quarterly, annually and during a change in condition. -

Based on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 18 CNAs who worked for the facility for at least one year. Two Certified Medication Technicians (CMTs), (CMT L and CMT K) and eight CNAs (CNA J, CNA I, CNA M, CNA N, CNA O, CNA P, CNA Q, and CNA R), were sampled. The facility failed to document the date and length of time the training was provided for 10 of 10 sampled staff. The census was 46. 1. Review of CMT L's employee file, showed: -Date of hire: 9/8/22; -Evaluation date: 9/8/24, in the date column, 21 topics were checked; -The in-service failed to show the date and length of time the training was provided. 2. Review of CMT K's employee file, showed: -Date of hire: 1/9/24; -Evaluation date: 1/9/25, in the date column, 26 topics were checked; -The in-services failed to show the date and length of time the training was provided. 3. Review of CNA J's employee file, showed: -Date of hire: 5/25/18; -Evaluation date: 5/23/24, in the date column, 11 topics were checked; -The in-services failed to show the date and length of time the training was provided. 4. Review of CNA I's employee file, showed: -Date of hire: 6/10/22; -Evaluation date was blank, in the date column 13 topics were checked; -The in-services failed to show the date and length of time the training was provided. 5. Review of CNA M's employee file, showed: -Date of hire: 4/5/24; -Evaluation date: 4/5/25, in the date column 27 topics were checked; -The in-services failed to show the date and length of time the training was provided. 6. Review of CNA N's employee file, showed: -Date of hire: 4/6/10; -Evaluation date: 4/6/24, in the date column 26 topics were checked; -The in-services failed to show the date and length of time the training was provided. 7. Review of CNA O's employee file, showed: -Date of hire: 9/9/20; -Evaluation date: 9/9/24, in the date column 22 topics were checked; -The in-services failed to show the date and length of time the training was provided. 8. Review of CNA P's employee file, showed: -Date of hire: 7/20/23; -Evaluation date: 7/20/24, in the date column 20 topics were checked; -The in-services failed to show the date and length of time the training was provided. 9. Review of CNA Q's employee file, showed: -Date of hire: 8/17/22; -Evaluation date: 8/17/24, in the date column 21 topics were checked; -The in-services failed to show the date and length of time the training was provided. 10. Review of CNA R's employee file, showed: -Date of hire: 10/9/18; -Evaluation date: 10/9/24, in the date column 11 topics were checked; -The in-services failed to show the date and length of time the training was provided. 11. During an interview on 5/13/25 at 10:28 A.M., the Director of Nursing (DON) said she started at the facility at the end of March 2025 and she did not know the dates or the length of time the education was provided. 12. During an interview on 5/14/25 at 11:50 A.M., the Administrator said she would expect for the CNAs to complete their 12 hours of required education yearly. The date and length of education should be tracked along with the topic discussed. The DON was responsible for tracking the CNA education.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice when one resident (Resident #3) had a significant increase in pain identified on 12/18/24 and had to wait over 12 hours for an x-ray order to be obtained. The x-ray completed on 12/19/24 showed the resident had a right hip fracture and the resident was sent to the hospital for further evaluation and treatment. The sample was 6. The census was 48. Review of the facility's Change in Condition Nursing Intervention policy, dated 2/18/16 and revised 9/19/19, showed: -Policy Statement: Because of the age and condition of residents in a nursing home, they are subject to many changes in condition. Changes in condition require assessment and documentation by a licensed nurse; -Policy: To assure that all residents receive appropriate care in accordance with acceptable medical practice and standards, changes in condition will be assessed in a timely manner with appropriate interventions and countermeasures as necessary. Hospitalizations/re hospitalizations are to be prevented whenever possible by clinical interventions within the scope of the skilled facility; -Procedure: Evaluate resident's overall physical and mental status. Check vital signs (Blood Pressure (BP), pulse, temperature, respirations, Oxygen saturation (percentage of oxygen in the blood) and glucose (blood sugar) for diabetics). -Document actions in Nurses Notes, Physician Order Sheet (POS), Medication Administration Record (MAR) and Care Plan accordingly; -Following any hospitalization/rehospitalization, even if only for emergency room (ER)/observation visit, review with resident, physician and family the interventions and care plan; -All charts are to be opened and documented on each shift following a change in condition. Review of Resident #3's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/24, showed: -Severe cognitive impairment; -Bilateral lower extremity impairment, uses wheelchair for mobility; -Dependent, helper does all effort and resident does none of the effort to complete activity, for eating, oral hygiene, toileting, shower/bath, upper and lower body dressing, and personal hygiene; -Frequently incontinent of bladder, always incontinent of bowel; -Diagnoses included heart failure, end stage renal disease (ESRD), Alzheimer's disease, hip fracture, anxiety, and depression. Review of the resident's Electronic Medical Record, showed: -A progress note on 12/18/24 at 6:02 P.M., placed a call to hospice, per Administrator's request, to obtain a right hip x-ray for resident. Spoke with Nurse Practitioner (NP) who states he/she will reach out to on call nurse and have him/her fax order to facility so that company can be contacted to come out and obtain x-ray. Awaiting response from hospice; -A progress note on 12/19/24 at 7:10 A.M., resident complains of right hip pain this morning and is guarding extremity, call placed to hospice for an order for an x-ray. Awaiting return call from on call nurse with order approval; -A progress note on 12/19/24 at 7:46 A.M., hospice nurse called back at 7:40 A.M. and gave orders from hospice physician to obtain an x-ray of the right hip. Order noted at this time. Resident awake, alert, and screams out loud in pain when nurse attempts to assess. Call placed to physician, follow up with hospice and Director of Nursing (DON). Call placed to hospice, awaiting call back from hospice Registered Nurse (RN); -An order dated 12/19/24 at 8:00 A.M., two view hip x-ray for post fall pain. -A progress note on 12/19/24 at 9:06 A.M., x-ray completed at this time; -A Hospice, Facility Communication Note, dated 12/19/24 at 10:15 A.M. through 11:15 A.M., Resident assessed obvious deformity to right lower extremity. Yesterday received call resident having pain and x-ray order received and called to nurse at 2:17 P.M. Resident being sent to hospital for fracture; -An x-ray report, dated 12/19/24 at 10:15 A.M. showed acute fracture of the intertrochanteric hip (area where the muscles of the thigh and hip attach). Osteopenia (bone loss, condition that occurs when the body does not make new bone as quickly as it absorbs old bone); -A progress note on 12/20/24 at 1:26 P.M., resident went out to the hospital yesterday. Facility received a call today stating that he/she will not be returning. No explanation at this point. Family plans to pick up his/her belongings tomorrow on 12/21/24; -A progress note on 12/23/24 at 9:14 A.M., resident family called over the weekend and stated that he/she will be coming back to this facility. This is after they called last week and stated that he/she would not be. Unsure as to what changed their minds but he/she is expected back today; -A progress note on 12/23/24 at 3:40 P.M., resident was returned to facility from hospital via emergency medical services (EMS) accompanied by family. Vital signs stable. Incision to right hip clean dry and intact with 11 intact staples noted. Physicians notified; -No documentation of the circumstances that resulted in the need to request an order for an x-ray on 12/18/24 or assessment of the resident. During an interview on 1/8/25 at 12:30 P.M., the Administrator said the resident did not have a fall. She started an investigation after the resident went to the hospital to investigate the cause of the injury. The resident was very active before the resident broke his/her hip. He/She was up walking around. Their investigation showed no fall occurred. She thinks based on the results showing osteopenia that the resident possibly broke it while turning over in bed. During an interview on 1/8/25 at 12:40 P.M., Licensed Practical Nurse (LPN) E said nurses are expected to document that in the EMR. Pain assessments are expected to be done every shift and as needed per the physician order. During an interview on 1/8/25 at 1:20 P.M., the Administrator said from her understanding, staff got the order for the x-ray on 12/18/24 but it was the company who was unable to come out to obtain the x-ray until 12/19/24 and caused the delay. Upon reading the progress note, the Administrator said it looks like that was not the case and they were waiting on hospice to return the call for the order. She was not aware staff were waiting on hospice, even though the progress note states that the Administrator was aware that the nurse was awaiting orders from hospice. She thinks the note may be referring to the previous DON being aware. The Administrator said she would expect the nurse to call the physician and get the order for an x-ray so the resident did not have to wait for hospice, who did not call back within a reasonable amount of time. They should not have waited until the next day to get an order with the resident showing signs of being in pain. MO00246826

Based on interview and record review, the facility failed to ensure services provided meet professional standards of practice when a facility nurse pre-pulled medications for residents, documented the medications as administered, and never administered the medications. This resulted in nine residents not receiving their ordered medications (Residents #4, #5, #11, #7, #9, #8, #10, #1 and #12). The census was 44. The sample was 14. The administrator was notified on 6/21/24, of the past non-compliance. The facility educated staff of the requirement to administer medications at the time they are pulled and that only the staff person who pulls the medications are allowed to administer the medication. The facility conducted an investigation to determine which residents were affected and are monitoring ongoing compliance. The deficiency was corrected on 6/10/24. Review of the Controlled Substance Policy, revised 2/2021, showed: Controlled substances are subject to special handling, storage. disposal and record-keeping requirements. The facility will maintain compliance with these special provisions. Procedures: -Controlled substances in Schedules II, III and IV are subject to special handling, storage, disposal and record-keeping requirements. Such drugs are to be accessible only to authorized nursing and pharmacy personnel. The Director of Nurses is responsible for the control of such drugs; -Drugs listed in Schedules II, III, and IV are to be stored under double-lock conditions. The key to the separately locked storage area is not the same key that is used to gain access to other drugs. The medication nurse on duty at the time will maintain possession of the key. The key must remain in the possession of the licensed nurse that completed the count at all times during their shift. Should it be necessary to give the keys to another licensed nurse( ex. Leaving the facility for lunch) a count will be done to verify the inventory. A count will be done again when the keys are returned to the original licensed nurse; -The authorized person receiving and checking in a drug in Schedules II, III, and IV is to prepare a controlled substance proof of use record form for that medication, if one is not provided by the pharmacy. Thereafter. a physical inventory of that medication will be made at the change of each nursing shift. Shift Verification Count Sheets/Packages shall be completed at the change of each shift; -The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift. The count is to be performed by the on coming licensed nurse and the off-going licensed nurse. The oncoming nurse will be responsible for looking at the medication to verify the amount of medication present at the time of the count. The off-going nurse will be responsible for viewing the Controlled Substance Proof of Use Record to verify the amount on the record at the time of the count. Both nurses will sign on the NARCOTIC SIGN IN & OUT SHEET that the count was completed; -Any discrepancy in the inventory of a controlled substance is to be reported to the Director of Nurses immediately. The Director of Nurses is responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. The discrepancy of a controlled substance is to be reported to the Administrator and the Regional Nurse immediately. If a discrepancy is not reconciled. the Director of Nurses is to document the details on the audit record, including the possible shift or persons responsible for the discrepancy, and the efforts made to reconcile it. Review of an undated picture, showed 11 medication cups sat on top of a medication cart. Each medication cup contained one pill. Names written on the bottoms of the cups and visible through the cup included Residents #4, #5, #11, #7, #9, #8, #10, #1, and #12. The name of the pill not identified. 1. Review of Resident #4's medical record, showed: -Diagnoses included osteoarthritis of the knee; -An order dated 4/25/24 for tramadol HCL (pain medication) 50 milligram (mg) for pain related to osteoarthritis of the knee, at bedtime; -Scheduled administration time 10:00 P.M.: -A narcotic medication run sheet, showed Licensed Practical Nurse (LPN) A pulled the tramadol 50 mg on 6/8/24 at 3:06 P.M.; -A progress note dated 6/10/24 at 10:40 A.M., showed the resident did not receive his/her tramadol 50 mg on 6/8/24. Physician made aware. 2. Review of Resident #5's medical record, showed: -Diagnoses included epilepsy (seizure disorder) and attention-deficit hyperactivity disorder; -An order dated 12/27/23, for lorazepam (Ativan, used to treat anxiety) 0.5 mg three times a day for anxiety: -Scheduled administration times at 9:00 A.M., 12:00 P.M., and 5:00 P.M.; -A narcotic medication run sheet, showed LPN A pulled lorazepam 0.5 mg on 6/8/24 at 10:21 A.M., 3:03 P.M., and 3:07 P.M.; -A progress note dated 6/10/24 at 10:17 P.M., showed the resident did not receive his/her Ativan on 6/8/24. Physician made aware. 3. Review of Resident #11's medical record, showed: -Diagnoses included anxiety disorder; -An order dated 5/21/24, for lorazepam 0.5 mg two times a day related to anxiety disorder: -Scheduled administration times 9:00 A.M. and 5:00 P.M.; -A narcotic medication run sheet, showed no documentation the lorazepam 0.5 mg was pulled for the resident; -A progress note dated 6/10/24 at 10:32 A.M., showed the resident did not receive his/her Ativan 0.5 mg on 6/8/24. Physician made aware. 4. Review of Resident #7's medical record, showed: -Diagnoses included fracture of the left arm; -An order dated 6/6/24, for oxycodone (narcotic pain medication) 5 mg every 12 hours as needed for pain related to fracture of the left arm; -A narcotic medication run sheet, showed LPN A pulled oxycodone 5 mg on 6/8/24 at 3:07 P.M.; -A progress note dated 6/10/24, showed the resident did not receive oxycodone on 6/8/24. Physician made aware. 5. Review of Resident #9's medical record, showed: -Diagnoses included injury at the cervical (neck) of spinal cord and anxiety disorder; -An order dated 4/9/24, for hydrocodone-acetaminophen (Norco, narcotic pain medication that also includes Tylenol) 5-325 mg, one tablet four times a day for pain related to cervical injury: -Scheduled administration times 9:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M.; -An order dated 4/22/24, for clonazepam (used to treat anxiety) 1 mg at bedtime for insomnia related to anxiety disorder: -Scheduled administration time liberalized at bedtime; -A narcotic medication run sheet, showed: -LPN A pulled hydrocodone/acetaminophen 5-325 mg on 6/8/24 at 3:06 P.M.; -LPN A pulled clonazepam 1 mg on 6/8/24 at 3:06 P.M.; -A progress note dated 6/10/24 at 10:38 A.M., showed the resident did not receive his/her clonazepam or Norco on 6/8/24. Physician made aware. 6. Review of Resident #8's medical record, showed: -Diagnoses included anxiety disorder; -An order dated 4/2/24, for diazepam (Valium, used to treat seizures, can also treat anxiety) 5 mg two times a day related to anxiety disorder: -Scheduled administration times 9:00 A.M. and 5:00 P.M.; -A narcotic medication run sheet, showed LPN A pulled diazepam 5 mg on 6/8/24 at 10:21 A.M. and 3:08 P.M.; -A progress note dated 6/10/24 at 10:19 A.M., showed the resident did not receive his/her Valium on 6/8/24. Physician made aware. 7. Review of Resident 10's medical record, showed: -Diagnoses included chronic pain; -An order dated 4/28/24, for Ultram (tramadol) 50 mg two times a day for chronic pain: -Scheduled administration times liberalized in the AM and PM; -A narcotic medication run sheet, showed LPN A pulled tramadol 50 mg on 6/8/24 at 10:22 A.M. and 3:08 P.M. -A progress note dated 6/10/24 at 10:21 A.M., showed the resident did not receive his/her tramadol 50 mg on 6/8/24. Physician made aware. 8. Review of Resident #1's medical record, showed: -Diagnoses included dementia and agitation; -An order dated 6/9/24, for Ativan 0.5 mg two times a day for agitation: -Scheduled administration times 9:00 A.M. and 5:00 P.M.; -A narcotic medication run sheet, showed LPN A pulled lorazepam 0.5 mg on 6/8/24 at 3:06 P.M.; -A progress note dated 6/10/24 at 10:36 A.M., showed the resident did not receive his/her Ativan 0.5 mg on 6/8/24. Physician made aware. 9. Review of Resident #12's medical record, showed: -Diagnoses included diabetes, stroke, and osteoarthritis; -An order dated 8/3/23, for tramadol 50 mg two times a day for osteoarthritis: -Scheduled administration times liberalized in the AM and PM; -A narcotic medication run sheet, showed LPN A pulled tramadol 50 mg on 6/8/24 at 3:08 P.M.; -No progress note to show that the resident did not receive this medication. 10. Review of the Medication Destruction Log, showed on 6/10/24, narcotic medications for Residents #4, #5, #11, #7, #9, #8, #10, #1, and #12 that were pulled on 6/8/24 and not given were wasted. 11. During an interview on 6/21/24 at 9:50 A.M., LPN A said nurses and Certified Medication Technicians (CMT) are not supposed to pre-pop medications, especially narcotic medications. Medications are to be given after they are removed and signed out. All narcotic medications are signed out on the computer. The facility does not have paper narcotic count or sign out sheets. LPN A said he/she does not pre-pop medications. 12. During an interview on 6/21/24 at 10:45 A.M., the Director of Nursing (DON) said approximately two weeks ago, on 6/8/24, Agency Nurse C was scheduled to work overnight. Around 4:00 A.M. on 6/9/24, he/she came across a cart that had what appeared to be narcotics not given. Agency Nurse C called to report this to her. Agency Nurse C also sent text messages and pictures of his/her concern. The picture showed 11 medication cups sat on top of a medication cart. Each medication cup contained one pill. Names written on the bottoms of the cups and visible through the cup included Residents #4, #5, #11, #7, #9, #8, #10, #1, and #12. The name of the pill not identified. The DON said she came to the facility later that morning. Agency Nurse C did not pass his/her 6:00 A.M. medications due to his/her concern with the medications left on the cart. The DON said nurses and CMTs have different medication records. A nurse is not supposed to give another nurse or a CMT their medications to pass, especially narcotics. On nights, there are no CMTs and the nurse is to pass all medications. The nurse should have passed those medications on the evening shift but he/she popped the medications and gave to CMT B to pass. CMT B never gave the medications but they were marked as given by LPN A. They called the doctor and destroyed the medications. They also completed medication error reports on each medicine. The DON said she talked to CMT B and informed the CMT that he/she should have notified management. The CMT said that he/she did not report the incident initially because he/she was worried about conflict and felt intimidated. 13. During an interview on 6/21/24 at 11:22 A.M., CMT B said LPN A asked him/her to pass the medications on the medication cart. CMT B said when he/she told LPN A no, LPN A laughed like he/she did not believe that he/she would not pass the medications. CMT B said this is an ongoing behavior from LPN A. LPN A just left them on the medication cart when he/she left the facility. CMT B said he/she has not been asked to do that since the incident. CMT B said the DON talked to him/her and asked CMT B to notify the DON if this happens again. 12. During an interview on 6/21/24 at 1:43 P.M. with the Administrator, DON, and Corporate Nurse, they said they would expect staff to follow facility policies. Staff should document accurately and should not document a medication as administered if it was not. Staff should not pull medications and ask another staff person to administer the medications. Medications should be administered at the time they are pulled. MO00237365

Based on interview and record review, the facility failed to ensure one resident (Resident #2), diagnosed as having dementia with behavioral disturbance and exhibiting increased symptoms/behaviors such as striking the same resident (Resident #1) in the head twice on two separate occasions (3/4/24 and 4/24/24), received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being, by failing to implement an ordered psychiatric consult or update the resident's care plan until after the second incident. The first incident caused a laceration above Resident #1's left eyebrow. The sample size was 3. The census was 47. Review of Resident #2's hospital records, prior to the facility admission, dated 9/26/23, showed: Patient is presenting with concern for self neglect and possible injury to himself/herself with firearm. He/She was brought in by family to emergency room (ER) on 9/23 after reportedly hitting his/her head near the support beam of his/her car port. He/She reports to me no loss of consciousness. Apparently family recently checked on him/her and found a hole in the ceiling as well as a shotgun that appeared to have been moved with blood on it as well. They were concerned that patient may have been using the shotgun inappropriately and could have hurt himself/herself. Per notes, patient denies touching the gun. He/She was recommended for admission to the behavioral health center for assessment and treatment for mood disorder as well as dementia with behavioral disturbances. Upon my exam he/she is stable and appears calm. He/She reports no major medical issues at this time and feels ok overall. He/She is not able to tell me which medications he/she takes for his/her chronic medical conditions however. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/24, showed: -Severe cognitive impairment; -Diagnoses included non-traumatic brain dysfunction and Alzheimer's dementia. Review of the resident's electronic Physician Order Sheet (ePOS) showed: -An order, 10/4/23, Remeron (antidepressant) oral 15 milligrams (mg). One tablet by mouth at bedtime related to Alzheimer's disease with early onset; -An order, dated 2/9/24, Refer to psychiatrist for psychiatric evaluation per physician request. Review of the resident's medical record, showed: -A progress note, dated 3/4/24 at 9:23 A.M., resident was in the dining room having breakfast and another resident was sitting at the same table when this resident reached and hit the other resident causing the other resident to bleed. The other resident was removed from the situation immediately and Administrator was informed. Physician made aware and family made aware; -A progress note, dated 3/13/24 at 12:48 P.M., resident brought from dining room to nursing station per Certified Nursing Assistant (CNA) due to started crying in dining room and had not eaten lunch. This nurse asked him/her why he/she was crying. The resident verbalized that he/she wanted to see his/her son/daughter. Asked if resident would like nurse to call son/daughter. Resident stated yes. Per this nurse, called his/her son/daughter and resident talked to him/her. The resident stopped crying and was asked if he/she would like for his/her lunch to be brought to room. Resident declined at this time verbalized he/she was going to his/her room to lay down; -A progress note, dated 4/5/24 at 12:36 P.M., resident returned from neurologist appointment accompanied by son/daughter. Paperwork given upon return with new orders as follow: Increase Remeron to 30 mg at bedtime. Order noted and sent to primary care physician and other providers in his/her network in agreement at this time. Review of the resident's ePOS, showed: -An order, dated 4/5/24, Refer to psychiatrist for psychiatric evaluation per physician request; -An order, dated 4/5/24, Remeron oral 30 mg. One tablet by mouth at bedtime related to Alzheimer's disease with early onset. Review of an Initial Psychiatric Evaluation, dated 4/11/24, by the Nurse Practitioner (NP) for the psychiatrist, showed: -Presenting problem: Resident is referred for a psych evaluation. Resident has a history of major neurocognitive disorder (MNCD, an acquired neuropsychiatric disorder, characterized by a clinically significant decline from a previous level of cognitive functioning) with depression; -Medical: Diabetes, chronic kidney disease, stroke, falls, current urinary tract infection (UTI); -Mental Status: Oriented to person only. Insight/judgement are fair. Sleep and appetite fair. Isolative to room. Little participation in activities. Current treatment for UTI. Mood fair. Denies anxiety. Denies psychotic symptoms; -Plan: Continue the recently increased Remeron dose for depression. Encourage out of room activities. Consider treatment for MNCD. Psychiatrist to see in one month. Review of the progress notes, showed: -4/25/24 at 8:10 A.M., reached out to psychiatrist regarding incident that took place yesterday with altercation with another resident for a medication review. Psychiatrist states he/she will be in the facility as soon as he/she can to evaluate/treat; -4/24/24 at 3:41 P.M., CNA brought the resident to the Director of Nursing (DON) and communicated that he/she had hit another resident while in dining room for lunch. Resident noted to be in a clam state sitting with legs crossed with elbow on right arm rest with fact resting on hand. Asked resident what happened in the dining room between him/her and the resident. Resident stated (he/she) was talking shit and I turned around and hit (him/her) back of head. I asked him/her to demonstrate with this nurse with his/her arm. Resident with closed fist hit on this nurse arm three times non forcibly. Asked if this is how hard that he/she hit him/her and the resident stated yes. Per this nurse, inspected his/her hands. No bruising, swelling, or bleeding or any injury to hand noted. Resident extensively encouraged about not to hit anybody and if he/she feels like he/she is becoming agitated to seek out staff assistance for interventions which would including calling his/her son/daughter for him/her to talk. Resident in agreement. Spoke with resident's son/daughter and made him/her aware of interventions. Son/Daughter thanked this nurse for calling and will talk to the resident. Resident assisted into bed per resident request. No skin issues. Denied any pain or discomfort. Review of the Psychiatric Evaluation, dated 4/25/24, showed: -Chief Complaint: Resident referred emergently for a psychiatric consultation by the primary care physician. The resident apparently had gotten in an altercation with an older resident earlier today though it is unclear what exactly caused that. The resident himself/herself could provide very little in terms of specific or meaningful complaints; -Past Psychiatric History: Is notable for history of dementia of the Alzheimer's type as well as depression. It is unclear if he/she had previously been seen by a mental health professional; -Mental Status Examination: The patient was alert and oriented to person only. His/Her mood is good. His/Her affect is pleasantly confused. His/Her speech is elicitable though limited to brief replies. Judgment and insight are poor as is focus and concentration. Thought processes are somewhat illogical and nonlinear. There are no overt hallucinations or delusions noted at this time. He/She reportedly is eating adequately and sleeping adequately. No real change in his/her cognitive, function, or affective presentation is appreciated; -Assessment: Major neurocognitive disorder most likely of the Alzheimer's type with agitation. -Recommendations: -At this time we will monitor the patient's symptoms closely for any repeat episodes of agitation and their possible triggers. That being said, he/she may benefit from a regular dose anti-agitant medication; -We will continue the memantine (medication used to treat memory loss and the symptoms of Alzheimer's disease) and mirtazapine (Remeron) at their current dosages for now. I do note that he/she has lost a bit of weight lately; -We will communicate our findings and recommendations to primary care physician and the staff; -A message was left for the patient's power of attorney to update them relative to my psychiatric recommendations and to try and obtain more history; -Follow up in approximately one month by the nurse practitioner and myself for psychotropic medication management and supportive psychotherapy. Review of the resident's care plan, dated 4/26/24, showed: -Focus: The resident has potential to demonstrate physical behaviors when agitated/overstimulated; -Goal: Resident will not harm self or others through the review date; -Intervention: Resident has a history of striking others when agitated, when resident becomes agitated intervene before agitation escalates; -Focus: The resident has a behavior problem; -Goal: The resident will have fewer episodes of behavioral outburst/aggressive behavior by the review date; -Intervention: Intervene as necessary to protect the rights and safety of others, monitor behavior episodes and attempt to determine underlying cause, anticipate and meet the resident's needs; -Focus: The resident has a mood problem; -Goal: The resident will have improved mood state, happier, calmer appearance, no signs/symptoms of depression, anxiety or sadness through the review date; -Intervention: Behavioral health consults as needed, monitor/document/report to physician as needed mood patterns signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of a Social Service progress note, dated 4/30/24/24 at 12:58 P.M., showed it was reported to Social Services (SS) that on several occasions, once with a hospice worker and once with Administration that resident has been getting a bit handsy. He/She is not touching in inappropriate places but is doing things such as running his/her hand up a person's arm. The resident was recently signed up for hospice and it was on of their staff that he/she did this with. He/She recently has had a few incidents of hitting another resident as well. SS has spoken with him/her about these, however with his/her decreased cognition/memory, it is doubtful that he/she remembers. Staff were in-serviced and were made aware of this change in his/her behavior. This is not the norm for him/her. SS will continue to monitor and assist as needed. Review of the care plan, showed no interventions to address the resident's inappropriate touching of others. During an interview on 4/30/24 at 9:50 A.M., Certified Medication Technician (CMT) B said he/she heard about the first incident and was told to keep them apart. The day of the second incident, he/she was at the medication cart in the dining room passing medications. The resident sat facing the front of the dining room and Resident #2 sat at the table behind the other resident. CMT said he/she saw Resident #2 pound the other resident in the back of his/her head two to three times with a closed fist. Resident #2 looked back before attempting to hit the other resident again. Another aide, CNA C, got a hold of the resident's arm before he/she could hit the other resident a fourth time. CMT B said he/she went to the other resident and took the resident out of the dining room. CMT B asked the resident if he/she was ok. The resident responded, why would (he/she) do me like that? CMT B said when he/she asked the other resident if he/she hurt and wanted Tylenol, the resident responded yes. CMT B is not sure why Resident #2 struck the other resident . The other resident was rambling/mouthing like he/she normally does. The next thing you know, Resident #2 turned around and hit him/her. CMT B guessed the other resident's voice gets to Resident #2. CMT B said a couple days later, the other resident sat at the back of the dining room and the other resident started to go after the other resident again. CMT B said he/she went right over to Resident #2 and redirected him/her out of the dining room before the resident got to the other resident a third time. CMT B brought the resident to the hallway outside of his/her room. CMT B told the Charge Nurse about that incident. CMT B said he/she feels bad for the other resident. It almost seems like Resident #2 is now going after him/her. The other resident suffered a cut above his/her left eyebrow after the first incident. This time, there were no visible injuries. CMT B does not understand why Resident #2 attacked the other resident again. Staff really have to keep them apart. CMT B said the psychologist was at the facility the other day. CMT B feels that Resident #2 knows what he/she is doing even though he/she does have a decline. The day the second incident occurred, the DON and CNA asked the resident a couple questions. The resident told the nurse he/she was going after the other resident. Staff just have to keep watching and make sure Resident #2 stays away from the other resident. During an interview on 4/30/24 at 10:00 A.M., the Social Worker (SW) said there have been two incidents between Resident #2 and the other resident. She did not see either incident. Both happened in the dining room. The SW was told Resident #2 hit the other resident. The other resident got to rambling and not sure if that annoyed Resident #2. Resident #2 tried to tell her that he/she did not hit the other resident. When the SW told the resident there were witnesses, the resident just said ok. The other resident is very loud and talks about anything and everything. Resident #2 has memory issues. During an interview on 4/30/24 at 1:04 P.M., the DON said after the first incident, they moved Resident #2 closer to the inside of the dining room by the kitchen so more staff can keep an eye on him/her. The psychologist came out to do a consult and medication review. So far they did not change behavior interventions, the resident had never hit anyone before these incidents. For the second incident, the CNA said he/she propelled Resident #2 and as he/she passed the other resident, Resident #2 struck at him/her. The CNA said they were able to pull the resident back. The DON said now that they have the other resident moved, the two residents should not have to cross paths because Resident #1 has to go a separate way. The DON believed Resident #1 was already seeing psychologist. The DON does not think it is possible it will happen again. The staff know now and will really monitor. She said it is hard for them to completely avoid each other but now there should be no way to cross paths in the dining room. During an interview on 4/30/24 at approximately 2:30 P.M., the Administrator said she is not sure why the resident had a psychiatrist consult order for 2/9/24 and 4/5/24 but he/she was not seen until April 11th. She expected staff to keep both residents separated and safe. She expected staff to notify management of any changes to behavior. MO00235200

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident's rights to be free from physical abuse was not violated (Resident #1) when a resident (Resident #2) hit the other resident in the eye. This resulted in a laceration. The census was 45. The sample was 3. The Director of Nursing (DON) was notified on 3/08/24, of the past non-compliance. The facility immediately took steps to protect the resident and set interventions in place to prevent further abuse. Staff were in-serviced on resident safety. The deficiency was corrected on 3/4/24. Review of the facility's undated Abuse, Prevention and Prohibition policy, showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family member or legal guardians, friend, or other individuals; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review of Resident #1's medical record, showed: -A quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 2/7/24, showed: -Resident is rarely/never understood; -Diagnoses included dementia and depression. -A progress note, dated 3/4/24 at 9:43 A.M., showed resident was sitting in the dining room eating at the table with another resident when the other resident reached out and hit this resident in the face causing resident's left eye (above) to bleed. Placed a call to the physician, physician made aware. Also, placed a call to the resident's family and made aware of the incident. The resident's left eye was cleaned and applied triple antibiotic ointment and bandage. The resident denies pain at this time. Observation and interview on 3/8/24 at 7:54 A.M., of Resident #1, showed the resident sat in the main dining room. He/She had a small scab above the left eyebrow. The resident was unable to answer how the injury occurred. Review of Resident #2's medical record, showed: -A quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included non-traumatic brain dysfunction and Alzheimer's dementia; -A progress note dated 3/4/24 at 9:23 A.M., showed resident was in the dining room having breakfast and another resident was sitting at the same table when this resident reached and hit the other resident causing the other resident to bleed. The other resident was removed from the situation immediately and administrator was informed. Physician made aware and family made aware. During an interview on 3/8/24 at 8:04 A.M., Resident #2 said he/she did not recall the incident. Review of the facility's investigation, showed on 3/4/24 at 8:25 A.M.: -Summary of alleged incident: While in the dining room, Resident #1 was rambling at Resident #2. Resident #2 made a grimace and then hit Resident #1. Resident #2 said Resident #1 aggravates him/her. Residents separated. Resident #2 has a laceration to the eye. Nurse provided assistance. Physicians and power of attorneys (POAs) notified. Social Services will provide one on one observation; -Both residents were in the dining room just finishing breakfast. Staff were in and out taking residents to their rooms. Resident #1 was rambling nonsense to Resident #2, aggravating him/her and he/she hit Resident #1 causing a 1 centimeter (cm) by 0.5 cm laceration to the left eyebrow. Resident #2 then proceeded to shake Resident #1's chair from behind. Certified Nursing Assistant (CNA) B got Resident #2 to stop and then notified another staff member, then took Resident #1 to the nurse. Both residents are alert and oriented to person only. Physicians and POAs notified. Education is being provided to staff about keeping the residents separated. Urine analysis will also be collected from Resident #2 due to this not being a normal behavior. Social Services complete one on ones with both residents. No other residents have expressed fear. Resident #1 is pleasantly confused, signed by the administrator on 3/4/24. During an interview on 3/8/24 at 8:47 A.M., the Assistant Director of Nursing (ADON) said on 3/4/24, she was working as the charge nurse on the hall. A Certified Nursing Assistant (CNA) brought Resident #1 to her and said another resident hit him/her in the head. The resident was bleeding. Licensed Practical Nurse (LPN) A cleaned up the resident's head while she informed the management, physicians and responsible parties. No sutures were required. The abrasion was superficial. During an interview on 3/8/24 at 8:55 A.M., LPN A said he/she was at the medication cart. The ADON said Resident #2 hit Resident #1 in the dining room. There was blood on Resident #2's head. He/She got supplies and cleaned the wound and got vital signs. The Administrator began the investigation. During an interview on 3/8/24 at 10:40 A.M., a tablemate to Resident #1 and Resident #2 said he/she saw the altercation. He/She said Resident #1 always talks and points and said something to Resident #2 while pointing. Resident #2 swiped and hit Resident #2. It happened so fast. Resident #1 grabbed his/her eye and when he/she lowered his/her hand down, there was blood. Staff in the area ran over to help. During an interview on 3/8/24 at 11:07 A.M., with the DON, she said they would expect residents to be free from abuse, it is their right. Resident #2 had never been aggressive with anyone prior to this incident.

Based on observation, interview, and record review, the facility failed to ensure a resident only self-administered medications after the interdisciplinary team had determined which medications may be self-administered, for one of one resident observed to have medications left at the bedside for later self-administration, for two of three days of survey. The sample was 13. The census was 49. Review of the facility's Resident Self-Administration of Medication policy, dated 9/1/21, showed: -It is the policy of this facility to support each resident's right to self-administer medications. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely; -The results of the interdisciplinary team assessment is placed in the resident's medical record; -The care plan must reflect resident self-administration and storage arrangements for such medications. Review of the facility's Medication Administration policy, dated 9/1/21, showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the medication administration record to identify medications to be administered; -Administer medications as ordered in accordance with manufacturer specifications; -Observe resident consumption of medication; -Sign the medication administration record after administration. During an interview on 12/13/23 at 8:58 A.M., the Administrator said she is not sure, but her best educated guess is the codes identified on the electronic medication record (eMAR) mean the following: -LIB A = AM; -LIB P = PM; -LIB H = nighttime/bedtime. Review of Resident #11's medical record, showed: -Diagnoses included venous insufficiency (poor blood flow), chronic obstructive pulmonary disease (COPD, lung disease), heart failure, high blood pressure, and atrial fibrillation (irregular heartbeat); -An order dated 7/1/21, for Xarelto (blood thinner) 20 milligram (mg) one time a day. Scheduled administration time LIB A; -An order dated 7/15/21, for Theophyline extended release (used to treat lung disease), 300 mg by mouth daily. Scheduled administration time LIB A; -An order dated 9/7/21, for metoprolol tartrate (used to treat high blood pressure), 12.5 mg two times a day. Scheduled administration times LIB A and LIB P; -An order dated 6/23/22, for Reglan (used to treat heartburn), 10 mg three times a day. Scheduled administration times of 9:00 A.M., 12:00 P.M., and 5:00 P.M.; -An order dated 6/28/22, for citalopram hydrobromide (used to treat depression) 15 mg one time a day. Scheduled administration time LIB A; -An order dated 11/1/23, for gabapentin (can be used to treat numbness and tingling in the extremities) 100 mg three times a day for neuropathy (numbness and tingling in the extremities caused by nerve damage) 100 mg three times a day. Scheduled administration times of 9:00 A.M., 12:00 P.M., and 5:00 P.M.; -An order dated 11/2/23, for magnesium oxide (supplement) 400 mg daily. Scheduled administration time 9:00 A.M.; -An order dated 11/7/23, for florastor (probiotic) 250 mg two times a day. Scheduled administration time 9:00 A.M. and 5:00 P.M.; -An order dated 12/5/23, for bumex (diuretic) 2 mg by mouth one time a day related to heart failure. Scheduled administration time 9:00 A.M.; -An order dated 12/12/23, for potassium chloride ER (extended release potassium supplement) 20 milliequivalents (mEq). Give two tablets one time a day. Scheduled administration time 9:00 A.M.; -No assessment or order to self-administer any oral medications; -The resident's care plan did not address self-administration of medications. Observation and interview on 12/11/23 at 8:25 A.M., showed the resident sat in a recliner in his/her room. No staff present in the room. A cup with approximately 5-9 pills sat on the resident's bedside table. The resident said they are his/her AM medications. Staff leave them at the bedside and he/she takes them after breakfast. Observation and interview on 12/12/23 at 7:27 A.M., showed staff in the room with the resident and talked about medications the resident is to receive. At 8:08 A.M., the resident sat in his/her recliner in his/her room. No staff present in the room. A cup of pills sat in the cup holder of the recliner. The resident said these are his/her AM medications. Staff left them with her/her. Approximately 7 pills were visible in the cup. During an interview on 12/13/23 at 12:09 P.M., with the Director of Nursing and Assistant Director of Nursing, they said residents can only self-administer medications if they can demonstrate they are safe to do so. They must have an order to self-administer medications. Medications should not be left at the bedside of residents not determined to be safe to self-administer medications.

Based on observation, interview and record review, the facility failed to ensure proper transfer techniques were utilized in the transfer of dependent residents. This failure occurred in one of one stand-by assist transfers observed, for one resident (Resident #13). The sample size was 13. The facility census was 49. Review of the facility's Transfer Techniques Policy, revised 4/17/19, showed: -The use of appropriate devices (lifts, gait belts, draw sheets, etc.) to provide a safe means of lifting or transferring residents, when used properly, protect both the resident and the employee from injury; -In order to prevent injury to staff or residents, employees shall use appropriate devices to transfer/ambulate/reposition residents; -Gait belts should be used for residents who are able to provide moderate assistance and are affected on one side of their body to ensure safe transfers/ambulation; -Assess resident needs when choosing transfer devices. It's always better to have more help than not enough, for you and the resident. Review of Resident #13's record, showed: -admission date of 10/10/19; -Medical diagnoses included: Sacroiliitis (painful inflammation of the large joints in the hips), age-related osteoporosis (a decrease in the density and mass of the bones caused by aging), and chronic kidney disease. Review of the resident's care plan, in use at the time of survey, showed: -A focus of limited physical mobility, with a goal of the resident remaining free of accidents and skin injuries through the review period. Interventions included ensuring the resident is transferred by at least one staff during transfers and utilizing the resident's Broda chair (padded wheelchair that helps with positioning). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/27/23 showed: -Caregivers often provided substantial support to the resident during transfers to the toilet or commode. Observation on 12/12/23 at 9:07 A.M., showed Certified Nursing Assistant (CNA) D took the resident to the bathroom in Shower Room A on the 300 hall. CNA D stood behind the resident prior to the transfer, and using both hands under the resident's armpits, helped the resident lift out of the Broda chair and onto the commode. CNA D did not use a gait belt during any portion of the resident transfer. The resident moaned during the transfer, and his/her legs were shaky while being transferred to the commode. During an interview on 12/12/23 at 9:07 A.M., CNA D said the resident had suffered from constipation last week, and has had loose bowel movements since being put on medication for the constipation. CNA D said he/she had been working with the resident in the restorative program due to the resident's activities of daily living (ADL) decline, and the resident used to be able to stand on his/her own previously. During an interview on 12/13/23 at 10:58 A.M. Licensed Practical Nurse (LPN) C said staff should transfer residents with equipment appropriate for a resident's transfer status. For example, if a resident was non-weight bearing, a Hoyer lift (a mechanical lift used by caregivers for safely transferring residents) should be used by two staff for transfers, and a resident who is considered a stand-by assist should be transferred with a gait belt on the waist for control and safety. LPN C said Resident #13 should be transferred with a gait belt for one-person stand-by assist transfers. During an interview on 12/13/23 at 12:09 P.M., the Director of Nursing and Assistant Director of Nursing said residents should be transferred with a gait belt if they are full weight bearing. If not full weight-bearing, they would require a mechanical lift. Grabbing a resident under the arms and not using a gait belt to transfer them is not acceptable and puts the residents at risk for skin tears or harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent a significant medication error when staff administered expired insulin to a resident (Resident #44). The census was 49. Review of the facility's Medication Administration policy, dated [DATE], showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the medication administration record to identify medications to be administered; -Identify expiration date. If expired, notify the nurse manager; -Administer medications as ordered in accordance with manufacturer specifications; -Sign the medication administration record after administration. Review of Resident #44's medical record, showed: -Diagnoses included diabetes; -An order dated [DATE], for Novolog (short acting insulin), inject 3 units subcutaneously (under the skin) with meals for diabetes. During a medication administration observation on [DATE] at 4:40 P.M., Registered Nurse (RN) E checked the resident's blood sugar level and received results of 183. At 4:53 P.M., RN E said the resident will receive his/her routine insulin but get no additional sliding scale insulin. RN E drew up 3 units of Novolog from a vial with a label that read do not use after [DATE] and administered the insulin into the resident's right abdomen. During an interview on [DATE] at 12:09 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said expired insulin should not be administered to residents. The risk of administering expired insulin is possible harm. Staff should check the expiration date prior to administration of insulin. They would consider the administration of expired insulin to be a significant medication error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities, three errors occurred, resulting in a 12% error rate (Residents #44, #254, and #30). In addition, the facility failed to have a policy to address when medications are due based on the codes entered into the medical record. The census was 49. 1. Review of the facility's Medication Administration policy, dated [DATE], showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the medication administration record to identify medications to be administered; -Administer medications as ordered in accordance with manufacturer specifications; -Sign the medication administration record after administration. 2. Review of Resident #44's medical record, showed: -Diagnoses included diabetes; -An order dated [DATE], for Novolog (short acting insulin), inject 3 units subcutaneously (under the skin) with meals for diabetes. During a medication administration observation on [DATE] at 4:40 P.M., Registered Nurse (RN) E checked the resident's blood sugar level and received results of 183. At 4:53 P.M., RN E said the resident will receive his/her routine insulin but get no additional sliding scale insulin. RN E drew up 3 units of Novolog from a vial with a label that read do not use after [DATE] and administered the insulin into the resident's right abdomen. During an interview on [DATE] at 12:09 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said expired insulin should not be administered to residents. The risk of administering expired insulin is possible harm. Staff should check the expiration date prior to administration of insulin. They would consider the administration of expired insulin to be a significant medication error. 3. During an interview on [DATE] at 7:09 A.M., the Administrator said she has checked with corporate and looked everywhere, she cannot find a legend that shows what the different codes in the electronic medication administration record (eMAR) mean. At 8:58 A.M., the Administrator said she is not sure, but her best educated guess is LIB A = AM, LIB P = PM, LIB H = nighttime/bedtime. She has the pharmacy trying to figure out the time parameters for those codes. Review of the facility's undated Liberalized Med Pass Information, provided by the Administrator to assist in determining when medications are due when compared to the facility records, showed: -Current med pass is standard, one size fits all, ridge, routine, noisy, institutional, staff tied to the med cart, medicine on the same scheduled made the massive intensive task more manageable; -Liberalized the med pass times. Currently meds are passed at certain times. We change the med times to a block of time, work with our current shift times and when you have a Certified Medication Technician (CMT). This is only an example. We cannot determine times based on what is currently being done; -AM - 6:00 A.M. to 11:59 A.M.; -PM - Noon to 5:59 P.M.; -HS - Hour of sleep varies by resident 6:00 P.M. to 11:59 P.M.; -Upon waking or upon rising - 12:00 A.M. to 5:59 A.M. 4. Review of Resident #254's annual Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Diagnosis included dysphagia (difficulty swallowing), oropharyngeal and gastro-esophageal reflux disease (heartburn) without esophagitis (inflammation of the throat and airway); -Cognitively Intact. Review of the resident's eMAR, showed an active order for Protonix oral tablet delayed release (use to treat and prevent heartburn) 20 milligram (mg) oral tablet one time a day, scheduled administration time LIB A. During a medication administration observation on [DATE] at 9:03 A.M., CMT A administered the resident's scheduled LIB A medicines. CMT A said the resident's Protonix was not available. CMT A failed to administer the resident's ordered Protonix. During an Interview on [DATE] at 8:41 A.M., CMT A said the resident's Protonix was still not available. He/She will call the pharmacy again today to find out when it is coming. During an Interview on [DATE] at 12:02 P.M., the DON and ADON both said the process to reorder medication is to call or fax the pharmacy when medication gets down to 5 or 6 tablets. Staff should call the pharmacy before they run out. The resident's medication should be administered as ordered. 5. Review of Resident #30's Medical Record, showed: -Medical diagnoses included heart failure, high blood pressure, and vitamin D deficiency. Review of the resident's active physician orders, showed: -An active order for Azelastine HCl Solution (an antihistamine to treat runny or stuffy nose and other seasonal allergy symptoms), spray 137 micrograms (mcg), with instructions to administer one spray in each nostril twice per day for seasonal allergies. Observation on [DATE] at 7:01 A.M., showed CMT B began the morning medication pass for Resident #30. During the preparation of medications, CMT B noted that he/she did not have the resident's ordered Azelastine nasal spray on his/her medication cart, and indicated that she would order the medication, as it was not available. The medication was not administered. Review of the resident's eMAR, reviewed on [DATE], showed the resident's Azelastine HCl Nasal Spray documented as administered to the resident on [DATE], [DATE], and [DATE] as ordered. During interview on [DATE] at 8:02 A.M., CMT F said the resident's Azelastine HCL was ordered on [DATE] but had yet to be delivered. During interview on [DATE] at 1:29 P.M., the DON and ADON said staff and administration do not rely on the eMAR accessed through the record system to ensure medications are administered because they don't know what most of those codes mean. The DON said the facility uses an eMAR feature accessed only by staff to track administration of resident medications. The facility DON was unable to provide a report that showed the resident received Azelastine HCl Nasal Spray as ordered. 6. During an interview on [DATE] at 12:09 P.M., the DON and ADON said medications should be administered as ordered.

Based on observation, interview and record review, the facility failed to ensure medications were discarded according to the expiration date for one of two medication carts reviewed with expired medicine that remained in the cart. This resulted in one resident being administered expired insulin (Resident #44). In addition, the facility failed to permit only authorized personnel to have access to the keys to the medication room. The facility identified having one medication room and four medication/treatment carts. The census was 49. Review of the facility's Labeling of Medications and Biologicals policy, dated 9/1/21, showed: -All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications; -Medication labels must be legible at all times. Review of the facility's Medication Storage policy, dated 9/1/23, showed: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security; -Only authorized personnel will have access to the keys to locked compartments; -The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed. 1. Observation and interview on 12/12/23 at 12:47 P.M., showed Licensed Practical Nurse (LPN) C opened a medication cart and said there are two certified medication technician (CMT) carts, a treatment cart, and a nurse medication cart. The cart he/she opened is the nurse medication cart. The blood sugar supplies and insulin for residents are on the nurse cart. Observation showed four insulin vials in the top drawer of the cart. One vial of NovoLog (short acting insulin) labeled do not use after 12/6/23 and one vial of NovoLog with a smudged label that appeared to read do not use after 12/4. LPN C looked at the label and verified it was very hard to read and said he/she believed it said, do not use after 12/11/23. He/She then placed the vial back into the medication cart. In one of the bottom drawers was a large bottle of geritussin (cough syrup) opened and dated as expired on 8/1/23. Only a scant amount remained in the bottle. 2. Review of Resident #44's medical record, showed: -Diagnoses included diabetes; -An order dated 1/26/23, for Novolog, inject 3 units subcutaneously (under the skin) with meals for diabetes. During a medication administration observation on 12/12/23 at 4:53 P.M., Registered Nurse (RN) E drew up 3 units of Novolog from a vial with a label that read do not use after 12/6/23 and administered the insulin into the resident's right abdomen. 3. Observation on 12/12/23 at 8:29 A.M., showed the Housekeeping Manager pulled a set of keys from her pocket and opened the medication room door. No licensed nursing staff or CMTs were in the nurse's station or in the medication room. The Housekeeping Manager obtained cigarettes that sat on the counter in the medication room and then headed to the resident smoke break. Observation of the medication room on 12/12/23 at 8:41 A.M., showed several bottles of stock over the counter medications accessible in the cabinets. 4. During an interview on 12/13/23 at 12:09 P.M., with the Director of Nursing and Assistant Director of Nursing, they said only CMTs and nurses should have access to the medication room. They were aware that the Housekeeping Manager had a key to the medication room so he/she can clean it. She had the key before the new management started, so they just let her keep it. The Housekeeping Manager should not enter the medication room if there is not a CMT or nurse present. Expired medications should be disposed of once expired. Not disposing of the expired medications may result in them being used on a resident.

Based on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained. The facility failed to follow manufactures directions for blood glucose (sugar) test strips to ensure accurate results. Improperly stored test strips were used to check residents' blood sugar levels (Resident #7, #1, #25, and #44). The census was 49. Review of the facility's Centers for Medicare and Medicaid Services (CMS) Clinical Laboratory Improvement Amendments (CLIA) certification of waiver, effective 9/1/22 and expiration 8/31/24, showed: -Laboratory name and address, listed the facility name and address; -The above named laboratory located at the address shown hereon may accept human specimens for the purpose of performing laboratory examinations or procedures. 1. Observation and interview on 12/12/23 at 12:47 P.M., showed Licensed Practical Nurse (LPN) C opened a medication cart and said there are two certified medication technician (CMT) carts, a treatment cart, and a nurse medication cart. The cart he/she opened is the nurse medication cart. The blood sugar supplies and insulin for residents were on the nurse cart. Observation showed Assure Prism blood sugar testing strip vial opened and lay on its side in the top drawer of the cart. LPN C looked at the vial of testing strips, closed to bottle, and left them in the cart. The top of the bottle was labeled 12/11. Review of the Assure Prism blood glucose monitoring system, manufacturers recommendations, showed: -The Assure Prism multi blood glucose monitoring system measures blood glucose quickly and accurately. It automatically absorbs the small blood sample applied to the narrow edge of the strip; -Safety instructions for using test strips: Close the vial tightly after taking out a test strip and use the test strip immediately. 2. Review of Resident # 7's medical record, showed: -Diagnoses included diabetes; -An order dated 8/6/21, for blood sugar monitoring and sliding scale insulin based on blood sugar value. Observation on 12/12/23 at 4:23 P.M., showed Registered Nurse (RN) E checked the residents blood sugar level with the Assure Prism strips labeled 12/11. 3. Review of Resident #1's medical record, showed: -Diagnoses included diabetes; -An order dated 12/30/22, for blood sugar monitoring and an order dated 12/31/22 for sliding scale insulin based on blood sugar value. Observation on 12/12/23 at 4:27 P.M., showed RN E checked the residents blood sugar level with the Assure Prism strips labeled 12/11. 4. Review of Resident #25's medical record, showed: -Diagnoses included diabetes; -An order dated 7/25/23, for blood glucose monitoring. Observation on 12/12/23 at 4:30 P.M., showed RN E checked the residents blood sugar level with the Assure Prism strips labeled 12/11. 5. Review of 44's medical record, showed: -Diagnoses included diabetes; -An order dated 1/26/23, for sliding scale insulin based on blood sugar value. Observation on 12/12/23 at 3:30 P.M., showed RN E checked the residents blood sugar level with the Assure Prism strips labeled 12/11. 6. During an interview on 12/13/23 at 12:09 P.M., the Director of Nursing and Assistant Director of Nursing said they would expect staff to store lab supplies, such as blood sugar testing strips, per manufacturers recommendations. The risk of not doing this could be obtaining incorrect results. If staff identify test strips were not stored properly, they should dispose of them and get a new one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect residents' personal privacy during personal care. One resident was left naked and exposed while staff allowed housekeeping into the room to clean (Resident #19). In addition, staff failed to ensure a resident was not visible from the hallway when partially dressed while staff were present and that the resident was not visible to the roommate during incontinence care (Resident #5). This affected two of four residents observed during incontinence care. The census was 51. Review of the facility's admission packet, provided to residents upon admission to the facility, showed Know Your Rights: You have the right to privacy in medical treatment and personal care. You should be treated with consideration and respect, with full recognition of your dignity and individuality. Review of the facility's Incontinence Care policy, dated 10/1/99, showed: -Each resident deserves to be clean and dry; -Policy: To ensure adequate hygiene and prevention of infection related to incontinence; -Procedure: -Wash your hands and put on gloves; -Explain what you are going to do; -Provide privacy. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/21, showed: -The resident is rarely/never understood; -Limited assistance of 1 person required for dressing support; -Extensive assistance of 1 person required in maintaining personal hygiene; -Not steady, but able to stabilize self during ambulation; -Does not require an assistive device for mobility; -Diagnoses included diabetes, Alzheimer's disease and dementia; -Received hospice care while a resident. Observation on 9/23/21 at 5:21 A.M., showed Certified Nursing Assistant (CNA) D exited the resident's room and left the door slightly opened. The resident was observed from the hallway as he/she stood in his/her room, and wore a visibly soiled brief with brown stool. CNA D knocked on one of the other resident's doors, across the hall, and requested CNA I to come assist him/her with the resident. CNA I asked CNA D if the resident did it again to which CNA D responded, yes he/she did. CNA D reentered the resident's room and prompted the resident to sit down in a chair located in the middle of the room. CNA D removed the resident's jacket and shirt. As the resident sat in the chair dressed in a stool covered brief and socks only, the CNA began cleaning stool off the floor with the soiled bed linen. CNA I then entered the resident's room with clean towels and bed linen. He/she said he/she needed more towels and obtained additional towels from the end table next to the bed. CNA D placed the soiled linen at the foot of the resident's bed and CNA I obtained an empty bag trash bag for this linen. At approximately 5:43 A.M., CNA D said he/she was going to get a mop and left the room. CNA I encouraged the resident to stand up and he/she did. While the resident stood, his/her brief slightly fell down in the front and exposed part of the resident's genital area. The resident walked from the middle of the room, where the chair sat, over to the sink vanity. As the resident faced the sink vanity, CNA I instructed him/her to grasp it with both of his/her hands. CNA I then removed the soiled brief from the resident. As the resident stood naked and faced the sink vanity, with both his/her hands clasping the counter, the housekeeping director knocked on the door, requested to come in, and CNA I gave her permission to enter. She entered the room and left the door slightly opened. She mopped then dried the floor. She then obtained disinfectant spray from the housekeeping-cart and sprayed it on the chair the resident had previously sat in. As the Housekeeping director wiped the chair off, CNA I cleansed in between the resident' buttocks with a towel. The housekeeper director exited the room. During an interview at this time, CNA I said that it is not typical for housekeeping to come in a room as perineal care is being provided to residents, but this situation was an emergency. During an interview on 9/24/21 at 10:34 A.M., the Director of Nursing (DON) and the Administrator said it was not appropriate for a resident wearing a soiled brief and no pants to be visualized in their room from the hallway while staff were present. Housekeeping should not clean a room as a resident stood in the room naked. The DON noted that there were extenuating circumstances and therefore an exception was made. The administrator said she guessed staff could have covered the resident before allowing housekeeping into the room. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence on staff for bed mobility, transfers, dressing, personal hygiene and eating; -Diagnoses included: Cachexia (general weight loss occurring during course of chronic disease), progressive neurological condition, high blood pressure, high cholesterol, non-Alzheimer's dementia and anxiety disorder. Review of the resident's electronic care plan, dated 12/17/18, and in use at the time of the survey, showed: -Focus: Resident decline in activities of daily living (ADL) status related to cognition decline and decline in mobility; -Goals: Resident will have all ADLs met in the next 90 days; -Interventions: Resident requires total care with dressing, toileting, transfers and personal hygiene. Observation on 9/22/21 at 9:30 A.M., showed the resident lay on his/her back on the left side. CNA G had gloves on and said he/she was going to start personal care. CNA G raised the resident's bed and then woke up the resident. The resident's gown was pulled up to his/her mid chest with the brief exposed. The privacy curtain was not fully closed and open towards the front of the room. A mirror was located between the first and second bed in the room and the resident's roommate lay in bed, visible through the mirror as the resident lay exposed as staff provided care. CNA F knocked and came in with two pitchers of water and pulled back the curtain by the door and left the room door open with the resident exposed to the hallway. CNA G asked CNA F to get the resident a new sheet. CNA F left and shut the door but left the curtain by the door open. CNA F knocked on the door again and came in with a sheet and CNA G asked him/her to stay and help. The privacy curtain was open and the resident visible to the roommate through the mirror. At 9:50 A.M., the CNA trainer knocked and came into room. She closed the privacy curtain, closest to the door and then said she was going to stay and watch since she does the staff in-services. The staff finished providing the resident with personal care. During an interview on 9/24/21 at 10:24 A.M., the DON said she would expect staff to keep the curtain and door closed when a resident was being provided care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of two mechanical lift transfers one of three stand by transfers observed (Residents #2 and #29). The census was 51. Review of the facility's Transfer Techniques policy, dated 4/17/19, showed: -Policy statement: Use of appropriate devices (lifts, belts, draw sheets, etc.) provide a safe means of lifting or transferring residents and, when used properly, protect both the resident and the employee from injury; -Lifts: Use for totally dependent residents or anyone with contractures (tightening of the tendons and joints resulting loss in range of motion), amputations, obesity, etc. Do not attempt to use the lift unless you have been trained and feel comfortable with the procedures. Do not lift alone, there must always be 2 staff members when using one of the lifts. Make sure to widen the base of the lift before use. Never use a frayed or ripped sling. Move the lift/sling/resident slowly safely; -Belts: Use for residents who are able to provide moderate assistance and are affected on one side of their body to ensure safe transfers/ambulation. During an interview on 9/24/21 at 10:06 A.M., with the Director of Nursing (DON) and administrator, they said they do not have a policy specific to mechanical lifts or gait belt transfers that show the step by step process. The transfer policy provided is the policy used. 1. Review of Resident #2's electronic health record (EHR), showed: -Diagnoses included stroke, depression, dementia, hearing loss, heart disease, insomnia (difficulty sleeping) and Parkinson's disease (a progressive disease of the nervous system that impacts movement); -A care plan in use at the time of survey, showed: -The resident has an activity of daily living (ADL) self-care performance deficit, limited physical mobility, a communication problem, and impaired thought processes; -Interventions included staff participation with hygiene and oral care, total dependence on staff for dressing and locomotion, and ensuring a safe environment that comprised of the bed being in the lowest position and the call-light being within reach; -A quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/31/21, showed: -The resident was rarely/never understood; -Had a memory problem; -Moderately impaired cognition; -Required cues and supervision; -Total dependence on staff for transfers, locomotion, dressing, eating and personal hygiene. Observation on 9/22/21 at approximately 7:09 A.M., showed the resident lay in his/her bed, flat on his/her back. The resident fully-dressed and a lifting-sling (a pad designed to be suspended from and attached to a mechanical lift) lay underneath him/her. The bed was elevated approximately 2 feet from the floor and staff were not in the resident's room, at the time. A Hoyer-lift (mechanical lift) sat in the hallway adjacent to the resident's room. The resident said he/she had to wait for the horse in order for him/her to get into his/her chair. The call-light cord ran from the wall, underneath the pillow that he/she rested his/her head on and then hung off the left-side of the bed, and dangled toward the floor. At 7:39 A.M., Certified Nursing Assistant (CNA) G stood in the 200 hallway and asked CNA F to help him/her get the resident up. He/she pushed the Hoyer-lift into the resident's room and positioned the sling bar above the resident, who lay in the bed. He/she hooked the straps of the lifting-sling, which lay under the resident, to the sling attachment points of the sling bar. CNA G said the resident called the lift a horse and he/she could not bend his/her legs. He/she had to go find his/her coworker and left the resident's room. The resident's bed continued to be elevated approximately 2 feet from the floor and he/she was attached to the Hoyer lift. CNA F and CNA G entered the resident's room. CNA G stood on the left side of the resident, toward the head of the resident's bed. A Geri-chair (geriatric chair, a large padded chair for those with mobility barriers to lounge in) was parked at the foot of the resident's bed, facing the door to the hallway. CNA F stood behind the Geri-chair on the right side of the resident, at the foot of the resident's bed. CNA G lifted the resident into the air using the remote that was attached to the Hoyer-lift. CNA G manipulated the Hoyer-lift to move the resident from over his/her bed to the left-side of his/her bed. He/she propelled the Hoyer-lift that held the resident toward the Geri-chair, at the foot of the bed. CNA F then moved from behind the Geri-chair to the back of the Hoyer-lift that held the resident. CNA G guided the resident over the Geri-chair. CNA F repositioned himself/herself back behind the Geri-chair and CNA G begun lowering the resident down into the Geri-chair. The right-side of the resident's right foot brushed against the bathroom door and he/she grimaced. CNA F redirected the resident's feet away from the bathroom door and he/she was lowered completely down into the Geri-chair. During an interview with CNA G, he/she said the call-light had been within the resident's reach and that the resident told him/her to get it out of his/her way. 2. Review of Resident #29's admission MDS, dated [DATE], showed: -Resident rarely/never understood; -Independent with bed mobility; -Limited assistance- one person physical assisted required for transfers; -Walk in room/corridor: activity did not occur; -Limited assistance required for dressing; -Extensive assistance required for toilet use and personal hygiene; -Balance during transitions and walking: -Moving from seated to standing position: Not Steady, only able to stabilize with human assistance; -Walking: Activity did not occur; -Turning around and facing the opposite direction while walking: Activity did not occur; -Moving on and off the toilet: Not steady, only able to stabilize with human assistance; -Surface to surface transfers (transfer between bed and chair or wheelchair): Not steady, only able to stabilize with human assistance; -Mobility device: Wheelchair; -Diagnoses included: Progressive neurological conditions, osteoporosis (thinning and weakening of the bone) and dementia. Review of the resident's electronic care plan, in use at the time of the survey, showed: -Focus: At risk for falls: -Goals: Resident will have no injuries related to falls; -Interventions: Keep room clutter free; -Focus: Activity of daily living (ADL) self-care performance deficit: -Goal: Resident will have all needs met; -Interventions: The resident requires one staff participation with bathing. The resident requires one staff participation to reposition and turn in the bed. The resident requires one staff participation to dress. The resident requires one staff participation with personal hygiene. The resident requires assistance, cueing with short, simple instructions such as hold your brush, wash your hands, hand over hand guidance. The resident requires one staff participation to use the toilet. The resident requires one staff participation with transfers. Observation on 9/22/21 at 5:48 A.M., showed the resident sat on the edge of the bed. CNA C washed his/her hands and placed gloves on. He/she the placed a clean hand towel directly into the sink and gathered supplies. The resident started to stand and CNA C yelled no, no don't get up. The resident wore a brief and shirt as he/she sat on the edge of the bed. CNA C placed a clean brief around the lower half of the resident's legs, followed by pants, non-skid socks and slippers. He/she then assisted the resident to stand without the use of a gait belt and stood behind and slightly to the side of the resident. The resident appeared unsteady and held onto the CNA. CNA C unsecured the resident's urine soiled brief and provided incontinence care. While still standing, CNA A pulled up the resident's clean brief and pants, that had already been placed around his/her ankles. CNA C then assisted the resident to sit on the bed. He/she told the resident to take his/her shirt off. The resident appeared to not understand. CNA C assisted the resident to take his/her shirt off. CNA C then assisted the resident to stand without the use of a gate belt. The resident did not appear steady and started reaching downward, as if reaching for the wheelchair, but the wheelchair was on the other side of the resident. CNA C guided the resident to sit in the wheelchair and then propelled the wheelchair to the sink to finish providing morning care. 3. During an interview on 9/24/21 at 10:06 A.M., with the Director of Nursing (DON) and administrator, they said if a resident is not steady for transfers, they would expect staff to use a gait belt. The transfer status should be included in the care plan. It is not acceptable to hook the lift pad with the resident in it to the Hoyer and then leave the room. The second person should be on the other side by the resident if the resident is being lifted. When being lowered to the chair, staff should be mindful of the resident's lower extremities. It is never acceptable for a resident to be alone if the Hoyer is attached.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents are free from any significant medication errors, for one resident (Resident #16) who was administered expired insulin. The census was 51. Review of the facility's Medication Storage in the Facility policy, dated [DATE], showed outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. Review of Resident #16's electronic medical record, showed: -Diagnoses included diabetes mellitus with ketoacidosis (a serous diabetes complication where the body produces excess blood acids) without coma and type 1 diabetes (a chronic form of diabetes that typically appears in adolescence) with unspecified complications; -Review of the resident's electronic physician order sheet, showed: -An order dated [DATE], for blood glucose (sugar) monitoring before meals and at bedtime; -An order dated [DATE], for Novolog (short acting) insulin, inject 6 units subcutaneously (under the skin) two times a day for diabetes; -An order dated [DATE], for Novolog insulin per sliding scale: -For a blood glucose of 451-500 (normal is less than 140), administer 14 units; -If greater than 500, call the physician. Observation on [DATE] at 7:12 A.M., showed Licensed Practical Nurse (LPN) A checked the resident's blood glucose level. The results read 562. LPN A asked the Director of Nursing (DON) to call the physician to report the elevated blood glucose level. At approximately 7:30 A.M., the DON reported the physician ordered to give the sliding scale insulin as ordered. LPN A said the sliding scale dose of 14 would be administered in addition to the routine dose of 6, to equal 20 units of Novolog insulin. LPN A removed a vial of Novolog from the medication cart and verified the name on the vial. Observation at this time, showed a label read do not use after and a hand written date of 9/20. LPN A verified the hand written date on the vial of insulin was the expiration date. LPN A drew up 20 units of the Novolog from the expired insulin vial and administered it to the resident. During an interview on [DATE] at 10:06 A.M., with the DON and administrator, they said when administering medications, staff should check the expiration dates. If a medication is expired, it should not be used. Once expired, the effectiveness of the insulin is either not effective or has decreased effectiveness. It would be important to ensure the full effectiveness of insulin for any resident who receives it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate assessment, reflective of the resident's status at the time of the assessment for one resident who had wounds at the time of the assessment (Resident #9) and for five of five residents investigated for hospice who had a life expectancy of less than six months (Residents #5, #12, #16, #14 and #34). The facility identified 12 residents as receiving hospice services. The sample was 13. The census was 51. 1. Review of Resident #9's admission wound assessment, dated 6/17/21, showed a left lower leg stasis ulcer (breakdown of the skin caused by fluid build-up from poor vein function) was present on admission and measured 13 centimeters (cm) in length, 11 cm wide, and 0.3 cm deep. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/18/21, showed the total number of arterial (caused by poor blood supply) and venous (result from valve incompetence in perforating veins) ulcers was 0. Review of the resident's most recent quarterly MDS, dated [DATE], showed the total number of arterial and venous ulcers left blank. During an observation on 9/20/21 at 9:05 A.M., the resident wore an Unna boot (a soft cast gauze dressing filled with Zinc paste to promote wound healing for leg ulcers) on his/her lower left extremity. When asked about it, the resident reported it was an old wound and he/she had no current issues with the treatment for it. During an interview on 9/24/21 at 9:13 A.M. the MDS coordinator said she would expect any wounds to be documented accurately in the resident's admission MDS and if a resident developed a wound while in the facility she would expect it to be documented on the next quarterly MDS. 2. Review of Resident #5's electronic medical record (EMR), showed: -On 4/10/20, primary payer changed to hospice Medicaid; -A quarterly MDS, dated [DATE], showed: -Hospice while a resident: Yes; -Does the resident have a life expectancy of less than 6 months: No; -A quarterly MDS, dated [DATE], showed: -Hospice while a resident: Yes; -Does the resident have a life expectancy of less than 6 months: No. 3. Review of Resident #12's EMR, showed: -On 1/7/21, primary payer changed to hospice Medicaid; -A significant change MDS, dated [DATE], showed: -Hospice while a resident: Yes; -Does the resident have a life expectancy of less than 6 months: No; -A quarterly MDS, dated [DATE], showed: -Hospice while a resident: Yes; -Does the resident have a life expectancy of less than 6 months: No; -A quarterly MDS, dated [DATE], showed: -Hospice while a resident: Yes; -Does the resident have a life expectancy of less than 6 months: No. 4. Review of Resident #16's EMR, showed: -On 1/11/21, primary payer changed to hospice Medicaid; -A quarterly MDS, dated [DATE], showed: -Hospice while a resident: Yes; -Does the resident have a life expectancy of less than 6 months: No; -On 7/1/21, primary payer changed to Medicaid. 5. Review of Resident #14's EMR, showed: -On 6/30/21, primary payer changed to hospice Medicaid; -A significant change MDS, dated [DATE], showed: -Hospice while a resident: Yes; -Does the resident have a life expectancy of less than 6 months: No. 6. Review of Resident #34's EMR, showed: -On 8/11/21, primary payer changed to hospice Medicaid; -A significant change MDS, dated [DATE], showed: -Hospice while a resident: Yes; -Does the resident have a life expectancy of less than 6 months: No. 7. During an interview on 9/24/21 at 9:12 A.M., the MDS coordinator said she is responsible to ensure MDS are accurate and she would expect MDS to be accurate. She marked no on the question about life expectancy of less than 6 months for residents on hospice because she did not have their certification of terminal illness. She was not aware that all hospice residents would have this certification to qualify for hospice and she would need to follow up in the future to ensure the facility has a copy of this documentation onsite when completing the MDS.

Based on interview and record review, the facility failed to ensure dialysis services received meet professional standards of practice for one resident who received dialysis services (Resident #17). The facility failed to ensure staff completed post dialysis assessments per their policy and acceptable standards of practice. The facility identified as only having one resident on dialysis services. The census was 51. Review of the facility's Dialysis Resident Care policy, dated 10/14/18, showed: -Policy statement: To maintain best clinical practices for shunt (dialysis access site) care and resident's receiving dialysis; -Policy: To monitor and educate staff and residents about good post-dialysis care; -Procedure included: -Assess residents upon return from dialysis treatment and document in nurse's notes: -Monitor blood pressure, report low or high blood pressure; -Watch for bleeding-apply direct firm pressure on area for 7-10 minutes if bleeding occurs. If bleeding cannot be controlled/continues longer than 30 min, call 911; -Assess access site for bruit (the sound heard as blood rushes through the dialysis access site), thrill (the vibration felt as blood rushes through the dialysis access site), exudate (drainage), signs of infection, and bleeding; -Give missed med, if indicated; -Assess fistula (dialysis access site) or graft (dialysis access site) for infection; -Assess site for redness, swelling, pain or drainage; -Assess circulation on distal (furthest from the center of the body) portion of extremity; -Do not have intravenous (IV) or blood draws in access arm; -Do not take blood pressure in access arm. Review of Resident #17's electronic medical record (EMR), showed: -Diagnose included chronic kidney disease stage 5 (dialysis dependent) and end stage kidney disease; -A progress note dated 3/6/21: Daily skilled nurses note: Left forearm fistula. The resident receives dialysis. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/28/21, showed: -Original admission date 8/19/19; -Re-entry date of 5/7/21; -Cognitively intact; -Primary medical condition category: Medically complex conditions; -Diagnoses included kidney failure; -Special treatments and programs: dialysis. Review of the resident's care plan, showed: -Focus, dated 6/30/21, resident receives dialysis related to stage 5 kidney disease: -Goal: The resident will have immediate interventions should the signs and symptoms of complications from dialysis occur; -Interventions included: Charge nurse to monitor/document/report to physician as needed signs and symptoms of infection to the access site. Dialysis fistula located to the left forearm. Do not take blood or blood pressure in left arm. Monitor/document/report to physician as needed for signs and symptoms of bleeding, bacteremia (blood infection), and septic shock (complication of a blood infection). Notify nephrologist (kidney doctor) or dialysis center immediately in case of: -No pulse, vibration or thrill in the fistula or graft (arteriovenous graft only); -Pus draining from catheter, fistula, or graft; -Redness or swelling in the accessed arm; -Enlarging hematoma (bleed under the skin) or pain in the accessed arm; -Coldness, numbness, aching, or weakness of the accessed arm. Further review of the resident's EMR, reviewed for the past 6 months from 3/22/21 through 9/22/21, showed: -An order dated 6/30/21, for dialysis three times a week, Monday, Wednesday and Friday; -No post dialysis assessments, no documentation of when the resident returned from dialysis on dialysis days, his/her condition upon return and no documentation of the resident's condition or when he/she left for dialysis on dialysis days. During an interview on 9/24/21 at 10:06 A.M., with the Director of Nursing (DON) and administrator, they said the resident is the only dialysis resident in the facility. He/she goes to dialysis every Monday, Wednesday and Friday. They would expect staff to follow the facility's dialysis policy. Dialysis assessments should be documented in the progress notes. Staff should document the resident condition when he/she leaves for dialysis in the progress notes as well. Communication with the dialysis company is as needed.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were not kept past their expiration date and that medications for residents who were no longer in the facility were removed from the active medication supply for one of one medication room, one of one medication cart and one of one treatment cart observed. In addition, the facility failed to store all drugs and biologicals in locked compartments and controlled substances behind two locked compartments when the medication room door was left propped open with no staff present and as a resident walked independently past the door (Resident #15). The facility identified having one medication room, three medication carts and one treatment cart. The census was 51. Review of the facility's Medication Storage in the Facility policy, dated June 1, 2018, showed: -Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 1. Observation on 9/21/21 at 3:05 P.M., of the medication storage room, showed: -The medication room locked. The Director of Nursing (DON) used a key to enter; -Expired medications included: i. Calcium 250 milligram (mg) + Vitamin D3 tablets, expired as of 6/2021; ii. Docusate Sodium (stool softener) 100 mg tablets, expired as of 1/2021; iii. Three bottles of Robafen DM cough syrup for a resident discharged on 4/2021; iv. One bottle of Sorbitol (laxative) solution, expired as of 8/2021; -A locked box that contained narcotic medications located inside the medication refrigerator. The DON verified stock narcotic medications are located in the lock box in the medication refrigerator. 2. Observation on 9/21/21 at 3:27 P.M., of the nurse cart, showed two residents' Lantus (long acting insulin) insulin vials with expiration dates of 9/20/21, and one resident's Lantus insulin vial with an expiration date of 9/18/21. One bottle of Docusate Sodium 100 mg tablets with an expiration date of 7/2020. The DON confirmed that the Docusate Sodium medication was expired and should have been removed from the cart by staff and not given to residents. 3. Observation on 9/21/21 at 3:25 P.M., of the treatment cart, showed a tub of Eucerin healing cream, labeled for a resident and with an expiration date of 12/9/20. The tub approximately 75 percent used. The DON verified the resident identified on the tube currently resides in the facility. She did not realize the cream was expired and the cream should not be on the cart. 4. During an interview on 9/23/21 at 10:50 A.M., the DON said she would expect staff to dispose of expired medications and supplies. She would expect staff to verify expiration dates on medications and supplies before using them for resident treatments. On 9/24/21 at 10:04 A.M., the DON said expired medications should not be used for patient treatments and that insulin used past the expiration date is not as effective. All diabetics in the facility should receive accurate insulin that is not expired. 5. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/5/21, showed: -Cognitively intact; -Independent with locomotion on and off the unit; -Diagnoses included heart failure, kidney disease and diabetes. Observation on 9/23/21 at 4:31 A.M., showed the medication room door propped open with the use of a cabinet door located inside the medication room and the medication room door rested against the cabinet door. No staff visible within eyesight of the nurse's station. At 4:46 A.M., Resident #15 walked past the opened medication room. At 4:55 A.M., Licensed Practical Nurse (LPN) B closed the medication room door. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said medications should be maintained behind one lock and controlled medications should be maintained behind two locks. The medication room door should not be left propped opened when no staff are present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide palatable food and serve what was listed on the menu for one resident (Resident #5) out of six residents who received a pureed diet. The facility also failed to follow the recipes for pureed diets and provide the amount of food specified on the menu. The census was 51. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/7/21, showed: Severe cognitive impairment; -Total dependence on staff for bed mobility, transfers, dressing, personal hygiene and eating; -Diagnoses included: Cachexia (general weight loss occurring during course of chronic disease), progressive neurological condition, high blood pressure, high cholesterol, non-Alzheimer's dementia and anxiety disorder. Record review of the resident's electronic physician order sheet (ePOS), showed regular diet, pureed texture, and regular consistency. Review of the residents, medical record, showed a dietary note, dated 9/14/21, the resident is on a pureed diet with one can of ensure three times a day. The resident's weight is stable at 103 pounds for 2 months. Loss of 5.8 pounds for 3 months and significant loss of 15.6 pounds for 6 months noted. Resident under hospice care. Resident is declining. Weight stability acceptable. Continue current high calorie regimen. Comfort is goal. Observation and interview on 9/21/21 at 5:50 P.M., showed Certified Nursing Assistant (CNA) E fed the resident a pureed dinner. CNA E verified the resident's diet is mashed/pureed. When asked what the resident was eating for dinner this evening, CNA E said he/she was not sure but thinks it is corned beef since [NAME] sandwich was on the menu. The resident also has what smells like sauerkraut, mashed potatoes without gravy, and watermelon for dessert. The resident took a few bites but wasn't able to open his/her mouth very wide and spilled several bites on a towel that was on the resident's chest. The resident did not eat the sauerkraut or much of the mashed potatoes. CNA E, while assisting the resident with the meal, mixed some of the pureed watermelon with the corned beef and fed it to the resident. CNA E said the resident typically eats 50-60% of dinner just depends on the day. The resident loves mashed potatoes and gravy, it is his/her favorite. When asked if the CNA could have asked for gravy to go with the mashed potatoes, CNA E said he/she could have asked for it tonight but they didn't serve it. The resident ate about half of the dinner. During an interview on 9/21/21 at 6:20 P.M., the dietary manager verified the pureed meat was corned beef and that gravy was on the menu to be served with the mashed potatoes. He said that normally he makes gravy with the mashed potatoes but he was in a rush because a cook called in. He would be able to make it if staff requested it for a resident or resident requested it. Even if it's not on the menu, he can make whatever is requested. During an interview on 9/22/21 at 1:00 P.M., the administrator said she would expect the kitchen staff to serve what is on the menu if they can. Sometimes they can't due to food shortage. The administrator then asked if this was about the incident last night because the dietary manager talked to her. Watermelon and corned beef should not be mixed together. 2. During observation and interview on 9/21/21 at 11:30 A.M., the cook said they had 5 pureed that they prepared for. He/she then took tongs of diced ham and scooped chunks from a pan. He/she said it was about 1/2 pound of meat and he/she added 4 slices of bread and 1/2 cups of pork broth. He/she said he/she likes to get it to applesauce and baby food consistency. He/she added more liquid. Observation at 11:41 A.M. showed the cook made the pureed sweet potatoes. He/she said it was about one pound. He/she said added 4 slices of bread and used its own juice. He/she blended it, then left some of the sweet potatoes in the mixer. He/she then mixed vegetables, and said it was about 1 pound, then addend 4 slices of bread mixed it and left some in the mixer. Review of the pureed recipes, showed for five pureed diets, staff should add 2 1/2 slices of bread for the vegetables and pureed meat and to add none for the side dish. Observation showed during the meal service, showed that there were six pureed diets staff prepared for. 3. Observation on 9/21/21 at 1:2:15 P.M. showed the cook gave two thin slices of ham for regular diets. At 1:00 P.M. the cook weighed two slices of ham and it registered 2 ounces. Review of the menu, showed staff should have given 3 ounces of ham with the meal. 4. During an interview on 9/21/21 at 2:03 P.M., the dietary manager said staff should follow portion sizes and recipes.

Based on observation, interview and record review, the facility failed to label and date food when it was removed out of the original container. The census was 51. Review of the facility's policy dated 8/12/18, regarding Food Safety Storage Labeling and Dating, showed: -Foods will be properly stored, labeled and dated according to current practice standards; -All items must be dated when received and not kept longer than three days after receipt; -Items past the safe use by date will be discarded; -Administrator will check in dietary and nursing refrigerators at least weekly. Observation on 9/22/21 at 9:26 A.M. and showed the following -In the freezer, three bags hash browns not dated and taken out of the original box; -In the freezer, four bags of spinach not dated and taken out of the original box; -In the freezer, one bag of mixed vegetables in a zip lock bag, 2 bags of peas, 4 bags of green beans, 5 bags of vegetables not dated, one bag of approximately 30 chicken patties in a zip lock bag not dated; one bag of several pizza crusts not in its original bag not dated; -In the storage room, one bag of open corn puffs in a zip lock bag not dated; -In the refrigerator, 3-13.9 Liters of coleslaw not dated and opened; -In the refrigerator one gallon 1000 island dressing not dated and open and 2/3 full; 1 gallon honey french dressing not dated, open and 2/3 full. During an interview on 9/23/21 at 2:07 P.M., the dietary manager said staff should be dating food in the refrigerator three days ahead of time when they put it in the refrigerator. That way they know when to throw it away. If things are taken out of their original package they should be dating them wether they are in the refrigerator or freezer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the transmission of infections. Staff failed to follow proper hand hygiene and infection control procedures for four of four perineal (the area to include the buttocks and the genitals) care observations (Residents #19, #5, #29 and #42). Staff failed to perform proper hand hygiene before adjusting or assisting a resident with their face mask (Resident #10). Staff touched a resident's sandwich with bare hands. Staff failed to properly sanitize a shared Hoyer lift (mechanical lift) before and/or after use (Resident #36). Staff used resident personal care items to turn on and off the water prior to using them on the resident (Resident #2). In addition, staff failed to ensure a resident who provided services for the facility, followed the same infection control practices expected of staff when setting up for meal services (Resident #15). The Census was 51. Review of the facility's Infection Control policy, dated 9/3/18, showed: -Policy Statement: To maintain infection control best practices and prevention at all times; -Policy: To monitor and educate staff, residents and visitors in infection control and prevention; -Procedure: -The Director of Nursing (DON) will direct and maintain an infection control program consistent with the Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), Federal and State regulations and recommendations; -Monitor handwashing, gloving, linen handling among staff through walking rounds observations and formal regular training/re-training. Review of the facility's Handwashing policy, dated 1/9/19, showed: -Policy statement: To ensure proper handwashing by all employees; -Policy: To ensure adequate hygiene and prevention of infection by all employees; -Procedure: Proper handwashing by all employees is necessary between all resident care activities, following use of bathroom, before and after gloves usage, before and after eating or any other time hands may become soiled by cot act with soiled surfaces or activities. Review of the facility's Perineal Care policy, dated 1/6/19, showed: -Policy statement: To ensure proper perineal care to all residents; -Policy: To ensure adequate hygiene and prevention of infection related to incontinence; -Procedure: -Wash your hands and put on gloves; -Explain what you are going to do; -Provide privacy; -Gather equipment- 2 wash basins, multiple towels/wipes; -Do not contaminate wash/rinse water by placing soiled towels/wash cloths in clean water; -Be sure towel/cloth/wipe does not become contaminated by accidentally touching soiled area(s); -Change gloves and wash/sanitize hands between soiled/clean task; -Never empty the water basins in the sink- use the commode only. 1. Review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandates assessment instrument completed by facility staff, dated 7/9/21, showed: -The resident is rarely/never understood; -Limited assistance of one person required for dressing support; -Extensive assistance of one person required in maintaining personal hygiene; -Not steady, but able to stabilize self during ambulation; -Does not require an assistive device for mobility; -Diagnoses included diabetes, Alzheimer's disease and dementia; -Received hospice care while a resident. Observation on 9/23/21 at 5:21 A.M., showed Certified Nursing Assistant (CNA) D washed his/her hands, placed gloves on and prompted the resident to sit down in a chair located in the middle of the resident's room. The resident's bedroom floor and bed linen were visibly soiled with stool. CNA D removed the resident's jacket and shirt. CNA D then removed stool-soiled bed linen from the resident's bed and used it to wipe stool off the floor. CNA I entered the room with one hospital gown, two large towels and clean bed linen. He/she said he/she needed more towels, then picked up additional towels that already sat on the end table next to the resident's bed. He/she placed a large towel halfway into the sink basin and let water run from the faucet directly onto it. CNA D placed the same soiled bed linen used to wipe stool up off the floor, directly onto the resident's exposed mattress, near the foot of the bed. CNA I, who now wore gloves, walked toward the foot of the bed with an empty trash bag, then retrieved the soiled bed linen from the foot of the bed and placed it into the trash bag and returned it to the foot of the bed. CNA D removed his/her gloves, washed his/her hands, then pulled up his/her own pants, that had begun to slide down, using both of his/her hands. He/she then put on a clean pair of gloves. CNA I retrieved the large towel from the sink basin and used the wet end of it to wash the resident's hands. He/she then dried the resident's hands using the dry end of this same large towel. At 5:43 A.M., the resident continued to sit in the chair, in the middle of his/her room and wore a stool-soiled brief. CNA I retrieved another large towel that had been placed in the sink basin, and cleansed the resident's right leg with it. CNA D removed his/her gloves and did not wash his/her hands. He/she touched the resident's doorknob to exit the room and said he/she was going to get a mop. CNA I retrieved an additional towel from out of the sink basin, then requested the resident to stand up. The resident then walked barefooted from the middle of the room, where the chair sat, over to the sink vanity. As the resident faced the sink vanity, CNA I instructed him/her to grasp it with both of his/her hands. CNA I then removed the soiled brief from the resident. He/she used the same large towel retrieved from the sink basin to cleanse the resident's buttocks, wiping front to back. He/she retrieved another towel from the sink basin, then rinsed the resident's buttocks with it. He/she placed another towel directly into the sink basin then poured liquid soap onto it, as the water ran from the faucet. He/she removed his/her gloves then washed his/her hands over the towel that sat in the sink basin and soap and water from his/her hands fell onto this towel. A pink bath basin sat to the right of the sink basin on a shelf above two drawers, not used by staff. He/she applied new gloves then used this same towel that he/she had washed his/her hands over, to cleanse the resident's perineal area. He/she instructed the resident to wash his/her hands at the sink. CNA I removed his/her gloves, washed his/her hands, and then used a paper towel to turn the faucet off. As the resident continued to stand facing the sink vanity, CNA I placed a clean brief on him/her. He/she then put a clean gown on the resident and had him/her sit back down in the foldable chair that was in the middle of the room. He/she grabbed a trash bag and placed it at the foot of the bed. He/she retrieved 2 bags of linen and 1 bag of trash from the foot of the bed, exited the room, and placed them into the appropriate bins that sat out in the hallway. He/she washed his/her hands, applied a new pair of gloves and then raised the resident's bed up. He/she sat the resident's pillow on the bedside table and made the bed, without first cleansing the area of the bed where the soiled linen sat. He/she then assisted the resident to lay back in the bed. He/she lowered the bed, removed his/her gloves, washed his/her hands and then used a paper towel to turn the faucet off. During an interview at this time, CNA I said that he/she preferred to use the sink basin as opposed to a bath basin when providing care to residents because the water in a sink basin gets cold and the residents do not like it. Sitting the towel into the sink basin and allowing the water to run directly onto it allows it to get the heat. He/she is aware doing this is an infection control issue. He/she should not have washed his/her hands over the towel that sat in the sink basin that was used to cleanse the resident. Beds are stripped and disinfected according to the bed schedule that is at the nurse's station. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence on staff for bed mobility, transfers, dressing, personal hygiene and eating; -Diagnoses included: Cachexia (general weight loss occurring during course of chronic disease), progressive neurological condition, high blood pressure, high cholesterol, non-Alzheimer's dementia and anxiety disorder. Review of the resident's electronic care plan, dated 12/17/18, and in use at the time of the survey, showed: -Focus: Resident decline in activities of daily living (ADL) status related to cognition decline and decline in mobility; -Goals: Resident will have all ADL met in the next 90 days; -Interventions: Resident requires total care with dressing, toileting, transfers and personal hygiene. Observation on 9/22/21 at 9:40 A.M., showed CNA G with gloves on, stood at the sink in the resident's room with the water running and towels in the sink. CNA G said he/she was going to start perineal care. CNA G raised the resident's bed and then woke up the resident. CNA G started care by wiping his/her eyes and face with a towel obtained from the sink basin. CNA G got a new towel and put in the sink under the running water then raised up the resident's bed. He/she then woke up the resident and started care by wiping resident's eyes and face. CNA G went back over to sink and got a new towel from the sink basin and put it under the running water and added soap. CNA G then walked over to resident and rolled the resident towards him/her. The resident's gown lifted up with the brief exposed when CNA F knocked and entered the room with a water pitchers. CNA F opened the curtain and left room when CNA G asked him/her to get a sheet for the resident. CNA G rolled the resident onto his/her back and pulled the gown over the resident's head then placed the gown over the resident's chest and stomach. CNA F returned to the resident's room, washed his/her hands, put on new gloves, and assisted CNA G with resident care and used the towels from the sink basin to cleanse the resident's perineal area. CNA G went next to the sink to get a new brief and gown for the resident and put on the resident's gown. CNA F put the dirty bedding in the bag at the end of the bed while CNA G placed a washcloth in the bag. A brown substance was noted on the washcloth, on the top of CNA G's glove and on the outside of the dirty bag. CNA G touched the substance while tying the bag. CNA F told CNA G that he/she needed to change gloves. CNA F removed his/her gloves, washed his/her hands, and took the dirty bags out of the room. CNA G finished tying the bag, removed gloves, washed hands, and applied new gloves. CNA G then removed the soiled brief from the resident and said he/she was going to leave the resident's brief off. CNA F came back into room, washed hands, applied new gloves, and helped CNA G position resident back onto the resident's left side. CNA G covered the resident with a blanket and then opened up the privacy curtain. 3. Review of Resident #29's admission MDS, dated [DATE], showed: -Resident is rarely/never understood; -Independent with bed mobility; -Limited assistance- one person physical assist required for transfers; -Limited assistance required for dressing; -Extensive assistance required for toilet use and personal hygiene; -Occasionally incontinent of urine; -Always incontinent of bowel; -Diagnoses included: Progressive neurological conditions, osteoporosis (thinning and weakening of the bone) and dementia. Review of the resident's electronic care plan, in use at the time of the survey, showed: -Focus: Activity of daily living (ADL) self-care performance deficit: -Goal: Resident will have all needs met; -Interventions: The resident requires one staff participation with bathing. The resident requires one staff participation to reposition and turn in the bed. The resident requires one staff participation to dress. The resident requires one staff participation with personal hygiene. The resident requires assistance, cueing with short, simple instructions such as hold your brush, wash your hands, hand over hand guidance. The resident requires one staff participation to use the toilet. The resident requires one staff participation with transfers. Observation on 9/22/21 at 5:48 A.M., showed the resident sat on the edge of the bed. CNA C washed his/her hands and placed gloves on. He/she then placed a clean hand towel directly into the sink and gathered supplies. The resident wore a brief and shirt as he/she sat on the edge of the bed. CNA C placed a clean brief around the lower half of the resident's legs, followed by pants, non-skid socks and slippers. He/she then assisted the resident to stand and stood behind and slightly to the side of the resident. The resident appeared unsteady and held onto the CNA. CNA C unsecured the resident's urine soiled brief and wiped the resident in a front to back motion while he/she stood behind the resident. While still standing, CNA A pulled up the resident's clean brief and pants, that had already been placed around his/her ankles. CNA C then assisted the resident to sit on the bed. CNA C wore the same gloves used to provide personal care. He/she told the resident to take his/her shirt off. The resident appeared to not understand. CNA C took the resident's left hand with his/her left, soiled gloved hand and assisted the resident to take his/her shirt off. CNA C then assisted the resident to stand. CNA C guided the resident to sit in the wheelchair and then propelled the wheelchair to the sink. CNA C continued to wear the same soiled gloves. He/she grabbed a clean towel and placed it into the sink, removed his/her gloves and without washing his/her hands, handed the resident the towel from the sink and said wash your face. The resident wiped his/her face with the towel from the sink. The resident then brushed his/her hair as CNA C obtained the resident's cloth face mask from the bedside table with his/her unwashed hands and placed the mask on the resident. After assisting the resident with the mask, CNA C washed his/her hands and propelled the resident into the hall. 4. Review of Resident #42's quarterly MDS, dated [DATE], showed: -re-admission date of 8/23/17; -Mental status memory problem; -Short term and long term memory problem; -Moderately impaired cognitively; -Extensive assistance for personal hygiene; -Total dependence for bathing activity; -Active diagnoses included stroke and neurogenic bladder (urinary condition in people who lack bladder control due to a brain, spinal cord or nerve problem). Observation on 9/22/21 at 5:56 A.M., showed CNA D applied clean gloves after he/she provided perineal care. He/she applied barrier cream to resident's buttocks, washed his/her hands and applied new gloves, turned the resident to the opposite side, touched the barrier cream on the resident's buttocks and spread it around. He/she then fastened the resident's incontinence brief. He/she covered the resident with sheets, used the bed remote to lower the bed, and placed call light within the resident's reach without removing his/her soiled gloves. He/she then removed the soiled gloves and touched the television channel buttons without performing hand hygiene. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said proper hand hygiene is to be followed based on the facility's policies and procedures. 5. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said staff should not touch the resident or resident surfaces with gloves that are potentially soiled. Personal care is completed with the use of two bath basins. It is not acceptable to use the sink. Staff should place soiled linen in the resident's sink or directly on the bed. Clean linen should not be placed in the sink, it should be placed in the bath basin. If staff washed their hands in the sink and linen were in the sink, those linen should not be used on the resident. 6. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/21, showed: -Implement source control measures; -Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. 7. Observation on 9/20/21 at 1:13 P.M., showed a housekeeper pushed a covered trash or linen bin down the 300 hall, with gloves on. He/she approached a resident in a wheelchair by the nurse's station, with a cloth facial mask lowered down to his/her chin. The housekeeper then pulled up the mask to cover resident's mouth and nose, and touched the resident's face with his/her soiled gloves on. 8. Review of Resident #10's electronic health record (EHR), showed: -Diagnoses included Alzheimer's disease, heart failure, vitamin D deficiency and and osteoporosis (a disease characterized by weak and brittle bones). -A care plan in use at the time of survey, showed: -Impaired cognitive function/dementia or impaired thought processes; -Potential for activities of daily living decline; -Interventions included redirecting and cueing the resident; -A MDS, dated [DATE], showed: -The resident is rarely/never understood; -Requires limited assistance of one person with dressing and personal hygiene. Observation on 9/22/2021 at 7:38 A.M., showed the activity director in the hallway near the nursing station. She touched the front of her cloth face mask with her right hand to adjust it. She did not wash her hands or use alcohol-based hand sanitizer afterwards. She then approached Resident #10, who sat in a wheelchair in the hallway adjacent from the nursing station and used her hands to position the resident's face mask over his/her nose and mouth. 9. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said if staff touch their mask, they should wash or sanitize their hands before touching a resident's mask. When housekeeping staff are pushing a soiled linen cart down the hall, their gloves would be considered soiled. It would not be acceptable for housekeeping staff to use the same gloved hands to adjust a resident's mask. 10. Observation in the dining room, on 9/21/21 at 5:39 P.M., showed staff served the dinner meal service. Staff passed trays to the residents. A resident, who was served a tray, ask that their sandwich be cut in half. A staff person unrolled the resident's utensils and then used his/her left hand to hold the sandwich in place. Four fingers and the top half of the palm pressed against the resident's sandwich. The staff person had very long, painted finger nails, approximately 1 inch long, and the fingernails touched the sandwich. He/she used the other hand to cut the sandwich with a knife. A second staff person approached the table and told the first staff person that they should be wearing gloves. The first staff person said ok, but finished cutting the sandwich. The resident sat at the table and ate some of the sandwich. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said staff should not touch resident's food with their bare hands. The staff person should have used the knife and fork to cut up the sandwich. 11. Review of the facility's Transfer Techniques policy, dated 4/17/19, showed: -Policy statement: Use of appropriate devices (lifts, belts, draw sheets, etc.) provide a safe means of lifting or transferring residents and, when used properly, protect both the resident and the employee from injury; -Lifts: Use for totally dependent residents or anyone with contractures (tightening of the tendons and joints resulting loss in range of motion), amputations, obesity, etc. Do not attempt to use the lift unless you have been trained and feel comfortable with the procedures; -The policy failed to direct staff when to sanitize the shared mechanical lift (before and/or after) or what is to be used to sanitize the lift. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said they do not have a policy specific to mechanical lifts that show the step by step process. The transfer policy provided is the policy used. Review of the facility's Cleaning Equipment policy, dated 2/3/19, showed: -Policy Statement: The prevention of infection and the spread there of, is of prime importance in a nursing home; -Policy: To ensure good infection and odor control by disinfecting patient care items on a routine basis. Items shared between residents include but are not limited to: Lifts; -Procedure: Between each use: -Use appropriate disinfectant (wipes or spray) according to manufacturer's recommendations; -Allow disinfectant to remain on item for manufacturers recommended contact time. Review of Resident #36's quarterly MDS, dated [DATE], showed: -admission date of 2/17/21; -Severe cognitive impairment; -Total dependence during transfers and personal hygiene; - Active diagnoses included stroke and high blood pressure. Review of the resident's care plan, in use at the time of survey, showed: -Totally dependent on staff for ambulation and locomotion; -Requires (X) staff participation with transfers; -No mentioned of Hoyer lift transfer. Observation on 9/23/21 at 5:43 A.M., showed CNA D placed a Hoyer pad on the resident's bed, and left the room to attend to another resident. He/she returned to the resident's room, performed personal care, and then placed the Hoyer pad underneath the resident. He left the room again, then returned with the Hoyer lift form the other hall. He/she did not wipe or disinfect the lift. He/she asked the Licensed Practical Nurse (LPN) B to assist with the transfer. LPN B did not sanitize his/her hands prior to applying gloves. CNA D did not sanitize his/her hands, and did not wear gloves during the transfer. CNA D did not disinfect the Hoyer lift after use. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said it is expected that shared equipment, such as the Hoyer lift, be cleaned before and/or after use with disinfectant wipes or spray. 12. Review of Resident #2's EHR, showed: -Diagnoses included stroke, depression, dementia, hearing loss, heart disease, insomnia (difficulty sleeping) and Parkinson's disease (a progressive disease of the nervous system that impacts movement); -A care plan in use at the time of survey, showed: -The resident has an ADL self-care performance deficit, limited physical mobility, a communication problem, and impaired thought processes; -Interventions included staff participation with hygiene and oral care, total dependence on staff for dressing and locomotion, ensuring a safe environment, and aiming to assign consistent caregivers to the resident; -A quarterly MDS, dated [DATE], showed: -The resident is rarely/never understood; -Had a memory problem; -Moderately impaired cognition; -Required cues and supervision; -Total dependence on staff for transfers, locomotion, dressing, eating and personal hygiene. Observation on 9/22/21 at approximately 7:40 A.M., showed CNA F used the bristle portion of a white hairbrush to push the faucet handle of a sink shared between two roommates, in order to turn on the faucet. He/she held the handle portion of the hairbrush in his/her hand. Linen sat adjacent to the sink basin, directly on the sink vanity, under the soap dispenser. CNA G, who was also in the room at the time, confirmed that this linen was dirty. CNA F wet the bristle portion of the hairbrush with the water that ran from the faucet, then brushed the resident's hair with it. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said it is reasonable to assume the sink water handles are contaminated. A resident's hair brush should not be used to turn on and off the water. 13. Review of Resident #15's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Independent with walking in the room and corridor; -Independent with locomotion on and off the unit; -Diagnoses included heart failure, kidney disease and diabetes. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Potential for decline in activities; -Goal: Attend activities of choice; -Interventions: Encourage to attend activities/social events of choice, the resident does participate in volunteering at an outside facility at times and really enjoys doing that; -The care plan did not identify the resident was volunteering within the facility or providing services for the facility, or interventions to ensure proper procedures are being followed when providing these services. Observation on 9/22/21 at 10:42 A.M., showed the resident placed towels on tables for the noon meal. He/she removed his/her glasses with his/her bare hands and cleaned his/her glasses with his/her shirt. Then he/she put more towels down, then he/she pulled up his/her pants with his/her bare hands and put more towels down on 2-3 more tables. He/she then took off his/her mask. He/she continued to put towels down on tables. Then he/she picked up sugar packets off of the floor, pushed a chair in and then continued to put more towels on the tables. He/she then pushed in a chair took the remaining towels and put them in to a plastic bag. He/she pushed the cart the whole time with no gloves on nor at any time did he/she wash his/her hands. Then he/she went and straightened more towels and took the cart out of the dining room. During an interview on 9/24/21 at 10:06 A.M., with the DON and administrator, they said when a resident performs services for the facility per their choice, they would expect them to follow the same infection prevention and control procedures as staff, including hand hygiene. The resident has been educated on infection control expectations, but he/she gets his/her feelings hurt when he/she is told he/she is doing something wrong. The resident is fully vaccinated against the COVID-19 virus. They would expect the resident to perform hand hygiene before starting the task and if he/she were to touch something potentially contaminated.

Based on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained when they failed to meet the applicable requirements for obtaining their own labs. The facility failed to follow manufactures directions for quality control check of the blood glucose (sugar) test machines to ensure accurate results. The census was 51. Review of the quality control solution for the blood glucose machine manufacturer's directions, also provided by the facility as the policy for completing quality control checks, titled Performing a Control Solution Test, showed: -You should check your meter and test strips using Assure Prism Control Solution. The control solution ranges are printed on the labels. Compare the results displayed on the meter to the control solution range printed on the vial or box. Before using a new meter or a new vial/box of test strips, you should conduct a control solution test; -Note: Check the expiration dates printed on the bottle. When you first open a control solution bottle, record the discard date (date opened plus 3 months) in the space provided on the label; -You should do a control solution test when using a meter for the first time, when a new vial or test strips is opened, if the meter or test strips do not function properly, if the resident's symptoms are inconsistent with the blood glucose test results, and if the meter is dropped or damaged; -When the control solution is past the expiration date printed on the bottle: Discard the used control solution and repeat the test using a new bottle of control solution. Review of the facility's Centers for Medicare and Medicaid Services (CMS) Clinical Laboratory Improvement Amendments (CLIA) certification of waiver, effective 9/1/20 and expiration 8/31/22, showed: -Laboratory name and address, listed the facility name and address; -The facility Director of Nursing (DON) listed as the laboratory director; -The above named laboratory located at the address shown hereon may accept human specimens for the purpose of performing laboratory examinations or procedures. Review of the www.CMS.gov CLIA regulations and guidance manual, effective 3/3/17, showed: -§493.37 Requirements for a certificate of waiver; -Health and Human Services (HHS) will issue a certificate of waiver to a laboratory only if the laboratory meets the requirements of §493.35; -Laboratories issued a certificate of waiver are subject to the requirements of this subpart and §493.15(e) of subpart A of this part; -Interpretive guidelines: Cite the laboratory's failure to follow manufacturer's instructions. Review of the facility's Resident Matrix, completed by the facility and provided for the current survey, showed 11 residents received insulin injections. Observation of the medication storage room on 9/21/21 at 3:19 P.M., showed all six boxes of Assure Prism control solution (solution used to test the accuracy of the blood glucose machine) labeled with the expiration date of 8/2020. During an interview on 9/22/21 at 7:42 A.M., with the DON and administrator, they said night shift is responsible to perform the quality control check of the blood glucose machines. There is a binder to document the checks. Observation at this time, showed the administrator looked in the medication room and at the nurse's station for the binder and said she was not able to find it. She would have to contact the night shift nurse and will provide the information when they find it. During an interview on 9/22/21 at 8:41 A.M., Licensed Practical Nurse (LPN) A said he/she works day shift and the night shift is responsible to complete the quality control checks of the blood glucose machines. Observation at this time, showed LPN A searched through the nurses cart, which contained the blood glucose machines, and said there was no control solution in the cart. During an interview on 9/23/21 at 4:55 A.M., LPN B said he/she documents the quality control check on a log, but the log has been misplaced. Observation at this time, showed LPN I entered the medication room and came out with a vial of low and high quality control solution and said this is the solution he/she had as been using to perform the quality control blood glucose machine checks. Observation of the solution vials, showed an expiration date of 8/27/20. LPN B said medical records might have the quality control check binder. They come in on the day shift. Review of the blood glucose control solution quality control log, provided by the facility, showed six boxes of Assure Prism control solution with expiration dates of 8/27/22. On 9/23/21 at 10:24 A.M., when asked for the location of these boxes with the expiration dates that conflicted with the expiration dates in the medication room, the DON said the facility was unable to produce the control solution boxes in question. During an interview on 9/24/21 at 10:04 A.M. the administrator said she would expect all documentation of medication quality control checks to be accurate.