**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from misappropriation (unauthorized, improper, or unlawful use of funds or other property) when staff misappropriated $90.00 of the resident's money from his/her personal account and without the resident's consent (Resident #8). The census was 84.Review of the facility's Abuse Prevention Plan policy, copyright 2017, showed: -3. Training of Employees, Contract Staff, and Volunteers: Training will be provided to all new and existing employees, contract employees, and volunteers through orientation and annual training programs related to effective communication, dementia management and abuse prevention, freedom from abuse, neglect, and exploitation. This includes training and orientation to resident needs for agency staff. Nurse's aides are required to have 12 hours of training annually. These programs include topics required by 42 C.F.R. S 483.95, including, but not limited to, the following: -a. Definitions of abuse, neglect, and financial exploitation; -b. Providing protection for residents involved in incidents of abuse, neglect, misappropriation of resident property and/or financial exploitation; -e. Annual training on state and federal abuse prevention and reporting requirements, e.g., the Resident's [NAME] of Rights, Elder Justice Act, and state-specific laws;-4. Prevention of Abuse, Neglect, Misappropriation of Resident Property, and Financial Exploitation: In order to prevent abuse, neglect, misappropriation of resident property, and financial exploitation, the facility shall do the following: -a. Identify, correct, and intervene in situations where abuse, neglect, misappropriation of resident property, and/or financial exploitation occurs; -d. Encourage residents and families to report concerns, incidents, and grievances to appropriate staff. Residents and resident representative will be informed of reporting procedures through Resident Council, Family Council, and upon admission; -e. Require staff to report concerns, incidents, and grievances immediately to their supervisor. Ensure concerns, incidents, and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrence;-5. Abuse Prevention Plans: -a. The facility will develop an individual abuse prevention plan for each vulnerable adult who receives services in the facility; -b. The plan shall contain an individual assessment of: -The resident's susceptibility to abuse, neglect, and financial exploitation by other individuals, including other vulnerable adults; -Specific measures to be taken to minimize the risk of abuse, neglect, and financial exploitation of residents and other vulnerable adults;-6. Identification of possible incidents which need investigation: -c. Any allegations involving abuse, neglect, misappropriation of resident property and/or financial exploitation will be investigated; -e. Events may include, but are not limited to, staff to resident physical abuse, staff to resident verbal abuse, resident to resident altercations (a resident to resident altercation is an incident involving a resident who willfully inflicts injury upon another resident. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm), misappropriation of a resident's funds, property or personal effects, etc. This list is not intended to be exhaustive and the facility will review any potential incident for conduct that meets the definitions of abuse, neglect, misappropriation of resident property, or financial exploitation; -f. Report within the timelines of the guidance: -Staff will notify the facility charge of building immediately of any reports of possible abuse, neglect, misappropriation of resident property, and/or financial exploitation. The charge of building will immediately notify the Administrator, Director of Nursing (DON), and Director of Social Services (DSS);-7. Investigation of Incidents and Allegations: -a. All accidents and incidents as well as allegations of abuse, neglect, misappropriation of resident property, and/or financial exploitation will be thoroughly investigated by DSS, DON, or their appropriate designees; -e. Identify and interview all who might have knowledge of the incident including the alleged victim, perpetrator, witnesses or others who may have had related contact with the alleged perpetrator, related to the incident in question; -f. The focus of the investigation is to determine the extent, cause and future prevention with thorough documentation of the investigative process completed;-9. Reporting of suspected resident abuse and/or neglect: -a. Staff will notify the facility charge of building immediately of any reports of possible abuse, neglect, misappropriation of resident property, and/or financial exploitation. The charge of building will immediately notify the Executive Director (ED) or designee in the ED's Absence; -b. The community is responsible for reporting suspected abuse, neglect, misappropriation of resident property, and/or financial exploitation in accordance with legal requirements. If the event that caused the suspicion involves abuse or results in serious bodily injury, the individual is required to report the suspicion immediately, but not later than two hours after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report no later than 24 hours after forming the suspicion; -h. The facility will not retaliate against an individual who notifies or reports a suspicion of abuse, neglect, misappropriation of resident property and/or financial exploitation in good faith. The facility must post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if they believe the facility has retaliated against an employee or individual who reported a suspected crime and how to file such a complaint;-Definitions: - Misappropriation of resident property: The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent; - Vulnerable Adult: Any person [AGE] years of age or older who is a client, tenant, or resident of the facility or is otherwise receiving care from the facility (collectively resident);- Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of Resident #8's medical record, showed:-Cognitively intact;-Diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD, lung conditions that cause breathing difficulties and airflow obstruction), shortness of breath (SOB), high blood pressure, and muscle weakness. Review of Certified Nurse Aide (CNA) K's Employee information sheet, showed: -Date of hire: 2/10/25;-Emergency contact(s) (EC): -Name: CNA K's EC; -Address: Same address listed as CNA K's address; -Relation: Son. Review of the resident's debit card transactions, dated 7/19/25 through 7/20/25, showed: -7/19/25, 7:14 P.M., Blitz - Win Cash New Approved [NAME] (mobile application that allows users to play skill-based games and potentially win cash prizes), $8.00, approved;-7/19/25, 11:11 P.M., Imo's [NAME] St. Louis 31, $55.55, approved;-7/20/25, 12:44 P.M., Cash App CNA K, $40.00, approved;-7/20/25, 1:18 P.M., Door dash NEWYORKGR 1, $12.22, approved;-7/20/25, 1:26 P.M., Cash App CNA K, $50.00, approved;-7/20/25, 1:32 P.M., Go Puff LIC (offers rapid delivery of everyday essentials, including groceries, home products, over-the-counter medications, and alcohol in St. Louis), $57.83, declined; -Charge attempted four times (at same time as listed above) all four times all were declined;-7/20/25, 1:33 P.M., Go Puff LIC, $43.43, declined; -Charge attempted four times (at same time as listed above) all four times all were declined;-7/20/25, 1:34 P.M., Go Puff LIC, $36.10, declined; -Charge attempted four times (at same time as listed above) all four times all were declined;-7/20/25, 1:51 P.M., Cash App CNA K's Emergency Contact (EC), $20.00, declined. Review of a text message from CNA K sent to the Assistant Executive Director (AED), dated 7/21/25 at 2:06 P.M., showed:-To whom it may concern: CNA K has been in this line of work since 2009. Never has CNA K took anything from a resident. CNA K never entered a residents room without the resident being there. CNA K takes pride in his/her work. (He/She) is upset at the fact that someone will tarnish (his/her) character in such a way. CNA K gives his/her all when caring for the resident's. This is his/her passion CNA K loves what he/she does. CNA K's name listed and his/her phone number. Review of facility's corrective action form, dated 7/21/25, showed:-Employee Name: CNA K;-Job title; CNA;-Summary of incident and/or behavior: CNA K has been suspended pending an investigation into allegations of stealing resident credit cards and financial information. He/She is accused of the following: -Stealing residents' financial information from their room; -Using that information to make unauthorized purchases; -Transferring funds to his/her personal CashApp account;CNA K's name was found on the resident's financial records, supporting the allegations. Additionally, local authorities have been contacted, and criminal charges have been filed;-Expectations and performance plan: -Any form of financial theft, or misuse of resident or funds is strictly prohibited and will result in immediate disciplinary action, up to and including termination and legal prosecution;-Action being taken: Suspension. Review of the facility's corrective action form, dated 7/21/25, showed:-Employee Name: CNA K;-Job title; CNA;-Summary of incident and/or behavior: Following a thorough investigation into allegations of financial abuse, we have determined that CNA K will be held responsible for multiple serious violations, including: -Accessing residents' financial information without authorization; -Making unauthorized purchases using resident credit cards; -Transferring money to her personal CashApp account; -Forging signatures on credit card transactions;-Due to the severity of these actions and the breach of trust involved, we are seeking immediate termination. Additionally, local authorities have been contacted, and criminal charges have been filed;-Action being taken: Termination. Review of a resident interview completed by the facility on 7/22/25, showed: -Resident said he/she did not witness anyone taking his/her debit card out. Resident said it was always kept in the drawer of the nightstand next to his/her bed. Review of the facility's investigation, dated 7/22/25, showed: -AED spoke with Police Officer (PO) L. PO L said he/she spoke with CNA K. PO L said he/she looked through CNA K's cell phone and could not find anything on it. PO L thinks CNA K might have gone in and cleared the items off of his/her phone since he/she was called and asked questions about the debit card by the facility. PO L is working on getting statements from the bank at this time. Review of the facility's investigation, dated 7/25/25, showed:-It was reported on 7/21/25 around 1:00 P.M. that resident's debit card was used to make purchases that he/she did not approve. The resident's spouse brought in the bank statements. After looking at the bank statements the AED noticed one of the facility's employee's names on it. The employee, CNA K works evenings as a CNA. CNA K has consistently had the assignment that the resident resides on. On the bank statement it shows that someone was trying to send CNA K $40.00 through cash app (mobile payment service that allows users to send, receive, and manage money digitally). CNA K was immediately suspended pending investigation, and the police were called to come take a police report. Two police officers came out and took report from the facility and spoke with the resident and his/her spouse obtaining their statements. CNA K's name, phone number, address and date of birth were provided to police. Police took a copy of the bank statement for their investigation and provided the report number. After the police left that same day, they called and left a voice mail that they will call back in 10 minutes since AED did not answer the phone. They did not call back. AED ended up calling them the next day. PO L informed AED that they went to CNA K's house and spoke with him/her. He/She showed them his/her phone and they did not see anything. PO L said he/she thinks CNA K might have cleared it since the facility called him/her to ask him/her about it and get his/her statement. The PO L said CNA K has not been arrested but they will get information from the bank. PO L said they will be in touch. I had social services go and talk with the resident to get his/her statement along with other residents to see if they noticed anything missing. All the other residents stated they were not missing anything. The resident said he/she kept his/her debit card in the top drawer. He/She never asked any of the staff to take it out for him/her. He/She thought her spouse was the only one that was aware of where it was located. Even though the police have not provided any further information, given the bank statement showing CNA K's name, we have requested approval for termination form the Human Resources (HR) department. During an interview on 7/29/25 at 1:18 P.M., CNA K said he/she has been a CNA since 2009. CNA K confirmed his/her home address and email address. He/She worked evening shifts for the facility from 3:00 P.M. until 11:00 P.M. CNA K denied having a door dash app, cash app, blitz app, and using the go puff app. CNA K said he/she does not use go puff, he/she only uses online shopping like Walmart, Macy's and target and he/she uses his/her own debit card. CNA K denied knowing the name that was listed first on his/her emergency contact list. CNA K said when the police officers came to his/her house, they looked through his/her phone and did not find anything on his/her phone related to the charges. During an interview on 8/8/25 at 12:00 P.M., PO M said he/she went to CNA K's house and interviewed him/her. CNA K admitted knowing CNA K'S EC who was listed on the bank statement for a $20.00 cash app charge that was declined. CNA K said someone was setting him/her up. CNA K allowed PO M to look through his/her phone on the cash app and nothing was there. PO M said CNA K had advanced noticed that PO M would be out to speak with him/her and he/she probably cleared it out of his/her phone before PO M arrived. PO M is in the process of getting more detailed information from the bank regarding the charges and will be issuing subpoenas for the other unauthorized charges that were made on the resident's debit card. During an interview on 7/28/25 at 1:41 P.M., the Executive Director (ED), AED, and the Interim Director of Nursing (IDON) said they expected staff to be knowledgeable of and follow the facility policies. They expected staff to never use any resident credit or debit card even if the resident where to ask. 2567421

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided met professional standards of practice when facility staff failed to administer physician ordered medications for three residents (Resident #1, Resident #2 and Resident #6) and failed to notify the physician and resident representative (RR) that the medications were not administered. The facility failed to follow parameters in the physician orders for one resident (Resident #5) and administered medications outside of the parameters and did not notify the physician or RR when medication was administered outside the set parameters. The census was 84.Review of the facility's physician services policy, copyright 2022, showed:-Policy: It is the policy of the facility to provide care and services related to Physician Services in accordance with State and Federal regulation;-Procedure: 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift. Review of the facility's physician services policy, copyright 2020, showed:-Policy: To administer resident medications in a safe and accurate manner that will ensure the 6 rights of patient identification for administration;-Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider;-Procedure:-1. Medications are administered by licensed nurses or as otherwise delegated, trained associates;-2. Medications are administered in accordance with the orders;-3. Medications are administered within their prescribed time;-4. The person preparing or administering the medication will contact the provider if there are questions or concerns regarding medication;-5. With any irregularities, appropriate notifications will be completed for clarification;-7. Obtain vitals as ordered with medication administration prior to administering the medications.-10. Administer medications following the 6 Rights of medication administration: -a. Right Resident; -b. Right Medication; -c. Right Dose; -d. Right Time; -e. Right Route; -f. Right Documentation;-11. Sign medication out in electronic record/Medication Administration Record (MAR) at time of medication administration. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/2/25, showed the following:-Cognitively intact;-Rejection of care not exhibited;-Upper and lower extremity impairment on both sides;-Intermittent catheterization (procedure where a flexible tube (catheter) is inserted into the bladder to drain urine); -Always incontinent of bowel and bladder;-Antibiotic (ABT) not marked as taking or indication noted;-Diagnoses included burns involving 50-59 percent (%) of body surface with 40-49% third degree burns (involves all of the layers of skin and sometimes the fat and muscle tissue under the skin), acquired absence of right leg above knee, acquired absence of left leg above knee, dependence on renal (kidney) dialysis (removes waste products and excess fluid from the blood when the kidneys can no longer perform this function adequately), osteomyelitis (a bone infection) of vertebra (individual bones of the spine), sacral (sacrum, the bony structure at the base of the spine) and the coccyx (known as the tailbone or the base of the spine) and sacrococcygeal region (the region of the body located between the sacrum, anuria (complete absence of urine production) and oliguria (decreased urine production) and weakness. Review of the resident's care plan, during the survey, showed:-Problem: Infection, created 6/16/25;-Goal: Resident will not develop newly acquired multidrug resistant organism (MDRO, infection that is resistant to many ABT), resident will not develop signs or symptoms of acute (condition that develops suddenly and lasts for a limited time that usually lasts less than six months) infection, created 6/16/25;-Approach: -Monitor for signs and symptoms of infection, created 6/16/25; -Notify physician or nurse practitioner (NP) as needed for signs and symptoms of active infection, created 6/16/25;-Problem: Indwelling catheter (a flexible tube inserted into the bladder to drain urine), resident requires bladder scans every six hours and required straight catheter if greater than 300 milliliters (mls) is detected, edited 6/9/25; -Goal: Resident will have a catheter care managed appropriately as evidenced by not exhibiting signs of infection or ureteral (the ureters, which are two narrow tubes that carry urine from the kidneys to the bladder) trauma, edited 6/9/25;-Approach: Bladder scans as ordered per physician every six hours, 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., created 6/9/25;-Problem: Medication, resident has the potential for discomfort and side effects related to the use of ABT for the diagnosis of active wound infection, edited 6/9/25;-Goal: Resident will be free of any discomfort or adverse side effects, edited 6/9/25;-Approach: -Administer medications as ordered, created 5/29/25; -Monitor for adverse consequences, created 5/29/25; -Observe for possible side effects every shift, created 5/29/25. Review of the resident's MAR and progress notes, dated 5/27/25 through 6/23/25, showed: -Ondansetron (medication used to prevent nausea and vomiting) 4 mg disintegrating tablet (ok to use regular tablets) every 12 hours, start date 5/28/25, discontinue (DC) date 7/14/25; -5/29/25, Not administrated: Drug item unavailable;-Tamsulosin (Flomax, treats symptoms of benign prostatic hyperplasia (BPH), also known as an enlarged prostate) 0.4 mg capsule at bedtime, start date 5/28/25, DC date 5/31/25; -5/29/25, Not Administered: Drug item unavailable;-Renvela (sevelamer carbonate, medication used to control high blood phosphorus levels for individuals with chronic kidney disease (CKD) and are on dialysis) powder in packet; 0.8 gram (gm) three times a day, start date 5/28/25, discontinue date 7/14/25; -5/30/25 at 9:00 A.M., Not administered: Drug item unavailable, Comment: waiting on order;-Progress note dated 5/30/25 at 12:58 P.M., Dialysis center contacted and Renvela ordered. Awaiting approval per nurse;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -5/30/25, 1:00 P.M., Not administered: On hold, Comment: On order; -5/30/25, 5:00 P.M., Not administered: Drug item unavailable; -5/31/25, 9:00 A.M., Not administered: Drug item unavailable; -5/31/25, 1:00 P.M., Not administered: Drug item unavailable; -5/31/25, 5:00 P.M., Not administered: Drug item unavailable; -6/1/25, 9:00 A.M., Not administered: Drug item unavailable; -6/1/25, 1:00 P.M., Not administered: Drug item unavailable; -6/1/25, 5:00 P.M., Not administered: Drug item unavailable; -6/2/25, 9:00 A.M., Not administered: Drug item unavailable; -6/2/25, 1:00 P.M., Not administered: Drug item unavailable; -6/2/25, 5:00 P.M., Not administered: Drug item unavailable;-Progress note, dated 6/3/25 at 12:39 P.M., NP D notified in regards to missed medication administration. Follow up with dialysis regarding missing medication Renvela;-Progress note, dated 6/3/25 at 12:57 P.M., Spoke to nurse at dialysis center. Stated medication will be sent with resident upon arrival. Will place an order in the system for nursing to follow up with dialysis if no medications are received by Monday;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/3/25, 1:00 P.M., Not administered: Drug item unavailable; -6/3/25, 5:00 P.M., Not administered: Drug item unavailable; -6/4/25, 9:00 A.M., Not administered: Drug item unavailable, Comment: Waiting for delivery from dialysis; -6/4/25, 1:00 P.M., Not administered: Drug item unavailable, Comment: Waiting for delivery from dialysis; -6/4/25, 5:00 P.M., Not administered: Drug item unavailable, Comment: Waiting for delivery from dialysis; -6/5/25, 9:00 A.M., Not administered: Other, Comment: Waiting for new order (NO); -6/5/25, 1:00 P.M., Not administered: Other, Comment: New admit; -6/5/25, 5:00 P.M., Not administered: Other, Comment: New admit; -6/6/25, 9:00 A.M., Not administered: Other, Comment: Giving at dialysis; -6/6/25, 1:00 P.M., Not administered: Other, Comment: Giving at dialysis; -6/6/25, 5:00 P.M., Not administered: Other, Comment: Giving at dialysis; -6/9/25, 9:00 A.M., Not administered: Other, Comment: On order; -6/9/25, 1:00 A.M., Not administered: Resident unavailable; -6/11/25, 9:00 A.M., Not administered: Drug item unavailable; -6/11/25, 1:00 P.M., Not administered: Drug item unavailable; -6/11/25, 5:00 P.M., Not administered: Drug item unavailable; -6/12/25, 9:00 A.M., Not administered: Other, Comment: Not available in automated dispensing unit (ADU, computerized cabinets or machines that store and dispense medications within the facility), nurse made aware, and pharmacy; -6/12/25, 1:00 P.M., Not administered: Other, Comment: Pharmacy called to send out medication; -6/12/25, 5:00 P.M., Not administered: Other, Comment: Pharmacy called to send out medication;-Renal Vitamin (vitamin supplement formulated to address the unique nutritional needs of individuals with chronic kidney disease (CKD) especially those undergoing dialysis (treatment that helps people whose kidneys are failing to remove waste products and excess fluid from the blood)) 0.8 mg tablet once a day, start date 5/28/25, DC 7/14/25; -6/13/25, Not Administered: Drug item unavailable;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/13/25, 9:00 A.M., Not administered: Drug item unavailable; -6/13/25, 1:00 P.M., Not administered: Drug item unavailable;-Progress note, dated 6/13/25, 2:27 P.M., Resident visited by physician, NO for one time order for potassium chloride (used to prevent or treat low levels of potassium) 20 milliequivalent (mEq);-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/13/25, 5:00 P.M., Not administered: Drug item unavailable; -6/14/25, 9:00 A.M., Not administered: Drug item unavailable; -6/14/25, 1:00 P.M., Not administered: Drug item unavailable;-Potassium chloride 20 mEq tablet extended release (ER), start date 6/14/25, DC date 6/14/25; -6/14/25, Not administrated: Drug item unavailable;-6/14/25, 3:28 P.M., Resident complained of shortness of breath (SOB). Oxygen saturation (Sp02, measures amount of oxygen in the blood, normal SpO2 is between 90 and 100%) would drop to 89% then recover at 94% instantly. Resident placed on two liters (l) of oxygen which improved resident symptoms. Lung sounds clear. Physician NO for chest radiographs (x-ray);-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/15/25, 9:00 A.M., Not administered: Drug item unavailable; -6/15/25, 1:00 P.M., Not administered: Drug item unavailable;-Progress note, dated 6/15/25, 3:33 P.M., Resident had abnormal lab reported. NO for Levaquin 500 mg now. Levaquin 250 mg daily for six days, on coming nurse aware;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/15/25, 5:00 P.M., Not administered: Drug item unavailable; -6/16/25, 9:00 A.M., Not administered: Drug item unavailable; -6/16/25, 1:00 P.M., Not administered: Drug item unavailable; -6/16/25, 5:00 P.M., Not administered: Drug item unavailable; -6/17/25, 9:00 A.M., Not administered: Drug item unavailable, Comment: Waiting on pharmacy; -6/17/25, 1:00 P.M., Not administered: Drug item unavailable; -6/17/25, 5:00 P.M., Not administered: Drug item unavailable;-Progress note, dated 6/17/25, 6:11 P.M., Levaquin (Levofloxacin, broad-spectrum ABT) order updated to be administered in the evening due to resident having dialysis during the day;-Levaquin 250 mg daily for six days, start date 6/18/25, DC date 6/20/25; -6/18/25, Not administrated: Drug item unavailable, Comment: No more in emergency medication kit (e-kit, supply of medications maintained within the facility to address medical needs of residents when standard pharmacy services are not immediately accessible);-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/18/25, 9:00 A.M., Not administered: Drug item unavailable; -6/18/25, 1:00 P.M., Not administered: Resident unavailable, Comment: Dialysis;-Progress note, dated 6/18/25, 2:23 P.M., Called dialysis to check on status of Renvela medication. Spoke to nurse will call back to verify if order has been received by dialysis. Will implement a generic order to follow up within 48 hours for completion;-Progress note, dated 6/18/25, 4:25 P.M., Dialysis returned call back at 3:36 P.M., spoke to nurse, stated the medication Renvela is not covered by the dialysis center. Nurse stated that the pharmacy the resident uses at the facility will have to supply this medication. Order was faxed to the pharmacy at this time;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/18/25, 5:00 P.M., Not administered: Drug item unavailable, Comment: Call out to dialysis client; -6/19/25, 9:00 A.M., Not administered: Drug item unavailable, Comment: Dialysis will provide;-Progress note, dated 6/19/25, 10:31 A.M., Follow up Renvela to confirm if medication can be delivered. Pharmacy stated if dialysis doesn't deliver the medication the facility must cover the cost. Requesting pharmacy to send a copy of the documentation to get an approval;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/19/25, 1:00 P.M., Not administered: Drug item unavailable, Comment: Dialysis will provide; -6/19/25, 5:00 P.M., Not administered: Drug item unavailable;-Levaquin 250 mg daily for six days, start date 6/18/25, DC date 6/20/25; -6/19/25, Not administrated: Drug item unavailable;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/19/25, 1:00 P.M., Not administered: Drug item unavailable, Comment: Dialysis will provide; -6/19/25, 5:00 P.M., Not administered: Drug item unavailable; -6/20/25, 9:00 A.M., Not administered: Drug item unavailable, Comment: Giving at dialysis; -6/20/25, 1:00 P.M., Not administered: Resident unavailable;-Progress note, dated 6/20/25, 2:22 P.M., Physician present NO for two view chest x-ray in seven days to evaluate right lower lobe pneumonia;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/20/25, 5:00 P.M., Not administered: Drug item unavailable;-Levaquin 250 mg once an evening for six days, start date 6/20/25, DC date 6/22/25; -6/20/25, Not administered, Other: New order;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/21/25, 9:00 A.M., Not administered: Drug item unavailable; -6/21/25, 1:00 P.M., Not administered: Drug item unavailable; -6/21/25, 5:00 P.M., Not administered: Drug item unavailable;-Levaquin 250 mg once an evening for six days, start date 6/20/25, DC date 6/22/25; -6/21/25, Not administrated: Drug item unavailable;-Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/22/25, 9:00 A.M., Not administered: Drug item unavailable; -6/22/25, 1:00 P.M., Not administered: Drug item unavailable; -6/22/25, 5:00 P.M., Not administered: Drug item unavailable;-Levaquin 250 mg once an evening for six days, start date 6/20/25, DC date 6/22/25; -6/22/25, Not administrated: Drug item unavailable; -Renvela powder in packet; 0.8 gm three times a day, start date 5/28/25, DC date 7/14/25; -6/23/25, 9:00 A.M., Not administered: Drug item unavailable;-Progress note, dated 6/23/25, 10:32 A.M., NP D called this A.M. and stated that resident will need to be sent out due to not receiving dose of ABT that was scheduled. RR notified that resident is being sent out. Emergency Medical Services (EMS) just arrived and resident is stable upon discharged . Review of the resident's Treatment Administration Record (TAR) and progress notes, showed: -Bladder scan and straight catheter if urine exceeds 300 cubic centimeter (cc) every 6 hours, start date 5/29/25, DC date 6/3/25; -5/29/25, 12:00 P.M., Not administered: Drug item unavailable; -5/29/25, 6:00 P.M., Not administered: Drug item unavailable; -5/30/25, 6:00 A.M., Not administered: Drug item unavailable; -5/30/25, 12:00 P.M., Not administered: Resident unavailable, Comment: Dialysis; -5/31/25, 12:00 A.M., Not administered: Other, Comment: Bladder scanner unavailable; -5/31/25, 6:00 A.M., Not administered: Other, Comment: Scan not unavailable; -5/31/25, 12:00 P.M., Not administered: Other, Comment: Bladder scanner unavailable; -5/31/25, 6:00 P.M., Not administered: Other, Comment: Resident urinating; -6/1/25, 12:00 A.M., Not administered: Other, Comment: Unable to complete; -6/1/25, 6:00 A.M., Not administered: Other, Comment: Unable to complete; -6/1/25, 12:00 P.M., Not administered: Drug item unavailable; -6/1/25, 6:00 P.M., Not administered: Drug item unavailable; -6/2/25, 12:00 A.M., Not administered: Drug item unavailable; -6/2/25, 12:00 P.M., Not administered: Resident unavailable; -6/2/25, 6:00 P.M., Urine: None; -6/3/25, 12:00 A.M., Not administered: Other, Comment: Night shift nurse unable to complete; -6/3/25, 6:00 A.M., Not administered: Other, Comment: Night shift nurse unable to complete; -6/3/25, 12:00 P.M., Not administered: Other, Comment: Bladder scanner unavailable.-Progress note dated -6/3/25, 12:39 P.M., NO for straight catheter every shift;-Progress note dated 6/3/25, 12:41 P.M., New order from NP D in place. Straight catheter every shift, discontinue (d/c) bladder scan. During an interview on 7/15/25 at 10:30 A.M., Certified Medication Technician (CMT) C said he/she remembered passing medication to the resident. CMT C said if any medication were not available on the medication cart, they would ask the nurse to pull the medication from the ADU. The nurse contacts the pharmacy if a medication is not available. During an interview on 7/15/25 at 11:48 A.M., NP D said the resident was started on Levaquin on 6/15/25 for pneumonia. NP D saw the resident on 6/17/25 and the resident was still on oxygen and had two doses of ABT at that point. NP D was not notified by the facility that the resident did not receive any more doses of the ABT after the first two initial doses. The RR called NP D and was upset because the resident had not received the ABT since 6/16/25. On 6/20/25, the resident still had not received the ABT that was ordered. If the facility would have notified NP D or the physician, they could have escalated the problem and brought it to management's attention. The physician was at the facility on 6/18/25 and nobody at the facility reported the resident not receiving the ABT to the physician. The physician could have changed the ABT on 6/18/25 if he/she would have been made aware of the facility not having the ABT. On 6/19/25 in late in the evening, they were notified by the RR that the resident still had not received the ABT. The physician looked at the resident on 6/20/25 and the resident looked clinically alright, and the physician reordered the ABT for 6 days and the nurse told the physician they would receive the ABT on 6/20/25. On 6/23/25, the RR called and reported the resident did not receive the ABT all weekend. NP D spoke to the physician, and they decided to have the resident sent out. They did not want to take the chance of the resident deteriorating. NP D did not know the facility didn't have the bladder scanner anymore. Apparently it went missing from the facility. The order was changed after she was notified the facility did not have the bladder scanner anymore. The order was updated to monitor output every eight hours and to straight catheter if there was no urine output. NP D was aware the resident missed a day or two of Renvela. She was not aware the facility never had the Renvela. NP D said Renvela is a phosphate binder and the resident's phosphate was alright when she reviewed his/her labs. NP D expected to be updated in real time when a medication was not available. During an interview on 7/21/25 at 12:44 P.M., Clinical Manager (CM) F said staff did not report the resident did not have his/her ABT as ordered. CM F was also not made aware of the resident not receiving the one-time order for potassium chloride. The potassium chloride would have been important because a one-time dose is usually due to labs being off. During an interview on 7/22/25 at 12:35 P.M., CMT E said he/she remembers the resident having an order for Levaquin. He/She said the RR asked him/her one evening about the ABT. CMT E looked in the cart and did not see it in the cart and told the RR it was not in the cart. The RR was upset and spoke to the nurse. CMT E said the nurse said the ABT was on the nurses' MAR and the nurse would move the ABT over to the CMT's MAR. CMT E checked the ADU for the ABT and the ADU did not have the ABT. CMT E said the ABT disappeared off his/her MAR again after that. CMT E said sometimes medications are placed onto the nurses' MAR if they have problems and want to make sure it is administered. 2. Review of Resident #2's medical record, showed: -admission: [DATE];-discharge: [DATE];-Severe cognitive impairment;-Diagnoses included Parkinsonism (collection of symptoms that resemble Parkinson's disease, including tremors, stiffness, and slow movement), muscle weakness, type two diabetes mellitus with diabetic chronic kidney disease and retention of urine. Review of the resident's MAR and progress notes, dated 7/5/25 through 7/7/25, showed: -Amlodipine (treats high blood pressure and chest pain) 5 mg once a day, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Glimepiride (medication used to manage blood sugar (BS) levels in individuals with type two diabetes) 1 mg daily at breakfast, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Meclizine (prevent and treat nausea, vomiting, and dizziness) 25 mg daily with breakfast, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Pioglitazone (used to treat type two diabetes) 30 mg daily at breakfast, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Quinapril (treats high blood pressure) 40 mg daily, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Provigil (used to improve wakefulness) 200 mg once a day, start date 7/5/25, no end date; -7/6/25, Not administrated: Drug item unavailable;-Sodium bicarbonate (antacid) over the counter (OTC) 650 mg three times daily, start date 7/5/25, no end date; -7/6/25, 9:00 A.M., Not administrated: Drug item unavailable;-Rivastigmine tartrate (treats mild to moderate dementia) 4.5 mg mouth two times daily, start date 7/5/25, no end date; -7/6/25, A.M. medication pass (6:00 A.M. to 10:30 A.M.), Not administrated: Drug item unavailable;-BS check (80-130 mg per (/) deciliter (dl) before meals and less than 180 mg/dL two hours after meals) three times a day, start date 7/5/25, no end date; -7/6/25, 7:30 A.M., 119 mg/dl; -7/6/25, 11:30 A.M., 114 mg/dl; -7/6/25, 4:30 P.M., 152 mg/dl;-Rivastigmine tartrate 4.5 mg mouth two times daily, start date 7/5/25, no end date; -7/6/25, P.M. medication pass (3:00 P.M. to 7:30 P.M.), Not administrated: Drug item unavailable;-BS check three times a day, start date 7/5/25, no end date; -7/7/25, 7:30 A.M., 229 mg/dl; -7/7/25, 11:30 A.M., 439 mg/dl; -7/7/25, 4:30 P.M., 476 mg/dl;-Progress note 7/7/25 at 6:24 P.M., BS 475 mg/dl. Vital signs Blood pressure (BP, read in milliliters of mercury (mmHg) when referring to Systolic (SBP, top number, normal is below 140), diastolic (DBP, bottom number, normal is below 90) 88/54, respirations (R, breaths per minute, normal is 12 - 18) 18, Pulse rate (PR, heart beats per minute (BPM), normal range 60 - 100) 52, temperature, (T, normal 98.6 degrees Fahrenheit (F)) 97.0 F. Resident slow to response to question and having some tremor. Physician notified of change N.O. send to emergency department (ED) for evaluation and treatment. Family notified and requested local ambulance, explained the only way to get the local ambulance was to call 911. Family states they did not care and requested nurse to call 911. Local ambulance arrived at 6:15 P.M. and resident transferred to local hospital ED. Review of the EMS run sheet, dated 7/7/25, showed: -Primary impression: diabetic hyperglycemia (high BS);-6:20 P.M., BP 101/51, PR 66, R 14, Sp02 98% on room air;-6:21 P.M., BP 114/52, PR 61, R 16, Sp02 87%, BS 551;-6:25 P.M., BP 99/49, PR 64, R 14, Sp01 85%;-6:28 P.M., BP 118/63, PR 65, R 19, Sp02 94%;-6:33 P.M., BP 113/64, PR 63, R 21, Sp02 91%;-6:38 P.M., BP 128/53, PR 73, R 17, Sp02 94%;-6:43 P.M., BP 128/64, PR 78, R 15, Sp02 98%;-Dispatched for sick case: Upon arrival, resident sitting in in wheelchair, resident is alert to person and place which is baseline per RR. Licensed Practical Nurse (LPN) G reported he/she got multiple hypotensive (low BP) readings. Resident is also a diabetic and resident's BS readings are hyperglycemic. Resident's skin feels clammy. Resident denies chest pain, shortness of breath (SOB), abdominal pain, nausea or vomiting. Resident is a two person lift onto EMS stretcher. Resident's BP is no longer reading hypotension, but BS is still reading hyperglycemic (high blood sugar (BS)). Resident transferred to hospital ED. During an interview on 7/22/25 at 9:50 A.M., NP D said if a resident has an order to check BS readings three times a day, the nurses should report high BS readings above 350 mg/dl if on oral medication for diabetes and should report low BS readings below 70 mg/dl. NP D said it was not reported that the resident did not receive medication, including the oral diabetic medication, on 7/6/25. NP D said the BS readings from 7/7/25 at 7:30 A.M., 229 mg/dl and 11:30 A.M., 439 mg/dl were not reported to her or the on-call physician. NP D said the first call regarding the resident was when the nurse reported, BS 497, Sp02 85-88 on room air, BP 88/44, P 94, and the nurse said the resident was lethargic, his/her skin was cold and clammy, the resident was alert to self, and this was the baseline and the resident had a poor oral intake and output. The nurse was instructed to send the resident to the hospital. During an interview on 7/23/25 at 12:32 P.M., LPN H said nurses are responsible for taking residents' BS and administering insulin. LPN H said a high BS that he/she would contact the physician would be anything above 160 mg/dl and a low BS that he/she would contact the physician would be anything below 60 mg/dl. LPN H worked on 7/7/25 day shift (6:45 A.M. to 3:00 P.M.). LPN H said he/she did not remember the resident. LPN H said the BS reading of 229 mg/dl that was documented as obtained by LPN H at 8:33 A.M. and the BS reading of 439 mg/dl that was documented as obtained by LPN H at 12:16 P.M., LPN H said he/she would have called the doctor and requested an order for something to lower the resident's BS. LPN H said he/she would have entered a progress note and any orders the physician would have given. There were no orders entered on 7/7/25 by LPN H and no progress notes entered by LPN H on 7/7/25. LPN H said there would not have been documentation anywhere else other than the orders and progress notes. LPN H would not have let a resident have a BS reading in the 400s and not contact the physician. LPN H did not remember any residents having a high BS on 7/7/25. During an interview on 7/28/25 at 11:02 A.M., LPN G said nurses are responsible for taking residents' BS and administering insulin. LPN G said a high BS that he/she would contact the physician would be anything above 400 mg/dl and a low BS that he/she would contact the physician would be anything below 80 mg/dl. LPN G said he/she worked with the resident on 7/7/25 on the evening shift (2:45 P.M. through 11:00 P.M.). LPN G said he/she did not get anything in report from the day shift nurse regarding the resident's BS being elevated during the day. LPN G said he/she learned the resident had high BS readings during the day when he/she reviewed the resident's chart. LPN G went into check the resident's BS and it was 476 mg/dl. LPN G told the RR he/she was going to contact the physician regarding the high BS after he/she completed taking the other residents' BS. LPN G said when he/she was getting ready to call the physician, a Certified Nurse Aide (CNA) brought vitals that were out of range, including a low BP and low SpO2 reading. LPN G manually checked the resident's vitals. The resident's SpO2 was at 88%, so LPN G had the resident take a deep breath and cough and it came up to 92%. LPN G called the physician and received an order to send the resident to the ED. The RR requested the local ambulance and told the RR he/she would have to call 911. The RR said that is what he/she wanted and LPN G called 911. During an interview on 7/28/25 at 1:44 P.M., the Executive Director (ED), Assistant Executive Director (AED), and the Interim Director of Nursing (IDON) said they expected the resident's BS reading on 7/7/25 at 12:16 P.M. to be reported to the physician and for staff to document the notification in the resident's progress notes showing what orders the physician gave. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Rejection of care not exhibited;-Diagnoses included high blood pressure, hemiparesis (weakness on one side of the body) and hemiparesis (weakness on one side of the body ) following cerebral infarction (stroke) affecting left non-dominate side, expressive language disorder, and dystonia (involuntary muscle contractions that cause twisting and repetitive movements or abnormal postures). Review of the resident's care plan, during the survey, showed:-Problem: Resident has the potential for discomfort and side effects related to the use of antihypertensive mediation for the diagnosis of high blood pressure, created 6/11/25;-Goal: Resident will be free of any discomfort or adverse side effects, created 6/11/25;-Approach: Administer mediations as ordered, hold for SBP less than 100 or P less than 60, created 6/11/25. Review of the resident's MAR and progress notes, dated 7/28/25, showed: -Nifedipine (treats high blood pressure) 60 mg once daily, start date 2/29/24, no end date; -7/28/25, A.M. medication pass, Not administered: Other comment: On order nurse aware called pharmacy and medication will be here with tonight's medication;-No progress notes of notifications the medication was not administered as ordered to physician and RR. During an interview on 7/28/25 at 12:56 P.M., CMT J said he/she made the nurse aware the resident did not receive his/her dose of Nifedipine. CMT J said the pharmacy said the medication should be delivered this evening. 4. Review of Resident #5's admission MDS, dated [DATE], showed the following:-Severe cognitive impairment; -Rejection of care not exhibited;-Diagnoses included dementia, Parkinson's disease, high blood pressure, pneumonia and type two diabetes. Review of the resident's care plan, during the survey, showed:-Problem: Administer medication per physician orders, created 6/24/25;-Goal: Administer medication per physician orders while daughter is present, created 6/24/25;-Approac[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system for records of disposition of all controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) in sufficient detail to enable an accurate reconciliation with the narcotic delivery reconciliation logs and shift to shift count sheets for four carts out of four carts that had controlled substances. This had the potential to affect all residents with controlled substance orders. The census was 84.Review of the facility's Controlled Substances Policy, copyright 2025, showed:-Purpose: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V (CII, medication with higher potential of dependency and abuse), Schedule three controlled medication (CIII, medication with low to moderate potential of dependency and abuse), Schedule four controlled substance (CIV, medication with low potential of dependency and abuse), Schedule five controlled substance (CV, lowest potential of dependency and abuse) of the Comprehensive Drug Abuse Prevention and Control Act of 1976);-Procedure: Handling Controlled Substances; -1. Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises; -2. The director of nursing (DON) services identifies staff members who are authorized to handle controlled substances; -3. Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication another associate must count the controlled substances together. Both individuals sign the designated controlled substance record. If the count is inconsistent with the prescription label, the licensed nurse will contact the pharmacy; -4. An individual resident-controlled substance record is made for each resident who will be receiving a controlled substance. The facility will maintain a bound book with a log of the receipt, release and destruction of any controlled substances. Do not enter more than one prescription per page. This record contains: resident and prescription specific information;-Storing Controlled Substances: -1. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected; -2. The licensed nurse on duty maintains the keys to controlled substance containers;-Dispensing and Reconciling Controlled Substances: -1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; -2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: -a. Records of personnel access and usage; -b. Medication administration records; -c. Declining inventory records; -d. Destruction, waste and return to pharmacy records; -3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; -4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. The oncoming nurse reconciles the controlled substance while the off going nurse reads the log. Both nurses are responsible for verification of accuracy; -5. The director of nursing services documents irreconcilable discrepancies and notifies the Administrator: -a. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing completes the Narcotic Discrepancy Report and notifies the Administrator and consultant pharmacist immediately; -b. The Administrator, consultant pharmacist, and/or director of nursing services determine whether other action(s) are needed, e.g., notification of police or other enforcement personnel and any state agency; -c. The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met (example: a resident receiving a pain medication complains of unrelieved pain); -d. The director of nursing services consults with the provider pharmacy and the administrator to determine whether any further legal action is indicated; -6. Unless otherwise instructed by the director of nursing services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given) the medication is destroyed, and may not be returned to the container; -7. Waste and/or disposal of controlled medication are done in the presence of the nurse and another licensed associate who also signs the disposition sheet; -8. Medications returned to the pharmacy are recorded and signed by the director of nursing services (or designee) and the receiving pharmacy; -9. Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances. Fentanyl patches are disposed of in one of the following ways: -a. Per state regulation, or; -b. Using approved drug disposal products specifically for fentanyl patches; -10. Controlled substances are not surrendered to anyone, including the resident's provider, except for the following: -a. For a resident on pass or therapeutic leave; as ordered by the attending physician; -b. To a resident or responsible party upon discharge from the facility, or; -c. To the DEA or other law enforcement officials functioning in a professional capacity in exchange for a receipt documenting the transaction; -11. In the event there is concern about controlled substances being discharged with the resident and/or resident's representative, the attending physician may choose not to discharge the resident with those medications; -12. Some controlled substances may be stored in the emergency medication supply. Reconciliation of controlled substances in the emergency supply is conducted at intervals established by the director of nursing services; -13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed; -14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation; -15. The consultant pharmacist, Director of Nursing or designee routinely monitors controlled substance storage records; -16. The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers; -17. For guidelines pertaining to disposing of controlled substances, see Discarding and Destroying Medications policy;-3. Controlled Substances Disposal: -a. Unused portions of a controlled substance may be given to a resident or resident's representative upon the resident's discharge or transfer to another setting if the following conditions are met: -i. The healthcare practitioner has provided an order authorizing the currently prescribed controlled substances to be released with discharge/transfer; -ii. If currently prescribed controlled substances are released to a responsible person, this person who, because of the resident's incapacity, makes decisions about the individual's care must be identified in the resident record; -iii. Associate documents the release of the controlled drug medication, listing the date, quantity, name, strength, and dosage form of the medication; prescription number, name, address and telephone number of dispensing pharmacy; name and signature of the person releasing the drug; and name and signature of the person receiving the controlled drug upon discharge; -b. When these four conditions are not met, unused portions of a controlled substance remaining must be disposed of with disposal documented in accordance with State and Local regulations; -c. Unused portions of a controlled substance remaining at the building following the resident's death may not be released to the responsible person but must be destroyed. Disposal must occur within a timely manner by a licensed nurse and witnessed by another licensed nurse or pharmacist. 1. Review of the [NAME] Hall, narcotic book count signatures, dated 6/21/25 through 7/17/25, showed:-Incoming nurse responsible for counting medications, outgoing nurse responsible for following index log and verifying count in narcotic book;-Signing indicates that controlled substances have been counted for this cart and are deemed correct;-Forty-two staff signatures missing out of 154 opportunities. Review of the [NAME] Hall, narcotic delivery reconciliation logs, dated 5/26/25 through 7/14/25, showed:-Reminder, each card of medication needs to be listed separately, even if they have the same prescription number;-When a medication is completed or destroyed, please locate the medication from the above list, have two nurses initial and highlight in yellow; -When a medication was completed or destroyed, it was not highlighted in yellow and did not always have two nurses' signatures/initials;-Twelve medications were completed/destroyed and had one nurse's initial:-Medication: Norco (Hydrocodone/Acetaminophen, medication containing hydrocodone and acetaminophen used to managing pain that is moderate to moderately severe);-Dosage: 7.5 milligram (mg) hydrocodone, 325 mg acetaminophen;-Date completed/destroyed: 5/26/25; -Medication: Lyrica (pregabalin, use to treat nerve pain); -Dosage: Not documented; -Date completed/destroyed: 5/30/25; -Medication: Norco; -Dosage: 7.5/325 mg; -Date completed/destroyed: 5/30/25; -Medication: Clonazepam (Klonopin, used to treat panic disorders, anxiety and seizures); -Dosage: 0.5 mg; -Date completed/destroyed: 5/31/25; -Medication: Norco; -Dosage: 7.5/325 mg; -Date completed/destroyed: 6/15/25; -Medication: Norco; -Dosage: 7.5/325 mg; -Date completed/destroyed: 6/22/25; -Medication: Percocet (Oxycodone/Acetaminophen, combination pain medication used to treat moderate to severe pain); -Dosage: 10/325 mg; -Date completed/destroyed:7/10/25; -Medication: Phenobarbital (used to treat anxiety and seizures); -Dosage: Not documented; -Date completed/destroyed: 7/10/25; -Medication: Tramadol (used to treat moderate to moderately severe pain); -Dosage: 50 mg; -Date completed/destroyed: 7/10/25; -Medication: Percocet; -Dosage: 5/325 mg; -Date completed/destroyed:7/10/25; -Medication: Vicodin (Hydrocodone/acetaminophen, combination pain medication used to treat moderate to severe pain); -Dosage: 5/325 mg; -Date completed/destroyed:7/11/25; -Medication: Morphine (used to treat moderate to severe pain); -Dosage: Not documented; -Date completed/destroyed: Not documented. 2. Review of the Fontbonne Hall, narcotic book count signatures, dated 6/27/25 through 7/17/25, showed:-Incoming nurse responsible for counting medications, outgoing nurse responsible for following index log and verifying count in narcotic book;-Signing indicates that controlled substances have been counted for this cart and are deemed correct;-Missing 12 staff signatures out of 124 opportunities. Review of the Fontbonne Hall, narcotic delivery reconciliation logs, dated 5/26/25 through 7/17/25, showed:-Reminder, each card of medication needs to be listed separately, even if they have the same prescription number;-When a medication is completed or destroyed, please locate the medication from the above list, have two nurses initial and highlight in yellow; -When a medication was completed or destroyed, it was not highlighted in yellow and did not always have two nurses' signatures/initials;-Seventeen medications were completed/destroyed and had one nurse's initial:-Medication: Lyrica; -Dosage: 150 mg; -Date completed/destroyed: 6/5/25;-Medication: Vicodin; -Dosage: 5/325 mg; -Date completed/destroyed: 6/5/25; -Medication: Lyrica; -Dosage: 75 mg; -Date completed/destroyed: 6/7/25;-Medication: Clonazepam; -Dosage: 0.5 mg; -Date completed/destroyed: 6/11/25; -Medication: Xanax (Alprazolam, used to treat anxiety); -Dosage: 0.25 mg; -Date completed/destroyed: 6/13/25; -Medication: Morphine; -Dosage: 100 mg per 5 milliliters (ml); -Date completed/destroyed: 6/13/25;-Medication: Lorazepam (Ativan, used to treat anxiety); -Dosage: 2 mg per ml; -Date completed/destroyed: 6/13/25;-Medication: Lyrica; -Dosage: 75 mg; -Date completed/destroyed: 6/22/25;-Medication: Lyrica; -Dosage: 75 mg; -Date completed/destroyed: 7/7/25;-Medication: Morphine; -Dosage: 100 mg per 5 milliliters (ml); -Date completed/destroyed: 7/8/25;-Medication: Lorazepam; -Dosage: 2 mg per ml; -Date completed/destroyed: 7/8/25;-Medication: Clonazepam; -Dosage: 0.5 mg; -Date completed/destroyed: 7/8/25;-Medication: Vicodin; -Dosage: 5/325 mg; -Date completed/destroyed:7/8/25; -Medication: Lyrica; -Dosage: Not documented; -Date completed/destroyed: 7/12/25;-Medication: Armodafinil (Stimulant, wakefulness-promoting medication which is used to treat excessive daytime sleepiness); -Dosage: 150 mg; -Date completed/destroyed: 7/15/25;-Medication: Clonazepam; -Dosage: 0.5 mg; -Date completed/destroyed: Not documented; -Medication: Lorazepam (Ativan, used to treat anxiety); -Dosage: Not documented; -Date completed/destroyed: Not documented. 3. Review of the [NAME] Hall, narcotic book count signatures, dated 6/25/25 through 7/17/25, showed:-Incoming nurse responsible for counting medications, outgoing nurse responsible for following index log and verifying count in narcotic book;-Signing indicates that controlled substances have been counted for this cart and are deemed correct;-Missing 38 staff signatures out of 112 opportunities. Review of the [NAME] Hall, narcotic delivery reconciliation logs, dated 5/30/25 through 7/16/25, showed:-Reminder, each card of medication needs to be listed separately, even if they have the same prescription number;-When a medication is completed or destroyed, please locate the medication from the above list, have two nurses initial and highlight in yellow; -When a medication was completed or destroyed, it was not highlighted in yellow and did not always have two nurses' signatures/initials;-Ten medications were completed/destroyed and had one nurse's initial:-Medication: Lorazepam; -Dosage: 0.5 mg per ml; -Date completed/destroyed: 6/30/25;-Medication: Tramadol; -Dosage: 50 mg; -Date completed/destroyed: 7/8/25; -Medication: Lorazepam; -Dosage: 0.5 mg per ml; -Date completed/destroyed: 7/8/25;-Medication: Hydromorphone (Dilaudid, used to treat moderate to severe pain); -Dosage: 1 mg per ml; -Date completed/destroyed: Not documented;-Medication: Clonazepam; -Dosage: 0.5 mg; -Date completed/destroyed: Not documented; -Medication: Percocet; -Dosage: 7.5/325 mg; -Date completed/destroyed: Not documented;-Medication: Hydromorphone (Dilaudid, used to treat moderate to severe pain); -Dosage: 1 mg per ml; -Date completed/destroyed: Not documented;-Medication: Morphine; -Dosage: 100 mg per 5 ml; -Date completed/destroyed: Not documented;-Medication: Lorazepam; -Dosage: 2 mg per ml; -Date completed/destroyed: Not documented;-Medication: Hydromorphone; -Dosage: Not documented; -Date completed/destroyed: Not documented. 4. Review of the [NAME] Hall, narcotic book count signatures, dated 6/20/25 through 7/17/25, showed:-Incoming nurse responsible for counting medications, outgoing nurse responsible for following index log and verifying count in narcotic book;-Signing indicates that controlled substances have been counted for this cart and are deemed correct;-Missing 25 staff signatures out of 148 opportunities. 5. Review of the Controlled Substance Emergency Drug Supply, shift change count record signatures, showed:-All discrepancies must be reported to the Missouri Bureau of Narcotics and Dangerous drugs;-Signing indicates package quantity matches package log and tablets remaining match medication administration count sheet;-Time: 7:00 A.M., 3:00 P.M., and 11:00 P.M.;-5/1/25 through 5/31/25: -One nurse initialed at 11:00 P.M., on 5/14/25 and on 5/22/45; -All other dates and times are blank with no documentation; -Missing 91 staff signatures/initials out of 93 opportunities.-June 2025: No documentation for June, 2025;-7/1/2025 through 7/17/25: -One nurse initialed at 7:00 A.M. on 7/3/25; -All other dates and times are blank with no documentation; -Missing 49 staff signatures/initials out of 50 opportunities. 6. During an interview on 7/17/25 at 10:16 A.M., Licensed Practical Nurse (LPN) A said the controlled medication count is completed at the beginning and end of each shift with the oncoming and off-going nurse. It takes two licensed nurses to count the controlled mediations, and they sign to verify the count is correct. If there is no signature, then it was not completed. Only licensed nurses have access to the controlled medications. The Certified Medication Technicians (CMT) do not pass controlled modifications at this facility. The controlled substance emergency drug supply is in the medication room in a cabinet on the wall. It should also be counted at the beginning and end of each shift. The nurse on the rehab floor has the key to the cabinet. If the Alixa (machine that dispenses medication) does not have the controlled medication, it can be pulled from the controlled substance emergency drug supply that is on the wall in the medication room. During an interview on 7/21/25 at 12:16 P.M., LPN B said the controlled medication count is completed at the beginning and end of each shift with the oncoming and off-going nurse. It is documented as completed by signing in the ongoing and off-going nurse spots. During an interview on 7/28/25 at 1:41 P.M., the Executive Director (ED), Assistant Executive Director (AED), and the Interim DON said they expected staff to be knowledgeable of and follow the facility policies. They expected when nurses are receiving controlled medication from the pharmacy to immediately validate the medication. Two nurses are to validate the medication with the manifest and log it appropriately on the narcotic delivery reconciliation log and on the controlled narcotic count book. They expected the nurses to count the controlled medications with the ongoing and off-going nurse and to document it was completed by signing their name. They expected the controlled substance emergency drug supply to be counted each shift by the ongoing and off-going nurses from the rehab hall. On 7/29/25 at 3:09 P.M., they said the reason it is important for staff to complete the controlled substance count at the beginning and end of each shift is to validate the medication is secure and the count is correct because it is the resident's property. 2562318

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges, and failed to provide a written notice of transfer/discharge to one resident (Resident #90) and/or resident representative when the resident was transferred to the hospital. The sample was 21. The census was 93. Review of the facility's Discharge Planning policy, dated 11/28/17, showed: -Purpose: To prepare the resident for and ensure a safe discharge from the facility; -The policy did not provide guidance related to notification to the Ombudsman regarding resident transfer and discharges; -The policy did provide guidance related to ensuring residents and/or resident representatives are provided with written notification as soon as practicable following a resident's transfer to the hospital. 1. During an interview on 3/6/25 at 2:07 P.M., the Ombudsman said he/she has not received monthly notification of transfers and discharges from the facility on a consistent basis. He/She has gone months without receiving notice of transfer/discharge from the facility. During an interview on 3/11/25 at 11:30 A.M., the Assistant Executive Director was asked to provide documentation of the facility's notification of transfer/discharge to the Ombudsman's office for the last six months. During an interview on 3/13/25 at 10:34 A.M., the Social Services Director (SSD) said she has been in her current position with the facility for two years. Until this week, she was not aware she needed to notify the Ombudsman's office of resident transfers/discharges. During an interview on 3/12/25 at 7:12 A.M. with the Executive Director and Assistant Executive Director, they said the current SSD began working with the facility in April 2023. She was not aware she needs to provide the Ombudsman's office with notification of transfers/discharges. The expectation is for the facility to notify the Ombudsman of transfers/discharges on a monthly basis. 2. Review of Resident #90's medical record, showed: -admission date 12/11/24; -discharged [DATE]; -No documentation the resident and/or their representative provided with a written notice of transfer/discharge. Review of the facility's admission/discharge report, dated 12/14/24, showed the resident discharged /transferred to hospital for inpatient care. During an interview on 3/13/25 at 10:34 A.M., the SSD reviewed the resident's medical record and did could not locate a discharge summary or notice of discharge. She thought the resident was discharged to the hospital. During an interview on 3/13/25 at 12:14 P.M. with the Executive Director and Assistant Executive Director, they said the resident wanted to go out to the hospital, so his/her family picked him/her up and brought him/her to the hospital. The resident called the facility later and said he/she was not coming back. Facility staff should have sent a notice of transfer with the resident when he/she went out to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement baseline care plans within 48 hours of a resident's admission for three residents (Residents #90, #195 and #194). The census was 93. Review of the facility's Comprehensive Assessments and Care Planning policy, revised [DATE], showed: -Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the Resident Assessment Instrument (RAI) specified by the State; -Policy: --The assessment process begins with the development of the baseline care plan within the first 48 hours of admission. The baseline care plan includes the minimum healthcare information necessary to care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury. Baseline care plans address, at a minimum, the following: -Initial goals based on admission orders; -Physician orders; -Dietary orders; -Therapy services; -Social services; -Preadmission Screening and Resident Review (PASARR) recommendation, if applicable; --The baseline care plan reflects the resident's stated goals and objectives, and includes interventions that address his or her current needs. If the resident experiences a significant change in condition prior to the implementation of the comprehensive care plan - changes will be made to the baseline care plan to reflect the new approaches. 1. Review of Resident #90's medical record, showed: -admission date [DATE]; -Diagnoses included Parkinson's disease (movement disorder), history of failing, hemiplegia (paralysis to one side of the body) or hemiparesis (weakness to one side of the body) following stroke, heart failure, other frontotemporal neurocognitive disorder, major depressive disorder, generalized anxiety disorder; -discharge date [DATE]; -No baseline care plan documented during the resident's stay at the facility from [DATE] to [DATE]. 2. Review of Resident #195's medical record, showed: -admission date [DATE]; -Diagnoses included right hip fracture, right joint replacement, emphysema (a lung disease), history of falling and high blood pressure; -No baseline care plan documented. Observation and interview on [DATE] at 6:10 P.M., howed the resident lay in bed. The resident said he/she fell while in the community and sustained a fractured right hip. The orthopedic surgeon said his/her hip was shattered and required a lot of fixing. The resident said he/she was having a lot of pain. He/She currently uses a wheelchair, and therapy is assisting him/her to walk. He/She requires assistance from staff to use the bathroom and today was the first shower he/she had received by the facility staff since he/she had been admitted to the facility. 3. Review of Resident #194's medical record, showed: -admission date [DATE]; -Diagnoses included clostridium difficile (C-diff, an infection in the intestine that causes diarrhea), bronchitis (inflammation of the lungs), repeated falls, COVID-19, influenza A (flu) with respiratory manifestations, orthostatic hypotension (low blood pressure that occurs when sitting or standing) and incontinence of feces; -No baseline care plan documented. Observation and interview on [DATE] at 1:45 P.M., showed the resident in bed and a wheeled walker was positioned next to the resident's bed. The resident said he/she was at home and fell, then went to the hospital. The resident said he/she arrived at the facility on [DATE] around 2:00 or 3:00 P.M. He/She has bruised ribs with pain on movement. He/She is incontinent of stool but had been changing him/herself and brought his/her own incontinent briefs. He/She was not told what type of infection he/she has, but noticed isolation gowns and masks were hanging on the outside of the door to be worn by staff. The resident did not receive any medications and felt as though he/she was just left alone in the room, like in a jail cell. The resident also said his/her family member died suddenly and was very sad. 4. During an interview on [DATE] at 9:14 A.M., Licensed Practical Nurse (LPN) A said nurses are responsible for completing baseline care plans within 48 hours of a resident's admission to the facility. Baseline care plans should include information related to the resident's mental status, activities of daily living (ADL) needs, diet, behaviors, and adaptive equipment. 5. During an interview on [DATE] at 11:13 A.M. the Director of Nurses (DON), Executive Director, and Assistant Executive Director said nurses are to complete baseline care plans within 48 hours of a resident's admission. The baseline care plan should be documented in the resident's electronic medical record (EMR). Baseline care plans should include information related to all of the resident's care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop a plan of care specific to each resident's needs. Concerns were found in the care plans for three out of 21 sampled residents when the facilty failed to include the presence of side rails (Resident #52), presence of a urinary catheter (Resident #11), and presence of hospice services (Resident #20) in the resident care plans. The facility census was 93. Review of the facility's Comprehensive Assessments and Care Planning Policy, revised 9/27/23, showed: -Purpose: To provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental, and psychological functioning possible, a facility must make a comprehensive assessment of each resident's needs, using the Resident Assessment Instrument, (RAI, a federal assessment tool used to identify specific resident needs) specified by the State; -A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals, and sign and certify the assessment is completed; -The assessment must accurately reflect the resident's status, and each person who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment; -The resident's comprehensive assessment, completed within 14 calendar days after admission, must include at least the following: Demographic information, customary routine, cognitive patterns, communication, vision, mood and behavior problems, psychosocial wellbeing, Preadmission Screening and Resident Review (PASARR, a federal assessment tool used to ensure proper placement of individuals in facilities equipped to handle their care) recommendations as applicable, physical functioning and structural problems, continence, disease diagnosis and health conditions, dental and nutritional status, skin conditions, activity pursuit, medications, special treatments and procedures, discharge planning, documentation of summary information regarding additional assessment performed through the resident assessment protocols, documentation of participation in assessment, resident strengths, goals, life history, and preferences. 1. Review of Resident #52's medical record, showed: -Diagnoses included spinal stenosis (chronic pain and stiffening of the spinal column), history of falls, high blood pressure, and muscle spasms; -No active physician order for side rails; -A Restraints/Adaptive Equipment Consent recorded on 3/3/25 and left blank; -A Restraints/Adaptive Equipment Use Observation recorded on 3/3/25. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/28/25, showed: -Cognitively intact; -Impairment to both lower extremities with full strength of upper extremities; -Independent with mobility areas: Roll left and right, sit to lying, and lying to sitting on side of bed. -Use of siderails not checked. Review of the resident's care plan, in use at the time of survey, showed no mention of the resident's use of side rails while residing in the facility. Observation and interview on 3/10/2025 at 11:31 A.M., showed the resident resting in bed with circular positioning rails installed on both sides of the bed. The resident said he/she uses the side rails for bed mobility and has had them since admission to the facility. During an interview on 3/14/25 at 7:58 A.M., Certified Nursing Assistant (CNA) Q said side rails should be included on a resident's care plan to help facility CNAs provide adequate and personalized care to each resident. Resident #52 utilizes the facility's halo rails for bed mobility and positioning. During an interview on 3/14/25 at 7:48 A.M., CMT (Certified Medication Technician) K said the resident utilizes side rails for positioning and bed mobility, and he/she would expect side rails to be included on the resident's care plan. 2. Review of Resident #11's medical record, showed: -Diagnoses included: Diabetes, retention of urine (the inability to routinely void urine), presence of urogenital implants (medical devices inserted in the urinary tract to aid in voiding of urine), high blood pressure, and spinal stenosis -A physician order placed on 2/4/25 to change indwelling catheter and bag as needed (PRN) based on clinical indications; -No further orders for the resident's indwelling catheter. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Use of catheter not checked; -Care Area Assessment triggers for Urinary Incontinence for level of assistance needed with toileting needs and actual incontinent episodes. Review of the resident's care plan, in use at the time of survey, showed no mention of the resident's catheter status, size of the catheter, or care needs. Observation and interview on 3/10/25 at 10:57 A.M., showed the resident resting in bed with his/her catheter covered and hanging from the wheelchair. During an interview, the resident said he/she has had intermittent problems with receiving catheter care, including the draining of the catheter bag. The resident said he/she has urinated on the bedsheets while residing at the facility because staff would not drain the catheter bag. Observation and interview on 3/12/25 at 10:27 A.M., showed the resident resting in bed with his/her catheter covered and hanging from the bed frame. During an interview, the resident said an agency CNA worked the hall overnight, and the resident had to get on them to drain his/her catheter bag. The resident said the CNA seemed surprised and confused the resident had a catheter when entering the room to provide care. During an interview on 3/14/25 at 7:58 A.M. CNA Q said he/she knew the resident well and was aware the resident had an indwelling catheter that required staff care. Care plans at the facility are made with input from facility CNAs, and the presence of an indwelling catheter should be included on a resident's care plan if it is in use and/or requires care. Care plans are important so that each resident's specific care needs are communicated to staff. During an interview on 3/14/25 at 7:48 A.M., CMT K said he/she was unaware the resident had an indwelling catheter and thought the resident had it removed some time ago. CMT K would expect the resident's urination status to be included on the resident's care plan, and all care plans should be developed and tailored to each resident's specific care needs. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included Alzheimer's disease, diabetes, and congestive heart failure (CHF); -Resident is on hospice. Review of the resident's physician order sheet (POS), in use at the time of the survey, showed: -An order, dated 4/24/24, resident admitted to hospice with the diagnosis of acute congestive heart failure. Review of the resident's care plan, in use at the time of the survey, showed: -The care plan did not address the resident receiving hospice care. During an interview on 3/14/25 at 7:38 A.M., Licensed Practical Nurse (LPN) A said the care plan should include hospice care. This is important so staff are aware of the care the hospice company provides, and so care is cohesive. During an interview on 3/14/25 at 8:51 A.M., CNA D said the resident's care plan should indicate if the resident is on hospice. 4. During an interview on 3/14/25 at 11:21 A.M., the Administrator and Director of Nursing (DON) said they would expect hospice care, presence of an indwelling catheter, and utilization of side rails to be included on resident care plans. Care plans are developed by the Interdisciplinary Team made up of nursing staff, therapy staff, the MDS coordinator, and social services staff. It is important that all residents' care plans address their specific care needs in order to provide care tailored to each specific resident.

Based on observation, interview and record review, the facility failed to provide services to meet professional standards of practice when staff held medications for two residents (Residents #79 and #83) with low blood pressure and failed to notify the nurse so the nurse could notify the physician to initiate parameters. Staff failed to ensure medication was available for administration and to administer available medications for one resident (Resident #15), and the facility failed to have a sufficient system in place to track pharmacy refill requests. The sample was 21. The census was 93. Review of the facility's Change in Condition policy, undated, showed; -Purpose: To provide care and services based upon the current needs of the resident under the direction of the attending provider; To inform the resident and/or resident's representative and attending provider with a significant change in a resident occurs; -Policy: When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is a need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident or the resident's representative; -Procedure: Assess significant change in the resident's condition noted through direct observation, interview or report from other staff; Obtain a set of vital signs and repeat as needed or ordered; Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed; Monitor and provide treatment as ordered by the attending provider. Review of the facility's Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy policy, dated December 2017, showed: -Policy: Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt; --Ordering Medications from the Dispensing Pharmacy: -Medication orders are written on a medication order form (i.e., telephone order sheet, reorder form, electronically, etc.) provided by the pharmacy, written in the chart by the physician, electronic order, or written on a transfer order form and transmitted to the pharmacy; -Reorder medication five days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. --Receiving Medications from the Pharmacy -A licensed nurse: -Receives medications delivered to the facility and documents that the delivery was received and was secure (on the medication delivery receipt, or other documentation system); -Verifies medications received and directions for use with the medication order form; -Immediately delivers the medications to the appropriate secure storage area (or a designee under the direct supervision of the licensed nurse); -Assures medications are incorporated into the resident's specific allocation prior to the next medication pass. 1. Review of Resident #79's face sheet, undated, showed diagnoses included kidney failure, high blood pressure, myocardial infarction (heart attack) and cardiomyopathy (enlarged heart). Review of the resident's Physician Order Sheet (POS), dated March 2025, showed; -An order, dated, 2/26/25, Aldactone (medication used to treat high blood pressure) 25 milligrams (mg), give one half a tablet, once a day at 6:00 A.M. through 10:30 A.M.; -No parameters to hold medication were included in the order; -An order, dated, 2/26/25, Entresto tablet (a medication used to treat heart failure) 24-26 mg, give twice a day at 6:00 A.M. through 10:30 A.M. and 6:30 P.M. through 7:30 P.M.; -No parameters to hold medication were included in the order; -An order, dated, 2/27/25, Toprol XL tablet extended release 24 hour, (a medication used to treat high blood pressure) 25 mg, give one tablet once a day at 6:00 A.M. through10:30 A.M.; -No parameters to hold medication were included in the order. Observation and interview on 3/11/25 at 9:17 A.M., showed Certified Medication Technician (CMT) J was preparing the resident's medications and entered the resident's room and obtained the resident's blood pressure with an automatic blood pressure machine. The reading on the machine was 93/56, (normal, 120/80). CMT J said the resident's blood pressure was too low and said he/she was going to hold the medication. CMT J exited the room and returned to the medication cart. CMT J removed the Aldactone, Entresto and Toprol XL tablets out of the medicine cup using a spoon. CMT J re-entered the resident's room and gave the resident the remaining medication. Review of the resident's Medication Administration Record (MAR), dated 3/1 through 3/12/25, showed; -On 3/11/25, at 9:20 A.M., Aldactone 25 mg, documented as held due to low blood pressure, 92/56; -On 3/11/25, at 6:00 A.M. through 10:30 A.M., Entresto 24-26 mg, documented as given; -On 3/11/25, at 9:20 A.M., Toprol XL 25mg, documented as held due to low blood pressure, 92/56. Review of the resident's progress notes, showed no documentation the physician was notified of the resident's low blood pressure. 2. Review of Resident #83's face sheet, undated, showed diagnoses included high blood pressure and kidney failure. Review of the resident's POS, dated March 2025, showed: -An order, dated, 1/9/25, amlodipine (medication used to treat high blood pressure) 5 mg, give one tablet one a day; -No parameters to hold medication were included in the order. Observation and interview on 3/11/25 at 9:11 A.M., showed CMT J had the resident's blood pressure written on a sheet of paper. CMT J said the resident's blood pressure was 119/63 and he/she was going to hold the medication because his/her blood pressure was too low. CMT J removed the amlodipine out of the resident's medication roll pack. Review of the resident's MAR, dated 3/1 through 3/12/25, showed: -On 3/11/25, at 9:13 A.M., amlodipine 5 mg, documented as held and the resident's blood pressure, 119/63. Review of the resident's progress notes, showed no documentation the physician was notified of the resident's low blood pressure. During an interview on 3/14/25 at 9:17 A.M., Licensed Practical Nurse (LPN) A said the CMT is expected to notify the nurse when medication is held, especially related to blood pressure medications. The physician should be notified if the resident's blood pressure is low, and blood pressure medications are being held. Parameters from the physician should be in place for the CMTs and nurses to hold medication. During an interview on 3/14/25 at 9:40 A.M., CMT J said the nurse is to be notified when any heart related medication is held for any reason. CMT J would go back and assess the resident's blood pressure in one to two hours after the last blood pressure was taken to see if the resident's blood pressure is better. Parameters for medications should be included in the orders to give the staff more guidance. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she expected the CMTs to inform the nurse if the resident's blood pressure is low and medication was held. The nurse is expected to notify the physician of the low blood pressure and determine if the physician wants to add parameters to the orders. This communication with the physician would be documented in the resident's progress notes. 3. During a group interview on 3/12/25 at 1:00 P.M., five out of five residents, whom the facility identified as alert and oriented, said there are ongoing issues with the facility running out of their medications or not administering medications as prescribed. 4. Review of Resident #15's medical record, showed diagnoses included cerebral palsy (movement disorder), major depressive disorder and anxiety disorder Review of the resident's POS and MAR for March 2025, showed: -An order, dated 5/22/18, for baclofen (muscle relaxer) 10 mg, one tab twice a day for cerebral palsy; -On 3/6/25 at 5:43 P.M., staff documented the medication not administered, drug/item unavailable; -On 3/7/25 at 8:53 A.M., staff documented the medication not administered, discontinued; -On 3/7/25 at 3:53 P.M., staff documented the medication not administered, drug/item unavailable; -An order, dated 10/6/20, for quetiapine (antipsychotic medication) 50 mg, one tablet once a morning for depression; -On 3/4/25 at 9:20 A.M., staff documented the medication not administered, drug/item unavailable; -On 3/5/25, 3/6/25, 3/7/25, and 3/8/25, staff documented the medication administered; -On 3/9/25 at 12:06 P.M., staff documented the medication not administered, drug/item unavailable; -On 3/10/25 at 8:05 A.M., staff documented the medication not administered, drug/item unavailable. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/6/25, showed he/she was cognitively intact. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident uses antipsychotic, antianxiety, hypnotic, and antidepressant medication for diagnoses of cerebral palsy, anxiety and depression; -Approaches included: Administer medication as ordered. During an interview on 3/10/25 at 12:31 P.M., the resident said he/she has been having issues with the facility running out of his/her medication. He/She takes medication for tremors and depression and has not received some of his/her medication in several days. Observation and interview on 3/12/25 at 9:48 A.M., showed CMT L removed all of the resident's medications from the medication cart. The resident did not have any quetiapine 50 mg on the medication cart. The blister pack of Baclofen 10 mg, showed the medication was filled by the pharmacy on 2/26/25 for a quantity of 60, with 48 tablets left on the card. CMT L said If administered twice daily per physician order, the card filled on 2/26/25 would have less than 48 tablets remaining. When a medication is not on the medication cart, staff should check the bottom drawer of the cart. If they cannot locate the medication, they should notify the nurse that the medication is not on hand. The nurse orders the medication from the pharmacy. Blister pack medications have a blue strip in the last row that prompt staff to reorder medication before the resident completely runs out. During an interview on 3/12/25 at 10:12 A.M., LPN I said the resident's pharmacy does not have an emergency kit in the facility. There is an emergency kit for residents who use a different pharmacy, but the resident's medications cannot be pulled from that kit since he/she goes through the other pharmacy. CMTs and nurses should order medications before a resident runs out of their medication. Refill requests are faxed to the pharmacy. There is no way for staff to track when refill requests are made. There is no system in place for who is responsible for following up on refill requests. When medications are received, they are put on the medication cart. During an interview on 3/13/25 at 11:53 A.M., Pharmacy Representative V said the resident's quetiapine 50 mg was filled 2/25/25 and there should be approximately two weeks' worth of medication left on the card. 5. During an interview on 3/13/25 at 1:01 P.M., CMT K said medications are reordered when the medications on the blister cards reach the last row. Staff should reorder medication before the cards are empty. Refill requests are faxed to the pharmacy. There is no way for staff to track if or when someone else ordered the medication. 6. During an interview on 3/14/25 at 8:52 A.M., CMT J said some staff don't remove medications from the blister cards in order, so they might not be able to clearly tell when a blister card is about to be out of medication. Seeing the medication left in the last row of the blister card is what prompts staff to reorder the medication. Reordering medications can get missed. There is no way to tell if an employee has already ordered a medication. If staff cannot find a resident's medication on the medication cart, they should check the bottom drawer of the medication cart, then notify the nurse. Facility staff can check the emergency kit. Agency staff do not have access to the emergency it. Agency staff might not know where they can find medications. CMT J has seen staff document on the MAR that medications are unavailable, but they are on the cart. When staff document in this way, there is no way to tell if a medication was actually administered. 7. During an interview on 3/14/25 at 10:57 A.M., the DON, Executive Director, and Assistant Executive Director said if staff cannot find a medication on the medication cart, they should check the emergency kit. If a medication is not in the emergency kit, staff should contact the pharmacy. Facility staff and supervisors have access to the emergency kit. Agency staff know what the facility's processes are from getting report from facility staff. Any attempts to reach the pharmacy for refills should be documented. If a medication cannot be administered because it is not on hand, the physician should be notified. The expectation is for staff to accurately document medication administration on the MAR. If a medication is available, staff should not document the medication was not available. When staff document a medication was unavailable when it is on hand at the facility, there is no way to tell if the medication was administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) care was provided for three of 21 sampled residents. The facility failed to ensure one resident had accurate skin assessments, trimmed nails and clean skin (Resident #82). The facility also failed to ensure two residents received facial hair grooming (Residents #65 and #20). The census was 93. Review of the facility's ADL policy, dated 2021, showed: -Policy: residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility; -Implementation: care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care, mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks), and communication (speech, language, and any functional communication systems); -If residents with cognitive impairment or dementia exhibit behavioral expressions of resistance to care, associates will attempt to identify the underlying cause of the problem and not assume the resident is declining or refusing care. Approaching the resident in a different way, or at a different time, or having another associate speak with the resident may be appropriate. If a resident refuses care, associates will approach at a different time, or have another associate speak with the resident as needed. Interventions to improve and/or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 1. Review of Resident #82's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 2/17/25, showed: -Cognitively intact; -Dependent on staff for toilet and bathing hygiene; -Required maximum assistance removing socks and foot wear; -Required moderate assistance from staff for personal hygiene; -Dependent on staff to roll left and right. Review of the resident's care plan, in use at the time of survey, showed the care plan did not address the resident's ADL needs related to bathing and showering. Review of the resident's face sheet, undated, showed his/her diagnoses included lymphoma (a type of cancer that is in the lymph nodes), respiratory failure, viral infection, urinary retention, gastrostomy tube (a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications), chest pain and atrial fibrillation (a-fb, an irregular heart beat). Review of the resident's Skin Monitoring : Comprehensive Certified Nursing Assistant(CNA) Shower Review sheets, showed: -On 2/12/25, the resident received a bed bath; Does the resident need their toe nails cut?; Box checked: Yes; -On 2/15/25, the resident received a bed bath; -On 2/19/25, the resident received a bed bath; Does the resident need their toe nails cut?; Box checked: Yes; -On 2/26/25, the resident received a bed bath; -On 3/1/25, the resident received a bed bath; Does the resident need their toe nails cut?; Box checked: Yes; -On 3/8/25, the resident received a bed bath; -On 3/10/25, the resident received a bed bath; Does the resident need their toe nails cut?; Box checked: No; Observation and interview on 3/10/25 at 11:00 A.M., showed the resident lay in bed. His/Her face was unshaven, hair appeared disheveled, and both of his/her hands had one fourth of an inch of jagged nails. The resident said he/she only gets bed baths because he/she did not think he/she could stand in the shower. He/She was never offered by a staff member a shower with the use of a shower chair. The last bed bath he/she received was approximately two weeks ago. Observation and interview on 3/11/25 at 10:30 A.M., showed the resident lay in bed. His/Her face was unshaven, hair appeared disheveled, and both of his/her hands had on fourth of an inch of jagged nails. Certified Nurse Aide (CNA) F assisted the resident with providing perinium care (peri-care, cleansing of the genitals and rectal area). The resident's abdomen had dark, caked like, discolored, flaky skin on his/her right torso, wrapping around to his/her flank area. CNA F removed the resident's socks and both of the resident's feet had thick crusted flakes and cracks of dry skin. Large white flakes of dry skin were falling out of the resident's socks onto the resident's navy blue mattress. The resident's toenails were extremely thick, jagged and approximately one fourth of an inch long. The resident said no staff member had trimmed his/her toenails. CNA F said to the resident, your feet are really dry. During an interview of 3/13/25 at 12:10 P.M., CNA E said he/she will apply lotion to dry skin and feet. Fingernail care can be provided during the bathing process by CNAs. Usually toenails are trimmed by the nurse or doctor. 2. Review of Resident #65's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required moderate assistance for toilet and bathing hygiene. -Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side and chronic kidney disease (CKD). Review of the resident's care plan, in use at the time of the survey, showed: -Problem: resident requires total care for bathing, grooming, dressing, toileting, oral hygiene, shaving and set up assist for eating; -Goal: ADLs completed each day to resident comfort and satisfaction; -Approach: assist resident with (setup, supervision, hands-on), assist of (one or two) with bathing. Do not leave resident unattended in shower chair. Provide privacy by closing cubicle curtains when personal care is given. Assist as indicated with hygiene after using toilet. Respect resident's personal preferences related to ADLs including allowing resident to make choices regarding his/her care and participate as much as possible. Observation and interview on 3/10/25 at 12:12 P.M. showed the resident's beard was unkempt with food particles and white flakes. The resident said he/she would like his/her beard trimmed and groomed. He/She said most of the time he/she has to wait for his/her family to come to the facility and help him/her with his/her beard because nursing staff do not assist him/her. Observation on 3/11/25 at 10:30 A.M., showed the resident's beard was unkempt with food stuck in the hair. Observation on 3/12/25 at 9:30 A.M., showed the resident's beard was unkempt and had food particles and white flakes. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Dependent on staff for toilet and bathing hygiene; -Diagnoses included Alzheimer's disease, type 2 diabetes and congestive heart failure (CHF, a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Review of the resident's care plan, in use at the time of the survey, showed: -Problem: resident needs assistance with dressings, toileting, personal hygiene and bathing. Resident requires supervision on the unit to ensure safety; -Goal: resident will have all ADL care completed with usual standards daily; -Approach: allow resident time to participate in his/her care. Please provide assistance with transfer, dressings, toileting, personal hygiene and bathing, nail care twice weekly or as needed. Observation on 3/10/25 at 1:35 P.M., showed the resident had a patch of hair on his/her chin. Observation on 3/11/25 at 5:19 A.M., showed the resident had a patch of hair on his/her chin. Observation on 3/12/25 at 8:40 A.M., showed the resident had a patch of hair on his/her chin. During an interview on 3/13/25 at 8:43 A.M., the resident nodded and said yes when asked if he/she would like his/her chin hairs shaved. During an interview on 3/14/25 at 7:40 A.M., Licensed Practical Nurse (LPN) A said facial hair maintenance is done by CNAs before or after showers or as needed. He/She expected staff to ask residents if they would like their facial hair trimmed, shaved or groomed. During an interview on 3/14/25 at 8:52 A.M., CNA C said facial hair grooming is a part of ADL care and is normally completed after showers. Staff are expected to ask residents if they want their facial hair trimmed, shaved or groomed. During an interview on 3/14/25 at 11:02 A.M., the Director of Nurses (DON) and Administrator said they expected staff to address resident skin conditions completely and accurately. They said the shower assessments should include any nail or skin issues. The CNA has the shower sheet signed by the nurse to ensure the nurse is aware of any concerns. They expected staff to ensure residents' facial hair is trimmed, groomed or shaved according to resident preference during ADL care.

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to obtain treatment orders for one resident (Resident #195) who had a recent hip surgery. The sample size was 21. The census was 93. Review of the facility's Prevention and Treatment of Skin Breakdown policy, dated 9/1/18, showed: -Purpose: Maintaining intact skin is integral to the resident's health and wellness. Care and service are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur; -Procedure: Skin is observed daily with care; Documentation of the skin impairment is completed in the medical record; Notify the attending provider and the attending provider may provide additional orders. Review of Resident #195's, face sheet, undated, showed: -An admission date of 3/6/25; -Diagnoses that included; right hip fracture, right joint replacement, emphysema (a lung disease), history of falling, and high blood pressure. Review of the resident's record showed: -No baseline care plan was available for review. Review of the resident's physician order sheets (POS), dated March, 2025, showed: -An order dated, 3/11/25, monitor surgical incision for signs and symptoms of infection, redness pain and exudate (pus), change dressing if saturated, daily and as needed. Review of the resident's progress notes dated, March, 2025, showed: -On 3/6/25 at 11:56 P.M., the resident arrived to the facility at 6:45 P.M., the resident is able to make needs known and is cognitively intact. The resident has 69 staples in place, with a dressing intact to his/her right hip from recent surgery. -On 3/13/25 at 11:40 A.M., resident seen for incisional skin check, some erythema (redness) noted at points along the staple line. -No further documentation related to the resident's incision was noted. Observation and interview on 3/10/25 at 6:10 P.M., showed the resident lay in bed. The resident said he/she fell while out in the community and sustained a fractured right hip. The resident said the orthopedic surgeon (a bone surgeon) said his/her hip was shattered and required a lot of fixing. The resident was having a lot of pain. The resident had a shower and his/ her dressing was saturated. The dressing to the resident's right hip was dated 3/8/25 and was saturated with a serous (yellow) fluid. The resident said he/she had asked a nurse to change it on 3/8/25 because the orthopedic surgeon said the resident needed to have a clean dressing applied to his/her incision line every day; that was the last time his/her hip dressing was changed. The resident worries about getting a hip infection. Observation and interview on 3/11/25 at approximately 8:30 A.M., showed the resident lay in bed and said that the same hip dressing was on his/her incision and no staff had changed it. The resident turned slightly to his/her left side and exposed his/her right hip dressing. The dressing was dated 3/8/25 and was saturated with serous drainage. Observation and interview on 3/12/25 at 7:21 A.M., showed the resident lay in bed. The resident said the Wound Nurse came in on 3/11/25 and changed his/her right hip dressing. The resident turned to his/her left side and had an undated, dry hip dressing present. During an interview on 3/13/25 at 12:50 P.M., Licensed Practical Nurse (LPN) N said on admission, the facility staff obtain orders for any type of skin condition. The Wound Nurse does the treatments during the week and the nursing staff complete the weekend treatments. The nurse can change a dressing anytime especially if it is soiled or wet. Nursing does not have to wait on the Wound Nurse to complete treatments. During an interview on 3/14/25 at 7:45 A.M., the Wound Nurse said he is to check every single wound, every single day, and complete the resident's treatment. When residents are new admissions he will generally scroll through the resident's electronic medical record (E-MAR) to see if the resident has any wounds. Sometimes the staff will just inform him verbally if the resident has a wound. He was not aware of the resident's right hip surgical incision and saw it for the first time on 3/11/25. The floor nurses are responsible to get admission orders for any type of skin condition. He is not sure what happened and why there were no treatment orders obtained for the resident. Nursing staff are responsible to change soiled or saturated dressings as needed. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she would expect staff to obtain orders related to the resident's skin condition on admission and change dressings if they are soiled or saturated. The Wound Nurse is responsible for wound checks and dressing changes.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #82) had urinary catheter (tube that drains the urine from the bladder) orders and failed to flush one resident's urinary catheter who had a history of hematuria (blood in the urine) (Resident #1). The sample was 21. The census was 93. Review of the facility's Prevention of Catheter-Associated Urinary Tract Infections policy, undated, showed when a resident is admitted to the facility with a catheter in place, a thorough physical assessment, as well as history review will be completed. 1. Review of Resident #82's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/17/25, showed: -Cognitively intact; -The resident has an indwelling urinary catheter; -Diagnosis included cancer, benign prostatic hypertrophy (BPH, an enlarged prostate gland) and renal failure, and obstructive uropathy (blockage that makes it difficult for urine to pass); Review of the resident's care plan, in use at the time of survey, showed; Problem: The resident has a indwelling urinary catheter related to obstructive uropathy; Approach: Change catheter per physician orders: Keep catheter in a closed system as much as possible; Position catheter below the bladder; Provide assistance with catheter care; Store urine collection bag in a dignity pouch. Review of the resident's Physician Order Sheet (POS), dated February, 2025, showed no orders related to the resident's urinary catheter. Review of the resident's Treatment Administration Record (TAR), dated 2/11 through 2/28/25, showed no orders related to the resident's urinary catheter. Review of the resident's POS dated March, 2025, showed no orders related to the resident's urinary catheter. Review of the resident's TAR, dated 3/1 through 3/11/25, showed no orders related to the resident's urinary catheter. Observation and interview on 3/10/25 at 11:00 A.M., showed the resident lay in bed. The resident had a urinary catheter hanging on the resident's bedframe in a privacy pouch. The resident's urine was yellow with some sediment in the urinary catheter tubing. The resident said he/she had problems urinating on his/her own and that is why he/she has a catheter. The resident also said he/she didn't think he/she could urinate laying down. Observation and interview on 3/11/25 at 10:30 A.M., showed the resident lay in bed. CNA F assisted the resident with providing perinium care (peri-care, cleansing of the genitals and rectal area). The resident had a urinary catheter in place. The urinary catheter bag was in a privacy pouch. The resident's urine was yellow with some sediment in the urinary catheter tubing. During an interview on 3/13/25 at 12:50 P.M., Licensed Practical Nurse (LPN) N said there is a set of orders the nurses can place in the physician orders that cover urinary catheter care. The orders for the resident should have been placed on admission. 2. Review of Resident #1's admission MDS, dated , 1/27/25, showed: -admission date of 1/21/25; -Cognitively intact; -Indwelling catheter present. Review of the resident's care plan, in use at the time of survey, showed; -Problem: The resident has an indwelling urinary catheter related to urogenic bladder; -Approach: Assess the drainage, record the amount, color type and odor. Change catheter per physician orders: Keep catheter in a closed system as much as possible; Position catheter below the bladder; Provide assistance with catheter care every shift and as needed; Store urine collection bag in a dignity pouch. Review of the resident's face sheet, undated, showed diagnoses included osteomyelitis (bone infection) to the sacrum (tailbone), Stage 4 pressure wound (a wound that has full thickness skin and tissue loss caused by extended pressure) to the sacrum, incomplete quadriplegia (paralysis of both arms and legs), chronic pain syndrome, and depressive disorder, hematuria (the presence of blood in the urine) and neurogenic bladder (an inability to urinate due to ta dysfunction of the nervous system). Review of the resident's POS, dated March, 2025, showed: -An order dated, 2/26/25, flush urinary catheter with 30 milliliters (ml) of sterile water, every shift. Review of the resident's TAR, dated 3/1 through 3/14/25, showed, -An order, dated 2/26/25, flush urinary catheter with 30 milliliters (ml) of sterile water, every shift, 7:00A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., and 11:00P.M. to 7:00 A.M. -On 3/11/25, the 7:00 to 3:00 P.M. shift, treatment was documented as completed. Review of the resident's progress notes, showed no documentation related to the resident's hematuria. Observation and interview on 3/11/25 at 7:07 A.M., showed the resident lay in bed with an indwelling catheter hanging on the resident's bedframe. There was a small amount of dark, maroon colored urine in the resident's urinary catheter bag, The resident said the night shift Certified Nursing Assistant (CNA) just emptied his/her catheter bag, The resident said he/she has a history of having hematuria because he/she is on a blood thinner. At 8:11 A.M., the resident's urinary catheter bag was filled with approximately 200 milliliters (ml) of dark maroon colored urine with stringy clots in the catheter tubing. At 12:15 P.M., the resident's urinary catheter bag was filled with approximately 300 mls of dark, maroon, colored urine and small clots in the catheter tubing. The resident said he/she is worried his/her catheter will become occluded because it has happened to him/her before and he/she had to have two giant bags of fluid connected to his/her catheter to irrigate his/her bladder while in the hospital. During an interview on 3/12/25 at 9:00 A.M., LPN W said he/she was assigned to the resident on 3/11/25 on the 7:00 to 3:00 P.M. shift. LPN W signed off on the urinary catheter flush treatment on the 7:00 A.M. to 3:00 P.M. shift. LPN W said he/she was not aware of the resident's hematuria on 3/11/25. LPN W remembered he/she did not complete the urinary catheter flush and should not have documented it was completed when it was not. LPN W just thought the evening shift could do it. 3. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she expected staff to obtain urinary catheter orders for residents who have catheters while they are a resident at the facility. It is unacceptable for staff document a treatment order completed when it is not. Once staff observe any type of dysfunction or change in the resident's urine, the physician should be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one resident had all the required physician's orders and documentation of oxygen usage (Resident #16), and failed to ensure one resident's discontinued physician's orders related to oxygen usage were reinstated after a hospital stay (Resident #2). The sample was 21. The census was 93. Review of the facility's oxygen therapy policy, dated 2017, showed: -Policy: Residents are assessed to ensure their respiratory needs are being met. Residents identified in need of oxygen therapy have interventions/equipment implemented in accordance with the resident-centered care plan; -Procedure: Obtain physician orders for specifics regarding administration. Administration of the oxygen therapy is completed by nursing associates. Document assessment of resident oxygen status, tolerance, vital signs, and respiratory status in medical record as necessary. Follow manufacturer recommendations for safe handling, cleaning, humidification, storage, and dispensing, maintenance of equipment in accordance with the manufacturer specifications and consistent with federal, state, and local laws and regulations. 1. Review of Resident #16's medical record, showed: -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), and lobar pneumonia (type of pneumonia affecting one or more sections of the lungs). Review of the resident's electronic physician order sheet (POS) and administration record for March 2025, showed: -An order, dated 1/25/25, for oxygen 2 liters (L) as needed (PRN) for shortness of breath; -No orders for changing the resident's oxygen tubing or humidifier; -No documentation the resident's oxygen was administered in March 2025. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/25, showed: -Cognitively intact; -Oxygen not documented as received. Review of the resident's care plan, in use at the time of survey, showed: -No documentation related to the use of oxygen. Observation and interview on 3/11/25 at 8:14 A.M., showed an oxygen concentrator next to the foot of the resident's bed. A piece of tape on the oxygen tubing dated 1/19/25 and initialed, SN. The nasal cannula was uncovered and tucked underneath the handle of the oxygen concentrator. During an interview, the resident said he/she uses his/her oxygen every night because he/she cannot breathe. Observation and interview on 3/12/25 at 8:12 A.M., showed an oxygen concentrator next to the foot of the resident's bed. A piece of tape on the oxygen tubing dated 1/19/25 and initialed, SN. The nasal cannula was uncovered and tucked underneath the handle of the oxygen concentrator, in a different position than the day before. During an interview, the resident said he/she used his/her oxygen again last night, as always. The resident did not know what cleaning was done with the oxygen tubing. Observation on 3/13/25 at 6:29 A.M., showed the resident in bed with nasal cannula on and oxygen concentrator running at 3 L per minute. The tape on the oxygen tubing dated 1/19/25 and initialed, SN. During an interview on 3/13/25 at 9:19 A.M., Certified Nursing Assistant (CNA) H said the resident uses his/her oxygen every night. He/She sometimes uses his/her oxygen in the morning if he/she is having shortness of breath. During an interview on 3/14/25 at 8:52 A.M., Certified Medication Technician (CMT) J said the resident uses oxygen at night and as needed. During an interview on 3/13/25 at 12:52 P.M., Licensed Practical Nurse (LPN) I said the resident wears his/her oxygen on and off. During an interview on 3/13/25 at 12:52 P.M., LPN I said residents have physician orders specifying their oxygen use. Residents receiving continuous oxygen should have physician orders for cleaning the oxygen tubing and humidifier. Humidifiers and tubing should be cleaned weekly. When tubing or humidifiers are cleaned, they should be dated and initialed by the staff who completed the task. Residents who use oxygen on a PRN basis do not need to have orders to clean or change the tubing or humidifier because the nurse has to bring the oxygen concentrator into the resident's room for PRN use, and it does not remain in the room when the resident stops using it. When a nurse administers a resident's oxygen, they should mark it as administered on the administration record. 2. Review of Resident #28's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included COPD, acute respiratory failure, and diabetes. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Resident has COPD and requires oxygen at 2 L via nasal canula (NC); -Goal: Resident will breathe easy without signs or symptoms of respiratory distress evidenced by oxygen saturations between 93-98%; -Approach: Monitor/Document respiratory status and oxygen saturations every shift and as needed. Monitor and report signs of respiratory distress. Review of the resident's progress notes, showed: -A progress note, dated 3/1/25 at 5:29 P.M., this writer has noted resident on floor and hospital ambulance service was immediately called. Resident had fallen out of bed and is alert. Resident has full cognition to relative baseline. Unable to retrieve vitals due to resident's positioning at this time. Emergency Medical Services (EMS) assisted with resident first aid. Resident has hematoma (collection of blood outside of the blood vessels) to left side of the head. Resident has no issues at this time. Family and attending physician notified; -A progress note, dated 3/3/25 at 9:40 P.M., resident returned to facility at 6:20 P.M. via EMS stretcher from the hospital. Review of the resident's POS, for March 2025, showed: -An order, discontinued on 3/1/25, oxygen at 4 liters/min per nasal cannula every shift; -An order, discontinued on 3/1/25, change oxygen tubing weekly. Once a day on Saturday; -An order, discontinued on 3/1/25, change humidifying jar weekly. Once a day on Saturday; -An order, discontinued on 3/1/25, please keep resident on oxygen at all times; -No active orders for oxygen. Observation on 3/10/25 at 5:07 P.M., showed the resident in his/her bed awake. The resident had a nasal canula in his/her nose which was connected to a concentrator. The concentrator had a humidifier bottle attached to it. The concentrator was set to 3. The nasal canula tubing was dated for 2/23/25. Observations on 3/11/25 at 6:05 A.M. and 10:32 A.M., showed the resident in his/her bed asleep. The resident had his/her nasal canula in his/her nose. The resident's concentrator was on and set to 3. The nasal canula tubing was dated 2/23/25. Observations on 3/12/25 at 7:05 A.M., 8:39 A.M., and 10:34 A.M., showed resident in his/her bed awake. The resident had a nasal canula in his/her nose which was connected to a concentrator. The concentrator had a humidifier bottle attached to it. The concentrator was set to 3. The nasal canula tubing was dated for 2/23/25. Observation on 3/13/25 at 8:47 A.M., showed the resident in his/her bed asleep. The nasal canula tubing had been changed and was dated for 3/13/25. The concentrator was on and set to 3. During an interview on 3/14/25 at 7:43 A.M., CNA D said residents' oxygen tubing and concentrator humidifier bottles should be changed according to the physician's orders and facility policy. If a resident's orders are discontinued when they go out to the hospital, he/she would expect the treatments to stop or for the nurse to obtain new orders. 3. During an interview on 3/14/25 at 9:14 A.M., LPN A said any resident who uses oxygen should have physician orders to change the oxygen tubing and humidifier, regardless of whether oxygen use is continuous or PRN. Oxygen tubing and humidifiers should be cleaned or changed by nurses weekly. If a resident goes out to the hospital, when they return, their physician orders should be reviewed. If a resident had orders for oxygen prior to going to the hospital the nurse who admits the resident back to the facility should ensure oxygen orders are re-obtained by the physician or that the orders should be stopped. The oxygen rate on the concentrator should match the physician's orders. The care plan should reflect the resident's current physician's orders. 4. During an interview on 3/14/25 at 11:21 A.M., the Administrator and Director of Nursing (DON) said they would expect residents' oxygen tubing and humidifier to be changed according to the facility's policy and physician's orders. Oxygen rates should be followed according to the physician's orders and be accurate on the resident's care plan. If a resident goes out to the hospital, their orders should be re-evaluated upon the resident's arrival back to the facility. If a resident's orders are discontinued, they would expect those treatments to be stopped or for the nurse to call the physician to obtain new orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pain management for three of 21 sampled residents who experienced pain, consistent with professional standards of practice (Residents #195, #1, and #7). The census was 93. Review of the facility's Pain Management policy, dated 2022, showed: -Policy: Benedictine considers pain that impacts the function or quality of life of our residents a significant concern and evaluation will be ongoing. The Benedictine interdisciplinary team will strive to manage pain in residents experiencing mild to debilitating pain to the point where functionality and quality of life can be increased. Benedictine clinicians will be aware of the unique needs and circumstances of residents from different age groups, ethnic and cultural backgrounds. Current and historical medical diagnoses including substance use disorders and mental health diagnoses will be considered when implementing an effective pain management plan of care; -Procedure: Evaluate the resident for verbal and nonverbal signs and symptoms of pain. Encourage the resident to tell the care giver about the pain. Educate the resident on the importance of reporting pain and the negative effects of pain, including but not limited to: Physical pain, emotional pain, social pain, spiritual pain, and financial pain. Identify the exacerbating factors and the type(s) of pain if possible, acute and/or chronic. Include the resident and responsible party in the development of pain management interventions. Review with the inter disciplinary team to develop and implement individualized measures to promote comfort. Communicate interventions to staff and provide training as needed. Provide resident and responsible party education as needed. Reevaluate pain and document: at regular intervals according to the needs of the resident, with each new report of pain, at appropriate intervals after pharmacological or non- pharmacological interventions. Review and revise the plan of care as necessary. Review of the facility's administering medication policy, dated 2020, showed: -Policy: To administer resident medications in a safe and accurate manner that will ensure the six rights of patient identification for administration; right resident, right medication, right dose, right time, right route, and right documentation; -Procedure: Medications are administered within their prescribed time. Sign medication out in electronic record at time of medication administration. Review of the facility's call light policy, undated, showed: -Purpose: The purpose of this procedure is to ensue timely responses to resident needs and requests. Residents are provided with a means to call for staff assistance through a communication system that directly notifies a staff member or a centralized work station; -Procedure: Calls for assistance may be triaged and answered as soon as possible based on immediate needs. 1. Review of Resident #195's, face sheet, undated, showed: -An admission date of 3/6/25; -Diagnoses that included: Right hip fracture, right joint replacement, emphysema (a lung disease), history of falling, and high blood pressure. Review of the resident's record showed: -No baseline care plan available for review. Review of the resident's physician order sheets (POS), dated, March, 2025, showed: -An order, dated, 3/6/25, Oxycodone (pain medication) 5 milligrams (mg), one tablet, every four hours as needed. Observation on 3/10/25 at 1:28 P.M., showed the resident's call light was on, and the resident was heard from the hallway shouting, Ow! I am in so much pain. I need a pain pill. At 1:30 P.M., the call light board located on the [NAME] Hall showed the resident's call light was on for 27 minutes and three seconds. At 1:32 P.M., the resident's call light was off. At 1:35 P.M., the resident's family member came out of the resident's room and walked to the [NAME] nurses' station and asked for a pain pill for the resident and said the resident was in a lot of pain. Observation and interview on 3/10/25 at 1:40 P.M., showed the resident sat in his/ her wheelchair and said he/she was in excruciating pain. The resident was rubbing his/her right leg and grimacing. The resident said he/she recently had hip surgery on 3/3/25 and required pain medication every four hours. The resident said he/she has been waiting for someone to answer his/her call light for over 30 minutes and it seemed like he/she had been waiting forever. Licensed Practical Nurse (LPN) N entered the room with a medicine cup and placed the medicine cup with a pill in it on the bedside table that was positioned in front of the resident and said, Here is your pain pill. LPN N did not observe the resident take the medication before he/she left the room. Review of the resident's progress notes showed: -On 3/10/25 at 1:45 P.M., the resident's family member came to the nurses' station and said that the resident was experiencing pain. Pain was noted to be seven out ten and PRN (as needed) oxycodone was administered at approximately 1:40 P.M. During observation and interview on 3/10/25 at 6:10 P.M., the resident lay in bed. The resident said he/she fell while out in the community and sustained a fractured right hip. The resident said the orthopedic surgeon (a bone surgeon) said his/her hip was shattered and required a lot of fixing. The resident said he/she was having a lot of pain. The resident said he/she currently uses a wheelchair, and therapy is assisting him/her to walk. The resident requires assistance from staff to use the bathroom The resident said there frequently is a delay in getting pain medication from the nurses. During an interview on 3/11/25 at 10:30 A.M., Certified Nursing Assistant (CNA) F said call lights are to be answered within 15 minutes. During an interview on 3/14/25 at 9:15 A.M., LPN A said residents' call lights are to be answered within 15 minutes. Waiting 40 minutes for pain medication is unacceptable, and the resident must feel like it is an eternity waiting so long. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/27/25, showed: -admission date of 1/21/25; -Cognitively intact; -Receives scheduled and PRN pain medication; -Experiences pain frequently; -Pain occasionally interferes with his/her sleep; -Pain occasionally interferes with therapy activities; -Pain rarely interferes with day to day activities; -Pain verbal descriptor scale: Moderate. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident experiences pain and discomfort related to chronic pain; The residents baseline pain is 4 out of 10; -Interventions: When the resident expresses pain, rest, repositioning, and medication administration are interventions used. Review of the resident's face sheet, undated, showed diagnoses that included: Osteomyelitis (bone infection) to the sacrum (tailbone), stage 4 pressure wound (a wound that has full thickness skin and tissue loss caused by extended pressure) to the sacrum, incomplete quadriplegia (paralysis of both arms and legs), chronic pain syndrome, and depressive disorder. Review of the resident's Medication Administration Record (MAR), dated 3/1 through 3/14/25, showed: -An order, dated, 2/10/25, hydrocodone-acetaminophen (narcotic pain medication) 5/325 mg administer one tablet every six hours, hold for sedation; -Scheduled times: 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. -On 3/3/25; Scheduled time: 12:00 A.M.; Charted: 3/3/25 at 1:34 A.M.; Reason: Administered late; -On 3/3/25: Scheduled time: 6:00 A.M.; Charted: 3/3/25 at 7:29 A.M.; Reason: Administered late; -On 3/9/25; Scheduled time: 12:00 P.M.; Charted: 3/9/25 at 11:36 A.M.; Reason: Not administered, the resident was sleeping; -On 3/9/25: Scheduled time: 6:00 P.M.; medication documented as given; -On 3/11/25; Scheduled time: 12:00 A.M.; Charted: 3/11/25 at 1:11 A.M.; Reason: Administered late; -On 3/11/25: Scheduled time: 6:00 A.M.; Charted: 3/11/25 at 8:16 A.M.; Reason: Administered late. -An order dated, 1/27/25, baclofen (muscle relaxer used to treat painful muscle spasms) 20 mg, give one tablet every eight hours; -On 3/1/25: Scheduled time: 8:00 A.M.; Charted date: 3/1/25 at 10:08 A.M.; Reason: Administered late; -On 3/2/25: Scheduled time: 8:00 A.M.; Charted date: 3/2/25 at 9:44 A.M.; Reason: Administered late; -On 3/4/25: Scheduled time: 8:00 A.M.; Charted date: 3/4/25 at 9:16 A.M.; Reason: Administered late; -On 3/5/25: Scheduled time: 4:00 P.M.; Charted date: 3/5/25 at 5:10 P.M.; Reason: Administered late; -On 3/8/25: Scheduled time: 8:00 A.M.; Charted date: 3/8/25 at 1:27 A.M.; Reason: Administered late; -On 3/9/25: Scheduled time: 8:00 A.M.; Charted date: 3/9/25 at 9:38 A.M.; Reason: Administered late; -On 3/10/25: Scheduled time: 8:00 A.M.; Charted date: 3/10/25 at 10:49 A.M.; Reason: Administered late; -On 3/11/25: Scheduled time: 4:00 P.M.; Charted date: 3/11/25 at 6:12 P.M.; Reason: Administered late; -On 3/12/25: Scheduled time: 8:00 A.M.; Charted date: 3/12/25 at 10:25 A.M.; Reason: Administered late; -On 3/14/25: Scheduled time: 12:00 A.M.; Charted date: 3/14/25 at 2:11 A.M.; Reason: Administered late. During an interview on 3/10/25 at 10:50 P.M., the resident said he/she has been paralyzed for at least 30 years. The resident said he/she was admitted to the facility because he/she had developed a pressure wound to his/her tailbone at home. The resident said he/she has been on pain medication which include hydrocodone with acetaminophen and baclofen for years. He/She has muscle spasms and pain in his/her back that he/she can feel. The resident said he/she is on routine pain medication and muscle relaxers currently at the facilty. The staff are frequently late with his/her muscle relaxer and narcotic pain medication. The resident said that on 3/9/25, the resident was not given his/her pain medication at noon because the staff said he/she was sleeping. When he/she asked the nurse about his/her pain medication, he/she was informed that he/she would have to wait until it was due again. He/She went without pain medication for 12 hours. The resident's pain level is a six out of ten when he/she has to wait for pain medication. During an interview on 3/14/25 at approximately 10:00 A.M., Certified Medication Technician (CMT) T said medications that have a specific time listed on the MAR should be administered one hour before or one hour after when the medicine is due. The nurses administer narcotic pain medications. During an interview on 3/14/25 at 10:32 A.M., LPN U said scheduled medications are to be given one hour before or one after the time it is due. If a resident was sleeping at the time a pain medication was due, LPN U said he/she would go back within an hour and see if the resident was awake and administer the medication at that time. Staff should not inform the resident that they will have to wait until the next dose is due because that is too long to wait. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said depending on what was happening on the floor, staff are expected to answer call lights in a reasonable time frame. The resident should not wait 40 plus minutes for pain medication. The staff are expected to give scheduled medications one hour before or one hour after the medication is due. If the resident were sleeping at the time of the scheduled medication, she would expect staff to go in and reassess within an hour to determine if the resident still requires the pain medication. The resident should not wait until the next time the pain medication is due. 3. Review of Resident #7's admission MDS, dated [DATE], showed: -admit date of 12/19/24; -Cognitively intact; -Diagnoses included end stage renal disease, congestive heart failure (CHF), and displaced bimalleolar fracture (ankle injury that involves breaks in both the medial and lateral malleolus bones, located at the ends of the tibia and fibula) of right lower leg. Review of the resident's care plan, in use at the time of the survey, showed: -The care plan did not address the resident's pain management. Review of the resident's POS, in use at the time of the survey, showed: -An order dated 1/8/25, dialysis three times a week; -An order, dated 3/7/25, apply cavilon (barrier film) skin sealant to unburst blister daily; -An order, dated 3/7/25, right heal wound, clean with normal saline, calcium alginate (wound dressing) and ABD (gauze pad), wrap with kerlix (gauze roll), change daily, and as needed if soiled, saturated, or dislodged; --An order, dated 12/31/24, hydrocodone-acetaminophen, 5-325 mg, one to two tablets taken orally, every four hours as needed for pain. Review of the resident's MAR, dated 3/1/25 through 3/11/25, showed: -The resident did not receive his/her PRN pain medication at all in the month of March. Observation on 3/11/25 at 7:52 A.M., showed the resident seated in his/her wheelchair in his/her room. The resident's family member was standing beside him/her. The Wound Nurse was changing the dressing on the resident's right heel wound. As the Wound Nurse lifted the resident's right leg, the resident grimaced and said Ow that hurts. The Wound Nurse did not address the resident's pain and walked out of the resident's room after finishing the dressing change. During an interview on 3/11/25 at 8:04 A.M., the resident's family member said the resident had been complaining to staff of pain in his/her right foot and lower leg. The family member was not sure if the facility was addressing the resident's pain. The resident had not received any pain medication prior to the Wound Nurse completing wound care. During an interview on 3/12/25 at 1:17 P.M., the Wound Nurse said the resident has experienced pain in his/her feet and legs since he/she admitted to the facility. He/She heard the resident say Ow while he/she was performing the dressing change but said the resident's pain was not significant enough to alert the resident's nurse or to provide the resident with pain medication. He/She does have access to resident medications and is able to administer pain medication to the residents. The resident has an as needed pain medication that could be given. During an interview on 3/14/25 at 7:45 A.M., LPN A said if a resident is complaining of pain, nurses should assess the resident and implement interventions for the pain. If the resident is non-verbal, nursing staff should be assessing the resident's body language to determine if the resident is in pain. He/She would expect staff to inform the nurse anytime a resident reports pain. Any time a resident experiences pain, it should be documented in the medical records. He/She would expect residents who are in pain to receive pain medication if that is their intervention. Resident #7 shows signs of pain, especially after dialysis. The resident has scheduled and as needed pain medication. 4. During an interview on 3/14/25 at 9:06 A.M., CNA D said if a resident is complaining of pain or showing signs of being in pain, nurses are responsible for assessing the resident and providing an intervention. All staff are to report to the nurse any time a resident reports pain. He/She would expect residents to receive their pain medication if they are in pain. 5. During an interview on 3/14/25 at 11:06 A.M., the DON and Administrator said if a resident is complaining of pain or is showing signs of pain, nurses should assess the pain and take care of it. They would expect all staff to report to the charge nurse if a resident is reporting or showing signs of pain. They would expect any pain to be documented in the residents' medical records. They would expect Resident #7 to have received his PRN pain medication. They would have expected the Wound Nurse to inform the resident's charge nurse of his/her pain.

**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 failed to ensure residents using bed/side rails had adequate and on-going assessments to determine the side rails were appropriate and safe for use, obtained informed consent from the resident and/or responsible party, obtained physician orders per facility policy, and included the use of siderails in the resident's care plan. The facility identified 34 residents with side rails in use. Two of 21 sampled residents (Residents #16 and #52) had side rails but were not properly assessed for side rails. The census was 93. Review of the facility's Chemical and Physical Restraints Policy, revised 8/31/23, showed: -The resident has the right to be free from any physical or chemical restraints not required to treat the resident's condition. Chemical and/or physical restraints are only used as ordered by the physician; -Consent is obtained after a review of the risks/benefits. In order for consent to be obtained, the Interdisciplinary Team (IDT) explains the potential risks and benefits of the options under consideration; -The resident centered care plan indicates the need for chemical/physical restraints; the community uses the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints; -The resident's condition is monitored; -Nursing documentation includes references to resident use of chemical/physical restraints and related behavior monitoring/management; -Nursing documentation should include care plan/progress note references to goals, approaches, and evaluations of strategies related to the chemical/physical restraint. -The IDT engages in a systematic and gradual process towards reducing the restraints. 1. Review of Resident #16's medical record, showed: -Diagnoses included spondylosis (degeneration of the spine) to lumbar and thoracic regions, primary generalized osteoarthritis, weakness, other lack of coordination, and other abnormalities of gait and mobility; -A physician order, dated 1/25/25, for quarter rails for repositioning; -No documentation of consent obtained for the use of side rails, and no documentation of therapy or nursing assessments for the use of side rails completed within the last 12 months. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/25, showed: -Cognitively intact; -Independent with mobility areas: Roll left and right, sit to lying, and lying to sitting on side of bed. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident utilizes quarter rails to promote increased independence and bed mobility; -Approaches included: Assess the resident for risk of injury/entrapment from bed rails prior to installation. Obtain informed consent from resident or resident representative prior to installation. Referral to therapy as needed; -Focus: Resident utilizes bilateral quarter rails/half rails related to decreased strength, decreased endurance, impaired range of motion, to promote self-performance with activities of daily living (ADL) tasks, increased independence, and bed mobility; -Approaches included: Evaluate for alternatives to the use of side rails. Evaluate need for use per facility protocol. Observation on 3/11/25 at 8:14 A.M., showed quarter rails raised bilaterally at the head of the resident's bed. During an interview, the resident said his/her side rails wiggle. He/She hit his/her face on one of the side rails this morning. The side rail on the right side of the bed was loose and wiggled back and forth and side to side, approximately one inch in all directions. Observation on 3/13/25 at 6:29 A.M., showed the resident in bed with quarter rails raised bilaterally at the head of the resident's bed. During an interview on 3/14/25 at 10:10 A.M., the Speech Therapist (ST) said he/she checked with the therapy department and did not find documentation that therapy recently assessed the resident for the use of side rails. 2. Review of Resident #52's medical record, showed: -Diagnoses included spinal stenosis (chronic stiffening of the spinal column), history of falls, high blood pressure, and muscle spasms; -No active physician order for side rails; -A Restraints/Adaptive Equipment Consent recorded on 3/3/25 and left blank; -A Restraints/Adaptive Equipment Use Observation recorded on 3/3/25. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Impairment to both lower extremities with full strength of upper extremities; -Independent with mobility areas: Roll left and right, sit to lying, and lying to sitting on side of bed. Review of the resident's care plan, in use at the time of survey, showed no mention of the resident's use of side rails while residing in the facility. Observation and interview on 3/10/25 at 11:31 A.M., showed the resident resting in bed with circular positioning rails installed on both sides of the bed. The resident said he/she uses the side rails for bed mobility and has had them since admission to the facility. The resident could not remember whether or not he/she had been evaluated for the use of these side rails. During an interview on 3/14/25 at 7:58 A.M. Certified Nursing Assistant (CNA) Q said every resident utilizing side rails on their bed is assessed for proper use of the side rail based on the device type, and a physician order should be obtained based on the assessment findings. Side rails should be included on a resident's care plan to help facility CNAs provide adequate and personalized care to each resident. Resident #52 utilizes the facility's halo rails for bed mobility and positioning. During an interview on 3/14/25 at 7:48 A.M. Certified Medication Technician (CMT) K said residents using any type of side rail at the facility are assessed for the proper use of the device prior to its permanent installation. CMT K said Resident #52 utilizes side rails for positioning and bed mobility, would expect side rails to be included on the resident's care plan, and would expect the resident to have an accompanying physician order. 3. During an interview on 3/14/25 at 9:14 A.M., Licensed Practical Nurse (LPN) A said therapy completes a physical assessment with the resident to determine if they can use side rails. Nurses are responsible for obtaining consent from the resident or their responsible party for the use of side rails. Nurses complete side rail assessments in the resident's electronic medical record and obtain physician orders for the use of side rails. Side rail use should be documented on the resident's care plan. 4. During an interview on 3/14/25 at 8:48 LPN R said all residents in the facility are assessed for the safe and appropriate use of side rails, and those assessments are documented in the medical record. Residents utilizing side rails should also have a physician order specifying the type of rail and the reason for its usage. Initiation of a side rail is made in conjunction with the resident, physical therapy department, nursing staff, and the facility MDS Coordinator. Side rails and justification for their use should be included on the resident's care plan to provide care tailored to each resident's needs. 5. During an interview on 3/14/25 at 10:57 A.M., the facility Administrator and Director of Nursing (DON) said all residents utilizing side rails are required to have a documented assessment completed quarterly and a physician order for the type of rail and its usage. Side rails should be included on a resident's care plan so that staff can provide care tailored to each resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one resident (Resident #194) was free of significant medication error by not obtaining the residents prescribed antibiotic and antiviral medication in a timely manner. The sample size was 21. The census was 93. Review of the facility's Administrating Medications policy, revised, 8/31/23, showed: -Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider; -Procedure: Medications are administered in accordance with the orders and within their prescribed times; The person preparing or administering the medication will contact the provider in if there are questions or concerns regarding the medication; With any irregularities, appropriate notifications will be completed for clarification. Review of the facility's Medication Ordering, Receiving and Storage policy, revised July, 2016, showed: -Emergency pharmacy services are available 24 hour basis; The pharmacy phone number is posted at each of the nurses' station; A list of medications and supplies approved for inclusion in the emergency kit or system shall be posted on the emergency system and available to staff. Emergency medications are only administered with a valid provider order. Review of Resident #194's face sheet, undated, showed: -An admission date of 3/9/25 at 1:41 P.M.; -Diagnoses included clostridium difficile (C-diff, an infection in the intestine that causes diarrhea), bronchitis (inflammation of the lungs), repeated falls, Covid-19, influenza A (flu) with respiratory manifestations, orthostatic hypotension (low blood pressure that occurs when sitting or standing), incontinence of feces. Review of the medical record, showed no baseline care plan. Review of the resident's progress notes, showed: -On 3/9/25 at 3:22 P.M., the resident was admitted to room [ROOM NUMBER], with a diagnosis of Influenza A, Covid-19, and c-diff. Monitoring will continue as the resident will be on contact isolation for c-diff and respiratory isolation. Medications faxed to pharmacy and available demographics for the attending physician to use for medicine reconciliation. -On 3/10/25 at 1:45 A.M., this writer has not been able to get in touch with the attending physician to verify medications. -No further documentation related to the resident's medication was documented. Review of the resident's Physician Order Sheet (POS), dated March, 2025, showed: -An order, with a start date, 3/10/25, no stop date, Vancomycin (antibiotic used to treat c-diff) 125 milligrams (mg), give every six hours, no diagnosis listed. -An order, with a start date, 3/11/25, stop date 3/11/25, oseltamivir (antiviral medication used to treat the flu) 30 mg capsule, give twice a day, no diagnosis listed; Review of the resident's prescription orders, showed: -An order, receive date, 3/10/25, start date, 3/10/25, Vancomycin 125 mg capsule give one capsule every six hours; -Transmission status: New order e-prescription sent successfully on 3/10/25 at 9:03 A.M.; -Pharmacy filled the order on 3/10/25 at 3:30 P.M.; -An order, receive date 3/10/25, start date, 3/11/25, oseltamivir 30 mg capsule, give twice a day; -Transmission status: New order e-prescription sent successfully on 3/10/25 at 9:02 A.M.; -Pharmacy filled the order on 3/10/25 at 3:30 P.M. Review of the resident's Medication Administration Record (MAR), dated 3/1 through 3/14/25, showed: -An order, start date 3/10/25, Vancomycin 125 mg capsule give one capsule every six hours, dose times 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.; -On 3/10/25 at 11:02 A.M. and 5:16 P.M., Vancomycin 125 mg documented as not administered, medication not available; -On 3/11/25 at 1:36 A.M. and 6:44 A.M., Vancomycin 125 mg documented as not administered, medication not available. -An order, start date 3/11/25, oseltamivir 30 mg capsule, give twice a day; dose times, 6:00 A.M. through 10:30 A.M. and 3:00 P.M. through 7:00 P.M. -On 3/11/25 at 7:25 A.M., oseltamivir 30 mg documented as not administered, medication not available. Observation and interview on 3/10/25 at 1:45 P.M., showed the resident lay in bed. The resident said he/she was at home and fell and then went to the hospital. The resident said he/she arrived to the facility on 3/9/25 around 2:00 or 3:00 P.M. The resident said he/she is incontinent of stool but had been changing him/herself and brought his/her own incontinent briefs. He/She was not told what type of infection he/she had but had noticed isolation gowns and masks were hanging on the outside of the door to be worn by staff. The resident did not receive any of his/her medications and felt as though he/she was just left alone in the room like in a jail cell. During an interview on 3/13/25 at 12:50 P.M., Licensed Pratical Nurse (LPN) N reviewed the medication orders for the resident and said he/she wasn't sure why the oseltamivir had a start date of 3/11/25 and the Vancomycin had a start date of 3/10/25 when the resident was admitted on [DATE] in the afternoon. LPN N said it is a challenge to get medications on the weekend because the pharmacy is located in another city. The emergency pull kit does not readily have oseltamivir, but Vancomycin was available in the emergency kit. LPN N went to the emergency kit computer on the [NAME] medication room and verified the Vancomycin is available in the emergency kit, but not the oseltamivir. LPN N said the inventory varies in the emergency kit and the Vancomycin may not have been filled in the emergency kit on those given days that the resident did not receive the medications. A combination of having the start date a day or two after the resident arrives and the lack of consistency when the medications arrive delayed the resident in getting his/her medication. Many residents complain frequently about not receiving their medication or receiving their medications late. The start date and times should be at minimum the next morning. If medications are not available, the nurse needs to keep calling the pharmacy and the physician. The Medical Director can be called if there are problems reaching the resident's physician. There was some confusion about what diagnosis the resident had, so that have may have played a part in the delay of medication. Any communication with the pharmacy or the physician should be documented in the resident's progress notes. Most of the agency staff do not have access to the emergency kit and they would have a ask a regular staff member to obtain the medications. During an interview on 3/13/25 at 2:27 P.M., the Director of Nurses (DON) said the facility tried to stop the resident from coming on 3/9/25, which was a Sunday afternoon because they knew there would be a delay in getting the resident's medications on the weekend. The family insisted the resident be admitted to the facility on [DATE]. The staff have difficulty obtaining medication in a timely manner due to the location of the pharmacy. The staff are expected to have all medications start as soon as possible, utilize the emergency kit, and call the pharmacy with any problems or delays in the residents getting their medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adequately develop and implement infection control practices to prevent the spread of infection caused by transmission-based conditions. The facility also failed to adequately follow its Enhanced Barrier Precautions (EBP) Policy (Residents #194 and #7). This failure had the potential to affect all residents and staff in the facility. The census was 93. Review of the facility's Enhanced Barrier Precautions policy, revised 4/1/24, showed: -Enhanced Barrier Precautions is a strategy in nursing homes to decrease transmission of CDC-targeted and other epidemiologically important multidrug-resistant organisms (MDROs, an infection resistant to common treatment therapies); -EBP will be used for residents actively infected or colonized with CDC-targeted and other epidemiologically important MDROs; -Additionally, residents at risk for MDROs, specifically those with an indwelling medical device and/or chronic wounds requiring a dressing will be required to use EBP; -EBP should be used during high-contact care activities for any resident infected or colonized with an MDRO, chronic wounds, indwelling medical devices, or an outbreak of Group A Streptococcus (a type of resistant bacteria that can cause a variety of infections). Gloves and gown should be donned prior to providing care to a resident on EBP, and PPE (personal protective equipment) should be removed prior to caring for another resident; -Clear signage for precautions should be posted at the resident's door and appropriate PPE should be made available in the resident's room. Review of the facility's Contact Precautions policy, revised 9/23, showed: - Contact Precautions are used when diseases are transmitted by contact with the resident or the resident's environment. Residents with disease caused by organisms that have been demonstrated to cause heavy environmental contamination will be placed on Contact Precautions; -Contact Precautions are used, in addition to Standard Precautions, to prevent nosocomial (infection originating in a hospital or other care environment) spread of organisms that can be transmitted by direct resident contact or by indirect contact of environmental surfaces or contaminated resident care equipment; -Contact precautions should be used when a resident has an acute infection with Methicillin-Resistant Staphylococcus Aureus (MRSA, an antibiotic resistant infectious organism) or Vancomycin-Resistant Enterococcus (VRE, a bacteria resistant to the common antibiotic Vancomycin); -Contact precautions should be used if a resident has Clostridium Difficile (C-Diff, a bacteria causing inflammation of the colon, has uncontained wound drainage from an infected wound, has diarrheal or fecal incontinence, or has another organism determined by the facility's Infection Preventionist (IP) and Medical Director; -Procedures for Contact Precautions include hand hygiene prior to PPE donning, PPE is donned prior to entering room and should include a gown and gloves, the use of a mask or face shield if indicated based on the infection and care provided, and performing hand hygiene after the removal of PPE. 1. Review of Resident #194's face sheet, undated, showed: -Diagnoses included clostridium difficile, bronchitis (inflammation of the lungs), repeated falls, Covid-19, influenza A (flu) with respiratory manifestations, orthostatic hypotension (low blood pressure that occurs when sitting or standing) and incontinence of feces. During the entrance conference on 3/10/25 at approximately 10:00 A.M., the resident was identified by the Administrator as requiring transmission-based precautions (TBP, extra infection control practices, used in addition to standard precautions, to prevent the spread of specific infectious agents that are transmitted through contact, droplets, or airborne routes). Review of the resident's progress notes, dated 3/9/25 at 3:22 P.M., showed the resident was admitted with a diagnosis of influenza A, Covid-19, and c-diff. Monitoring will continue as the resident will be on contact isolation for c-diff and respiratory isolation. Observation and interview on 3/10/25 at 1:45 P.M., tshowed he outside of the resident's door had an EBP sign with a caddy hanging filled with PPE supplies. The resident's door was closed. The resident lay in bed and said he/she was at home and fell and then went to the hospital. The resident said he/she arrived to the facility on 3/9/25. The resident said he/she is incontinent of stool but had been changing him/herself and brought his/her own incontinence briefs. The resident denied having a fever or coughing. He/She was not told what type of infection he/she had, but had noticed isolation gowns and masks were hanging on the outside of the door to be worn by staff. Observation on 3/11/25 at 6:40 A.M., showed the resident's door had an EBP sign posted on the outside of his/her door with a caddy filled with PPE supplies. Observation on 3/12/25 at 7:21 A.M., showed the resident's door had an isolation sign: -Droplet Contact Precautions and the word droplet was crossed off with a black X and the word contact was circled. The sign showed instructions for the staff to clean hands when entering and exiting, apply isolation gowns, N95 mask (a specialized mask worn for airborne infections) eye protection (goggles or face shield), and gloves. Keep door closed. Use resident dedicated or disposable equipment. Clean and disinfect share equipment. Observation on 3/12/25 at approximately 8:50 A.M, showed the resident's door was open, and the same droplet contact isolation sign with the word droplet crossed off with a black X and the word contact was circled. The sign was posted on the outside of the resident's door with a caddy filled with PPE. Certified Nurse Aide (CNA) M entered the resident's room with the resident's breakfast tray. The door remained open. CNA M approached the resident as he/she lay in bed and CNA M said, Good morning to the resident. CNA M then opened items for the resident that were on the resident's breakfast tray. CNA M left the room without sanitizing his/her hands and then closed the resident's door. CNA M did not wear an isolation gown, gloves, N-95 mask, or eye protection while in the resident's room. Observation on 3/13/24 at 10:10 A.M., and 3/14/25 at 7:46 A.M., showed the resident's door was open and an EBP sign was posted on the outside of the door with a caddy filled with PPE supplies. During an interview on 3/13/25 at 10:30 A.M., Licensed Practical Nurse (LPN) N said the resident was tested for Influenza A and Covid-19 on 3/12/25 and the resident was negative, therefore the droplet precautions were removed. The resident does not have current symptoms of a respiratory infection. The resident's contact precautions related to c-diff were removed because the resident is no longer having diarrhea. LPN N was not sure why the EBP sign was on the door because the resident does not have medical reasons indicating the use of EBP. Staff should follow what the isolation sign says on the door related to PPE usage and hand hygiene. The resident's door should remain closed when on droplet and contact precautions. The staff should wear the PPE that is listed on the sign for droplet and contact precautions when entering the room and providing direct care. EBP is only used when staff is providing direct care to the resident. During an interview on 3/14/25 at 9:05 A.M., Lead CNA G said all staff are to follow exactly what is posted on the resident's door related to infection control. During an interview on 3/13/25 at 2:27 P.M., the Director of Nursing (DON) said she was also the Infection Preventionist (IP). Staff are to follow what is on the signs that are posted on the door. There was some confusion on what the resident's diagnoses were when the resident was admitted from the hospital to the facility. The resident should have been on droplet and contact isolation when he/she arrived to the facility until further testing and assessments were completed. Once the droplet precautions were removed, the resident was on contact precautions. She expected appropriate signage related to the resident's infectious process to be accurate. She wasn't sure where to find the appropriate signage for the resident's precautions so that is why the droplet contact precautions sign was used and edited to read only contact isolation. Staff are expected to wear the isolation gown, N-95 mask, gloves, and eye protections when entering the resident's room, perform hand hygiene before entering and exiting the resident's room, and the resident's door should be closed when the resident is on contact precautions. C-diff can be easily spread. Once the isolation precautions were lifted on 3/13/25, the resident was not to be on any type of precautions, on including EBP. 2. Review of Resident #7's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included end stage renal disease and congestive heart failure(CHF). Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Resident is at risk for pressure ulcers due to impaired mobility; -Goal: Resident's skin will remain intact; -Approach: conduct a systematic skin inspection weekly and as needed. Pay particular attention to the bony prominences. Report any signs of skin breakdown (sore, tender, red, or broken areas). Use moisture barrier product to perineal area; -Problem: resident currently on Dialysis: dialysis scheduled three times per week. Left upper arm fistula (an abnormal connection between two body parts). -Goal: resident will exhibit no shortness of breath, chest pain, edema (fluid retention), elevated blood pressure, infection, itchy skin or bleeding. Resident will tolerate dialysis and fatigue will be minimal after sessions; -Care plan does not mention EBP precautions for close contact care due to dialysis and skin wounds. Review of the resident's POS, in use at the time of the survey, showed: -An order dated 1/8/25, Dialysis three times a week; -An order, dated 3/7/25, apply cavilon (barrier film) skin sealant to unburst blister daily; -An order, dated 3/7/25, right heal wound, clean with normal saline, calcium alginate (wound dressing) and ABD, wrap with kerlix (gauze), change daily, and as needed if soiled, saturated, or dislodged. Observation on 3/10/25 at 11:08 A.M., showed the door to the resident's room had an EBP sign along with PPE storage. Observation on 3/11/25 at 7:52 A.M., showed the Wound Nurse seated on the ground in front of the resident, who was in his/her wheelchair. The Wound Nurse wore gloves but no gown or mask. The Wound Nurse lifted the resident's right foot towards him/her to take the resident's old wound dressing off his/her right heel. He/She changed the dressing, took his/her gloves off, grabbed a marker and dated the resident's wound dressing and then set down the resident's foot. With ungloved hands, the Wound Nurse picked up the resident's sock and put it back on the resident's right foot. He/She then repositioned the resident's right foot back on the wheelchair foot rest. The Wound Nurse then got up and left the resident's room. During an interview on 3/14/25 at 7:48 A.M., LPN A said if a resident is on EBP precautions a gown and gloves should be worn during close contact care. He/She said a sign should be on the resident's door if EBP is required. He/She said the resident requires EBP due to his/her dialysis and wounds. During an interview on 3/14/25 at 9:07 A.M., CNA D said if a resident is on EBP, a sign is on their door and PPE is kept outside the resident's room. He/She said PPE should be worn during close contact care. He/She said the resident requires EBP due to dressing changes and his/her dialysis site. During an interview on 3/14/25 at 11:25 A.M., the Administrator and the DON said PPE should be worn during close contact care if the resident is on EBP. They said the resident requires EBP and staff should be wearing PPE when providing close contact care to him/her. 3. During interview on 3/14/25 at 10:57 A.M., the Administrator and DON, who serves as the facility IP, said they expected all staff to don gown and gloves when entering the room of a resident on contact precautions in order to limit the spread of infection. A mask and face shield may not be indicated based on the infectious organism and level of care provided. Staff are expected to consult the precautions signage placed on a resident's door to determine what PPE is necessary for the activity. Residents with chronic wounds or an indwelling medical device are automatically placed on EBP, and staff should wear a gown and gloves when providing care for these residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify possible areas of entrapment to reduce the risk of accidents for two residents (Residents #16 and #52). The facility identified 34 residents with side rails in use. The census was 93. Review of the FDA (Federal Drug Administration) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed: -It is suggested that facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment; -The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement; -Bed rails (commonly used synonymous terms are side rails, bed side rails, grab bars and safety rails), may be an integral part of the bed frame or they may be removable and at times are used either as a restraint, a reminder or an assistive device; -There are seven potential entrapment zones in hospital beds. Review of the facility's Chemical and Physical Restraints policy, revised 8/31/23, showed: -Purpose: Resident are provided services to attain and maintain the highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience, and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints; -No documentation regarding the facility's procedures for inspecting bed/side rails to identify possible areas of entrapment. 1. Review of Resident #16's medical record, showed: -Diagnoses included spondylosis (degeneration of the spine) to lumbar and thoracic regions, primary generalized osteoarthritis, weakness, other lack of coordination, and other abnormalities of gait and mobility; -A physician order, dated 1/25/25, for quarter rails for repositioning; -No documentation of maintenance inspection for possible areas of entrapment. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/25, showed: -Cognitively intact; -Independent with mobility areas: Roll left and right, sit to lying, and lying to sitting on side of bed. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident utilizes bilateral quarter rails/half rails related to decreased strength, decreased endurance, impaired range of motion, to promote self-performance with activities of daily living (ADL) tasks, increased independence, and bed mobility; -Approaches included: Assess the resident for risk of injury/entrapment from bed rails prior to installation. Zones of entrapment have been evaluated to meet regulatory requirements. Observation and interview on 3/11/25 at 8:14 A.M., showed quarter rails raised bilaterally at the head of the resident's bed. During an interview, the resident said his/her side rails wiggle. He/She hit his/her face on one of the side rails this morning. The side rail on the right side of the bed was loose and wiggled back and forth and side to side approximately one inch in all directions. Observation on 3/13/25 at 6:29 A.M., showed the resident in bed with quarter rails raised bilaterally at the head of the resident's bed. 2. Review of Resident #52's medical record, showed: -Diagnoses included spinal stenosis (chronic stiffening of the spinal column), history of falls, high blood pressure and muscle spasms; -No documentation of maintenance inspection for possible areas of entrapment. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Impairment to both lower extremities with full strength of upper extremities; -Independent with mobility areas: Roll left and right, sit to lying, and lying to sitting on side of bed. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's use of side rails. Observation and interview on 3/10/25 at 11:31 A.M., showed the resident in bed with circular positioning rails installed on both sides of the bed. The resident said he/she uses the side rails for bed mobility and has had them since admission to the facility. 3. During an interview on 3/14/25 at 9:14 A.M., Licensed Practical Nurse (LPN) A said maintenance staff install and inspect the side rails on resident beds. 4. During an interview on 3/13/25 at 1:57 P.M., the Environmental Services Director said maintenance staff install side rails on resident beds. They have not been inspecting side rails on a routine basis. 5. During an interview on 3/13/25 at 1:52 P.M., the Executive Director said the facility has not been completing routine inspections of side rails. Side rails should be inspected on a routine basis to obtain gap measurements and to ensure side rails are secure. Side rails inspections should be completed by maintenance staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for three out of four medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 93. Review of the facility's Controlled Substance Storage policy, revised, March, 2017, showed: -Policy: Medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including, refrigerated items is conducted by two licensed nurses and is documented on the shift verification of controlled substance count. 1. Review of [NAME] Hall narcotic book count sheets, dated , 3/1 through 3/11/25, showed: -Eleven out of 30 shifts have no nurse signature on the shift change count; -Four out of 30 shifts only have one nurse signature on the shift change count; -No documentation that a shift change count was completed 3/8/25 through 3/11/25. 2. Review of the [NAME] narcotic book count sheets, dated, 3/1 through 3/11/25, showed: -Seven out of 30 shifts have no nurse signature on the shift change count; -Eleven out of 30 shifts only have one nurse signature on the shift change count; -No documentation that a shift change count was completed 3/10/25 through 3/11/25. 3. Review of [NAME] Hall narcotic book count sheets, dated 3/1 through 3/11/25, showed: -Eight out of 30 shifts have no nurse signature on the shift change count; -Thirteen out of 30 shifts only have one nurse signature on the shift change count. During an interview on 3/11/25 at 10:30 A.M., Licensed Practical Nurse (LPN) I said the nurses are the only staff that administer narcotics. The narcotic sheets are to be signed by one oncoming and one off going nurse every shift, every day. 4. During an interview on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she would expect the nurses to count narcotics with one oncoming nurse and one off going nurse every shift, every day. Nurses are expected to sign the narcotic count sheet once the count is completed.

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 31 opportunities observed, twelve errors occurred, resulting in a 38.71% error rate (Resident #83, Resident #196, Resident #79 and Resident #197). The census was 93. Review of the facility's Administrating Medications policy, revised 8/31/23, showed: -Purpose: To ensure safe administration of resident's medication as indicated and ordered by the provider; -Procedure: Medications are administered in accordance with the orders and within their prescribed times; The person preparing or administering the medication will contact the provider if there are questions or concerns regarding the medication; With any irregularities, appropriate notifications will be completed for clarification. -Administer medications following the six rights of medication administration; -Right resident; -Right medications; -Right dose; -Right time; -Right route; -Right documentation. Review of the facility's medication crushing guidelines, dated 12/17, showed: -Medications that should not be crushed or chewed: -Enteric Coated tablets are designed to pass through the stomach whole and then dissolve in the intestinal tract. Review of the manufacturer's instructions for fluticasone propion-salmeterol inhaler, showed the resident should rinse his/her mouth without swallowing to prevent oropharyngeal candidiasis (mouth and throat yeast infection). 1. Review of Resident #83's face sheet, undated, showed diagnoses that included fracture of the humerus (arm bone), infection of orthopedic devices, anxiety, high blood pressue, kidney failure and obesity. Review of the resident's Physician Order Sheet (POS), dated 3/25, showed; -An order, dated, 2/27/25, Astepro Allergy (medication to treat allergy symptoms) 205.5 micrograms (mcg), two sprays, each nostril, once daily; -An order, dated, 1/9/25, Cyclosporine (medication to treat dry eyes) dropperette, 0.05%, give one drop to both eyes, twice a day; -An order, dated, 1/9/25, daily multi-vitamin give one tablet, once daily; -An order, dated, 1/9/25, fluticasone furate-vilanterol (inhaler used to treat lung disease) 100-25 mcg one puff, once daily; -An order, dated, 1/9/25, fluticasone propion-salmeterol (inhaler used to treat lung disease) 100-50 mcg, one puff, twice daily; -An order, dated, 1/9/25, fluticasone propionate spray (medication to treat allergy symptoms), 50 mcg, two sprays, nasally, once daily; -An order, dated ,1/9/25, Metamucil powder (fiber supplement), 3.4 gram (gm)/ 5.4 gm, give orally, once daily; -An order dated, 1/9/25, polyethylene glycol powder (laxative)17 gm, give orally, once a day; -An order dated, 1/9/25, sennosides-docusate sodium (stool softener), 8.6-50 milligrams (mg), give one tablet, once daily. Observation on 3/11/25 at approximately 9:00 A.M., showed Certified Medication Technician (CMT) J prepared the resident's medication at the medication cart. CMT J entered the resident's room and gave the resident his/her oral medication. CMT J then positioned the fluticasone propion-salmeterol inhaler at the resident's mouth, had the resident inhale, and instructed the resident to hold his/her breath once the medication was inhaled. CMT J removed the fluticasone propion-salmeterol inhaler from the residents mouth. CMT did not instruct the resident to rinse his/her mouth afterwards. CMT opened the cyclosporine vial and administered 4-5 drops in the left eye and 4-5 drops in the right eye. The medication was dripping down the resident's cheeks and CMT J provided the resident with a tissue to wipe his/her face. CMT J did not administer a multi-vitamin, Astepro Allergy nasal spray, fluticasone furate-vilanterol inhaler, fluticasone propionate spray nasal spray, Metamucil powder, polyethylene glycol powder, and sennosides-docusate sodium. During an interview with the resident on 3/12/25 at 1:00 P.M. and on 3/14/25 at 7:55 A.M., the resident said there is always a mix up with his/her medications. His/Her medications are frequently late or not given. There is no consistency. 2. Review of Resident #196's face sheet, showed diagnoses included Alzheimer's disease, dementia, weakness, high blood pressure and chronic kidney disease. Review of the resident's POS, dated 3/25, showed: -An order, dated, 2/27/25, aspirin tablet 81 mg, delayed release, enteric coated (EC), give one tablet daily. During observation and interview on 3/11/25 at 8:40 A.M., CMT J said the resident had to have his/her medication crushed. CMT J prepared the resident's medication, including the aspirin 81 mg EC, placed them in a clear pouch and crushed them, using the pill crusher. The medication was mixed in yogurt. CMT J entered the resident's room and administered the medication to the resident by using a spoon and encouraging the resident to swallow the medication. 3. Review of Resident #79's face sheet, undated, showed diagnoses included kidney failure, high blood pressure, myocardial infarction (heart attack), cardiomyopathy (enlarged heart), malnutrition (poor nutrition) and brain cancer. Review of the resident's POS, dated 2/13/25 through 3/13/25, showed: -An order, dated 1/28/25, stop date, 2/24/25, Megace (medication used to stimulate appetite) 40 mg, give one tablet four times a day. Observation on 3/11/25 at 9:17 A.M., showed CMT J was preparing the resident's medications at the medication cart and entered the resident's room. CMT J administered the resident's medication. Megace 40 mg was administered to the resident. 4. Review of Resident #197's face sheet, undated, showed diagnoses included, femur (leg bone) fracture, muscle weakness and osteoarthritis (arthritis in the bone). Review of the resident's POS, dated 3/25, showed: -An order, dated, 3/1/25, cholecalciferol (vitamin D3) 50 mcg, give one capsule daily. Observation on 3/11/25 at 9:00 A.M., showed CMT J prepared the medications at the medication cart and entered the resident's room and administered the resident his/her medication. CMT J did not administer the resident's cholecalciferol 50 mcg capsule. 5. During an interview on 3/11/25 at 8:50 A.M., CMT J said pill packs are what the facilty uses, along with floor stock medcations that are in bottles located on the medication cart. The medication orders are compared against the pill packs prior to administering the medications. Discontinued medications have to be removed by staff out of the pill packs. 6. During an interview on 3/13/25 at 12:50 P.M., Licensed Practical Nurse (LPN) N said CMTs and nurses should follow the six rights of administration and follow the physician orders. The pill packs the resident's medication is dispensed from should be accurately checked against the resident's POS before giving medication. If the staff member is giving medication just off of memory or assuming the pill packs are correct and not comparing the medcation to the POS, medication errors will likely occur. Any discontinued medication should be removed from the pill packs. 7. During an interview on 3/14/25 at 11:13 A.M., the Director of Nurses (DON) said she expected staff administering the resident's medication, to give the medication accurately and with proper technique. When inhalers are administered to the residents, she expected staff to instruct the resident to rinse after use if the inhaler required them to do so. She expected staff to not crush EC medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals (medications that are grown from bacteria or viruses) stored in the medication room refrigerator were being stored at a proper temperature for 1 out of 1 medication rooms observed. The facility failed to have medication storage boxes filled with medication in a secure area. The census was 93. Review of facility's Medication Storage Policy, dated, March, 2017, showed: -Policy: Medication and biologicals are stored safely, securely and properly, following manufacturer's recommendation 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. -Procedure: The facility should maintain a temperature log in the storage area to record temperatures at least once a day. 1. Observation on 3/11/25 at 10:30 A.M., of the medication room on Fontbonne/[NAME] Hall, showed a black refrigerator with a lock. Inside the refrigerator was a thermometer, insulin pens, Aranesp injections (medication to increase red blood cells in the body), intravenous (IV) antibiotics and Tylenol suppositories. Review of the refrigerator log, dated February, 2025, showed the temperatures were not checked on: 2/1, 2/2, 2/5, 2/6, 2/11, 2/12, 2/13, 2/14, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/21, 2/23, 2/24, 2/25, 2/26, 2/27, and 2/28/25. Review of the refrigerator log, dated March, 2025, showed the temperatures were not checked on: 3/1 though 3/11/25. During an interview on 3/11/25 at 10:30 A.M., Licensed Practical Nurse (LPN) I said he/she thought the temperatures were to be checked daily by the nurses but wasn't sure. 2. Observation on 3/12/25 at 7:45 A.M., and on 3/13/25 at 10:10 A.M. and 12:05 P.M., at the [NAME] nurses' station, showed two red medication storage containers and one black medication storage container, on the floor in nurses' station. Pill packages and IV antibiotics were overflowing from the boxes. The boxes did not have locks and the nurses' station did not have a door. Residents and visitors were walking past the [NAME] nurses' station while the unsecured boxes were positioned on the floor. During an interview on 3/13/25 at 12:50 P.M., LPN N said he/she saw the unsecured boxes at the [NAME] nurses' station and was going to work on getting them packed up and sent to the pharmacy for a credit. The boxes are to be secured with a special tape they use until the pharmacy can remove them. The pharmacy technician can only take two boxes at a time. The boxes should be in the locked med room until they are ready to be picked up. 3. During an interview on 3/11/25 at approximately 12:00 P.M. and on 3/14/25 at 11:13 A.M., the Director of Nursing (DON) said she expected the temperatures to be checked for the med room refrigerator once a day. It is expected for the night shift nurse to obtain the temperatures and write them on the temperature log. All medications should be secured with a lock. She expected staff to not leave the medications in a box, unsecured at the nurses' station. The unsecured medications could be taken by the residents or visitors.

Based on observation, interview, and record review, the facility failed to ensure daily weights were obtained as ordered (Resident #1). The resident sample was 6. The census was 87. Review of Resident #1's hospital discharge/transfer sheet, dated 5/29/24, showed: -Weigh daily; -Contact the physician if there is a weight gain of 3 pounds or more in a day or 5 pounds or more in two days. Review of Resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 6/4/24, showed: -admission date 5/29/24; -Cognitively intact; -Diagnoses included congestive heart failure (the heart does not pump enough blood); -Weight loss of 5% or more in last month or a weight loss of 10% or more in last six months; -On a physician's weight loss program -Weight 160 pounds. Review of the resident's electronic physician order sheet (ePOS), dated 5/29/24 through 6/27/24, showed the following orders: -Weigh daily; -Call physician for weight gain greater than 2.5 pound in 48 hours or 5 pounds above admission weight. Review of the resident's baseline care plan, dated 5/29/24, showed no documentation of obtaining daily weights or the diagnosis of heart failure. Review of the resident's treatment administration record (TAR) dated 5/29/24 through 6/28/24, showed no documentation of weights on 5/30, 5/31, 6/2, 6/3, 6/7, 6/19, 6/20, or 6/21/24. During an interview on 7/24/24 at 3:30 P.M., the Interim Director of Nursing (DON) and the Administrator said they would expect staff to follow physician's orders. Nursing staff are responsible to weigh residents and document weights in the medical record. MO00238381

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide eating assistance to one resident (Resident #44) for two of two observed meals. The resident was observed feeding himself/herself with his/her fingers. Staff did not provide assistance. The sample was 18. The census was 86. Review of the undated Activity of Daily Living (ADL) policy, showed: -Purpose: To provide residents with care, treatment and services appropriate to maintain or improve the ability to carry out ADLs; -Policy: Residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene; -Implementation: -Care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks); -If residents with cognitive impairment or dementia exhibit behavioral expressions of resistance to cares, associates will attempt to identify the underlying cause of the problem and not assume the resident is declining of refusing care. Approaching the resident in a different way, different time or having another staff speak with the resident maybe appropriate; -The resident's response to interventions will be documented, monitored, evaluated and revised as appropriate. Review of Resident #44's medical record, showed: -re-admitted [DATE]; -Diagnoses included: Alzheimer's disease, severe protein malnutrition, depression, anxiety, need for assistance with personal care and dementia. Review of the care plan, in use during the survey, showed: -Problem: Nutritional status- inadequate energy related to dementia and weight loss; -Goal: Stop significant weight loss; -Approach: Provide encouragement at meals, offer fortified foods and house shakes three times a day with meals, offer Magic Cups (ice cream supplement to add calories and protein), the resident is fond of ice cream. Review of the nutritional assessment, dated 9/1/23, showed: -At risk for weight loss due to diagnoses of dementia and Alzheimer's disease and protein calorie malnutrition and the resident has had a significant weight loss in the past; -Offer encouragement and assistance as needed; -The resident's appetite varies from poor to fair and seems to be better when family is present. The resident may consume 25-50 percent (%) at meals. The resident is offered house shakes three times day with meals and also likes ice cream and likes drinking milk. He/She also has a history of weight loss. Observations of meals, showed: -On 10/24/23 at 7:50 A.M., the resident sat in his/her chair at the main dining room table. The resident was served a bowl of Cream of Wheat (hot cereal). The resident leaned forward and used his/her right index finger to scoop cereal out of the bow and placed the finger in his/her mouth then scooped out more cereal. Large portions of the cereal dripped off the resident's fingers onto his/her clothing and down his/her chin. At 8:15 A.M., the resident sat back in her/she chair and feel asleep. The resident consumed approximately 25 % of the cereal. The resident did not attempt to use the utensils or attempt to eat other food provided. Staff did not offer to assist or encourage the resident to eat more of his/her breakfast meal. No nutritional house shake supplements were offered; -On 10/25/234 at 8:10 A.M., the resident was up in his/her Broda chair (tilt in space positioning chair) at the breakfast table in the main dining room. Staff prepared and served a bowl of oatmeal and placed the oatmeal in front of the resident. The resident leaned forward and used his/her right index finger to scoop the oatmeal into his/her mouth. The oatmeal dripped off the resident's fingers onto his/her clothing and down his/her chin. The resident did not attempt to eat other food provided. Staff did not assist or encourage the resident to eat. No house shake supplements were offered at the meal. During an interview on 10/25/23 at 8:20 A.M., Certified Nurse Aide (CNA) J said he/she was the only staff in the main dining room to assist residents to eat. Two additional residents required eating assistance. Resident #44 appeared to need assistance. There were not enough aides to provide assistance or sit next to him/her to provide cueing. CNA J did not ask other staff for assistance. During an interview on 10/26/23 at 10:15 A.M., the Director of Nursing said residents who required eating assistance should have assistance when the meal was served. The resident should not have had to wait for assistance. If a resident was observed eating with their fingers, staff should have offered assistance or encouragement with the use of utensils. The resident should have received the ordered supplements. CNAs should request assistance if residents needed help.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #92) was free from significant medication error when staff failed to ensure the resident's ordered breathing treatment was delivered timely. The resident was admitted to the facility from the hospital with respiratory failure and Covid-19. The resident did not receive the ordered breathing treatments all days of the stay, from 9/29/23 through 10/4/23. The sample size was 37. The census was 86. Review of the Verbal and Telephone Order policy, showed: -Purpose: To ensure timely and efficient verbal and telephone orders from the provider; -Policy: Verbal and telephone orders are obtained in a situation when the provider is unable to write or sign the order at the time of entry and are transcribed; -Procedure: The nurse receiving the verbal order will write it on the physician order sheet or enter it into the electronic health record (EHR). Review of Resident #92's medical record, showed: -admitted : 9/29/23; -discharged : 10/4/23; -Diagnoses included: respiratory failure related to Covid-19, heart failure, irregular heart beat, obstructive lung disease. Review of the physician order sheet, showed an order, dated 9/29/23, for Anoro Ellipta (a combination inhaled drug used to treat lung disease) 62.5-25 micrograms (mcg). Take one blister pack (unit dose packaging) via inhalation once daily. Scheduled daily from 6:00 A.M. to 10:30 A.M. Review of the September 2023 an October medication administration records (MAR), showed: -An order, dated 9/29/23, for Anoro Ellipta 62.5-25 mcg. Take one blister pack via inhalation once daily. Scheduled daily from 6:00 A.M. to 10:30 A.M.; -Staff documented: not administered, drug not available for six of six opportunities. During an interview on 10/26/23 at 9:10 A.M., the Director of Nursing said the admitting nurse was responsible to enter the medication orders into the EMR and fax the orders to the pharmacy. The facility did not carry combination inhaled medication in the emergency kit. The resident did not receive his/her ordered inhaled medication. The medication was not delivered by the pharmacy. The Certified Medication Technician (CMT) should have notified the charge nurse that the medication had not arrived. The nurse would have contacted the pharmacy and ordered the medication to be delivered immediately. The nurse should have notified the physician and perhaps a different medication could have been used until the ordered medication was delivered. MO00225310

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections for one resident observed during personal care and transfer when staff failed to change gloves, sanitize hands, and sanitize shared medical equipment using acceptable standards of practice (Resident #82). The census was 86. Review of the facility's Using a Mechanical Lifting Machine policy, dated July 2017, showed lift care: -Disinfect lifting surfaces; -Wipe with a clean towel until dry. Review of the facility's Hand Hygiene policy, dated June 2017, showed: -Infection prevention begins with the basic hand hygiene. By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization caused by germs acquired from the residents; -It is the policy that all associates will be trained and competent in the following proper hand hygiene practices; -Hand hygiene simply means cleaning hands using either handwashing or antiseptic hand rub; -Times to perform handy hygiene are, but not limited to: When hands are visibly soiled wash hand with soap and water; before and after direct resident contact; before and after assisting a resident with personal care; before and after assisting a resident with toileting- wash hands with soap and water; after contact with a resident's mucus membranes and body fluids and excretions; after handling soiled or used linen, dressings, bedpans, catheters, and urinals; after removing gloves. Review of Resident #82's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/13/23, showed: -admitted [DATE]; -Cognitively intact; -Rolling from left to right, moving from sitting to lying and lying to sitting: Substantial/maximal assistance needed; -Diagnoses include kidney disease and diabetes. Review of the resident's comprehensive care plan, in use at the time of the survey, reviewed on 10/23/23, showed it did not address activities of daily living care, incontinence status, or transfer status. Observation on 10/24/23 at 10:22 A.M., showed Certified Nursing Assistant (CNA) A and CNA B provided care to the resident. Staff gathered supplies, set the resident's indwelling urinary catheter bag on the bed and lowered the resident's pants. Staff then assisted the resident to the left side. The resident had a small, pasty and think bowel movement on his/her buttocks. CNA B stood on the resident's right side as CNA A assisted the resident to lay on his/her left side. CNA B wiped the bowel movement. The bowel movement smeared and was not easily removed. After several wipes, the resident's buttocks wiped clean. Observation showed CNA B had a smear of bowel movement on the outer side of his/her right gloved hand. CNA B grabbed a wipe and attempted to wipe the bowel movement off of his/her hand, but the thick and pasty bowel movement remained smeared on the gloves. CNA A gathered a clean brief and the Hoyer lift (full body mechanical lift) transfer pad and brought it to the bedside. CNA B used the soiled gloved hand and tucked the clean supplies under the resident. He/She then grabbed the resident's indwelling urinary catheter with his/her soiled gloved hands and repositioned it in the bed. He/She then pulled the resident over towards the right side by touching his/her back and shoulder with his/her soiled gloves. The same soiled gloves were then used to roll the resident back and forth until the brief and Hoyer pad was flat under the resident. He/She again picked up the indwelling urinary catheter with his/her soiled gloved hand and positioned it in the bed between the resident's legs. CNA B grabbed the Hoyer lift with his/her soiled gloves and positioned it over the resident. He/She used the controller to lower the Hoyer lift arms over the resident, then both CNAs assisted to connect the Hoyer pad to the lift. CNA B lifted the resident with the use of the Hoyer lift, moved the lift away from the bed, and lowered the resident into his/her wheelchair. CNA B grabbed and positioned the resident's legs in the wheelchair while wearing the same soiled gloves. CNA B removed his/her gloves, grabbed the soiled linen bag, and exited the room. During an interview on 10/24/23 at 11:04 A.M., CNA A said staff were in-serviced last month on hand hygiene and gloves changes. They were told no gloves could be worn in the hall. Gloves are to be changed when going from one area to another and before touching things in the room. Hands are to be washed before leaving the room. Nursing staff is not responsible for cleaning of the Hoyer lifts. The only responsibility they have is with changing the battery and making sure it stays charged. He/She believes maintenance is responsible for cleaning the Hoyer lifts. During an interview on 10/24/23 at 2:02 P.M., the Director of Environmental Services said he is not responsible to clean the mechanical lifts. That would be nursing's responsibility. If nursing staff report issues with the lifts, then he will check them, but he has no other responsibilities as it relates to the mechanical lifts. During an interview on 10/26/23 at 9:15 A.M., with the Director of Nursing (DON), Administrator, and Executive Director, they said the process for cleaning equipment, such as mechanical lifts is the responsibility of nursing staff. There is a schedule for the CNAs to clean the mechanical lifts on a routine basis, but they should also be sanitized between resident use with the use of disinfectant wipes. During an interview on 10/26/23 at 12:38 P.M., the DON and Skilled Nursing Facility Clinical Manager/Infection Preventionist said during incontinence care, gloves are changed anytime they become visibly soiled, after done cleaning one area and before going to another, and before application of barrier creams. Hand hygiene is performed before care, with any glove changes, and after care is completed. Nursing staff are responsible to clean the mechanical lifts. This should be done between resident uses. Soiled gloves should not be used to touch clean surfaces or the resident.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two out of two sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #191 and #101). The facility census was 86. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. 1. Review of Resident #191's medical record, showed the resident currently resided in the facility. Review of the resident's Skilled Nursing Facility Beneficiary Protection Notification Review, showed: -Last covered day of Medicare Part A service as 10/18/2; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS-10055 or alternative denial letter. 2. Review of Resident #101's medical record, showed the resident currently resided in the facility. Review of the resident's Skilled Nursing Facility Beneficiary Protection Notification Review, showed the following: -Last covered day of Medicare Part A service as 10/22/23; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -Facility staff did not provide the resident or his/her legal representative the SNFABN form CMS-10055 or alternative denial letter. 3. During an interview on 10/23/23 at 6:04 P.M., the Executive Director said for residents discharged from skilled services who remained in the facility and did not run out of coverage days, she would expect them to receive both the NOMNC and SNFABN or one of the approved letters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident care plans were complete, accurate, reviewed, and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for five of 18 sampled residents (Residents #82, #83, #44, # 48, and #68). The census was 86. 1. Review of Resident #82's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/13/23, showed: -admitted [DATE]; -Cognitively intact; -Rolling from left to right, moving from sitting to lying and lying to sitting: Substantial/maximal assistance needed; -Diagnoses include kidney disease and diabetes; -Care Area Assessment Summary (CAAS) triggered and was identified as care planned by the facility for: Visual function, activity of daily living (ADL) functional/rehab potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, and pain. Review of the resident's comprehensive care plan, in use at the time of the survey, reviewed on 10/23/23, showed: -Problem: Activities: Prefer activities that identify with prior lifestyle; -Goal: Will express satisfaction with daily routine and leisure activities; -Approach: Inform of upcoming activities by providing a monthly calendar of activities that include those which are accessible for viewing the chapel channel; Provide materials of interest to include access to the phone for listening to music and audio books and to television for watching favorite programs; Providing setting in which activities are preferred e.g., own room, day room, access to the outdoors as the weather permits; -No other problems/goals/approaches listed; -Visual function, ADL functional/rehab potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, and pain not included in the care plan, as indicated in the resident's CAAS; -The resident's transfer status, use of a mechanical lift, or use of a transfer board not care planned. Observation and interview on 10/24/23 at 10:22 A.M., showed Certified Nursing Assistant (CNA) A and CNA B provided incontinence care to the resident and transferred the resident from bed to his/her wheelchair with the use of a Hoyer lift (full body mechanical lift). The resident had an indwelling urinary catheter in use. The resident said he/she has some days he/she is stronger than others, but today he/she felt weak, so he/she required the use of the Hoyer lift, rather than a transfer board (piece of equipment that helps you transfer (move) from one surface to another). During an interview on 10/24/23 at 11:04 A.M., CNA A said staff know the resident's transfer status because it is communicated from therapy. The resident uses a Hoyer lift to transfer, but can use a transfer board if he/she feels he/she is strong enough. During an interview on 10/25/23 at 12:19 P.M., the Administrator said some rooms have a white board where therapy can write the resident's transfer status. This resident does not have the white board, but there is a care card in the closet that staff can use to know a residents care needs. Review of the resident's care card, located inside his/her closet, showed: -Dressing: Extensive; -Grooming: Limited assist; -Bathing: Extensive 7-3 shift Mondays and Thursdays; -Ambulation: Not applicable; -Transfer: Total/full body lift assist; -Transfer status did not identify the use of a slide board when the resident felt strong; -Safety: Low bed; -Nutrition: Blank; -Mental status: Alert and oriented; -Continents: Foley (a brand of indwelling urinary catheter). During an interview on 10/26/23 at 12:38 P.M., with the Director of Nursing (DON) and Skilled Nursing Facility (SNF) Clinical Manager/Infection Preventionist, the DON said the resident transfers with the use of a Hoyer lift. Therapy is trialing the use of a slide board. Staff know how residents transfer by use of the care card. Individualized interventions, to include transfer status, should be included on the care plan. 2. Review of Resident #83's admission MDS, dated [DATE], showed: -admitted [DATE]; -Severe cognitive impairment; -Diagnoses include fractures, kidney disease, urinary tract infections, anxiety, and depression; -CAAS triggered and was identified as care planned by the facility for: Cognitive loss/dementia, communication, ADL functional/rehab potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer, and psychotropic drug use. Review of the resident's care plan, in use at the time of the survey, reviewed on 10/23/23, showed: -Problem: Nutritional status: Diagnoses of kidney and heart failure, requires proper nutrition to help with healing of surgical wound; -Goal: Maintain usual body weight during rehabilitation with no significant weight change; -Approach: Regular diet, provide encouragement and assistance at meals as needed; -No other problems/goals/approaches listed; -Cognitive loss/dementia, communication, ADL functional/rehab potential, urinary incontinence and indwelling catheter, falls, pressure ulcer, and psychotropic drug use not included in the care plan, as indicated in the resident's CAAS; -The resident's primary language or interventions used to communicate with the resident were not indicated on the care plan. Review of the resident's care card, located inside his/her closet, showed: -Dressing: Blank; -Grooming: Blank; -Bathing: Blank; -Ambulation: Not applicable; -Transfer: Assist/gait belt. Non weight bearing left upper extremity, weight bearing as tolerated left lower extremity; -Safety: Blank; -Nutrition: Blank; -Mental status: Blank; -Continents: Blank; -The resident's primary language or interventions used to communicate with the resident not listed on the care card. Observation and interview on 10/23/23 at 8:47 A.M., showed the resident in his/her room seated in a wheelchair. Upon attempted interview, the resident spoke a different language, gave a thumbs up and waived. He/She was able to communicate answers to simple questions such as saying the food was good. During an interview on 10/23/23 at 4:58 P.M., Certified Medication Technician (CMT) H said the resident speaks Greek. There is a communication board in the room staff use to communicate with the resident. The resident is able to point at words to let staff know his/her needs. During an interview on 10/24/23 at 6:14 A.M., Nurse E said the resident Speaks Greek. The resident knows some English words and is able to make his/her needs known with the use of hand gestures, an interpreter and a communication board in the room. During an interview on 10/26/23 at 12:38 P.M., with the DON and SNF Clinical Manager/Infection Preventionist, the DON said she is not sure what language the resident speaks, but knows it is not English. Staff use a communication board and an interpreter to communicate with the resident. She would expect concerns, such as communication and language barriers to be included on the care plan. 3. Review of Resident #44's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Unable to make wants/needs clearly known; -Diagnoses included: Alzheimer's disease and protein malnutrition; -Staff provide supervision, verbal cues and touching and steadying to eat; -CAAS triggered and was identified as care planned by the facility for: delirium, cognitive loss/dementia, communication, ADL functional/rehab potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer, and psychotropic drug use. Review of the care plan, in use during the survey, reviewed on 10/24/23, showed: -Problem: Inadequate energy intake related to dementia as evidenced by weight loss; -Goal: Halt weight loss; -Approach: Provide encouragement at meals, offer fortified foods and house shakes three times a day with meals, offer magic cup. Weekly weights; -Delirium, communication, ADL functional/rehab potential, urinary incontinence and indwelling catheter, psychosocial well-being, and pressure ulcer, not included in the care plan, as indicated in the resident's CAAS. Observation on 10/24/23 at 7:50 A.M., showed the resident sat at the main dining room table. Staff served the resident a bowl of cream of wheat, scrambled eggs and sausage, and left the table. The resident leaned forward and used his/her right index finger to eat the hot cereal. At 8:15 A.M., approximately 25% of the cream of wheat was consumed. No other food eaten. No staff offered to encourage or assist the resident to eat. During an interview on 10/24/23 at 8:25 A.M., CNA J said the resident probably needed help to eat but he/she is unsure of the assistance the resident needed. The resident did not have a care card in his/her room. CNA J saw the resident feeding himself/herself and CNA J had another resident to assist to eat. 4. Review of Resident #48's admission MDS, dated [DATE], showed: -admitted [DATE]; -Able to make needs and wants known; -Diagnoses included: Psychological disorders, anxiety, adult failure to thrive, and mental disorders; -CAAS triggered and was identified as care planned by the facility for: cognitive loss/dementia, communication, ADL functional/rehab potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration, pressure ulcer, psychotropic drug use, and pain. Review of the resident's psychiatric care visit note, dated 8/23/23, showed: -The resident has cognitive impairment, recent delirium and probably psychosis. He/She will make bizarre references that seem delusional. He/She struggles with personal care, trazadone (used for depression) is used as needed and recently added and benefit/effectiveness is not yet observed. If Trazadone is not effective would increase quetiapine (used as an antipsychotic). Review of the resident's care plan, in use during the survey, reviewed on 10/25/23, showed: -Problem: Psychotropic drug use: the resident is at risk for adverse consequences to antipsychotic medication use: -Goal: Resident will not exhibit drug related side effects; -Approach: attempt to give the lowest dose possible, assess and record effectiveness of the drug, monitor behaviors, pharmacy consult, document the resident's behaviors; -The care plan did not address the addition of Trazadone; -Cognitive loss/dementia, communication, ADL functional/rehab potential, urinary incontinence and indwelling catheter, psychotropic drug use and dehydration not included in the care plan, as indicated in the resident's CAAS. 5. Review of Resident #68's admission MDS, dated [DATE], showed: -admitted [DATE]; -Moderate cognitive impairment; -Diagnoses included: dementia without behavior disturbance, psychotic disorder, mood disorder, anxiety, insomnia, diabetes, restlessness and agitation; -CAAS triggered and was identified as care planned by the facility for: cognitive loss/dementia, communication, ADL functional/rehab potential, urinary incontinence and indwelling catheter, falls, pressure ulcer and psychotropic drug use. Review of the resident's current physician order sheet, showed: -An order for Zoloft (used to treat depression) 25 mg once daily; -Novolog (used to treat diabetes) Flex pen per sliding scale. Review of the care plan, in use during the survey, reviewed on 10/25/23, showed: -Problem: Psychotropic drug use: the resident is at risk for adverse consequences to antipsychotic medication use: -Goal: Resident will not exhibit drug related side effects; -Approach: attempt to give the lowest dose possible, assess and record effectiveness of the drug, monitor behaviors, pharmacy consult, document the resident's behaviors; -The care plan did not address the diabetes diagnoses or medications; -Communication, ADL functional/rehab potential, psychotropic drug use or pressure injury were not included in the care plan, as indicated in the resident's CAAS. 6. During an interview on 10/26/23 at 1:13 P.M., the MDS Reimbursement Coordinator and Clinical Reimbursement Coordinator said they are responsible for completion of the MDS assessments for all residents. They are also responsible for the care plans. When a resident is admitted , they have seven days to do the admission assessment. The admission assessment identifies care areas that trigger and those triggers help develop the care plan. If an area triggers in the CAAS, they are responsible to care plan the area. They have up to 21 days to complete the comprehensive care plan. Sometimes they can become overwhelmed with the number of admissions and the number of care plans due. They are responsible for the care plans, the other department heads do not add new focus areas or interventions. Sometimes staff will email them with care concerns they have for the residents so they can update the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of record for controlled drugs with sufficient detail to enable an accurate reconciliation for three out of three controlled substance shift change count sheets reviewed. The census was 86. Review of the facility's Consultant Pharmacist Services Provider Requirements policy, revised August 2014, showed: -The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility; -Establishing a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and determining that drug records are in order and that an account of all controlled medications is maintained and periodically reconciled. 1. Review of the [NAME] Hall Certified Medication Technician (CMT) controlled substance shift change count sheet, dated 10/1/23 through 10/24/23, showed 25 out of 69 opportunities were left blank and undocumented for on-coming and off-going staff signatures. 2. Review of the Fontbonne Hall CMT controlled substance shift change count sheet, dated 10/1/23 through 10/23/23, showed 53 out of 67 opportunities left undocumented and blank for on-coming and off-going staff signatures. 3. Review of the Fontbonne Hall Nurse controlled substance shift change count sheet, dated 10/1/23 through 10/23/23, showed 49 out of 68 opportunities were undocumented and blank for on-coming and off-going staff signatures. 4. During an interview on 10/24/23 at 10:28 A.M., Nurse E said shift change narcotic counts should occur before the on coming Nurse or CMT accepted the medication cart keys. Narcotic count was done to verify all the narcotic medications were accurate and none were missing. Nurses and CMTs were responsible to perform the narcotic counts at shift change or when accepting keys to the medication cart. 5. During an interview on 10/24/23 at 2:18 P.M., CMT C said on coming and off going CMTs were responsible to perform narcotic counts prior to accepting the medication cart keys. Narcotic counts ensured the accuracy of the narcotic medication in the carts. 6. During an interview on 10/25/23 at 1:17 P.M., the Director of Nursing said all CMTs and Nurses were expected to conduct on-coming and off-going narcotic counts before leaving or beginning the shift. The counts maintained narcotic accuracy. The DON should be notified if the shift narcotic count did not occur. On-coming staff should not accept medication cart keys until the narcotic count was completed with an off going staff.

Based on observation, interview and record review, the facility failed to ensure orders for psychotropic medications are limited to 14 days, except when the prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days, has documented the rationale in the resident's medical record, and indicated the duration of the as needed order. The facility failed to ensure a gradual dose reduction was attempted or documented as contraindicated for residents who receive psychotropic medications. In addition, the facility failed to ensure non-pharmacological interventions were attempted and documented prior to administration of a psychotropic medication, for three of five residents investigated for unnecessary psychotropic medications (Residents #65, #8, and #68). The census was 86. Review of the facility's Psychotropic Medication Use policy, last reviewed 9/7/23, showed: -Purpose: Psychotropic medications are used when ordered by medical providers after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral expression have been identified and addressed; -Psychotropic medications are given upon a medical provider order. The nursing associates collaborate with the medical provider to ensure the lowest possible dosage is given for the shortest period of time and are subject to gradual dose reductions and re-review. As needed orders for psychotropic drugs are limited to 14 days. As needed anti-psychotic orders are limited to 14 days and cannot be renewed unless the attending provider evaluates the resident for the appropriateness of that medication; -Gradual dose reduction begins within the first year in which a resident is admitted with or is newly prescribed a scheduled psychotropic medication. A gradual dose reduction is attempted in two separate quarters with at least one month between the attempts, unless clinically contraindicated and documented by the medical provider; -Residents do not receive psychotropic drugs pursuant to an as needed order unless that medication is necessary to treat a diagnosed specific condition that is documented in the medical record. 1. Review of Resident #65's care plan, in use at the time of the survey, showed: -Problem start date 11/15/22, physical behavioral symptoms towards others, grabbing at staff when being repositioned in his/her wheelchair; -Goal: Accept assistance; -Interventions: Avoid power struggles; maintain a calm environment and approach. Review of the resident's medical record, showed: -Diagnoses included dementia and anxiety disorder; -An order dated 11/10/22, open ended, for lorazepam (medication used to treat anxiety) schedule IV (controlled narcotic medication) concentrate, 2 milligram (mg) per milliliter (ml). Administer 0.5 ml oral every 4 hours as needed for agitation/anxiety; -An order dated 12/7/22, for lorazepam schedule IV concentrate, 2 mg/ml, administer 0.5 ml oral at bedtime, 8:00 P.M.; -No documentation the attending physician believes that it is appropriate for the as needed lorazepam to be extended beyond 14 days or the rationale for the duration of the as needed order beyond 14 days; -No documentation a gradual dose reduction attempted on the routinely administered lorazepam or documentation a gradual dose reduction was contraindicated. Review of the resident's September 2023 electronic treatment administration record, showed as needed lorazepam schedule IV concentrate, 2 mg/ml, 0.5 ml administered on 9/23/23 at 5:54 P.M. As needed reason: Behavior issue. Swinging at staff trying to give shower. Review of the resident's progress notes, showed no documentation of non-pharmacological interventions attempted prior to administration of lorazepam. Review of the resident's Consultant Pharmacist Recommendation to Physician, dated 5/26/23, showed: -Recommended discontinuing as needed use of lorazepam for this resident, or reorder for a specific number of days, per the following federal guidelines: -In accordance with state and federal guidelines, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days. Then he or she should document the rationale in the resident's medical record and indicate the duration of the as needed order; -No documentation of follow up on the recommendation. Observation of the resident on 10/23/23 at 5:07 P.M. and on 10/24/23 at 9:28 A.M., showed the resident sat in a wheelchair at the nurse's station. No symptoms of anxiety or agitation observed. During an interview on 10/25/23 at 9:25 A.M., Certified Nursing Assistant (CNA) B said the resident will sometimes fight staff during care. This can be prevented or diminished by having two staff available. One can distract the resident while the other provides care. During an interview on 10/25/23 at 12:30 P.M., the Director of Nursing (DON) said she could not locate any documentation to show a gradual dose reduction was attempted or contraindicated for the resident's routinely scheduled lorazepam or documentation from the physician why the residents as needed lorazepam would be required longer than 14 days. During an interview on 10/26/23 at 3:04 P.M., with the DON, Skilled Nursing Facility (SNF) Clinical Manager/Infection Preventionist, Administrator, and Executive Director, they said the resident's behaviors are related to sun downing (a condition where an individual with dementia has increased confusion and agitation during the evening and nighttime hours). The resident can become anxious with care during this time. 2. Review of Resident #8's care plan, in use at the time of the survey, showed: -Problem: Psychotropic drug use; -Resident is at risk for adverse consequences related to receiving psychotropic medication for treatment of a disorder associated with episodes of mood swings ranging from depressive lows to manic highs (bipolar disorder); -Goal: Resident will not exhibit signs of drug related side effects or adverse drug reaction; -Approach: Gradual Dose Reduction denied per Medical Director on 08/31/22. History of bipolar mood which is stable; -Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic (effects of medications that can cause dry mouth and blurred vision) and/or drug induced involuntary movements that cannot be controlled (extrapyramidal) symptoms; -Pharmacy consultant review; -Problem: Unsteady gait related to Parkinson's disease (movement disorder); -Goals: Have no falls; -Approach: Transfer with gait belt and assist of one staff. Do not rush; -Problem: Resident has impaired vision; -Goal: Resident will see large print reading material; -Approach: Arrange appointment with a specialist who can treat complex medical issues related to eyes (ophthalmologist)/primary care eye doctor (optometrist), consult as ordered. Review of the resident's diagnoses, showed Parkinson's disease, bipolar disorder, nausea, weakness, and repeated falls. Review of the resident's physician order sheet, showed an order dated 3/6/23: -End date: Open ended; -Xanax (alprazolam, used to treat anxiety) - Scheduled IV tablet: 0.5 ml; -Special instructions: Give ½ to one tablet by mouth daily as needed; -Diagnosis: Bipolar disorder. Review of the Consultant Pharmacist Recommendation to Physician, dated 9/26/23, showed: -Recommend discontinuing as needed us of Xanax for this resident, or reorder for a specific number of days, per the following federal guideline: In accordance with State and Federal Guidelines, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days. Then he or she should document the rationale in the resident's medical record and indicate the duration for the as needed order; -Physician/Prescriber Response showed no response. Review of the resident's progress notes, showed: -On 3/6/23 at 2:05 P.M., the CNA made the nurse aware that the resident passed out during his/her shower. New orders for daily vitals every four hours for twenty-four hours, per Assistant Director of Nursing (ADON). Medical Doctor is aware and gave orders for as needed Xanax for anxiety but the nurse had to find out the dosage he/she got from a bottle the resident had at home. Waiting for a response from the spouse; -On 4/27/23 at 12:08 P.M., medication Xanax script faxed to the pharmacy at 12:00 P.M. for refill; -On 8/24/23 at 5:33 P.M., received call from Medical Director's office with new order to obtain a basic metabolic panel (BMP, a test that measures eight different substances in your blood)/ complete blood count (CBC, a set of tests that provide information about cells in a person's blood and indicates the counts of white blood cells, red blood cells and platelets, the concentration of hemoglobin, and the hematocrit) on 8/25/23. Resident's spouse called the Medical Director's office and reported the resident having increase in tremors and appeared to be more aggressive than baseline per spouse; -On 8/26/23 at 2:26 P.M., resident's spouse in the room requesting some Xanax for the resident due to increase in body tremors. The nurse in resident's room noted some involuntary hand and leg movements. Resident's spouse made nurse aware that the last time the resident had such an experience of the tremors was four years ago and it was minimal incident that later stopped on its own, but thinks the reoccurrence this time is consistent. He/She made the nurse aware he/she had talked to the doctor; -On 9/4/23 at 12:16 A.M., resident requesting Xanax 0.5 mg given by mouth with midnight medications. Increase in tremors continue. During an interview on 10/26/23 at 12:47 P.M., the DON said she expected there to be rationale documentation for the uses of as needed Xanax and expected the resident's use of as needed Xanax to be re-evaluated every 14 days, unless the physician had documented rationale for extended use. She expected the pharmacy recommendations to have been followed. 3. Review of Resident #68's care plan, in use during the survey, showed: -Problem: Cognitive loss/dementia; -Goal: allow the resident to make decisions that are within his/her ability; -Approach: provide the resident with opportunities to make simple choices with care. Review of the resident's medical record, showed: -Diagnoses included: Dementia, psychotic disturbance, mood disturbance, and anxiety; -An order dated 5/9/23, for Trazodone (used to treat depression and sleeplessness) 50 mg. Take one tablet every 6 hours as needed for insomnia, open ended; -No documentation the attending physician believes that it is appropriate for the as needed Trazodone to be extended beyond 14 days or the rationale for the duration of the as needed order beyond 14 days; Review of the resident's October 2023 electronic medication administration record (eMAR), showed Trazodone 50 mg administered: -On 10/1/23 at 1:40 A.M., and 3:14 P.M., for sleeplessness, anxiety and agitation; -On 10/8/23 at 6:51 A.M., for behaviors of yelling out and unable to calm him/her; -On 10/15/23 at 8:21 A.M., for behavior issue, yelling out he/she can't sleep; -On 10/16/23 at 1:35 A.M., for behavior issue, yelling out; -On 10/16/23 at 5:20 P.M., for agitation; -On 10/20/23 at 1:30 P.M., for behavior issue, anxiety/agitation; -On 10/21/23 at 3:39 A.M. for yelling out; -On 10/22/23 at 7:40 P.M., for behavior issue, yelling out; -On 10/22/23 at 8:49 P.M., no reason documented; -On 10/23/23 at 11:16 P.M., no reason documented; -On 10/24/23 at 9:51 A.M., for behavior issue, yelling out; -On 10/24/23 at 9:15 P.M., for behavior issue, yelling out. 4. During an interview on 10/26/23 at 3:04 P.M., with the DON, SNF Clinical Manager/Infection Preventionist, Administrator, and Executive Director, they said they would expect as needed psychotropic medications to be reevaluated every 14 days. If a psychotropic medication is administered for behaviors, staff should attempt non-pharmacological interventions prior to administration of a psychotropic medication and these interventions should be documented in the medical record.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals are labeled and stored in accordance with currently accepted practices. These practices affected two of four medication carts reviewed and one out of two medications rooms reviewed. The census was 86. Review of the facility's Medication Storage in the Facility policy, revised on 2014, showed: -Policy: -Medications and biologicals (vaccines) 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; -Procedure (includes): -The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopoeia. Medications are kept in containers; -All medications dispensed by the pharmacy are stored in the container with the pharmacy label; -Except for medications requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area; -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 medications disposal; -Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective actions taken if problems are identified; -Expiration Dating (Beyond Use Dating): -Expiration dates of dispensed medications shall be determined by the pharmacist at the time of dispensing; -Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date; -Certain medications such as multiple dose injectable vials, ophthalmics, once opened require an expiration date shorter that the manufacturer's expiration date to insure medication purity and potency; -The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility; -Checking the medication storage areas at least monthly, and the medication carts at least quarterly, for proper storage and labeling of medications, cleanliness, and removal of expired medications; -Submitting a written report and recommendations for each review of medication storage. 1. Observation on 10/23/21 at 8:57 A.M., showed Certified Medication Technician (CMT) H stood at the medication cart, passing medications. Observation of resident eye drops/ointments inside the medication cart showed the following opened medications with no date documented of when they were opened: -Resident #189: -Moxifoxacin (used to treat a variety of bacterial infections) ophthalmic solution, instill one drop in the left eye daily, and delivered from the pharmacy on 10/17/23; -Timolol (used to treat high pressure inside the eye due to glaucoma (a progressive vision condition that can lead to permanent blindness)) ophthalmic solution, instill one drop in the left eye two times a day, and delivered from the pharmacy on 10/17/23; -Resident #83: -Two bottles of Lumigan (used to treat high pressure inside the eye due to glaucoma) ophthalmic solution, one drop in affected eye at hour of sleep, and delivered from the pharmacy on 9/8/23. Both bottles were contained in a plastic bag with an open date of 9/28, written on the plastic bag. During an interview at this time, CMT H said he/she was not sure if eye drops are required to be dated when opened, and did not know how long eye drops could be used before being discarded. During an interview on 10/24/23 at 10:48 A.M., the Director of Nurses (DON) said she was not sure if eye drops needed to be dated when opened and then discarded after a set amount of days, but she would check to see. The stock medications in the refrigerator on the rehab unit should have been discarded by the expiration date. The nurses and the pharmacy are responsible to ensure medications are replaced before expiring. During an interview on 10/26/23 at 8:23 A.M., the DON said eye drops should be discarded 28 days after opening. 2. Observation on 10/23/23 at 9:10 A.M., showed a medication refrigerator in the rehabilitation medication room. The refrigerator contained the following stock medications: -Admelog (a fast acting insulin), two boxes in a plastic bag with an expiration date of 2/2/23; -Cathflo Activase (a clot busting medication), with an expiration date of 2/28/23. During an interview at this time, Nurse I said nurses are responsible to check the contents of the medication refrigerators. If any medications are expired, they are to contact the pharmacy so the medication can be replaced. If he/she needed one of those medications, he/she would not be able to use them due to their expiration dates. During an interview on 10/26/23 at 8:23 A.M., the DON said she expected the nurses and/or pharmacy to monitor for discarded medications and have them replaced. 3. Observation of the long term care nurse medication cart on 10/23/23 at 10:00 A.M., showed: -36 Heparin (used as a blood thinner) 5000 unit injection vials, for intravenous flush-expired 9/2023; -Lispro (short acting insulin) kwikpen: undated when opened, no expiration date; -Humalog (short acting insulin) kwikpen: opened 10/21/23, no expiration date; -Insulin Aspart (short acting insulin) flex pen: undated when opened, no expiration date; -Tresiba (long acting insulin) pen: opened and in use, unlabeled, undated when opened and no expiration date; -Lispro kwikpen: opened 10/3/23, no expiration date; -Lispro kwikpen: opened 10/21/23, no expiration date; -Insulin aspart vial 100 units/milliliter: no opened date documented, no expiration date documented; -Basaglar (long acting insulin) kwikpen: illegible resident name, opened 6/2/23, no expiration date; -Insulin aspart kwikpen: illegible resident name, opened 10/22/23, no expiration date; -Basaglar kwikpen: opened 10/21/23, no expiration date; -Lispro kwikpen: opened 10/14/23, no resident name, no expiration date; -Tuberculin vial: opened and in use, undated when opened. Box showed discharge after 30 days, keep refrigerated. 4. During an interview on 10/23/23 at 10:15 A.M., Nurse K said the Unit Nurse Managers should check the medication carts weekly to ensure the medications are labeled correctly. He/She did not know who the Nurse Manager was who would check the nurse cart or when the check occurred. All insulins should be dated when opened and should be labeled with an expiration date. He/She did not know how to determine the expiration dates of various insulins. The nurse should ensure all medications are labeled correctly before administrating the medications. 5. During an interview on 10/26/23 at 9:15 A.M., with the DON, Administrator, and Executive Director, they said the consultant pharmacist should be auditing the medication rooms, medication carts, and checking the residents' ordered medications monthly as part of their responsibility. Staff should follow facility policies. The Unit Nurse Managers are responsible to conduct weekly medication cart audits to ensure all medications are appropriately labeled, dated when opened and expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacist reports any irregularities to the attending physician and the facility's medical director and director of nursing, and ensure these reports were acted upon. In addition, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident for four of seven residents investigated for the monthly medication regimen review (Residents #65, #68, #48, and #8). This had the potential to affect all residents with irregularities identified during the monthly medication review. The census was 86. Review of the facility's Consultant Pharmacist Service Provider Requirements policy, provided as the facility's policy and procedure for the required monthly medication review for residents, revised August 2014, showed: -Regular and reliable consultant pharmacist services are provided to residents. A written agreement with a consultant pharmacist stipulates financial agreements, at fair market price, and the terms of the services provided; -The consultant pharmacist agrees to render the required service in accordance with local, state, and federal laws, regulations, and guidelines; facility policies and procedures; community standards of practice; and professional standards of practice; -The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In Collaboration with facility staff, the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This includes, but is not limited to: -Working with facility staff on the development, implementation, evaluation, and revision of pharmaceutical services procedures; -Evaluating the process of receiving and interpreting prescribers' orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, and using and/or disposing of all medications, biologicals, and chemicals; -Reviewing the medication regiment (medication regimen review) of each resident at least monthly, or more frequently under certain conditions (e.g., upon admission or with a significant change in condition), incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review and documenting the review and findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation; -A written or electronic report of findings and recommendations resulting for the activities as described above is given to the attending physician, director of nursing (DON) and others as may be appropriate at least monthly. The facility has a process to ensure that the findings are acted upon; -The policy failed to identify time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. 1. Review of the facility's Consultant Pharmacist Review Summary, for the dates of 5/2023 through 10/2023, showed: -Data compiled on 5/26/23 for outcomes entered between 5/1/23 and 5/26/23: -Residents reviewed: 87; -This visit, 40 recommendations were forwarded to the following disciplines: -33 written to the physician; -7 written to nursing; -Data compiled on 6/24/23 for outcomes entered between 6/1/23 and 6/24/23: -Residents reviewed: 99; -This visit, 90 recommendations were forwarded to the following disciplines: -36 written to the physician; -54 written to nursing; -Data compiled on /26/23 for outcomes entered between 7/1/23 and 7/26/23: -Residents reviewed: 89; -This visit, 64 recommendations were forwarded to the following disciplines: -23 written to the physician; -41 written to nursing; -Data compiled on 8/28/23 for outcomes entered between 8/1/23 and 8/29/23: -Residents reviewed: 87; -This visit, 27 recommendations were forwarded to the following disciplines: -16 written to the physician; -11 written to nursing; -Data compiled on 9/26/23 for outcomes entered between 9/1/23 and 9/26/23: -Residents reviewed: 91; -This visit, 25 recommendations were forwarded to the following disciplines: -14 written to the physician; -11 written to nursing; -Data compiled on 10/17/23 for outcomes entered between 10/1/23 and 10/18/23: -Residents reviewed: 84; -This visit, 28 recommendations were forwarded to the following disciplines: -17 written to the physician; -11 written to nursing. During an interview on 10/25/23 at 12:30 P.M., the DON said she is not sure the last time the facility had access to the consultant pharmacist's reports. She had never seen the pharmacy recommendation reports prior to when they were requested by the survey team. She had these recommendation reports printed after they were requested by the survey team. 2. Review of Resident #65's medical record, showed: -Diagnoses included dementia and anxiety disorder; -An order dated 11/10/22, open ended, for lorazepam (medication used to treat anxiety) schedule IV (controlled narcotic medication) concentrate, 2 milligram (mg) per milliliter (ml). Administer 0.5 ml oral every 4 hours as needed for agitation/anxiety. Review of the resident's Consultant Pharmacist Recommendation to Physician, dated 5/26/23, showed: -Recommended discontinuing as needed use of lorazepam for this resident, or reorder for a specific number of days, per the following federal guidelines: -In accordance with state and federal guidelines, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days. Then he or she should document the rationale in the resident's medical record and indicate the duration of the as needed order; -No documentation of follow up on the recommendation. During an interview on 10/25/23 at 12:30 P.M., the DON said she could not locate any documentation from the physician why the residents as needed lorazepam would be required longer than 14 days. 3. Review of Resident #68's medical record, showed: -admitted [DATE]; -Diagnoses included: dementia, psychotic disturbance, anxiety and delirium; -An order dated 5/9/23, for Trazodone (antidepressant and sedative) 50 mg take one as needed, open ended. Review of the consultant pharmacist recommendation to physician, dated 6/22/23, showed: -Recommend discontinuing the as needed use of Trazodone for the resident or reorder for a specific number of days, per the following guidelines: in accordance with state and federal guidelines, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days. Then he/she should document the rationale in the resident's medical record and indicate the duration for the as needed order; -The recommendation not reviewed by the resident's physician. 4. Review of Resident #48's medical record, showed: -admitted [DATE]; -Diagnoses included: dementia with behaviors, anxiety and psychosis disturbances. - An order dated 2/16/23, for Trazodone 50 mg, give half a tablet (25 mg) daily at bedtime. Open ended. Review of the consultant pharmacist recommendation to physician, dated 6/22/23, showed: -Practice guidelines for major depression in primary care recommend continuing the same dose for 4-9 months following the acute phase. Whether a patient is to continue therapy in this maintenance phase depends on the established history of previous depressive episodes and the physician assessment. A trail dose reduction may be reasonable at this time. The resident has been using Trazodone (used for depression) 25 mg daily at bedtime since 2/16/23. If this therapy is required to prevent future depressive episodes, please document to that effect in your progress notes; -The recommendation not reviewed by the resident's physician. The medical record did not reflect further follow up by the facility. 5. Review of Resident #8's care plan, in use at the time of the survey, showed: -Problem: Psychotropic drug use: Resident is at risk for adverse consequences related to receiving psychotropic medication for treatment of a disorder associated with episodes of mood swings ranging from depressive lows to manic highs (bipolar disorder); -Goal: Resident will not exhibit signs of drug related side effects or adverse drug reaction; -Approach: Gradual Dose Reduction denied per Medical Director on 8/31/22. History of bipolar mood which is stable. Review of the resident's diagnoses, showed Parkinson's disease, bipolar disorder, nausea, weakness, and repeated falls. Review of the resident's physician order sheet, showed an order dated 3/6/23: -End date: Open ended; -Xanax (alprazolam, used to treat anxiety) - Scheduled IV tablet: 0.5 mg; -Special instructions: Give ½ to one tablet by mouth daily as need; -Diagnosis: Bipolar disorder. Review of the Consultant Pharmacist Recommendation to Physician, dated 9/26/23, showed: -Recommend discontinuing as needed use of Xanax for this resident, or reorder for a specific number of days, per the following federal guideline: In accordance with State and Federal Guidelines, orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days. Then he or she should document the rationale in the resident's medical record and indicate the duration for the as needed order; -Physician/Prescriber Response showed no response. During an interview on 10/26/23 at 12:47 P.M., the DON said she expected there to be rationale documentation for the uses of as needed Xanax and expected the resident's use of as needed Xanax to be re-evaluated every 14 days, unless the physician had documented rationale for extended use. She expected the pharmacy recommendations to have been followed. 7. During an interview on 10/25/23 at 12:30 P.M., the DON said she is not sure the last time the facility had access to the consultant pharmacist's reports. She had never seen the pharmacy recommendation reports prior to when they were requested by the survey team. She does not receive them and she does not have access to them. A month ago, they got a new consultant pharmacist. When the pharmacist started, he/she said he/she did not know who he/she should be providing the pharmacist recommendations to. This is when the facility realized there was no process for acting on the monthly pharmacy medication regimen reviews. The prior pharmacist said he/she was hand delivering them, but she never received any prior to October 2023. The recommendations that were provided by the new pharmacist in October 2023 were given to one of the charge nurses who is on personal leave. This is who was responsible to provide them to the physicians. She provide 6 months of recommendations, but the only ones that have been acted on were the recommendations provided October 18, 2023. She is still waiting to hear back from the doctors on some of them. Prior to October 2023, the facility had no process for the monthly medication regimen review. 7. During an interview on 10/26/23 at 9:15 A.M., with the DON, Administrator, and Executive Director, they said the consultant pharmacist should be auditing the medication rooms, medication carts, and checking the residents' ordered medications monthly as part of their responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow professional standards of care when staff failed to ensure orders were in place and verified for a resident (Resident #1) who admitted to the facility with an intact peripherally inserted central catheter (PICC line, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart and used to administer medications). The facility also failed to ensure discharge hospital medication orders were transcribed onto the facility orders accurately. As a result, the resident did not receive the ordered anticoagulant for all days of the stay. The facility also failed to administer an ordered breathing treatment 22 out of 59 opportunities (Resident #3). The sample was 6. The census was 85. Review of the facility's Central Vascular Access Device (CVAD) Flushing and locking policy, revised on 5/1/15, showed: -To be performed by: Licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. -Considerations: 2. Specific flush/locking orders must be documented (Refer to appendix A.1, infusion maintenance table). -Guidance: 1. A physician/licensed independent practitioner order (LIP) is required to flush/lock a catheter (Refer to appendix A.1, infusion maintenance table). The order must include: 1.1 Flushing/locking agents, 1.2 strength/concentration, 1.3 volume, 1.4 frequency; -Procedure: 15. Documentation in the medical record includes, but is not limited to: -15.1 date and time, 15.2 prescribed flushing/locking agents, 15.3 site assessment, 15.4 patient response to procedure and/or medication. Review of the facility's Appendix A.1 Infusion maintenance table policy, revised March 2010, showed: -Peripherally inserted central catheter (PICC): -Maintenance flush each lumen; -Non-valved every 12 hours with 5 milliliters (ml) of normal saline (NS), 5 ml 10 units/ml heparin; -Valved catheter 10 ml NS every week; -Site maintenance: -Transparent dressing changes, 24 hours post insertion or on admission then every week and as needed (PRN), measure upper arm circumference and external catheter length on admission, with each dressing change. -Measurements: -For PICC and midlines: Measure upper arm circumference and external catheter length upon insertion, admission, with each dressing change, and PRN. Review of the undated physician service policy, showed: -Policy: provide care and services related to physician services in accordance with state and federal laws; -Procedure: -All physician of other health care professional verbal orders, including telephone orders, will be immediately recorded, dated and signed by the person receiving the order; -All orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift. Review of the administration medication policy, dated 2020, showed: -Purpose: ensure safe administration of the resident's medication as indicated and ordered by the provider; -Policy: administer medications in a safe and accurate manner that will ensure the six rights of identification for administration; -Procedure: -Medications are administered in accordance with the orders. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/18/22, showed: -admission date of 10/12/22; -Cognitively intact. -Diagnosis included hip fracture, anemia (decrease in the number of red blood cells), deep venous thrombosis (DVT, a blood clot that forms in a deep vein), hypertension (HTN, high blood pressure), renal insufficiency (partial kidney function failure characterized by less than normal urine excretion) and diabetes mellitus (DM, metabolic disease). Review of the resident's care plan, in use at the time of survey, showed no identification of interventions for care of the resident's PICC. Review of the resident's progress notes, dated 10/12/22 through 10/31/22 showed; -On 10/12/22 at 4:38 P.M., patient has PICC in left upper arm. Nurse practitioner (NP) notified and states to monitor and wait for physician to see patient for orders; -On 10/12/22 at 5:31 P.M., resident has PICC line to left arm. Facility nurse called the hospital to ask if resident needed PICC for any reason. Nurse at hospital stated no the patient did not need it and the hospital nurse stated he/she forgot to take it out; -On 10/31/22 at 3:57 P.M., PICC discontinued with tip intact. Pressure held 5 minutes, gauze tape applied. Review of the resident's electronic physician order sheet (ePOS), dated 10/1/22 through 10/31/22 showed; -On 10/31/22 order created at 11:05 A.M., order description, please pull PICC line; -No active orders for maintenance to PICC. During an interview on 11/1/22 at 11:08 A.M., Licensed Practical Nurse (LPN) A said he/she was aware the resident had a PICC line since admission. When a resident is admitted with a PICC line, orders should be obtained for flushing every shift, changing the dressing weekly and to monitor the site for any signs of infection every shift. LPN A said the resident did not have these orders in place for the PICC line and should have. During an interview on 11/1/22 at 12:17 P.M., the clinical manager said she spoke with the NP the day the resident admitted and the NP said to monitor until the physician saw the resident. The clinical manager said she didn't think to write an order for monitoring. The clinical manager said normally she would have followed up with the physician, but she was off work for a week because she was ill. She expected staff to follow up with the resident's physician in her absence. If a resident has a PICC that is not being used, an order would be requested to discontinue the PICC. She was under the impression staff would get those orders. During an interview on 11/1/22 at 12:48 P.M., the Director of Nursing (DON) said he expected staff to follow the facility's policies. If a resident is admitted to the facility with a PICC, he expected staff to get orders to maintain patency (the condition of being open, or unobstructed), dressing changes, and monitoring the site for any signs of infection. Not having these orders in place could have caused an infection to the resident. It is the charge nurses' responsibility to ensure that hospital orders are entered correctly into the ePOS. The facility had recently implemented a double check system to ensure physician orders are complete. 2. Review of Resident #3's hospital summary of care, dated 8/25/22, showed: -discharged : 8/25/22; -Diagnoses included shortness of breath, altered mental status and acute kidney injury; -Medications to be continued after discharge: -Albuterol (used to open airways in the lungs) sulfate 2.5 milligram per milliliter (mg/mL) 0.083% nebulizer solution. Inhale one vial by mouth three times daily; -Eliquis (anticoagulant, used to prevent blood clot development) 5 milligram (mg) tablet. Take one tablet twice daily. Review of the care plan, dated 8/27/22, showed no documentation regarding heart or lung diagnoses. Review of the nurse practitioner visit note, dated 8/31/22, showed: -Chief complaint: the resident is being seen for multiple medical conditions; -History of present illness: recent hospitalization 8/20/22 through 8/25/22 the resident was diagnosed with heart failure, shortness of breath and acute kidney injury; -The medication list did not include Eliquis 5 mg. Review of admission MDS, dated [DATE], showed: -admitted : 8/25/22; -discharged : 9/14/22; -Severe cognitive impairment; -Diagnoses included: atrial fibrillation (a-fib, irregular heart beat) and stroke; Review of the ePOS, showed: -Albuterol sulfate 2.5 mg/3 mL inhalation. Give one vial, three times daily. Scheduled daily at 9:00 A.M., 1:00 P.M. and 5:00 P.M.; -No Eliquis 5 mg order documented. Review of the MAR, dated 8/25/22 through 9/14/22, showed: -An order dated, 8/26/22 for Albuterol sulfate 2.5 mg/3 mL inhalation. Give one vial, three times daily. Scheduled at 9:00 A.M., 1:00 P.M. and 5:00 P.M.; -22 of 59 opportunities documented as nurse task and not administered. No progress notes reflected why the medication was not administered. -No documented order noted for Eliquis 5 mg twice a day. Review of the progress notes, showed: -On 9/14/22 at 11:00 A.M., the resident to be discharged home with home health care, skilled nursing and therapy services. The resident had no distress and denies discomfort. During an interview on 11/4/22 at 9:45 A.M., the next of kin/responsible party said the resident discharged home from the facility on 9/14/22 in the care of family. The resident was sent home with medications, however the Eliquis was not included. Family called the resident's primary physician on 9/16/22 and asked about restarting the Eliquis. During an interview on 11/4/22 at 10:05 A.M., the physician's office manager said the resident's family called the office and notified the physician the resident had not received his/her Eliquis while in a long term care facility. The resident had been taking the ordered Eliquis as of 9/16/22. The resident had a history of a-fib, stroke, seizures and dementia. During an interview on 11/1/22 at 12:48 P.M., the DON said he expected staff to follow the facility's policies. The resident's Eliquis order had not been carried over from the hospital orders and the resident had not received any of the Eliquis during his/her stay. Inhaled medications should be administered by the nurse. Resident #3's inhaled medications were placed onto the Certified Medication Technician's (CMT) MAR since it was ordered three times a day. The CMT should have notified the charge nurse the albuterol inhaler was routinely scheduled so the order could be moved to the nurse task. MO00208557 MO00208930

Based on interview and record review, the facility failed to report alleged violations of abuse to the Department of Health and Senior Services (DHSS) immediately, but not later than 2 hours after the allegation was made, after two allegations of abuse. This affected one of 19 sampled residents (Resident #42). The facility census was 81. Review of the facility Abuse Prevention Plan, dated 11/28/17 and revised on 8/14/20, showed: -Prevention of abuse, neglect, misappropriation of resident property and financial exploitation: -Identify, correct and intervene in situations where abuse, neglect, misappropriation of resident property and/or financial exploitation occurs; -Require staff to report concerns, incidents and grievances immediately to their supervisor. Concerns, incidents and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrences; -Identification of possible incidents which need investigation: -Any person with the knowledge or suspicion of suspected abuse, neglect, misappropriation of resident property, and/or financial exploitation must report immediately, without fear of reprisal and/or retaliation; -All accidents and incidents, as well as allegations of abuse, neglect, misappropriation of resident property, and/or financial exploitation will be investigated by the Director of Social Services, Director of Nursing (DON), or their appropriate designees; -Reporting of suspected resident abuse and/or neglect: -Staff will notify the facility Charge of the Building immediately of any reports of possible abuse, neglect, misappropriation of resident property and/or financial exploitation. The Charge of the Building will immediately notify the Executive Director (ED) or designee in the ED's absence; -The community is responsible for reporting suspected abuse, neglect, misappropriation of resident property and/or financial exploitation in accordance with legal requirements. If the event that caused the suspicion involves abuse or results in serious bodily injury, the individual is required to report the suspicion immediately, but not later than two hours after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report no later than 24 hours after forming the suspicion; -Refer to state-specific instructions below for additional guidance: -Missouri: Report by submitting form, Mandated Reporter Form, or calling to make a report by phone. Staff will notify the physician and family as appropriate; -Within five working days, the DON, Director of Social Services or their designee will electronically submit the facility's investigative report to the appropriate state agency; -The results of the investigation are reported to the Administrator. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/5/20, showed: -Cognitively intact; -One staff person assist for bed mobility, transfers, dressing and toileting; -No behaviors; -Indwelling catheter (a flexible tube that is used to drain urine from the bladder); -Wheelchair for mobility; -Diagnoses included high blood pressure, cerebral palsy (a disorder of movement, muscle tone or posture), anxiety disorder, depression and chronic lung disease. Review of the resident's care plan, in use during the survey, showed: -Problem: Psychotropic drug use. At risk for adverse consequences due to receiving antidepressants/antipsychotic/antianxiety medications routinely for treatment of depression, anxiety and insomnia. Can get upset/angry and has injured himself/herself in the past because of this behavior; -Approach: Chart behaviors in the progress notes as they arise. Monitor mood and response to medications, provide emotional support as needed. Redirect behaviors and start a behavior log if behaviors escalate and notify physician; -No direction for staff regarding types of behaviors exhibited by the resident and/or types of redirection/interventions to use specific to the behavior; -Problem: Indwelling catheter. Required a Suprapubic catheter (indwelling catheter inserted through the abdominal wall into the bladder) due to retention/neurogenic bladder (loss of bladder control due to brain, spinal cord or nerve problems); -Approach: Assess drainage. Record the amount, type, color and odor. Avoid obstructions in the drainage. Do not allow tubing or any part of the drainage system to touch the floor. Review of the facility's investigation, dated 9/3/30, typewritten and signed by the administrator, showed an investigation for alleged abuse. On Thursday, 9/3/20 at approximately 1:30 P.M., a call was received from the resident's private counselor. He/she spoke with the DON and stated the resident had called him/her and reported during a shower last evening, the Certified Nursing Assistant (CNA) inserted his/her finger far up his/her genital area and he/she was complaining of pain. At approximately 1:45 P.M., the administrator contacted the Hotline to report the alleged incident. At 2:02 P.M., the administrator entered the resident's room, along with the Assistant Director of Nursing (ADON). The resident was on the phone with a surveyor for the DHSS. The administrator spoke to the surveyor and told him/her that he/she was there to begin the investigation. The surveyor asked if he/she would call when he/she was finished. The administrator told the resident that they had received a call from his/her private counselor, letting them know that he/she called the abuse/neglect hotline to report what he/she had told him/her. The administrator asked the resident if he/she could please tell him/her what exactly happened. According to the resident, his/her CNA was someone he/she did not know and who had never taken care of him/her. The resident adamantly stated, I wanted another CNA to help, not (him/her). The administrator asked the resident to describe what happened. He/she said that everything was going just fine until this happened. The resident stated the CNA was washing him/her and then all of a sudden, started rubbing his/her genitals very hard and it hurt. He/she asked the resident if he/she told the CNA to stop and he/she stated that he/she did, but not before he/she put his/her finger up his/her private area. The ADON asked if the CNA was using a soapy washcloth and the resident confirmed. The ADON asked the resident if he/she was able to wash him/herself and he/she said yes (resident has Cerebral Palsy and has limited use of fingers due to slight contractures). The Assistant DON asked the resident if he/she told the CNA he/she could wash him/herself and the resident stated the CNA told him/her that he/she would do it and get him/her washed really good. The Assistant DON asked the resident if he/she reported this to the nurse or anyone when this happened and he/she said no, not until this morning. When asked what happened after the shower, the resident stated the CNA brought him/her back to his/her room, and put on his/her clothes. He/she stated nothing else happened. The administrator said to the resident that he/she had heard the resident got very upset when his/her parent left to be transferred to another facility, and asked if what happened during the shower could have been due to his/her being upset. The resident stated loudly, it had nothing to do with his/her parent and everything to do with that n . putting his/her finger up his/her private area. The administrator told the ADON to do a full body assessment of him/her due to the nature of the allegation. They wanted to be certain there was no reddened area or signs of bruising. He/she told the resident that he/she would be conducting a very thorough investigation and that allegations such as this could mean the CNA gets reported and possibly loses his/her livelihood if it was true. The resident became very quiet (note, during the interview, the resident barely looked her in the eyes. The resident visits frequently when in her office just to chat.) The administrator spoke with two of the residents near his/her room to see if they had any issues with the caregiver last night. Both indicated that they were happy with their care and had no issues or concerns. One stated that sometimes they get in a hurry, but they are young and have a lot to learn. The administrator contacted the surveyor with DHSS to inform him/her of his/her immediate findings. He/she let the surveyor know that this resident has made allegations before about being sexually abused. In the past, he/she accused the driver of touching his/her breast when he/she put the seatbelt on during transfer. The second was that his/her parent exposed him/herself to the resident while in the bathroom. As a result, the resident could not visit with his/her parent in his/her room and had to be in a public space. The driver is not allowed to drive him/her and he/she must be transported by someone else if needed. The administrator interviewed CNA I, who was the resident's caregiver, and asked him/her to recall the shower he/she gave the resident. He/she stated everything was going fine until he/she got to the perineal area. He/she described the resident is obese and his/her thighs were very tightly held together. He/she stated that he/she had to move the washcloth from side to side to try and get to the perineal area. He/she stated when he/she did, the resident made a noise. He/she stated that he/she asked the resident if he/she was okay and he/she said he/she was. CNA I stated when his/her hand reached the perineal area, his/her hand slid forward quickly and his/her finger did slide into the genital area by accident. The administrator spoke to the resident following the discussion with CNA I. He/she explained what happened according to him/her. The resident shook his/her head and said he/she understood. Based on his/her knowledge of the resident, conversations with both resident and caregiver, it is his/her opinion the resident was touched as described, but it was not deliberate and happened as a result of the attempt to clean the resident's perineal area. Review of a facility investigation witness statement, handwritten and signed, dated 9/3/20 at 7:10 A.M., showed CNA F document he/she went into the resident's room to get him/her up for breakfast. The resident told him/her that he/she didn't know who to report this to, but the staff person that gave him/her a shower the night before washed his/her body good, but when he/she washed his/her private area, he/she scrubbed too hard and the resident felt like the CNA washed the genitals and pushed his/her fingers up too far. CNA F then reported the incident to the nurse. During an interview on 10/7/20 at 2:24 P.M., CNA F said the resident told him/her the caregiver the night before, washed him/her too hard and put a finger in him/her. The resident said that he/she was not sure who to report it to and CNA F told the resident he/she could tell him/her. The resident didn't say where, he/she said in his/her privates. CNA F asked for clarification, the top or bottom. The resident said the top. The resident said he/she was having some discomfort, but not painful at that time. CNA F said he/she reported the incident to Licensed Practical Nurse (LPN) H who said he/she reported it to the Assistant DON. Review of the facility investigation witness statement, handwritten and signed, dated 9/3/20, showed LPN H wrote this morning, CNA F came to him/her and said the resident had told him/her the CNA on 3:00 P.M. through 11:00 P.M. shift, when giving a shower, washed his/her genitals and went too high in his/her genital area, and it was hurting still. LPN H told the Assistant DON. LPN H then told the resident he/she had told the Assistant DON about it and he/she would be talking to him/her about it. Review of the facility investigation witness statement, typewritten, dated 9/3/20 at 2:15 P.M., showed the ADON documented, after receiving permission from the resident, a head to toe skin assessment was completed. Physical exam of his/her body revealed a small scab on his/her right upper thigh from the catheter lock (a device attached to the catheter tubing to prevent pulling). No redness or skin irritation noted anywhere on his/her body. Perineal area without redness, irritation, or bruising. Noted to have a foul smell to entire perineal area. Resident did allow the CNA to clean him/her up with soap, water and a washcloth. Resident was then dried and redressed. Further review of the resident's medical record and the facility's investigation, showed the allegation that was reported to CNA F at breakfast time on 9/3/20 not called in to DHSS until 9/3/20 at approximately 1:45 P.M. During an interview on 10/6/20 at 7:48 A.M., the resident said the incident happened on the evening shift. CNA I was agency, and he/she didn't know his/her name, he/she did not wear a badge. The resident was seated in the large shower chair and CNA I said, I'm going to wipe your bottom. The resident said it felt like he/she was digging in his/her rectum, it was unusual, staff don't normally do that. CNA I didn't say anything to him/her, there wasn't any stool on his/her bottom. The resident said he/she was thinking to him/herself, what are you doing, he/she was afraid to say anything. CNA I did not penetrate his/her genital area, it was his/her rectum. The resident said he/she washed his/her own perineal area. CNA I didn't say anything to him/her, not one word. He/she kind of jumped when it happened, jerking away from him/her. CNA I said nothing. The resident said he/she felt humiliated, he/she has had experiences with abuse in the past. He/she was scared and didn't know who would believe him/her. Further review of the resident's social service notes, dated 9/14/20, showed the social worker was notified by the resident's private counselor, the resident reported being sexually assaulted while taking a shower. The social worker notified the administrator and psychiatrist and the psychiatrist will write a letter stating he/she did not feel this to be true. The social worker met with the resident and asked how things were going in general. The resident said he/she loved his/her new private room and had received photographs of his/her grandbaby. The resident was all smiles and happy. The resident was asked how the care was going now that the facility had made a couple changes in staffing. The resident did not report any concerns, and did not show he/she was having any problems with the staff or residents. During an interview on 10/8/20 at 10:50 A.M. and on 10/12/20 at 4:26 P.M., the social worker said the resident's private counselor called and said the resident told him/her that he/she had been assaulted by a nurse in the shower on 9/14/20. This is a separate allegation from the one called in about the CNA. The private counselor said he/she hot-lined the incident. The social worker said they called the psychiatrist for a letter and no one came to investigate. The social worker said she talked to staff and no nurse matching the description was assigned to the resident and he/she did not get a shower that evening. He/she did not write down everything from his/her discussion with the resident, but did ask if he/she had any problems with any of the staff. Some of the visit was just them talking and she doesn't write down everything. She felt the resident was comfortable. The resident didn't tell her anything. The social worker said she was afraid to cross the lines of confidentiality. The resident forgets what he/she tells people and the stories change, his/her psychiatrist believes he/she does it for attention. Administration was aware of these incidents and the social worker called the Ombudsman and spoke with them, and was told to care plan in regard to the accusations. He/she did not report the allegation to DHSS. Further review of the resident's medical record, showed no additional information in regard to the alleged incident on 9/14/20. During an interview on 10/9/20 at 2:10 P.M., the administrator said all allegations should be reported and thoroughly investigated. Witnesses should be interviewed and include statements of additional residents. A person with a history of making allegation abuse should be care planned, unless it's a breach of privacy, but could include attention seeking behaviors and could include false accusations. The allegation regarding the CNA in the shower, the resident reported to the counselor and to facility staff the next day. Regarding the other alleged incident, had the facility investigated, there would have been a breech between the facility and his/her private counselor. The resident never said anything to the facility. The private counselor is a mandated reporter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice when staff failed documented the fluid and meal intake of two residents as indicated in their plan of care (Residents #27 and #179). In addition, the facility failed to ensure daily weights were obtained as ordered (Resident #179). The resident sample at 19. The census was 81. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 8/5/20, showed: -Severe cognitive impairment; -Required supervision with meals; -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months, marked yes. Not on physician prescribed weight loss. Review of the resident's medical record, showed: -admitted on [DATE]; -Diagnosis included: anxiety, dementia, and contracture of left hand (rigidity of the muscles). Review of the resident's electronic physician order sheet (ePOS), dated 10/7/20, showed the following current orders: -Pureed diet with thin liquids; -Ensure (nutritional supplement) three times a day; -Monitor intake and output every shift, start date 5/5/20; Review of the resident's dietary note, dated 8/6/20, showed the resident was on a pureed diet and required total assistance with his/her meals. According to nursing documentation, resident has lost eight pounds in one month. Resident's appetite and consumption of meals seems to have decreased and he/she was eating 25-50% at meals. Resident's weight now, 108 pounds and three months ago it was 118 pounds. Will continue to monitor resident's weight and meal consumption. Review of the residents consumption record, dated 9/8/20 through 10/8/20, showed: -No documentation for all three meals or supplements on 9/8 through 9/18 and 9/20 through 10/7/20; -On 9/19/20, only dinner intake documented. Observation of the resident during the lunch meal service on 10/7/20, showed the resident became agitated and was taken from the dining room to his/her room. The resident's food tray remained on the table. As of 1:45 P.M., the food tray remained on the table. During an interview on 10/9/20 at 2:00 P.M., the Assistant Director of Nursing (ADON), said the certified nursing assistants (CNAs) are responsible for documenting the intake (meal consumption). Also, the nurses can document intake. All three meals and supplements should be documented in the medical record, under vital signs and in point of care charting. If a resident does not eat a meal, the staff will try to find out what the resident would like to eat and get it for them. Nurses are made aware of a change in intake by the CNAs. If a resident does not eat for three days, the doctor would be notified because this would be considered a change in condition. The ADON would expect staff to follow physician orders and document intake. Resident #27's weight was stable and the lack of intake documentation was an omission of staff, the doctor was not notified. Further review of the resident's medical record, showed the most recent weight obtained on 10/8/20 and registered 105 pounds. 2. Review of the Resident #179's face sheet, showed the resident admitted to the facility on [DATE]. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, high blood pressure, and acid reflux; -Limited assistance required with bed mobility, transfers, dressing, toileting, and hygiene; -Independent with eating; -Weighs 103 pounds. Review of the resident's ePOS, dated 10/1/20 through 10/8/20, showed: -An order dated 10/1/20, 1200 cubic centimeters (cc) fluid restriction per 24 hours; -An order dated 10/1/20, document milliliter (ml, equivalent to a cc) of fluid intake every shift, restricted to 1200 per 24 hours; -An order dated 10/1/20, weigh daily before breakfast. Call for weight gain greater than 2.0 pounds in 24 hours or 5 pounds above admission weight. Assess lung sounds, peripheral edema (swelling in the extremities) and respiratory effort daily. Review of the resident's baseline care plan, dated 10/5/20, showed no documentation of the resident's fluid restriction and the diagnosis of heart failure. Review of the resident's weight record, reviewed on 10/8/20, showed: -On 10/2/20, weight recorded at 103.3 pounds; -No further documentation of weights. Review of the resident's fluid intake per shift, dated 10/1/20 through 10/8/20, showed: -On 10/3/20 at 7:37 P.M., showed a fluid intake of 100 milliliter (ml); -On 10/4/20 at 1:16 P.M., showed a fluid intake of 100 ml; -On 10/5/20 at 2:18 P.M., showed a fluid intake of 360 ml; -On 10/7/20 at 2:52 A.M., showed a fluid intake of 100 ml; -On 10/7/20 at 1:06 P.M., showed a fluid intake of 480 ml; -No further documentation of the resident's fluid intake. Observation and interview on 10/7/20, showed: -At 8:50 A.M., the resident was served breakfast. The resident said he/she drinks Ensure (a supplement) to keep his/her energy up. He/she was also served a carton of milk; -At 12:19 P.M., the resident ate his/her meal. There was a large cup of water on the bedside table. During an interview, Nurse R confirmed that the resident was on fluid restriction. The large cup on the resident's table can hold 500 cc of water and there was currently 350 cc of water in the large cup. Nurse R lifted the Ensure and said it was still full. The resident said he/she took small sips from his/her cup. 3. During an interview on 10/9/20 at 2:00 P.M., the Director of Nursing (DON) said the CNAs and the nurse are responsible for documenting the fluid intake. It is documented in the electronic medical record under vital signs and the point of care charting. She would expect staff to follow physician's orders and to see patterns of poor intake or unintended weight changes. She would expect a resident with a diagnoses of congestive heart failure with orders for daily weights, to have the weights be done as ordered. The DON and ADON are responsible for overseeing the weights and notifying the physician of any issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received services to maintain good personal hygiene by failing to shave and provide nail care for two residents who were dependent on staff for care needs (Residents #23 and #29). The sample was 19. The census was 81. Review of the facility policies, showed; -No policy for fingernail care, shaving care or oral; -A staff skill competency check form for fingernail care, oral care and shaving with electric razor (dated 2009). The competency check forms did not indicate how often to provided nail care or shaving care or when this care would be indicated as needed. 1. Review of Resident #23's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/18/20, showed extensive assistance required for personal hygiene. Review of the resident's electronic medical record (EMR), showed diagnoses included altered mental status, muscle weakness and congestive heart failure (CHF, impaired heart function). Review of the resident's care plan, revised 8/3/20, showed: -Problem: Weakness and decline of activities of daily living (ADL) due to recent hospitalization for anemia and CHF; -Goal: ADLs competed each day to the resident's comfort and satisfaction; -Approach: Fingernail care provided to be completed during shower with cleansing of nails and trimming if needed. Assist of one with bathing. Review of the facility shower assignment book on [NAME] Hall showed, the resident's showers assigned on evening shift, Wednesdays and Saturdays. Observation of the resident during the survey on 10/6/20 at 8:10 A.M., 10/7/20 at 9:35 A.M. and 10/8/20 at 4:45 P.M., showed his/her face unshaven and a brown substance underneath his/her long fingernails, on both hands. During an interview on 10/8/20 at 10:05 A.M., the resident said he/she did not like to be unshaven and would like to be shaved every day. 2. Review of Resident #29's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -One staff person assist required for bed mobility, transfers, dressings, toileting and personal hygiene; -Wheelchair/walker for mobility; -No behaviors; -Diagnoses included high blood pressure, Alzheimer's disease, and depression. Review of the resident's care plan, in use during the survey, showed: -Problem: Dental care, requires assistance with oral hygiene due to upper/lower dentures; -Approach: Provide assistance with oral hygiene twice a day and as needed; -Problem: Behavioral Symptoms, sometimes does not want to take medications or acts our with staff related to dementia; -Approach: Try to redirect resident when behaviors are present. Observation of the resident during the survey, showed: -On 10/5/20 at 12:25 A.M., he/she sat in the hallway in his/her wheelchair, socks on his/her feet and no shoes, with long hairs that extended from his/her chin; -On 10/6/20 at 7:42 A.M., he/she sat in the dining room, long hairs extended from his/her chin; -On 10/7/20 at 2:20 P.M., he/she sat in his/her room, long hairs extended from his/her chin; -On 10/8/20 at 3:06 P.M., he/she sat in a wheelchair, long hairs extended from his/her chin; -On 10/9/20 at 11:09 A.M., he/she sat in his/her room, long hairs extended from his/her chin. 3. During an interview with the assistant director of nursing (ADON) on 10/9/20 at 3:30 P.M., she said that nail grooming should be done on bath or shower days and residents should be shaved every day or every other day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received Restorative Therapy (RT) as indicated for three resident's (Residents #23, #30 and #22) sampled who had orders for RT. The sample was 19. Census was 81. Review of the facilities Restorative Program policy, dated 2017, showed: -Purpose: To ensure residents are comprehensively assessed/reassessed for restorative needs; -Policy: To provide a basic outline and guidance for implementation and tracking of restorative programs established so that each resident can attain and maintain highest physical, mental and psychosocial well-being. Restorative nursing care promotes resident's highest level of independence in each of the following areas: -Activities of Daily Living (ADLs); -Splints/brace; -Range of Motion (ROM); -Ambulation; -Bed Mobility; -Procedure: Upon admission/readmission/significant change in status the resident will be assed for potential restorative needs; -Analysis of the assessment will determine which restorative interventions are indicated; -A registered nurse (RN) will provide oversite to the program to ensure the restorative interventions are being implemented as planned; -An RN in collaboration with the therapist will design the individualized restorative program for the resident; -Associates must be trained prior to performing the restorative skills, and documents must be maintained in the employee training file. 1. Review of Resident #23's electronic medical record (EMR), showed diagnoses included altered mental status, muscle weakness and congestive heart failure (CHF, impaired heart function). Review of the resident's quarterly change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/18/20, showed: -Severe cognitive impairment; -Extensive assistance required for bed mobility, dressing and personal hygiene; -Total dependence on staff for transfer and toilet use; -Balance during transitions and walking: -Moving from seated to standing positon: Not steady, only able to stabilize with human assistance; -Moving on and off toilet: Not steady, only able to stabilize with human assistance; -Surface to surface transfer: Not steady, only able to stabilize with human assistance; -Functional limitations in ROM: -Upper extremity: No impairment; -Lower extremity: No impairment; -Restorative nursing program: Number of days restorative program was performed in the last 7 calendar days: 0. Review of the resident's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence on staff for bed mobility, transfer, dressing, toilet use and personal hygiene; -Balance during transitions and walking: -Moving from seated to standing positon: Not steady, only able to stabilize with human assistance; -Moving on and off toilet: Not steady, only able to stabilize with human assistance; -Surface to surface transfer: Not steady, only able to stabilize with human assistance; -Has the resident had any falls since admission or the prior assessment, whichever is more recent: Yes; -Functional limitations in ROM: -Upper extremity: Impairment on one side; -Lower extremity: Impairment on both sides; -Restorative nursing program: Number of days restorative program was performed in the last 7 calendar days: 0. Review of the resident's medical record, showed: -A progress note dated 8/7/20 at 12:14 P.M., resident was discharged from skilled physical therapy today and put on restorative therapy for ROM to all four extremities with gentle stretching at end range. Resident should continue with wearing of abductor wedge (pillow used to prevent moving hip joints out of position) at all times except for bathing and ROM; -A physician order sheet (POS) showed an order dated 8/7/20, for RT two to three times a week to maintain current level of functioning; -No order to hold RT the week of 9/14/20 through 9/25/20. Review of the resident's RT tracking form for, September 2020, showed the form listed Monday through Friday: -The week of 9/1/20 through 9/5/20, RT documented as completed only one day; -The week of 9/7/20 thorough 9/11/20, RT not documented as completed; -The week of 9/14/20 through 9/18/20, RT not documented as completed. Hold hand written over the week; -The week of 9/21/20 through 9/25/20, RT documented as completed two days. Review of the resident's RT tracking form for October 2020, showed the form listed Monday through Friday for the week of 10/5/20 through 10/9/20, RT documented as completed only one day. Observation on 10/6/20 at 8:10 A.M., showed the resident lay in bed on his/her left side with a wedge pillow. 2. Review of Resident #30's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Rejection of care: Behavior not exhibited; -Diagnosis included: dementia, anxiety and depression; -Required extensive assistance for bed mobility, dressing and personal hygiene; -Total dependence on staff for transfers and toilet use; -Functional limitation in ROM: upper extremity, impairment on one side; -Restorative Program, number of days each of the following restorative programs were performed (for at least 15 minutes a day) in the last seven days: passive ROM, active ROM and splint or brace, all were marked zero. Review of the residents care plan, in use at time of survey, showed: -Focus: ADL functional/rehabilitation Potential: ADLs require extensive assist of one for grooming, am/pm care, dressing, and oral hygiene. Total dependence for bathing and toileting and set up for meals; -Goal: ADLs completed each day to comfort and satisfaction; -Interventions included: Splint to left hand at night and off in the daytime; -The need for restorative therapy not addressed. Review of the resident's POS, dated 10/5/20, showed restorative therapy two to three times a week, to maintain current level of function. Start date 7/19/20. Review of the resident's RT tracking form for, September 2020, showed the form listed Monday through Friday: -The week of 9/1/20 through 9/5/20, RT documented as completed only one day; -The week of 9/7/20 thorough 9/11/20, RT not documented as completed; -The week of 9/14/20 through 9/18/20, RT documented as completed two days; -The week of 9/21/20 through 9/25/20, RT not documented as completed. Review of the resident's RT tracking form for October 2020, showed the form listed Monday through Friday for the week of 10/5/20 through 10/9/20, RT documented as completed only one day. Observation on 10/7/20, during the lunch meal service, showed the resident sat up in a chair in his/her room. Staff sat by the resident and assisted with lunch. The staff person said the resident's left arm is contracted and he/she required help. 3. Review of Resident #22's admission MDS, dated [DATE], showed: -Cognitively intact; -One staff person assist for bed mobility, transfers, dressings, and toileting; -Set up only for personal hygiene; -Wheelchair for mobility; -Diagnoses included gastroesophageal reflux disease (GERD, acid reflux), and anxiety. Review of the resident's POS, showed an order dated 9/4/20, for restorative therapy, 2-3 times a week for gait and exercise. Review of the resident's restorative tracker form for September showed, no documentation of therapy provided the week of 9/28/20, a refusal documented on 9/29, with no additional documentation of therapy through 10/1/20. Observation on 10/5/20 at 11:50 A.M., showed the resident in his/her room in bed. A bell located on the bedside table. He/she said staff do not always assist him/her as needed. 4. During an interview on 10/8/20 at 1:00 P.M., Restorative Coach D said restorative therapy had their own paper forms they document on. The blanks on the form are days he/she got pulled to the floor or days when he/she did not get to that resident. If a resident refused treatment, or was sent to the hospital, that information would be documented on the form. 5. During an interview on 10/9/20 at 9:08 A.M., Restorative Coach S said he/she gets pulled to the floor a lot. 6. During an interview on 10/9/20 at 2:30 P.M., the administrator and the Assistant Director of Nursing said the Director of nursing (DON) over sees the restorative program. If the restorative aide is pulled to the floor, the expectation would be, if feasible, the treatment would be performed by a certified nurse aide on the floor. The DON would communicate with the charge nurse and the charge nurse would communicate the information to the CNAs. Restorative therapy staff document on their own paper forms. If there is no documentation on the form, the services were either not provided or not documented. If a CNA would notice a change in function/condition in a resident, the CNA would notify the nurse. The nurse would assess the resident and notify the doctor and family, if needed. MO00176130

Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents when staff transferred a resident improperly when using a mechanical lift for one of three transfers observed. In addition, staff failed to investigate the cause of a skin tear so interventions could be implemented to prevent further injury for one (Resident #23). The sample size was 19. The census was 81. Review of the facility's policies showed: -No mechanical lift policy; -A staff skill competency form for mechanical lifts, dated 2009 provided. Review of the undated staff skill competency form, showed: -Obtain assistance from experienced team member; -Instruct your assistant to guide resident to chair. Watch that arms, legs and tubing are safe; -Check that the base of the legs for the lift are properly positioned to support resident weight. Review of the manufacturer's instructions for the facility's Hoyer lift (mechanical lift), showed it included the following: -Before lifting or transferring the resident, the base legs MUST be LOCKED in the OPEN position for optimum stability and safety. Review of Resident #23's electronic medical record (EMR), showed diagnoses included altered mental status, muscle weakness and congestive heart failure (CHF, impaired heart function). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/18/20, showed: -Severe cognitive impairment; -Total dependence on staff for bed mobility and transfer. Review of the resident's care plan, dated 2/26/20, showed: -Problem: Weakness and decline in activities of daily living (ADL) due to recent hospitalization for anemia and CHF; -Goal: ADLs completed daily to comfort and satisfaction; -Approach: Dependent on two staff with a Hoyer lift for transfers. Observation of the resident on 10/7/20 at 9:35 A.M., showed Certified Nursing Assistant (CNA) F and Licensed Practical Nurse (LPN) G applied a Hoyer sling (a large piece of fabric that cradles resident during a mechanical lift transfer) underneath the resident by turning him/her from side to side. On the resident's right forearm, a dressing with no date was noted. LPN G removed the dressing with gloved hands and said it was an old skin tear and he/she did not know when it occurred. The skin tear appeared to have a dark colored scab. CNA F then attached the Hoyer sling to the lift and the resident was raised from bed and transferred to a Broda chair (a specialized reclining chair propelled by staff) while LPN G remained on the other side of the bed and did not assist to guide the resident. The Hoyer lift legs were left in a closed position during the transfer. The resident was in private room and there was approximately 6 feet of distance between the bed and Broda chair. The resident dangled from the Hoyer lift without LPN G there to guide him/her during the transfer. During an interview with LPN G on 10/7/20 at 10:02 A.M., he/she said the lift legs should have been in the open position during transfer. The skin tear on resident's right forearm was not documented in the EMR under incidents, which is where it should be documented. He/she does not know how or when it occurred and there were no treatment orders. During an interview with the Assistant Director of Nursing (ADON) on 10/9/20 at 3:30 P.M., she said mechanical lift legs should be in open position when transferring resident from bed to chair and the second person should assist to guiding the resident to the chair safely. Skin tears should be measured and documented in the skin and wound section of the EMR. The physician should be notified of the skin tear and treatment orders need to be obtained. Family needs to be notified as well. Review of incident report that was provided during survey showed, resident's skin tear to right forearm not listed.

Based on observation, interview, and record review, the facility failed to provide thorough assessments, monitoring and ongoing communication with the dialysis center. The facility also failed to obtain a dialysis contract. The facility identified one resident receiving dialysis (Resident #40). The resident sample was 19. The census was 81. Review of the facility's 2017 dialysis (process for removing toxins from the blood for individuals with kidney failure) policy, showed: -Policy: Dialysis is provided via contract with an external agency. Care for residents that requires dialysis will be managed by licensed associates and through communication with a certified dialysis service; -Procedure: Residents are informed of the dialysis services the community can accommodate at the time of admission and dually informed if such services are required for the resident following admission; -The licensed nurse and other professionals provide ongoing assessment of the residents' condition from a multidisciplinary standpoint and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; -The licensed nurses have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; -A resident-centered, care plan is implemented for the resident who receive dialysis services to meet their preferred needs and includes the following: monitoring for complications, weights, access sites, nutrition and hydration, lab tests, vital signs and medical administration emergency number for communication with dialysis facility; -Transportation is arranged by the community. Review of the Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/31/20, showed: -Cognitively intact; -Diagnoses included renal (kidney) failure, diabetes, hyperlipidemia (high cholesterol), and malnutrition; -Limited assistance with bed mobility, transfers, and hygiene; -Extensive assistance with dressing and toileting; -Independent with eating; -Received dialysis. Review of the resident's electronic physician order sheet (ePOS), dated 10/1/20 through 10/31/20, showed: -An order dated 8/19/20, for dialysis on Monday, Wednesday, and Friday; -An order dated 8/27/20, for low concentrated sweet (LCS) diet; -No orders to check the dialysis access site. Review of the resident's care plan, dated 9/3/20, showed: -Problem: Currently on dialysis related to end stage renal failure. At risk for shortness of breath, chest pain, edema, elevated blood pressure, infected or occluded access area, nausea, and vomiting due to dialysis. Dialysis schedule three times per week. Location of shunt/access: left upper arm; -Goal: Will exhibit no shortness of breath, chest pain, edema, elevated blood pressure, signs and symptoms of infection, itchy skin or bleeding. Resident will tolerate dialysis and fatigue will be minimal after sessions; -Approach: Administer medications as ordered and draw labs per order. Report lab abnormalities promptly; -Do not don tight clothing, jewelry or dressing on arm with access site; -Do not take blood pressure, give injections, start IVs, or draw blood in arm with access site; -Follow fluid restrictions and diet as ordered. Provide resident a written list of acceptable foods/fluids; -If resident is unable or refuses to attend dialysis, call dialysis to reschedule and follow their instructions for medication administration for missed dialysis and/or any treatments; -Monitor access site for redness, bleeding, pain, and swelling. If above are noted report promptly; -Monitor for bleeding at access site. Monitor after returning from dialysis. If bleeding noted apply direct pressure, contact dialysis and follow their directions; -Monitor for fever, signs and symptoms of infection and contact dialysis if noted: drainage or feeling of warmth at access site, fever of greater than or equal to 100 degrees or shows signs or symptoms of infection; -Monitor shunt every shift for bruit and thrill (the sound you hear and vibration you feel at the access site as blood travels through the artificially created shunt). If note absence of bruit, report to dialysis and resident's physician. Signs of possible occlusion of shunt includes: pain in extremity, fingers cool to touch, unable to palpate or feel the bruit through the shunt; -Obtain dialysis care plan and coordination of care communication sheet. Check orders or changes from dialysis; -Obtain weight per dialysis. Notify physician of weight gain and/or fluid volume excess -No documentation the resident was educated on a renal diet and/or that the resident chose to eat bananas despite the education. Review of the resident's progress notes, dated 10/1/20 through 10/8/20, showed no documentation of a dialysis assessment. Review of the resident's point of care, dated 10/1/20 through 10/8/20, showed no documentation of a dialysis assessment. Observation and interview on 10/7/20 at 8:55 A.M., showed the resident in his/her room. He/she was served banana (a food high in potassium and is contraindicated for an individual on a renal diet) and two pieces of bacon. The resident peeled the banana and cut it in slices and began to eat it. During an interview on 10/8/20 at 2:00 P.M., the administrator confirmed facility did not have a dialysis contract, but would get one if required. During an interview on 10/8/20 at 2:00 P.M., the Director of Nursing (DON) said according to the policy, residents are expected to be assessed before and after dialysis. The charge nurse should obtain the resident's blood pressure, temperature, assess the access site, and monitor for bleeding. It is not documented, but it would be in the progress notes or under the daily skilled nursing documentation. There is no communication logs between the facility and the dialysis center, a blank physician sheet is sent with the resident if there is an issue. Consults are checked from the dialysis center as well. The facility offers a liberal diet, but if a resident is on dialysis, the DON would expect there to be documentation that the resident is not on a renal diet and can make choices with their diet.

Based on interview and record review, the facility failed to ensure as needed psychiatric medications were evaluated after 14 days of use for one of seven residents reviewed for unnecessary psychotropic medications (Resident #66). The sample was 19. The census was 81. Review of Resident #66's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/20, showed diagnoses included Alzheimer's disease, heart failure and diabetes. Review of facility's policy for psychotropic medication use, dated 2018, showed: -Psychotropic medications ae given upon a medical provider order; -The nursing associates collaborate with the medical provider to ensure the lowest possible dosage is given for the shortest period of time and are subject to gradual dose reductions and re-review; -As needed (PRN) orders for psychotropic drugs are limited to 14 days. Review of the resident's electronic physician order sheets (ePOS), showed the following: -An order dated 9/11/20, for Ativan (used to treat anxiety) 0.5 milligrams (mg), one tablet, every six hours PRN anxiety; -No 14 day end dated noted on the order. During an interview with the Assistant Director of Nursing (ADON) on 10/9/20 at 3:30 P.M., she said she would expect Ativan to be discontinued or reviewed for continuation within 14 days and stop dates should be entered in ePOS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their abuse and neglect policy and complete a prompt and thorough investigation for an allegation of abuse, for three of 19 sampled residents (Residents #42, #3 and #13). The census was 81. Review of the facility's Abuse Prevention Plan, dated 11/28/17 and revised on 8/14/20, showed: -Prevention of abuse, neglect, misappropriation of resident property and financial exploitation: -Identify, correct and intervene in situations where abuse, neglect, misappropriation of resident property and/or financial exploitation occurs; -Require staff to report concerns, incidents and grievances immediately to their supervisor. Concerns, incidents and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrences; -Abuse prevention plans. The facility will develop an individual abuse prevention plan for each vulnerable adult who receives services in the facility; -The plan shall contain an individual assessment of: -The resident's susceptibility to abuse, neglect, and financial exploitation by other individuals, including other vulnerable adults; -The resident's risk of abusing other vulnerable adults; -Specific measures to be taken to minimize the risk of abuse, neglect and financial exploitation of residents and other vulnerable adults; -Identification of possible incidents which need investigation: -Resident incident/accident reports and medical records shall be routinely monitored for indicators of possible abuse, neglect, and/or financial exploitation; -Any person with the knowledge or suspicion of suspected abuse, neglect, misappropriation of resident property, and/or financial exploitation must report immediately, without fear of reprisal and/or retaliation; -All accidents and incidents, as well as allegations of abuse, neglect, misappropriation of resident property, and/or financial exploitation will be investigated by the Director of Social Services, Director of Nursing (DON), or their appropriate designees; -Measures will be taken to identify the source of the alleged abuse and prevent future incidents; -Reporting of suspected resident abuse and/or neglect: -Staff will notify the facility Charge of Building immediately of any reports of possible abuse, neglect, misappropriation of resident property and/or financial exploitation. The Charge of Building will immediately notify the Executive Director (ED) or designee in the ED's absence; -The community is responsible for reporting suspected abuse, neglect, misappropriation of resident property and/or financial exploitation in accordance with legal requirements. If the event that caused the suspicion involves abuse or results in serious bodily injury, the individual is required to report the suspicion immediately, but not later than two hours after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report no later than 24 hours after forming the suspicion; -Refer to state-specific instructions below for additional guidance: -Missouri: Report by submitting the Mandated Reporter Form, or calling to make a report by phone. Staff will notify the physician and family as appropriate; -Within five working days, the DON, Director of Social Services or their designee will electronically submit the facility's investigative report to the appropriate state agency; -The results of the investigation are reported to the Administrator. Review of the facility's undated allegation of abuse, neglect, misappropriation investigation guide, showed: -Procedure to be undertaken upon learning of allegation: -Protect residents; -Remove person(s) upon whom allegation is made from work setting, do not allow back into the work setting until authorized to do so by a supervisor; -Contact supervisor or administrator; -Gather written statement(s) from person(s) upon whom allegation is made, must leave building; -Interview residents including any who may be witnesses; -Complete body exam (as appropriate); -Contact police (if theft or assault has possibly occurred); -Secure all documents in order to provide original documents to supervisor/administrator; -If not done already, contact administrator; -Administrator or designee make initial report of allegation. 1. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/5/20, showed: -Cognitively intact; -One staff person assist for bed mobility, transfers, dressings and toileting; -No behaviors; -Indwelling catheter (a flexible tube that is used to drain urine from the bladder); -Wheelchair for mobility; -Diagnoses included high blood pressure, cerebral palsy (a disorder of movement, muscle tone or posture), anxiety disorder, depression and chronic lung disease. Review of the resident's care plan, in use during the survey, showed: -Problem: Psychotropic drug use. At risk for adverse consequences due to receiving antidepressants/antipsychotic/antianxiety medications routinely for treatment of depression, anxiety and insomnia. Can get upset/angry and has injured himself/herself in the past because of this behavior; -Approach: Chart behaviors in the progress notes as they arise. Monitor mood and response to medications, provide emotional support as needed. Redirect behaviors and start a behavior log if behaviors escalate and notify physician; -No direction for staff regarding types of behaviors exhibited by the resident and/or types of redirection/interventions to use specific to the behavior; -Problem: Indwelling catheter. Requires a Suprapubic catheter (indwelling catheter inserted through the abdominal wall into the bladder) due to retention/neurogenic bladder (loss of bladder control due to brain, spinal cord or nerve problems); -Approach: Assess drainage. Record the amount, type, color and odor. Avoid obstructions in the drainage. Do not allow tubing or any part of the drainage system to touch the floor. Review of the resident's social service notes, dated 8/19/20, showed he/she spoke with the resident's private counselor's supervisor. The resident had made allegations his/her parent exposed him/herself to the resident while he/she was visiting him/her in his/her room. The social worker called the resident's psychiatrist, knowing his/her past, he/she did not believe this happened. The social worker asked nursing, and all certified nurses aides (CNA)s and nurses state they would not do any type of perineal care or changing of clothing, or treatments if family was in the room. The family member would be asked to leave while treatment was being done. Review of the resident's social service notes, dated 8/27/20 at 2:00 P.M., showed he/she spoke with the resident's psychiatrist regarding the possibility of the resident's parent staying at the facility for long-term. The psychiatrist agreed with the plan of calling the state and letting them know the situation. The resident had made allegations in the past that had been reported and unsubstantiated. He/she said the state could call him/her and he/she would confirm his/her past history of storytelling. The facility is planning on keeping both the resident and his/her parent separated, with no visiting each other in rooms, visits must be in open areas in the facility. The facility will put in place a care plan with no male caregivers at this time to be alone with the resident, although a male could assist another care giver with treatments if necessary. Review of the resident's social service notes, dated 8/27/20 at 4:35 P.M., showed he/she spoke with the resident concerning his/her parent staying at the facility for long-term care. The rules would be no visiting each other in rooms, visits should be in open areas. His/her parent will be in a semi-private room. With a past history of allegations, they want to make sure he/she and the parent are kept safe. The resident stated he/she understood. The resident came back to the social worker and stated he/she did not want his/her parent to stay at the facility. The resident understood he/she will not be able to see him/her again and stated he/she is alright with the decision. The resident said he/she had time to be with him/her and with his/her dementia, there are times he/she did not remember him/her and it hurts him/her. During an interview on 10/9/20 at 11:42 A.M., the resident said his/her parent was living on the rehabilitation wing, he/she went in the room to visit with him/her and he/she was naked from the waist down, and he/she left. His/her parent said, Where are you going? The resident told him/her that he/she would be back. The incident scared the resident. The resident told one of the nurses and they told him/her, the parent has dementia and he/she doesn't know what he/she is doing. A similar incident happened a few years ago, he/she was visiting him/her and the resident went into the bathroom and when he/she came out of the bathroom, the parent was seated on the bed and exposed his/her genitals. He/she knew what he/she was doing, but he/she didn't tell anyone. During an interview on 10/8/20 at 10:49 A.M., the social worker said the resident's parent was staying at the facility for rehabilitation and the resident had fabricated stories of his/her parent abusing him/her, his/her whole life. On 8/19/20, he/she received a call from the resident's private counselor, and was told the resident, while nursing was changing the parent's brief, the nurse turned around and the parent exposed him/herself to the resident. The social worker said he/she told the resident he/she might never see his/her parent again if he/she were to leave and the resident said he/she was okay with that. Following the allegation, there was an investigation. The resident's parent resided at the facility from 8/7/20 through 9/2/20. As of survey exit, on 10/9/20, no investigation was provided. No investigation was sent to the Department of Health and Senior Services (DHSS) within 5 days as required. Further review of the resident's social service notes, dated 9/14/20, showed the social worker was notified by the resident's private counselor, the resident reported being sexually assaulted while taking a shower. The social worker notified the administrator and psychiatrist and the psychiatrist will write a letter stating he/she did not feel this to be true. The social worker met with the resident and asked how things were going in general. The resident said he/she loved his/her new private room and had received photographs of his/her grandbaby. The resident was all smiles and happy. The resident was asked how the care was going now that the facility had made a couple changes in staffing. The resident did not report any concerns, and did not show he/she was having any problems with the staff or residents. During interviews on 10/8/20 at 10:50 A.M. and on 10/12/20 at 4:26 P.M., the social worker said the resident's private counselor called and said the resident told him/her he/she had been assaulted by a male nurse in the shower on 9/14/20. The private counselor said he/she hot-lined the incident. They called his/her psychiatrist for a letter and no one came to investigate. She talked to staff and no staff matching the description was assigned to the resident and he/she did not get a shower that evening. He/she did not write down everything from his/her discussion with the resident, but did ask if he she had any problems with any of the staff. Some of the visit was just them talking and she doesn't write down everything. The resident didn't tell her anything. The social worker said she was afraid to cross the lines of confidentiality. The resident forgets what he/she tells people and the stories change, his/her psychiatrist believes he/she does it for attention. Administration was aware of these incidents and the social worker called the Ombudsman and spoke with them, and was told to care plan in regard to the accusations. Staff are aware no males are to work with him/her. Review of the resident's psychiatrist's letter, dated 9/14/20, showed it had come to his/her attention, the resident has made some accusations of inappropriate behaviors on the part of the staff at the facility. It is his/her opinion, to a reasonable degree of certainty, based on the many years of interactions with the resident, as well as his/her longstanding psychiatric history, these accusations have no basis in fact. It is more than likely the resident has confabulated these issues within the context of his/her longstanding psychiatric conditions. Further review of the resident's medical record, showed no additional investigation conducted in regard to the alleged incident on 9/14/20. As of survey exit, on 10/9/20, no full investigation was provided. No investigation was sent to the DHSS within 5 days as required. During an interview on 10/9/20 at 2:10 P.M., the administrator said all allegations should be reported and thoroughly investigated. Witnesses should be interviewed and include statements of additional residents. A person with a history of making allegations of abuse should be care planned, unless it's a breach of privacy, but could include attention seeking behaviors and could include false accusations. Regarding the alleged incidents, had the facility investigated, there would have been a breech between the facility and his/her private counselor. The resident never said anything to the facility. She was not aware exactly what the resident alleged because he/she said it to his/her private counselor. The private counselor is a mandated reporter. The administrator did not feel there was any wrong doing. She was not sure if the facility social worker spoke with the resident following the allegation of his/her parent exposing him/herself. This did not put other residents at risk because it was between him/herself and a family member. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included high blood pressure, stroke, dementia and malnutrition; -Extensive assistance with transfers, dressing and toileting; -Used a wheelchair. Review of Resident #13's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, anxiety and depression; -Extensive assistance with transfers, dressing and toileting. Review of the facility's abuse and/or neglect investigation, showed: -Nurse E's written statement, dated 7/22/20 at approximately 1:30 P.M., showed Nurse E entered the room of Resident #3 and Resident #13 to assess their skin condition and pressure sores. Nurse E explained to Resident #3 that he/she was there to see his/her bottom and if he/she had any open areas. Resident #3 had a questionable look on his/her face and then stated, you mean you want to look at my knee don't you, not my back? Resident #3 said, well you can take a look at my bottom but I will tell you that it isn't sore, but my knee is sore from that (person) that was pushing me around the other night. Nurse E assessed Resident #3's knee and noticed that his/her right knee was considerably larger in circumference than his/her left knee with a small circular abrasion present that measured 1.1 x 1.0 with no active bleeding, redness present. Nurse E asked Resident #3 if his/her right knee was always this swollen. His/her response was no this was from the other night. Resident #3 informed Nurse E that he/she wanted to go to bed and noticed that the CNA had been sitting at the nurse's station for over two hours and that he/she wanted to go to bed and so he/she put his/her light on. When the aide came to assist him/her, he/she was very rude in a bad mood. He/she stated, after he/she was so mean, he/she was just as bad to him/her, and Resident #3 gestured with his hand-pointing to his/her roommate, Resident #13. Resident #13 began to explain that the CNA put them to bed was rude and that you did not do anything wrong, he/she came in that way, in a bad mood. Resident #13 continued to inform Nurse E that the aide should have used the lift on Resident #3 and that he/she did not and that he/she fell because of it. Resident #3 informed Nurse E that that is when I hit my knee on the underneath part of the bed, but he/she should have used the lift; -Assistant Director of Nursing (ADON) written statement, dated 7/22/20, showed the ADON said Resident #3 and his/her roommate Resident #13 stated they had complaints about the staff member who put them to bed Tuesday evening. The staff person told them he/she would put them to bed early. He/she did not return until 10:00 P.M. He/she was extremely rough with them, almost throwing Resident #3 into bed. Resident #3 is complaining of right knee pain after being thrown in bed. He/she has visible swelling to the knee. Resident #3 states he/she does not want this staff member to care for him/her again. Resident #3 and #13 stated they were abused last evening; -Director of Nursing (DON) written statement, dated 7/22/20, showed Resident #3 reported to Nurse E that an aide was rough with him/her last night. After this report, Nurse E spoke with the resident in more detail and also spoke with the roommate. The ADON spoke with another alert resident on the same unit, but he/she did not have any complaints. Resident #3 reported that his/her right knee has been sore ever since his/her encounter with this aide and, upon assessment, the knee does appear swollen and has an abrasion. The physician was made aware and an x-ray was ordered. A self-report was made to the State regarding the incident and the Residents' families were notified of the situation. The DON, along with the ADON, contacted CNA M and notified him/her that he/she was suspended pending an investigation. He/she stated he/she was shocked that there was a complaint, but he/she understood; -Social Worker M's email, dated 7/29/20 at 11:34 A.M., showed Resident #3's family member left a voicemail indicating the resident called and said someone hurt him/her last night. Social Worker M interviewed Resident #3, who stated last night before he/she went to bed, a staff person entered the room with two pads/briefs. He/she patted my private area. During the night, the pads were soaked, as was his/her clothing and bed. He/she was not changed until around 6:00 A.M.; -The DONs email, dated 7/29/20, showed the DON spoke to the aide that had him/her last evening to see if there were any issues. He/she said that when he/she went in to do perineal care, Resident #3 refused. He/she was already in bed and asked if he/she could just put his/her feet in bed. He/she did not do any perineal care on him/her last night; -Social Worker N's email, dated 7/31/20 at 8:14 A.M., showed Social Worker N interviewed Resident #3 and Resident #13 separately yesterday. Social Worker N rephrased questions several times asking about any concerns or issues that may have occurred in the past several days. Asked how they were both being treated by staff and others here at the facility. Asked about any rude or misconduct they could recall. Social Worker N asked if either of them had been mistreated in anyway. Neither of them recalled any issues. Social Worker N asked Resident #3 if anyone touched him/her inappropriately and he/she denied it saying he/she knew how to protect him/herself. Further review of the investigation, showed: -No written statement from CNA M regarding the incident that occurred on 7/22/20; -No interviews from other residents on CNA M's assignment to show a possible pattern of behavior; -No interviews from other staff that worked on 7/22/20; -No interviews provided from staff regarding the complaint from the resident that occurred on 7/28/20 through 7/29/20, as stated in the emails between the DON, Social Worker M and Social Worker N. During an interview on 10/8/20 at 8:37 A.M. and 2:24 P.M., Resident #3 said he/she did not remember the incident with CNA M. He/she did not remember an incident when he/she injured his/her knee. He/she was doing well and did not have any concerns. During an interview on 10/8/20 at 11:09 A.M., the DON confirmed that CNA M had not worked at the facility since July 2020. She/he was suspended pending the investigation. He/she is still suspended until DHSS completes the investigation. During an interview on 10/9/20 at 10:45 A.M., Resident #3's family member said the facility notified him/her after the incident happened. The resident's knee injury was something that was on-going before and after the incident. The resident did not have any complaints about staff. The family member was aware the facility investigated it and the CNA was suspended. During an interview on 10/9/20 at 2:27 P.M., Resident #13 said he/she did not remember the incident that occurred with his/her roommate. During an interview on 10/14/20 at 1:00 P.M., CNA M said he/she remembered assisting Resident #3. He/she attempt to transfer the resident using the stand-up lift. During the transfer, the resident's legs buckled and he/she tried to grab him/her by the waist from behind, so he/she would not fall. The resident said CNA M was being rough and said ouch and you people are always rough. He/she never said what was hurting; however, CNA M thought it was because his/her legs buckled and he/she had to catch the resident so he/she would not fall. The resident did not fall and CNA M was able transfer him/her to the bed. The bed was right next to the lift. CNA M said he/she did not report it to the nurse because the resident did not fall, and it was no big deal. CNA M did not ask the resident what was hurting when he/she said ouch. He/she was informed about the incident and was suspended pending the investigation. He/she had not worked at the facility since the incident. 3. During an interview on 10/9/20 at 2:00 P.M., the administrator said she would expect all allegations of abuse and neglect to be reported immediately and thoroughly investigated. The investigation should include written statements and interviews from witnesses, staff, and the alleged perpetrator. She would expect other residents who are alert and oriented to be interviewed to determine if there is a pattern of abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. In addition, the facility failed to properly document narcotic counts for controlled substances, for five of six medication carts. The census was 81. 1. Review of the nurse's narcotic count sheet, dated 10/1/20 through 10/6/20, for [NAME] Hall, showed the following: -No signature by the on-coming nurse, total of five shifts; -No signature by the off-going nurse, total of five shifts; -Total narcotic drug cards not documented as counted, a total of five shifts; -Total narcotic drug cards not legible counted, a total of one shift. 2. Review of the nurse's narcotic count sheet, dated 10/1/20 through 10/6/20, for FontBonne Hall, showed the following: -No signature by the on-coming nurse, total of three shifts; -No signature by the off-going nurse, total of two shifts; -Total narcotic drug cards not documented as counted, a total of three shifts. 3. Review of the Certified Medication Technician (CMT) narcotic count sheet, dated 10/1/20 through 10/6/20, for [NAME] Hall, showed the following: -No signature by the on-coming CMT, total of three shifts; -No signature by the off-going CMT, total of three shifts; -Total narcotic drug cards not documented as counted, a total of one shift; -Total narcotic drug cards not legible counted, a total of two shifts. 4. Review of the nurse's narcotic count sheet, dated 10/1/20 through 10/6/20, for the front hall of [NAME], showed the following: -No signature by the on-coming nurse, a total of five shifts; -No signature by the off-going nurse, a total of four shifts; -Total narcotic drug cards not documented as counted, a total of two shifts. 5. Review of the nurse's narcotic count sheet, dated 10/1/20 through 10/6/20, for the back hall of [NAME], showed the following: -No signature by the on-coming nurse, a total of nine shifts; -No signature by the off-going nurse, a total of nine shifts; -Total narcotic drug cards not documented as counted, a total of seven shifts; -Total narcotic drug cards not legible counted, a total of four shifts. 6. During an interview on 10/6/20 at 12:45 P.M., Licensed Practical Nurse (LPN) B said some nursing staff worked eight or 12 hour shifts. Nursing staff should count narcotics at the beginning and end of each shift and sign with their initials for counting narcotics on the narcotic count sheet. 7. Review of the facility's Narcotic Count Policy/ Procedure, dated June 1995 and revision dated March 2009, showed the following: -Objective: To justify amount of narcotics remaining when control of supply is released to the nursing coming on duty; -Procedure: -1. One Registered Nurse (RN) or LPN going off duty and one RN or LPN coming on duty must count and justify unit's narcotics at change of shift; -2. After the supply is counted and justified each nurse must record the date and his/her signature. The nurse going off duty surrenders the narcotic keys to the nurse coming on duty after the narcotics count is verified; -3. If the count is not correct, it must be justified. The nurse going off duty is not to leave until the count is correct. 8. During an interview on 10/6/20 at 1:15 P.M., the Director of Nurses (DON) said she expected nursing staff to correctly count and reconcile the narcotic count at the beginning and end of each nursing shift. The narcotic count sheets should contain the off-going and on-coming licensed nursing staff and CMT signature and amount of narcotic drug cards counted between the off-going and on-coming nursing staff. She said it does not matter if the nursing staff worked eight or 12 hour shifts, they should still count the number of narcotic drug cards at the beginning and end of each scheduled shift. 9. During an interview on 10/9/20 at 12:18 P.M., the Assistant Director of Nurses (ADON) said nursing staff signatures/initials and number of narcotic drug cards counted should be legible. The nursing staff should document the amount of narcotic drug cards counted on the narcotic count sheet and would expect nursing staff to follow the facility's policy/procedure regarding receipt, disposition and reconciliation of controlled drugs.

Based on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations were reviewed and the facility failed to notify the physician, medical director, and director of nursing of irregularities, for two of 9 residents sampled for medication review (Residents #57 and #29). In addition, the facility's policy failed to include time frames for the different steps in the process and steps the pharmacist must take when he/she identifies an irregularity that requires urgent action to protect the resident. The sample was 19. The census was 81. Review of the facility's Medication Regimen Review (MRR) policy, dated 12/1/07, showed: -The facility should ensure that facility physicians/prescribers are provided with copies of MMRs; -Facility should encourage physician/prescribers or other responsible parties receiving the MMR and the Director of Nursing to act upon recommendations contained in the MMR. For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendation contained within the MMR or reject all or some of the recommendations contained in the MMR and provide an explanation as to why the recommendation was rejected; -Facility should provide the medical director with a copy of the MMRs and should alert the medical director where MMRs require follow-up; -The policy failed to include time frames for the different steps in the process and steps the pharmacist must take when he/she identifies an irregularity that requires urgent action to protect the resident. Review of the facility's Verbal and Telephone Orders Policy, dated 2018, showed: -Purpose: To ensure timely and efficient verbal and telephone orders from a provider; -Policy: Verbal and telephone orders are obtained in a situation when the provider is unable to write or sign the order of entry and are transcribed; -Procedure: -The nurse receiving the verbal order will write it on the physician order sheet or enter it into the electronic health record (EHR); -The nurse will transcribe the verbal or telephone order including ordering providers name with credentials and date/time of the order received. 1. Review of Resident #57's medical record, showed diagnosis included heart failure, major depression, altered mental status and leukemia (cancer of the blood). Review of the residents pharmacy Consultation Report, recommendation dated: 9/21/20, showed: -Time sensitive recommendation prescriber response and facility action required by 11:59 P.M. on 9/22/20, per federal impact act requirements; -Resident was recently readmitted to the facility, prior to going to the hospital, the resident was taking trazadone (a medication used to treat depression and sedative) 50 milligram (mg) take, take half (½) tab (25 mg) at bedtime. The hospital admission records indicate that the resident had been taking trazadone 50 mg at bedtime. It doesn't appear they noticed the actual dose was ½ tab so the discharge back to the facility orders list, trazodone 50 mg to be continued at bedtime. Please clarify if the resident should be back on 25 mg at bedtime; -Hand wrote on the bottom of the page, undated, was: order corrected, VO (verbal order) and initials. Review of the residents physician order sheet (POS), dated 10/7/20, showed: -Trazadone 50 mg tablet, take one tablet at bedtime daily, start date 9/20/20; -No clarification order for the trazadone. During an interview on 10/9/20 at 9:30 A.M., the Assistant Director of Nursing (ADON), verified the resident was on trazadone 25 mg at bedtime prior to going to the hospital. The current POS listed trazodone as 50 mg daily at bedtime. The dose should have been changed back to 25 mg daily at bedtime. The facility would contact the doctor to verify the correct the dose. 2. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/7/20, showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, Alzheimer's disease, and depression. Review of the resident's current POS, showed: -An order dated 9/20/20, for omeprazole (used to treat heartburn) capsule, delayed release, 20 mg, one tablet, once a day. Review of the residents pharmacy Consultation Report, dated 9/23/20, showed a recommendation to reevaluate the continued need for routine omeprazole and consider changing it to 20 mg, as needed (PRN), dyspepsia (indigestion), while monitoring for recurrence of symptom or discontinuing omeprazole and initiating famotidine (used to treat and prevent ulcers in the stomach and intestines), 20mg at bedtime as maintenance therapy. The physician's response was not signed or dated, and initiated as done at the bottom of the paged. 3. During an interview on 10/9/20 at 2:20 P.M., the DON said pharmacy reviews entered in the EMR, should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff labeled drugs and biologicals per acceptable standards of practice when staff failed to date insulin flexpens (prefilled injectable insulin) once they were opened, ensure legible dates and resident names were on the label and failed to discard opened insulin flexpens for residents discharged from the facility, for two of four medication carts checked. The census was 81. 1. Observation on 10/6/20 at 7:56 A.M., of the nurse's medication cart, front hall of [NAME], showed the following: -One Novolog (fast acting) insulin flexpen opened without a date written when opened. Licensed Practical Nurse (LPN) B said the resident was discharged ; -One Lantus (long acting) insulin flexpen opened without a date written when opened; -One Humalog (fast acting) insulin flexpen opened without a legible date written when opened and labeled with illegible resident's name; -One Novolog flexpen opened without a legible date written when opened and labeled with illegible resident's name. During an interview on 10/6/20 at 7:56 A.M., LPN B said all opened insulin flexpens are in use on the residents on the front hall of [NAME]. He/she verified one opened Novolog insulin flexpen was not dated when opened and the resident discharged from the facility, one opened Lantus insulin flexpen not dated when opened, one opened Humalog insulin flexpen not dated with legible date when opened/resident's name not legible and one opened Novolog insulin flexpen not dated with legible date when opened and resident's name not legible. LPN B said nursing staff should date the insulin flexpens with the date when opened, the resident's name/date should be legible and staff can administer insulin for up to 30 days from the date when opened. 2. Observation on 10/6/20 at 8:00 A.M., of the nurse's medication cart, back hall of [NAME], showed one Humalog insulin flexpen opened without date written when opened and not labeled with resident's name. During an interview on 10/6/20 at 8:00 A.M., LPN C verified the opened insulin flexpens are in use for the residents on the back hall of [NAME]. He/she verified the opened Humalog insulin flexpen was not dated when opened and not labeled with a resident's name. He/she said all opened insulin flexpens should be dated with the date when opened and labeled with the resident's name. 3. Review of the facility's Dating Insulin Vials Policy, dated January 2013, showed: -Purpose: Provide safe and effective insulin administration; -Policy: All insulin vials are to be dated when opened and discarded utilizing drug manufacturing recommendations; -Procedure: Medication carts and refrigerated storage areas are to be checked by charge nurses weekly and by clinical manager, nursing supervisors, or designee monthly. 4. During an interview on 10/6/20 at 1:04 P.M., the Director of Nurses (DON) said nursing staff should date insulin vials/flexpens with the date when opened. All opened insulin vials/flexpens should be labeled with legible dates when opened and resident's name. All residents who are discharged , their opened insulin vials/flexpens should be discarded and not left on the medication cart. The charge nurses are responsible for checking opened insulin vials/flexpens daily to ensure proper dates when opened. The DON said it depends on the manufacturer guidelines regarding the different types of insulin for how long the insulin can be administered once the insulin vials/flexpens are opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure acceptable infection control standards were used when staff failed to clean/disinfect a gait belt (a device used to transfer residents from one position to another) that is used on multiple residents, before or after use for one resident (Resident #66) and failed to clean/disinfect the sit to stand lift (mechanical lift) that is used on multiple residents, before/after use for one resident (Resident #57). In addition, staff failed to wash or sanitize their hands after removing gloves while providing personal care to one resident (Resident #69) and failed to cover clean laundry that was hanging in the hall, five out of five days observed. The resident sample was 19. The census was 81. Review of the facility's Cleaning, Disinfection and Sterilization-Overview Policy, dated 2017, showed: -Purpose: To prevent the growth of organisms on equipment thus preventing the transmission of infection; -Policy: Cleaning, disinfection, and/or sterilization of equipment is done as necessary to decrease the risk of transmission of infectious organisms and maintain a clean and sanitary environment for the residents to reside. The method used will be determined by the objects intended use and type of contamination; -General Guidelines: All items, other than disposable, are cleaned, disinfected or sterilized, following federal, state and local guidelines and manufactures recommendations; -All products and processes used for cleaning, disinfection and sterilization are approved by the Infection Preventionist. 1. Review of Resident #66's medical record, showed diagnoses included diabetes and major depression. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/2/20, showed: -Required extensive assistance from one staff for transfers; -Incontinent of bowel and bladder. Observation on 10/6/20 at 7:27 A.M., showed Certified Nurse Aide (CNA) A entered the resident's room, washed his/her hands and applied gloves. CNA A removed a gait belt from around his/her right shoulder, did not clean/disinfect his/her gait belt and placed the gait belt around the resident's waist. CNA A then transferred the resident from the bed to the wheelchair, removed the gait belt from the resident's waist, did not clean/disinfect the gait belt and placed the gait belt around his/her right shoulder. CNA A verified he/she used the gait belt on other residents. During an interview on 10/7/20 at 11:23 A.M., the Director of Nurses (DON) said she expected nursing staff to clean/disinfect their gait belts with disinfecting wipes before/after use and between each resident due to infection control purposes. 2. Review of Resident #57's medical record, showed diagnosis included heart failure, major depression, altered mental status and leukemia (blood cancer). Review of the resident's annual MDS, dated [DATE], showed: -Moderately impaired cognition; -Required extensive assistance of one staff for transfers; -Frequently incontinent of bowel and bladder. Observation on 10/7/20 at 10:15 A.M., showed CNA K entered the resident's room with the sit to stand lift, washed his/her hands, placed the lift cloth around the resident and fastened it. CNA K then attached the lift cloth to the lift, had the resident hold onto the handles and used the lift to raise the resident up. He/she then moved the lift and resident into the bathroom and assisted the resident to sit on the toilet. When the resident was finished, the resident was transferred back to his/her wheelchair with the use of the lift. CNA K hung the cloth strap back on the lift, removed his/her gloves and performed hand hygiene, then removed the lift from the room and placed the lift in the hall without cleaning/disinfecting the lift. Approximately five minutes later, CNA K took the same sit to stand lift from the hall into another resident's room without cleaning/disinfecting the lift. During an interview on 10/7/20 at 10:35 A.M., CNA K said staff usually wipe down the lifts after use, but the facility has not had a lot of wipes lately. Sometimes staff take the lift to another floor and clean it. During an interview on 10/7/20 at 11:00 A.M., Licensed Practical Nurse (LPN) H said the facility had plenty of bleach wipes. The CNAs should know where to find the bleach wipes, they are on the cart and the housekeepers have some. The CNAs are to ask a nurse or a housekeeper if they need supplies. During an interview on 10/9/20 at 9:30 A.M., the Infection Control Preventionist (ICP) said the facility has bleach wipes, and the CNAs know where they are located. CNAs can ask the nurse if they need more supplies. The nurses know how to get more supplies if they need them. The ICP would expect staff to use proper hygiene and wipe down the lift where the resident had touched it, before moving the lift out into the hall, where someone could take the lift before it was cleaned. 3. Review of Resident #69's medical record, showed diagnosis included weakness, disease of the spinal cord, dementia and anxiety. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident had severe cognitive impairment; -Required extensive assistance of one staff for transfers, toileting and personal hygiene; -Frequently incontinent of bowel and bladder. Observation on 10/7/20 at 7:50 A.M., showed CNA L entered the resident's room and assembled supplies to provide care. CNA L performed hand hygiene and donned gloves. The resident lay in bed on his/her back. CNA L sprayed perineal wash onto the wash cloth and provided perineal care to the resident using proper technique. CNA L then removed his/her gloves, no hand hygiene was performed, and CNA L had a second pair of gloves on under the gloves he/she had just removed. He/she applied barrier cream, assisted the resident to put on an under garment and covered the resident up with a blanket while wearing the same gloves. He/she removed his/her gloves and washed his/her hands. 4. During an interview on 10/8/20 at 12:00 the administrator said they do not have a policy for perineal care, they use the competency skills test. Review of the facility's Perineal Care Competency test, dated 2012, showed: -To master the skill, the student must complete 80% of the items, use principles of infection control; -Procedure: Position resident in bed, maintain privacy, check water temperature in basin or sink, apply gloves; -Dry area thoroughly; -Remove gloves and wash hands; -Replace gloves before applying protective undergarment; -Remove gloves and wash hands. During an interview on 10/9/20 at 9:30 A.M., the ICP said hand hygiene should be done at least three times during perineal care. At the beginning, when staff go from dirty to clean and at the end. Staff should wash their hands when they remove their gloves and before applying the barrier cream. The expectation is for staff to perform hand hygiene when they change their gloves. Staff should have washed their hands after they removed their gloves and before applying the barrier. 5. Observation on 10/5/20 at 10:30 A.M., showed a linen cart with approximately 20 reusable gowns that hung in the Fontbonne hall, uncovered. On 10/5/20 at 11:00 A.M., a second linen cart with approximately 20 reusable gowns hung in the [NAME] hall, uncovered. On 10/6, 10/7, 10/8 and 10/9/20 at various times, linen carts with gowns remained uncovered and hung in both halls. During an interview on 10/9/20 at 9:30 A.M., the ICP said he/she did not know if the gowns hanging in the hallway should be covered or not. During an interview on 10/9/20 at 2:30 P.M., the administrator said gowns should be covered.