**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Resident and Family Group Policy and Grievance Policy and Procedure to maintain an effective grievance process for residents in resident council meetings and resolve them in a timely manner. The failure had the potential to affect all residents. The sample size was 4. The census was 54.Review of the facility's Resident and Family Group Policy, undated, showed the following:-Purpose: To ensure residents of facility and their family members or representatives, have the right to organize and participate in resident and family groups. This policy affirms our commitment to supporting such groups by providing space, privacy, staff support, and prompt consideration of their recommendations;-The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility;-A. The facility must be able to demonstrate their response and rationale for such response.-B. This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. Review of the facility's Grievance Policy and Procedure, undated, showed the following:-This policy is intended to provide fair and prompt consideration to all residents' complaints. The facility encourages all residents to use the grievance procedurewithout fear of retaliation within the grievance process and with the assurance that his/her concerns will be respected. It is the policy of St. [NAME] Place to maintain allgrievances for at least three years from resolution. A copy of the grievance, documentation reflecting the process used and resolution/remedy of the grievance anddocumentation; in applicable, of extenuating circumstances for extending the time period for resolving the grievance beyond twenty-one calendar days. -Procedure: All grievances must be in writing, containing the name and address of the person filing the grievance. The complaint must state the problem or action alleged along with the date, approximate time, place, name(s) of individuals involved in the incident that is being grieved. You cannot file anonymously. Review of the Resident Council Minutes, dated 4/24/25 at 2:30 P.M., showed the following:-Old Business: The care lights are not being answered in a timely manner;-Nursing: The nursing staff are making smart remarks to the residents when they are asked questions or for help;-Dietary: The breakfast is getting bad, and the residents are given food they cannot eat;-Laundry: The residents have missing clothes.-There was no documentation of resolution for these grievances or concerns. Review of the Resident Council Minutes, dated 5/22/25 at 2:30 P.M., showed the following:-Old Business: The call lights are not being answered in a time manner. The residents are missing clothes when laundry washes them. The breakfast has not been tasting all that good. The residents are getting food they cannot eat.-There was no documentation of resolution for these grievances or concerns.-Nursing: Nursing is not doing their job. The Certified Nurse Aides (CNA) are not answering call lights in five minutes but taking two hours and have an attitude. The night shift is terrible. The night shift is loud and the residents cannot sleep;-Dietary: The residents are receiving food they are not supposed to eat and some foods are salty;-Laundry: The residents are not getting their clothes back. Review of the Resident Council Minutes, dated 6/25/24 at 10:30 A.M., showed the following:-Old Business: The residents are not getting the correct medications. The call lights are being answered in a timely manner. The night shift staff are not nice and they are loud and the residents are being kept up at night. The resident are not getting their clothes returned to them. The residents are not being listened to and the problems are not being taken care of promptly.-There was not documentation of resolution for these grievances or concerns.-Nursing: The night shift is loud and they use profanity and are keeping the residents from sleeping;-Laundry: Some residents are still missing their clothes. During an interview on 8/13/25 at 12:09 P.M., the Activity Director (AD) said he/she oversees the resident council meeting and the meetings are held once a month. The residents have not had the meeting for the month of August. The AD said in the meetings, the residents discuss the previous minutes and discuss current concerns and grievances regarding each department. The AD said he/she will write down the concerns and grievances and give them to the Director of Nursing (DON) for her review. The AD said he/she would like a resolution before the next meeting. The AD has been with the facility since January, 2025 and has not gotten a resolution for any of the grievances or concerns. He/She did not know if the grievances or concerns had been addressed. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/23/25, showed the following:-Moderate Cognitive Impairment;-No moods or behaviors;-Independent with most activities of daily living;-Diagnoses of high blood pressure and high cholesterol. During an interview on 8/13/25 at 1:26 P.M., the resident said he/she is the resident council president. The resident said in the meetings, concerns include people missing clothes and the night staff talking and laughing loud. The resident said nothing has been done about these concerns and it makes the residents feel terrible. During an interview on 8/13/25 at 1:55 P.M., the DON said she has been coming in (the facility) in the middle of the night and has seen the concerns. The DON said some staff have been terminated and some staff were talked to by the CNA Supervisor about being loud. During an interview on 8/21/25 at 11:39 A.M., the Administrative Assistant (AA) said he/she expected the policies to be followed. The residents are able to file a grievance or concerns anonymously. The AA said resident council meeting is not for grievances. The meetings are for concerns of the residents. If the residents have a grievance, it must be filed with the Grievance Officer, which is the Social Services Designee. The AA said they do address all grievances and concerns, they just do not document all the resolutions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two residents from misappropriation of property when former Office Manager (OM) E had one resident write checks made out to OM E to pay for room and board instead of the facility (Resident #1). In addition, OM E mislead a family member make electronic transactions to the employee's personal account to pay for room and board (Resident #11). These monetary transactions were intended as payments for the facility's care and services. The sample was 11. The census was 55. The facility was notified on 7/1/25 of the past non-compliance. The facility terminated OM E. He/She did not return to work following suspension and has had no further engagement with the facility post-investigation. The facility updated their forms of payment accepted to checks, money orders, cash with a receipt at time of transaction for resident-related charges. In addition, the facility no longer accepted electronic peer-to-peer payments. The updated policy was included in their amended admission packet policy. Going forward, Administration will conduct monthly audits of all resident billing and payment reconciliation. The deficiency was corrected on 5/9/25.Review of the facility's undated Abuse Prevention policy, showed:-Each resident has the right to be free from mistreatment, neglect and misappropriation of property;-Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful use of resident's belongings or money;-If any employee is in question, employee shall be suspended during the rest of the investigation;-If an employee is named by an alert and oriented resident, employee may be terminated. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/25, showed:-Cognitively intact;-No psychosis or delusional behaviors;-No functional impairment to upper extremities. Review of the resident's electronic health records showed:-admission date of 3/28/23;-Responsible party: Self;-Care Plan showed limited assist to mostly independent in the current functional performance;-Diagnoses included heart failure, kidney disease and diabetes. During an interview on 7/1/25 at 2:45 P.M., the resident said OM E had been assisting him/her with payments and had no issues in the past. The resident found out in May 2025 that the employee had been stealing money. He/She was approached by OM E in the beginning of May about dental and vision care services that were due. He/She told OM E no funds available in the bank at that time. OM E told the resident to go ahead and write the check, and OM E would take care of it. The resident found out an attempt was made to cash the check in a store across the street from the facility and it bounced. The resident was notified the facility started an investigation and terminated the employee.Review of the facility's photocopies of the resident's checks written to OM E and cashed, showed:-Check dated, 12/30/24, pay to the order of OM E, $197.00;-Check dated, 12/31/24, pay to the order of OM E, $197.00;-Check dated, 1/16/25, pay to the order of OM E, $394.00;-Check dated, 2/28/25, pay to the order of OM E, $188.00;-Check dated, 2/28/25, pay to the order of OM E, $394.00;-Check dated, 3/20/25, pay to the order of OM E, $900.10. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Independent with self-care and mobility. Review of the resident's electronic health records showed:-admission date of 3/1/23;-Responsible Party: Son;-Diagnoses included heart valve disorders, high blood pressure, major depressive disorder. During an interview on 7/3/25 at 10:12 A.M., the resident's Responsible Party (RP) said OM E would call on the 3rd of every month without fail. He/She worked close by the facility and finished work after banking hours. The RP would usually get cash from automated teller machine (ATM). He/She would mostly give OM E cash to pay the facility. He/She did not receive receipts. He/She had at least two cashier's check payments while the Administrator was present and provided receipts on those times. He/She notified the Administrator at one time that he/she had made cash payments to OM E. The Administrator told the RP to refrain from doing so and asked for the receipts. The RP said there were Cash App (a mobile payment service that allows users to send money peer to peer) transactions to OM E for payments to the facility and provided screen shots. The RP said he/she trusted OM E and did not think OM E was capable of taking people's money. Review of the Cash App transactions provided by the facility, showed:-7/2/24, OM E's name, note: payment sent;-8/2/24, Om E's name, note: facility name;-9/5/24, Om E's name, note: pension payments;-10/5/24, Om E's name, note: payment sent;-11/4/24, Om E's name, note: facility's name;-12/4/24, Om E's name, note: facility's name;-3/6/25, Om E's name, note: facility's name monthly care payment for resident. 3. On 7/2/25 at 9:28 A.M., attempts were made to contact OM E using two different telephone numbers on file. OM E could not be reached at either number provided. 4. During an interview on 7/1/25 at 12:06 P.M., and 7/3/25 at 2:30 P.M. the Administrator said the facility reimbursed and issued the residents credit for the total amount OM E had taken from the residents. He was not aware OM E had collected payments from self-pay residents with electronic transactions and checks made directly to OM E's account or name. The store owner across the street from the facility, which also cashes checks, contacted the Administrator on 5/7/25, notifying that a resident's check had bounced. The Administrator started an investigation and found out there were previous checks written to OM E for funds which were not given to the facility. The facility started investigating other residents who were self or private pay and discovered that Resident #11's RP also had multiple cash and electronic monetary transactions with OM E. The Administrator attempted to report the issues to the local police department, but the responding officer denied filing a report. The Administrator said he would expect employees to refrain from personal monetary transactions or receive residents' payments without providing receipts. He would check or have the responsible staff to check payments made by residents as frequently as monthly. MO00253928

Based on interview and record review, the facility failed to ensure a resident was free from significant medication errors when the facility failed to administer ordered pain medication for one resident (Resident #5). The sample size was 11. The census was 55.Review of the facility's Medication Orders policy, revised 11/14, showed:-Each resident must be under the care of a licensed physician authorized to practice in this state and must be seen at least every sixty days;-A current list of orders must be maintained in the clinical record of each resident;-When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. Review of the facility's Controlled Substance Policy, revised 4/19, showed:-Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications;-Upon Administration: The nurse administering the medication is responsible for recording name of the resident receiving the medication, name, strength and dose of the medication, time of administration, method of administration, quantity of the medication remaining, and signature of nurse administering medication. Review of Resident #5's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/25, showed:-Moderately impaired cognition;-No hallucinations and delusions behavior;-Impairment on one side to lower and upper extremities;-Diagnoses included atrial fibrillation (heart rhythm disorder), high blood pressure, aphasia (communication disorder), hemiplegia or hemiparesis (weakness or paralysis on one side of the body), and depression. Review of the resident's electronic medication administration record (eMAR), for June 2025, showed:-Acetaminophen Oral tablet (used to relieve mild to moderate pain and fever), give 650 milligrams (mg) by mouth every 4 hours as needed for elevated temperature and pain;-Staff documented the medication as given one time for the month, on 6/21/25 at 12:46 A.M.;-Tylenol with Codeine #3 (used to help relieve mild to moderate pain) oral tablet 300-30 mg, give 1 tablet by mouth two times a day for pain, order date 3/25/25, discontinued date 6/8/25;-Oxycodone HCL (opioid pain reliever used to manage moderate to severe pain) oral tablet 5 mg, give one tablet by mouth three times a day related to hemiplegia and hemiparesis, start date 6/8/25; -No documentation to show Oxycodone HCl was administered until 6/25/25. The first dose was given on 6/26/25. The MAR showed blank boxes for all dates prior to 6/26/25;-On 6/28/25, the 8:00 A.M. and 12:00 P.M. doses were marked #9 by an agency staff, which according to the Chart Codes, #9 indicated Other/ See Progress Notes. No progress notes documented. Observation and interview on 7/1/25 at 12:40 P.M., showed the resident in bed, grimacing and complaining of left leg pain. He/She said he/she was in pain every day. He/She only received headache medicine, and it did not help with the severe chronic pain he/she experienced daily. During an interview on 7/1/25 at 12:47 P.M., Registered Nurse (RN) A said the resident just had his/her pain medicine. He/She would have the resident repositioned to help alleviate the pain. Observation and interview on 7/2/25 at 10:02 A.M., showed the resident sat up in a wheelchair, in the hallway, right outside of his/her room. The resident said he/she was in continuous pain and wanted to have stronger pain medications.During an interview on 7/2/25 at 10:06 A.M., RN A said the resident always complained of pain and it became worse and more excruciating when he/she needed to get up. The resident was on routine Tylenol #3 and which was replaced with Oxycodone HCl on 6/8/25 per physician's order. During an interview on 7/2/25 at 10:41 A.M., the Director of Nursing (DON) said the resident did not like to get up so he/she would complain of pain when up. The resident had an order for Tylenol #3 two times a day for a while, then it was changed to Oxycodone 5mg three times a day. She was not aware and did not know why there was no documentation in the eMAR from 6/8/25 to 6/25/25. She would do some research on what happened. She said there was a revision of the Oxycodone order on 6/26/25. The resident was seen by the pain management provider at least every three weeks, but the Primary Care Physician (PCP) prescribed the Oxycodone on 6/8/25. However, it was not active and did not show in the staff eMAR until 6/26/25. The DON said she was not certain how the order remained in queue or not activated. If the order was queued, the nurses or Certified Medication Technicians (CMTs) would not show as to be administered, until the physician un-queued the order. During an interview on 7/2/25 at 12:41 P.M., the Primary Care Physician (PCP) confirmed the Oxycodone HCl 5 mg order on 6/8/25. The psychiatrist recommended the medication to help with the resident not only for the pain but mostly for his/her behaviors. He/She placed orders in the resident's electronic medical record (EMR), then sent an electronic prescription to the pharmacy. Normally the pharmacy received the prescriptions immediately. He/She said there may have been a computer glitch, which could be a reason why the pharmacy did not receive his/her electronic prescription. The PCP added that the resident was seen by the pain physician during the time in-between 6/8/25 through 6/26/25, and the resident did not complain of pain. At 12:54 P.M., the PCP showed his/her phone with a screenshot of the Oxycodone HCl 5 mg electronic prescription that was sent to the pharmacy on 6/8/25. The image showed an escript (electronic prescription) dated 6/8/25, to dispense Oxycodone HCL 5 mg TID (three times a day), quantity 90. The PCP said the pharmacy should have received the prescription. She expected the medication orders to be followed and administered as ordered.During an interview on 7/2/25 at 12:57 P.M., the pharmacy staff said they received a prescription for the resident on 6/8/25. The prescription was for Oxycodone 5 mg, 90 pills, for a 30 day supply. The medication was delivered to the facility on 6/8/25 at 6:56 P.M., and was received and signed by Licensed Practical Nurse (LPN) A. Observation and interview on 7/2/25 at 1:49 P.M., showed the narcotics locked box in the medication cart had 18 tablets of Oxycodone 5 mg in plastic sachet, in an individualized continuous packaging. RN A said they were not in bubble cards because they were pulled from their emergency kit (e-kit). They pulled 19 tablets with 1 tablet administered to the resident at 10:00 A.M. RN A said CMT C notified him/her that morning there were no cards of the resident's Oxycodone. RN A said she did not know where the medication cards were but had to use their stock from the e-kit immediately so the resident could have his/her pain medicine. He/She pulled the medication in the e-kit with the DON.During an interview on 7/2/25 at 3:24 P.M., the DON said there had not been any issues with drug diversion for a long time. She would initiate an investigation immediately.During an interview on 7/3/25 at 8:22 A.M., the DON provided an investigation report and said the Oxycodone cards for the resident were not found. The facility had surveillance cameras but did not save recorded images and videos. She said the agency staff who worked on 6/28/25 walked out of the facility after two hours of starting the shift. They were not able to contact the agency staff.Review of the investigation report provided by the DON, showed:-Date of incident: 7/2/25;-Summary of Incident: On the morning of 7/2/25, a CMT reported to the charge nurse that he/she needed medication for the resident. The charge nurse notified the facility's RN who immediately began a preliminary investigation;-The facility initiated an initial investigation that included staff interviews, medication reconciliation, physical search, and record reviews;-Findings: As of the evening of July 2, 2025, following a full review of the eMAR and physical documentation, approximately 74 pills of narcotic medications remain unaccounted for. There is no documentation, paper trail, or physical record currently explaining their use, destruction, or removal from the facility. In addition, a full narcotic audit of all residents was completed. All other resident medications, including controlled substances, were found to be accounted for and properly documented. This indicates that the discrepancy is isolated to the specific medications reported missing on July 2, 2025;-Immediate actions and preventive measures: Resident medications will continue to be administered and supplied by facility, until a new script is filled. The facility is in the process of updating its narcotic handling protocols. A new narcotic resident inventory list will be implemented and placed at the front of the Control Count Book to assist with rapid reconciliation and tracking. Ongoing review and monitoring of narcotic handling procedures will be conducted to identify any procedural gaps and prevent recurrence;-Status: The investigation is now closed. Despite a thorough review of medication records, staff interviews, and a facility-wide narcotic audit, the source of the discrepancy involving the missing 74 pills of narcotic medication could not be definitively identified. All other resident medications, including controlled substances, have been accounted for. The incident has been documented, and the facility has implemented procedural improvements to prevent recurrence.On 7/3/25 at 11:39 A.M., attempts were made to contact CMT C with no return-call.During an interview on 7/3/25 at 11:42 A.M., LPN B said he/she received and signed the Oxycodone medication from the pharmacy for the resident on the evening of 6/8/25. LPN B placed the medication cards in the medication cart's locked box with the other narcotics. LPN B did not have to administer the medication during his/her shift. The nurses count the narcotics at the beginning or end of the shift. He/She did not recall any issues with the count.During an interview on 7/3/25 at 11:52 A.M., the DON said she expected staff to assist the residents in pain properly and provide the medications as ordered. The PRN (as needed) medication should be administered, if available. She said even if the medication cards were available, they would not be administered if there was no active order. The Oxycodone medication was started on 6/26/25 after the PCP activated the order. The DON expected physician's orders to be followed as ordered. MO00256411

Based on record review and interview, the facility failed to ensure that nurse aides (NA) completed a nurse aide certification training program within four months of hire for three of 18 NAs, who worked in the facility for more than four months (NA A, NA B, and NA C). The census was 49. Record review of all NA hire dates on 8/27/24, showed: -The facility hired NA A on 4/17/24; -The facility hired NA B on 3/12/24; -The facility hired NA C on 12/28/23; -The three NAs were not certified within the required four-month period. During an interview on 8/27/24 at 11:40 A.M., the Director of Nursing (DON) said she knew all NAs had to be enrolled in a state approved training program which resulted in their certification within four months of hire. The problem the facility was having was getting the NA's to an approved clinical testing location. All the classroom lessons and tests are provided online. The final exam could be taken online. The final clinical test had to be done at an approved testing facility. Their facility was not an approved testing facility. The NA's had to go in person to a testing site for their final clinical exams. The waiting list to take the final clinical exam could take up to a month or two to get an appointment to be tested. The closest testing facility was 15-20 miles away and some staff didn't have transportation to the testing site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident is treated with dignity and respect when staff stood over residents in the resident use dining room, while assisting the residents with their meals. This affected two out of 13 sampled residents (Residents #11 and #10). The census was 45. Review of the Facility Resident's Rights Policy, revised February 2021, showed: -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -To be treated with respect, kindness, and dignity. 1. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/18/24, showed: -Severe cognitive impairment; -Eating: Staff does all of the effort; -Diagnoses included dementia and kidney failure. Review of the resident's care plan, undated and in use during the survey, showed: -Focus: The resident has a self-care performance deficit; -Goal: The resident will maintain current level of function through the review date; -Interventions: Encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts at self-care; -Focus: The resident has nutritional problem or potential nutritional problem; -Goal: The resident will comply with recommended diet for weight reduction daily through review -Interventions: Provide and serve diet as ordered. Review of the resident's medical record, showed: -On 12/31/23 at 10:03 A.M., Registered Dietician (RD) Note: Resident continues to receive a regular diet for meals, eats meals in the dining room with assistance from staff for intake. Intakes range from fair to good, 25-75% of most meals. Current weight 187 pounds, remains relatively stable overall. No change warranted in current nutritional regimen at this time. Observation on 3/18/24 at 12:51 P.M., showed Nurse Assistant (NA) H wearing black surgical gloves to pass trays to residents in the dining room. NA H served the resident his/her lunch tray and began to feed the resident large chunks of breaded chicken, while standing next to the resident, who was seated in his/her wheelchair. The resident could be seen vigorously leaning towards both the table and the staff member, who stood a few feet away from the resident, while feeding the resident at arm's length. NA H asked a passing dietary aide how the resident prefers to eat lunch, to which the dietary aide gave no instruction, but did give the resident two drinks from a glass while standing. At 1:06 P.M. NA H removed his/her black surgical gloves and continued to feed the resident while standing. NA H finished feeding the resident at 1:17 P.M., standing for the entirety of the meal assistance. 2. Review of Resident #10's quarterly MDS, dated [DATE], showed: -Cognitively severely impaired; -Eating, staff does all the effort; -No behaviors; -Diagnoses included stroke, seizure disorder, depression, anxiety and psychotic disorder (severe mental disorder that cause abnormal thinking and perceptions. People with psychoses lose touch with reality). Review of the resident's medical record, showed: -On 2/14/2024 at 9:41 A.M., Nutrition/Dietary Note, RD NOTE: Weight has remained stable in the 130s since November. Receiving no added sodium (NAS) diet order with assistance at meals. Review of the resident's care plan, undated, and in use during the survey, showed: -Focus: The resident is resistive to care due to anxiety; -Goal: The resident will cooperate with care through the next review date; -Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control; -Focus: The resident uses psychotropic (a chemical substance that changes the function of the nervous system and results in alterations of perception, mood, cognition, and behavior) medication due to schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly); -Goal: The resident will remain free of psychotropic drug related complications; -Interventions: Monitor/document/report any adverse reactions of psychotropic medications: unsteady gait, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, and weight loss; -Focus: The resident has self-care performance deficit due to confusion; -Goal: Resident will improve current level of function by review date; -Interventions: Encourage the resident to participate to the fullest extent possible with each interaction; -Focus: The resident has unplanned/unexpected weight loss due to poor food intake; -Goal: The resident will consume 50% of meals, three times a day; -Interventions: Give the resident supplements as ordered. Alert nurse or dietitian if not consuming or if weight decline persists, contact physician and dietician immediately. Observation on 3/19/24 at 8:28 A.M., showed the resident sat at a table in the main dining room. NA H stood in front of the resident, who remained seated, holding a bowl of cereal in his/her hand. NA H stood in front of the resident and continued to spoon cereal into the resident's mouth until the resident was finished eating. 3. During an interview on 3/20/24 at 12:25 P.M., the Administrative Assistant said residents should be treated with dignity, and staff should provide assistance when needed. While providing meal assistance, he said he did not think it would inappropriate to feed residents while standing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote and facilitate self-determination for residents who were dependent on staff for transfer assistance by failing to ensure residents were out of bed daily, in accordance with resident preferences for two of 13 sampled residents (Residents #30 and #38). The census was 45. Review of the facility's Resident Rights policy, revised February 2021, showed: -Policy Statement: Employees shall treat all residents with kindness, respect and dignity; -Policy Interpretation and Implementation; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness and dignity; -Self-determination. 1. During a group interview on 3/19/24 at 9:47 A.M., five residents, whom the facility identified as alert and oriented, attended the group meeting. All five residents said dependent residents had to wait to get out of bed if they needed assistance in transferring with the mechanical lift. Sometimes, residents lay in bed all day if there was no available staff. The group felt it was due to a lack of staff. 2. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/14/24, showed: -Moderate cognitive impairment; -Exhibited no behaviors; -Dependent on staff for all transfers. Helper does all the effort; -Diagnoses included high blood pressure and bipolar disease (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Review of the resident's care plan, revised 8/16/23, showed: -Focus: Current functional performance; -Goal: Resident's functional status will progress towards personal discharge goal during stay; -Interventions: Mechanical lift for all transfers. Resident performance. Transfer-extensive assist/two person physical assist. Observation and interview on 3/18/24 at 10:34 A.M., showed the resident lay in bed on his/her back. The resident said he/she was waiting on staff to return to get him/her out of bed. He/She had company visiting at 10:30 A.M. and he/she told staff around 7:30 A.M. that he/she needed to be up. He/She felt it was a bother and apologized for needing assistance. Tell them I don't want to cause any trouble by asking and I apologize for needing to be up. I just can't do it on my own. I'm sorry. The resident said he/she laid in bed waiting for at least an hour. Some days he/she does not get out of bed because they were short staffed and needed two staff to transfer him/her using the mechanical lift. Observation on 3/18/24 at 10:44 A.M., showed Nursing Aide (NA) A arrived with a mechanical lift and entered the resident's room. The resident apologized to NA A for asking for assistance. NA A did not say anything to the resident. NA E joined to assist NA A in the transfer. 3. Review of Resident #38's care plan, revised 8/25/23, showed: -Focus: Risk for falls; -Goal: Resident will be free of falls; -Interventions: Assist resident with ambulation and transfers, utilizing therapy recommendations. Review of the resident's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -Exhibited no behaviors; -Dependent on staff for transfers. Helper does all the effort; -Diagnoses included Huntington's disease (an inherited condition in which nerve cells in the brain break down over time). Observation and interview on 3/17/24 at approximately 8:30 A.M., showed the resident sat in bed with a gait belt around his/her waist. The resident said he/she was waiting to be placed in his/her wheelchair. Today staff was assisting the resident in transferring into the wheelchair. Over the last several days, the resident lay in bed because staff would not assist in getting him/her out of bed. I am bedridden and can't do it myself. The resident said he/she wanted to be out of bed daily. 4. During an interview on 3/20/24 at 9:22 A.M., NA E said residents requiring transfers with a mechanical lift may have to wait until an extra staff person was available to assist with the transfer, since two staff were needed for transfers. There were times when residents were not getting out of bed, due to a lack of staff to assist with the transfer. Resident #30 required the use of a mechanical lift and had to wait an extended amount of time to get up on 3/18/24. 5. During an interview on 3/20/24 at 10:21 A.M., NA C said residents who required a mechanical lift in getting out of bed had to wait sometimes, due to being short staffed. There was usually one aide assigned to a hall. If an aide on another hall was unavailable, residents would have to wait until they had two staff available to assist. 6. During an interview on 3/20/23 at 12:24 P.M., the Administrative Assistant and Director of Nursing said residents should be up at a reasonable time. Priority was given to residents needing to be changed or fed. Afterwards, staff could get residents up who needed assistance. If residents wanted to be out of bed daily, it is their choice and should be accommodated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a mental disorder had a DA-124 Level I screen (Pre-admission Screening and Resident Review (PASARR) used to evaluate for the presence of psychiatric conditions to determine if a PASARR Level II screen is required) as required, for one resident investigated for the PASARR requirement (Residents #6). The census was 45. Review of the facility's admission Policy, revised March 2019, showed: -All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid PASARR process; -The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD; -If the Level I screen indicates that the individual may meet the criteria for a ND, ID, or RD, he or she is referred to the state PASARR representative for the Level Il (evaluation and determination) screening process; -The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD; -The social worker is responsible for making referrals to the appropriate state-designated authority; -Upon completion of the Level Il evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate; -The state PASARR representative provides a copy of the report to the facility; -The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation; -Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified. Review of the Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/23, showed: -Date of admission on [DATE]; -Moderate cognitive impairment; -Diagnoses included cancer, high blood pressure, diabetes, high cholesterol, dementia and schizophrenia. Review of the resident's medical record, showed no PASARR Level I on file. During an interview on 3/18/24 at 1:42 P.M., the Director of Nursing (DON) said the resident did not qualify for Level II screening with the primary diagnosis of cancer. The DON did not provide a Level I. During an interview on 3/19/24 at 11:52 A.M., the DON said the facility did not have the resident's Level I screening. She said the resident did not require the screening from the previous facility and would not re-screen unless there was a change of condition or level of care. At 12:54 P.M., the DON said that if a resident transferred from nursing home to a nursing home, they did not require a PASARR. During an interview on 3/20/24 at 12:24 P.M., the DON and Administrative Assistant said PASARR should be done for new admissions for residents entering the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for two of 13 sampled residents (Residents #26 and #6). The census was 45. Review of the Facility Care Plans, Comprehensive Person-Centered Policy, dated March 2022, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The comprehensive, person-centered care plan: -Includes measurable objectives and timeframes; -Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: -Services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; -Includes the resident's stated goals upon admission and desired outcomes; -Builds on the resident's strengths; -Reflects currently recognized standards of practice for problem areas and conditions. 1. Review of Resident #26's medical record, showed: -The resident was admitted on [DATE] and currently resides at the facility; -Diagnoses included stroke, history of diabetic foot ulcers, Type II diabetes and slurred speech. Review of the resident's most recent quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/5/24, showed the resident is independent with all care areas and utilizes a walker and wheelchair for mobility. Observation on 3/18/24 at 11:51 A.M., showed the resident's bed equipped with half rails (a mechanically-assembled rail that extends nearly half the bed in length) that appeared to be in working order. Observation on 3/19/24 at 12:48 P.M., showed the resident's bed equipped with half rails that appeared to be in working order. During an interview on 3/19/24 at 12:51 P.M., the resident said he/she has had the bed rail for as long as I can remember and had no concerns regarding its utility or safety. Review of the resident's Bed Rails risk assessment, dated 1/22/24, showed the resident utilized a half rail for positioning and mobility while in bed. Review of the resident's care plan, showed no focuses or goals related to continued monitoring of the resident for safety concerns posed by bed rails. 2. Review of Resident #6's medical record, showed: -Physician orders showed resident may have side rails up for mobility and self-care; -A quarterly Bed Rail Assessment, dated 1/13/24, showed bilateral side rail placement recommendations, side rails are indicated as an enabler to promote independence, and the resident has expressed a desire to have side rails; -The care plan in use at the time of survey did not address the use of bedrails. Review of the resident's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Dependent with mobility, such as roll left to right, sit to lying and chair/bed-to-chair transfer; -Diagnoses included cancer, high blood pressure, diabetes, high cholesterol, dementia and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 3/17/24 at 10:25 A.M., the resident said the bedrails were always up while he/she was in bed. They help with turning side to side. Observation on 3/17/24 at 11:42 A.M., 3/18/24 at 10:31 A.M., 3/19/24 at 8:15 A.M. and on 3/20/24 at 8:48 A.M., showed full bedrails were placed or raised up to both sides of the resident's bed. During an interview on 3/20/24 9:22 A.M., Nurse Assistant (NA) E said the resident's bedrails are used for positioning or turning the resident from side to side. 3. During an interview on 3/20/24 at 10:21 A.M., NA C said the bedrails are used for residents, so they do not fall out of bed. 4. During an interview on 3/20/24 at 12:25 P.M., the Director of Nursing (DON) said care plans for all residents should be specific to each resident, and should be updated quarterly. The DON expected side rails and their uses to be included on a resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADL) care received assistance with meals in accordance with their personal needs for two (Residents #10 and #35) of 13 sampled residents. The census was 45. Review of the Activities of Daily Living (ADL), Supporting Policy, dated March 2018, showed; -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. -The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. -Unavoidable decline may occur if he or she: -Has a debilitating disease with known functional decline; -Has suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; and/or -Refuses care and treatment to restore or maintain functional abilities and: -The resident and/or representative has been informed of the risk and benefits of the proposed care or treatment; and -He or she has been offered alternative interventions to minimize further decline; and -Appropriate 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); -Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. -If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate; -A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff). Functional decline or improvement will be evaluated in reference to the assessment reference date (ARD) and the following MDS definitions: -Independent -Resident completed activity with no help or staff oversight at any time during the last 7 days; -Supervision -Oversight, encouragement or cueing provided 3 or more times during the last 7 days; -Limited Assistance -Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days; -Extensive Assistance -While resident performed part of activity over the last 7 days, staff provided weight-bearing support; -Total Dependence -Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period; -Interventions to improve 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; -The resident's response to interventions will be monitored, evaluated and revised as appropriate. 1. Review of Resident #10's quarterly MDS, dated [DATE], showed: -Cognitively severely impaired; -Eating, staff does all the effort; -No behaviors; -Diagnoses included stroke, seizure disorder, depression, anxiety and psychotic disorder (severe mental disorder that cause abnormal thinking and perceptions. People with psychoses lose touch with reality). Review of the resident's physician's orders, showed: -An order dated 2/2/24, for med pass (Fortified Nutritional Shake), twice a day for weight loss prevention. Review of the resident's care plan, undated and in use during the survey, showed: -Focus: The resident is resistive to care due to anxiety; -Goal: The resident will cooperate with care through the next review date; -Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control; -Focus: The resident uses psychotropic (a chemical substance that changes the function of the nervous system and results in alterations of perception, mood, cognition, and behavior) medication due to schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly); -Goal: The resident will remain free of psychotropic drug related complications; -Interventions: Monitor/document/report any adverse reactions of psychotropic medications: unsteady gait, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, and weight loss; -Focus: The resident has self-care performance deficit due to confusion; -Goal: Resident will improve current level of function by review date; -Interventions: Encourage the resident to participate to the fullest extent possible with each interaction; -Focus: The resident has unplanned/unexpected weight loss due to poor food intake; -Goal: The resident will consume 50% of meals, three times a day; -Interventions: Give the resident supplements as ordered. Alert nurse or dietitian if not consuming or if weight decline persists, contact physician and dietician immediately. Review of the resident's medical record, showed: -On 2/14/2024 at 9:41 A.M., Nutrition/Dietary Note, Registered Dietician (RD) NOTE: weight status. Weight loss between 9/15-11/20. Noted that resident with long hospitalization in November as well as some decreased fluid contributing to loss. Weight has remained stable in the 130s since November. Receiving no added sodium (NAS) diet order with assistance at meals. New order on 2/2/24 for med pass twice a day-monitor acceptance. During an interview on 3/17/24 at 12:01 P.M., and on 3/18/24 at 10:33 P.M., the resident said he/she eats in the dining room at the feeder table. Everyone calls it the feeder table, but it's not unusual for him/her to go without assistance. When he/she asks for assistance, the aides tell him/her they have to pass hall trays. By the time they come back, he/she said he/she is tired and asks to go to his/her room. No one asks him/her if he/she is finished, they just take him/her to his/her room. He/She said he/she is getting assistance now because the surveyors are in the building. He.she said if they put the food on his/her lap, he/she can feed him/herself, but he/she did not want sandwiches all the time, he/she wanted to eat what everyone else is eating. Observation on 3/18/24 at 12:34 P.M., showed Dietary Aide (DA) D placed a clothing protector on the resident's lap, and, per the resident's request, placed a sandwich on the clothing protector. DA D walked away. The resident leaned over the table and drank from the straw of a glass of milk sitting on the table beside him/her, without reaching for his/her glass or holding his/her glass steady. He/She continued to eat his/her sandwich and drank from the straw of his/her milk. A bowl of green beans, pudding and an orange drink were placed out of the resident's reach, and he/she received no additional assistance with his/her meal. The green beans and pudding remained uneaten and the drink remained full. During an interview on 3/19/24 at 8:24 A.M., the physical therapist said the resident is getting therapy and can physically feed him/herself. Because he/she can physically feed him/herself, the staff are under the belief he/she can feed him/herself, even though she/she says he/she can't. Regardless, staff should be assisting with the resident with his/her meals. During an interview on 3/20/24 at 10:30 A.M., Nurse Aide (NA) C said the resident can feed him/herself, but he/she is always asking for help. If you don't feed him/her, he/she will say if you don't help him/her eat, he/she will just sit right here and starve. NA C said he/she wondered why would someone just sit there and starve if you can feed yourself. NA C said when he/she sees family bring him/her food, he/she eats by him/herself, when they leave, he/she acts like he/she can't do anything. NA C overheard the resident on the phone saying, they won't feed him/her. NA C said if the food is on his/her lap, he/she can eat. He/She believed the issue is more the resident's lifting hands to the table, and he/she won't lift his/her hands to the table. During an interview on 3/20/24 at 12:45 P.M., the Director of Nursing (DON) said the resident had a hospitalization in November, the resident was placed on a ventilator, which contributed to his/her weight loss. Sometimes the resident refuses because he/she doesn't like who is helping him/her. The stories change. His/her issue with meal assistance is more mental than physical, but assistance should be provided despite him/her being able to eat without assistance. 2. Review of Resident #35's care plan, initiated 8/16/23, showed: -Focus: Current functional performance; -Goal: Resident's functional status will progress towards personal discharge goal during stay; -Interventions: Resident performance. Eating-Supervision/set up help only. Review of the resident's weight summary, showed: -8/23/23, a weight of 145 pounds; -9/15/23, a weight of 140 pounds; -11/20/23, a weight of 138 pounds; -12/28/23, a weight of 135 pounds; -1/11/24, a weight of 130 pounds. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -No rejection of care; -Set up or clean up assistance with eating; -Diagnoses included dementia, anxiety and depression. Review of the resident's Nutrition Quarterly Review, dated 2/14/24, showed: -Weight loss greater than 10%; -Dining location: Dining room; -Resident's ability to eat: Assisted; -Additional comments: Encourage intakes. Observation on 3/18/24 at 12:34 P.M., showed the resident sat in the dining room waiting on lunch. His/Her wheelchair was tilted as he/she drank coffee. At 12:47 P.M., staff placed a plate of food in front of the resident. The meal consisted of juice, water, coffee, a cup of pudding, a chicken patty, vegetables, rice and a slice of bread. The staff placed utensils wrapped in a napkin on the table and walked away without assisting the resident in opening up his/her utensils or straightening up the wheelchair. The resident picked up the cup of pudding and began to lick it. He/She then picked up the chicken patty with his/her hands and began to eat. He/She placed the chicken back on the plate and picked up the pudding and began to lick the cup. The resident placed the cup down and reached for the serving of vegetables, using his/her hands. The resident had a difficult time reaching for the vegetables and instead, picked up the chicken patty and took a bite. At 1:01 P.M., the Dietary Manager (DM) entered the dining room. At 1:03 P.M., she approached the resident and opened the napkins and placed the utensils in front of the resident. The resident grabbed the fork and attempted to eat the vegetables. The vegetables were not positioned in front of the resident. As the resident tried to reach for the vegetables, his/her hand shook. The resident set the fork down and picked up the chicken patty with his/her hands and began to eat. He/She ate the entire chicken patty and picked up the cup of pudding and began to lick the cup. At 1:10 P.M., the resident's family member arrived and sat next to the resident. The family member pushed the plate closer to the resident and turned the plate around so the vegetables were in front of the resident. The resident picked up the fork and began to eat his/her vegetables. He/She then used the spoon and ate the rest of the pudding. At 1:25 P.M., the resident ate all of the chicken, vegetables and pudding. At 1:29 P.M., the resident said he/she was done with lunch and ate french fries the family member brought. During an interview on 3/18/24 at 1:30 P.M., the family member said the resident could feed him/herself, but needed assistance with setting up the plate. He/She had arrived to the facility in the past and the resident's food was not eaten because staff had not opened the utensils or set up the plate so the resident could have access to everything on the plate. During an interview on 3/20/24 at 9:33 A.M., NA E said the resident could feed him/herself, but needed assistance with setting up his/her plate. Set up included opening the napkin and placing the utensils in front of the resident and ensuring the plate of food was within reach. During an interview on 3/20/24 at 11:52 A.M., the DM said the resident needed assistance with setting up his/her meal. There were times when aides passed trays but did not assist with set up. When she observed residents struggling with meals, she would instruct dietary staff to open utensils and assist the residents with setting up their trays. During an interview on 3/20/24 at 12:24 P.M., the Administrative Assistant and DON said the resident needed assistance with setting up his/her meals and expected staff to assist in setting up the resident's meals. MO00232721 MO00233034

Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 45. Review of the facility's Surety Bond Invoice, dated March 19, 2024, showed a bond amount of $100,000.00. Review of the facility's average resident trust fund balance for the previous twelve months, showed: -A monthly average of $73,000.00; -For this amount, the bond amount should have been $109,500.00. During an interview on 3/20/24 at 12:02 P.M., the Facility Accountant said she was unaware of the bond amount and she had been overseeing the accounting over the last six months due to changes in staff. During an interview on 3/20/24 at 12:04 P.M., the Administrative Assistant said he was unaware the bond amount was not sufficient. He would have the bond amount increased immediately.

Based on observation and interview, the facility failed to provide to residents a place in the facility where personal phone calls can be conducted in private and without being heard. In addition, the facility failed to ensure residents had access to mail delivered on Saturday. These failures has the potential to affect all residents in the facility. The survey sample was 13. The facility census was 45. 1. Observation on 3/17/24 at 6:40 A.M., showed a small conference room at the beginning of the 100 residents' hall. Signage at the entrance to the conference room read Resident Phone in large green lettering. Observation of the conference room, showed no phone available to residents for private use, but contained multiple office chairs, a table, and a toilet seat cover left on the ground. Observation on 3/17/24 at 8:58 A.M., showed Resident #31 at the nurse's station using a wired connection phone to speak to his/her family member. Observation on 3/19/24 at 9:48 A.M., showed Resident #1 at the nurse's station using a wired connection phone to speak to his/her family. During the phone call, five residents were seated just a few feet behind him/her, and a housekeeping staff member operated a tile buffer to clean the floors in the area. During the call, the resident appeared frustrated with the amount of noise during the call, appearing to have difficulty hearing the person on the other end of the call. During an interview on 3/19/24 at 12:51 P.M., Resident #26 said he/she does not often make calls from the facility, but the only phone he/she is aware of that is available for resident use is the wired phone placed at the nurse's station. During an interview on 3/20/24 at 10:26 A.M., Nurse Aide (NA) C said residents are assisted in placing phone calls to outside contacts, and staff provide a phone at the nurse's station for residents to use. NA C believed there was a phone in the conference room at one time, but that room is not used for anything currently. The NA said conversations that residents may have at the nurse's station are not private, and residents should be provided a more private space to conduct personal conversations if they wish. During an interview on 3/20/24 at 10:49 A.M., the Activities Director said the phone room near the 100 hall is not used for anything, and currently is just an empty room. The Activities Director said a phone is available at the nurse's station but was unaware of any other method of private communication that the facility provided to residents. The Activities Director would not consider conversations residents have at the nurse's station to be private, and that if the room was used for resident phone calls, it would be a more private location to conduct conversations. During an interview on 3/20/24 at 12:25 P.M., the Administrative Assistant said a cordless phone had been previously kept in the phone room at the facility, but residents would use it and fail to place it back on its charger, meaning the phone would die and be unavailable for use in the future. The cordless phone was placed at the nurse's station for residents to take to a more private place for conversations if needed. At that time, the resident council was made aware of this change, but the Administrative Assistant was unsure if residents are still aware the cordless phone is available. 2. During a group interview on 3/19/24 at 9:47 A.M., five residents, whom the facility identified as alert and oriented, attended the group meeting. All five residents said mail was not delivered on Saturdays. One resident said he/she had a package delivered on Saturday but had to wait until activities staff returned on Monday to receive the package. During an interview on 3/20/24 at 10:27 A.M., the Activities Director said she had one assistant who assisted with activities a couple of days during the week. She works Monday through Friday and was not at the facility during the weekend. Mail and packages delivered on Saturday are placed in her mailbox, and she delivers the packages when she returns on Monday. During an interview on 3/20/24 at 12:24 P.M., the Administrative Assistant and Director of Nurses (DON) said residents should receive packages on Saturdays if it was delivered on a Saturday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a comfortable and homelike environment for residents when staff failed to ensure resident hallways were free from strong odors throughout the survey process. The census was 45. Review of the facility's Departmental (Environmental Services)-Laundry and Linen policy, revised January 2014, showed: -Purpose: The purpose of this procedure is to provide a process for the safe use and aseptic handling, washing and storage of linen; -General Guidelines; -Standard precautions; -Consider all soiled linen to be potentially infectious and handle with standard precautions; -Bagging and Handling Soiled Linen; -All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. Observation on 3/17/24 at 6:31 A.M., showed a hospital gown and two other items piled outside of room [ROOM NUMBER], directly on the floor, unbagged. The hallway emitted a strong smell of urine. Across from the soiled linen were two large white bins. One bin indicated use for trash and the other for soiled linen. Observation on 3/18/24 at 7:38 A.M. showed a small pile of dirty linens, washcloths, and a hospital gown on the floor in an opened trash bag near the doorway of room [ROOM NUMBER]. A slight malodorous scent was observed near the pile of linens. Observation on 3/18/24 at 12:24 P.M., showed a covered soiled linen cart and covered trash can on the 400 hall unit, outside of room [ROOM NUMBER]. The trash can and soiled cart emitted strong odors of urine. Observation on 3/19/24 at 8:14 A.M., showed a soiled linen cart on the 400 unit. The cart emitted a strong odor of urine. During a group interview on 3/19/24 at 9:47 A.M., five residents, whom the facility identified as alert and oriented, attended the group interview. All five residents said the facility smells like urine and bowel, but mostly early in the morning. Once day shift aides and housekeeping arrived, they cleaned the area and the smells would disappear. During an interview on 3/20/24 at 10:21 A.M., Nursing Aide (NA) C said he/she normally worked day shift and when he/she arrived to his/her shift, the smell of urine and trash was strong. Sometimes night shift staff did not remove soiled linen to the laundry room or empty trash. He/She will remove the soiled linen when he/she started his/her shift. During an interview on 3/20/24 at 10:11 A.M., Housekeeping Aide I said trash cans and the linen cart were left on the hallways during the night shift and were not emptied until the day shift aides arrived. He/She smelled urine and trash on occasions and has witnessed dirty linen on the floor. He/She had addressed this with management in the past. The soiled linen cart and trash can should be changed out every 30 minutes to prevent the smell of trash and urine. During an interview on 3/20/24 at 12:24 P.M., the Administrative Assistant and Director of Nursing said they expected the facility to be clean, comfortable, homelike and free of offensive odors. Trash cans and linen carts should be emptied after each shift. MO00232721

Based on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to store food in a safe and sanitary manner to prevent potential cross-contamination, label and date food items, and failed to ensure pans, bowls and utensils were dry prior to storage. This had the potential to affect all residents who consumed food from the facility kitchen, The facility had a census of 45. Review of the Facility Food Safety High Five Policy, undated, showed; -Do not store raw foods over cooked or ready to eat foods; -Never prepare ready to eat foods on the same surface or with the same utensils used to prepare raw animal proteins; -Properly wash, rinse and sanitize all food contact utensils and equipment; -Label all food clearly, and use the first in, first out system (food that has been in storage longest, first in, should be the next food used, first out). Observation of the kitchen on 3/17/24 at 9:33 A.M., showed: -Inside the stand alone refrigerator: -A bag of wrapped lettuce sitting on top of a pan of packaged hamburger. Uncovered heads of lettuce were beneath the packaged hamburger; -A jar of chicken base, opened, undated; -A jar of garlic, opened, undated; -A package of sliced American cheese, opened, undated; -A package of shredded American cheese, opened, undated; -Two large serving trays, with pre-poured cups of mayonnaise and catchup, undated; -Containers of sweet sauce and zesty orange sauce, opened, undated; -A large bag of diced white cheese, opened, undated; -Inside the dry storage area: -A large bag of sugar inside the sugar bin. A Styrofoam cup was inside the bag of sugar and used as a scoop; -A fifty pound bag of rice, opened, undated; -Inside the stand alone freezer; -A bag of french fries, opened, undated; -Two bags diced chicken, opened, undated; -A bag of sliced bread pieces, opened, undated; -A bag of french fries, opened, and undated. Observation of the kitchen on 3/18/24 at 9:33 A.M., showed: -Inside the refrigerator, a bag of cheese cubes, opened, undated; -Inside the dry storage; -A fifty pound bag of rice, opened, undated; -A bag of pasta, opened, undated dated -Inside the freezer: -A bag of frozen fries, opened, undated; -A bag of french toast, opened, undated; -A package of chicken cubes, opened, undated; -A package of sausage links, opened, undated. Observation of the kitchen on 3/19/24 at 11:33 A.M., showed: -Inside the dry storage area, a bag of rice, opened, undated; -On the storage rack were stacked pans and bowls, with visible water droplets; -Dietary Aide B rolling utensils into cloth napkins with visible water droplets on the utensils. During an interview on 3/20/24 at 11:48 A.M., the Dietary Manager said potentially hazardous foods, such a hamburger, should be stored on the bottom rack of the refrigerator to prevent the chance of cross contamination onto the food underneath. She expected staff to date and label opened food prior to placing the food in storage. Scoops should not be stored inside containers, including Styrofoam cups, which should have been discarded. She expected pans, bowls and utensils to be fully dried before stacking or wrapping them in napkins. During an interview on 3/20/24 at 1:15 P.M., the Director of Nursing said hamburger should be stored on the bottom shelf, because the hamburger liquid could run onto the food stored below. The food underneath could potentially be contaminated by the liquid. The potential harm for storing pans, bowls and wrapped wet utensils would be a potential for mold growth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control for one resident observed during personal care (Resident #30). Staff failed to change their gloves or sanitize their hands after removing a dirty brief and performing perineal care (cleansing of the area including the hips, genitals and anal area), prior to applying a clean brief and touching the resident. In addition, staff failed to apply hand hygiene when handling the residents' meal trays and assisting with meal set-up. Furthermore, facility failed to keep the soiled linens and gowns bagged, tied and off the floor by the residents' rooms. The sample was 13. The census was 45. Review of the facility's Standard Precautions Policy, revised September 2022, showed: -Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water; -Hand hygiene is performed with ABHR or soap and water; -Before and after contact with the resident; -Before performing an aseptic task; -Before moving from work on a soiled body site to a clean body site on the same resident; -After contact with items in the resident's room; -After removing gloves; -Hands are washed with soap and water; -When visibly soiled with dirt, blood, or body fluids; -After contact with blood, body fluids, or contaminated surfaces; -After caring for a resident with Clostridioides difficile (C. diff or Clostridioides difficile, inflammation of the colon caused by the bacteria C. diff); -In general, if rates of C. diff infection are high; -After caring for a resident with norovirus infection during an outbreak; -Before eating and after using the restroom; -Except as noted above, ABHR is preferred for hand hygiene; -Sinks, soap, water, disposable towels and ABHR are available to personnel and visitors in readily accessible and visible locations throughout the facility; -Artificial fingernails are discouraged among staff with direct resident contact; -Personnel assist the residents with hand hygiene before meals, after toileting and when indicated; -Gloves are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material; -Gloves are worn when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms; -Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care; -Gloves with fit and durability appropriate to the task are available to personnel at all times; -Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one); -Gloves are not to be reused; -Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident; -After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments. Review of the facility's Departmental (Environmental Services)-Laundry and Linen policy, revised January 2014, showed: -Purpose: The purpose of this procedure is to provide a process for the safe use and aseptic handling, washing and storage of linen; -General Guidelines; -Standard precautions; -Consider all soiled linen to be potentially infectious and handle with standard precautions; -Bagging and Handling Soiled Linen; -All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. 1. Review of Resident #30's medical record, showed: -Diagnoses included cardiomyopathy (a disorder that affects the heart muscle), high blood pressure, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone); -A care plan used at time of survey, showed: -Focus: Potential for impaired skin integrity; -Goal: Skin will remain intact; -Interventions: provide skin care per facility guidelines. Observation on 3/18/24 at 10:48 A.M., showed Nurse Assistant (NA) A placed gloves on his/her hands and removed the cover off of the resident. He/She unfastened the resident's incontinence brief and rolled it under the resident while NA E assisted the resident to turn to his/her left. The resident's brief was soiled with urine. NA A cleaned the perineal area with washcloths and dried the resident. The resident was rolled side to side and NA A removed the soiled brief, and placed it with the soiled washcloths at the foot of the resident's bed. NA E assisted the resident to turn side to side and removed the incontinence pad from underneath the resident. He/She then obtained a clean brief and handed it to NA A. Neither of the NAs changed and sanitized their hands after touching the soiled brief, washcloths and pad. NA A applied the clean brief onto the resident and fastened each side. He/She then picked up the unbagged dirty brief and washcloths, exited the resident's room and placed them in the hamper and trash bin located in the hallway, two doors down across from the resident's room. During an interview on 3/20/24 at 10:21 A.M., NA C said during resident's personal care, he/she changes gloves once with pee and twice with boo-boo. He/She washed or sanitized hands before and after care. 2. Observation on 3/17/24 at 8:14 A.M., showed nursing staff retrieving breakfast trays in the main dining room from the kitchen service window and serving them to residents. During the observation, NA C passed seven resident trays to residents in the dining room, assisting with the setup of their plates, silverware, and drink cups with his/her bare hands. NA C did not complete hand hygiene with soap and water or an antibacterial solution before, during, or after passing each resident tray. NA F passed six resident trays to residents in the dining room, assisting with the setup of their plates, silverware, and drink cups with his/her bare hands. NA F did not complete hand hygiene with soap and water or an antibacterial solution before, during, or after passing each resident tray. NA G also passed resident trays in the dining room, occasionally wiping his/her nose with his/her bare hands, and assisting with the setup of plates, silverware, and drink cups with his/her bare hands. NA G did not complete hand hygiene with soap and water or an antibacterial solution before, during, or after passing each resident tray. Observation on 3/20/24 at 8:37 A.M., showed NA C and NA F passing resident trays to residents in the main dining room with their bare hands, assisting with plate setup, silverware setup, and drinks. No hand hygiene was completed by either of the NAs before, during, or after passing each resident tray for the duration of the meal service. 3. Observation on 3/17/24 at 6:31 A.M., showed a hospital gown and two other items piled outside room [ROOM NUMBER], directly on the floor, unbagged. The hallway emitted a strong smell of urine. Across from the soiled linen were two large white bins. One bin indicated use for trash and the other for soiled linen. Observation on 3/18/24 at 7:38 A.M. showed a small pile of dirty linens, washcloths and a hospital gown on the floor in an opened trash bag near the doorway of room [ROOM NUMBER]. A slight malodorous scent was near the pile of linens. During an interview on 3/20/24 at 10:21 A.M., NA C said he/she normally worked day shift and when he/she arrived at his/her shift, the smell of urine and trash was strong. Sometimes, night shift staff did not remove soiled linen to the laundry room or empty trash. He/She will remove the soiled linen when he/she started his/her shift. During an interview on 3/20/24 at 10:11 A.M., Housekeeping Aide I said trash cans and the linen cart were left on the hallways during the night shift and were not emptied until the day shift aides arrived. He/She smelled urine and trash on occasions and witnessed dirty linen on the floor. He/She addressed this with management in the past. The soiled linen cart and trash can should be changed out every 30 minutes to prevent the smell of trash and urine. 4. During an interview on 3/20/24 12:24 P.M., the Director of Nursing (DON) said staff should wash or sanitize their hands before and after contact with the residents, before touching clean from dirty items or areas, and after removing gloves. She also expected staff to change gloves in the same manner, from handling dirty and prior to clean. In addition, the Administrative Assistant and DON said they expected the facility to be clean, comfortable, homelike and free of offensive odors. Trash cans and linen carts should be emptied out after each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to electronically submit to The Center of Medicare and Medicaid services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for the quarter immediately preceding the annual survey. The census was 45. Review of the facility's Payroll Based Journal (PBJ) staffing Data Report, for fiscal year quarter 1, 2024 ([DATE] through [DATE]), showed the facility triggered for failing to submit data for the quarter. During an interview on [DATE] at 12:24 P.M., the Administrative Assistant and Director of Nursing said PBJ information had not been submitted. The Administrative Assistant said the passwords expired.

Based on observation, interview and record review, the facility failed to ensure only residents assessed as safe and appropriate to self-administer medication were allowed to self-administer medications, for one resident observed with medications left at the bedside (Resident #5). The sample was 9. The census was 41. Review of the facility's Self-Administration of Medications policy, dated February 2021, showed: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status; -Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Review of Resident #5's medical record, showed: -Diagnoses included high blood pressure, chronic kidney disease, and heart failure; -Oral medications scheduled at 8:00 A.M. included: Arava (used to treat rheumatoid arthritis) 20 milligram (mg), cholecalciferol (vitamin D3) 125 micrograms (mcg), furosemide (water pill) 40 mg, isosorbide mononitrate extended release (treats high blood pressure) 30 mg, methimazole (used to treat thyroid disorder) 10 mg, pantoprazole sodium (used to treat heart burn) 40 mg, apixaban (used to prevent blood clots) 5 mg, buspirone HCL (mood stabilizer) 5 mg, carvedilol (treats high blood pressure) 6.25 mg, metoprolol tartrate (used to treat high blood pressure) 100 mg, and hydralazine HCL (used to treat high blood pressure) 100 mg; -No order to self-administer medications; -The care plan did not indicate the resident as assessed to self-administer medications; -No assessment completed to determine if the resident was safe to self-administer medications. Observation and interview on 12/26/23 at 9:10 A.M., showed the resident sat up in bed. A medication cup sat on the meal tray and contained approximately 8 pills. The resident said he/she usually receives his/her pills earlier than now, but he/she was told staff were shorthanded, so they left them at the bedside. During an interview on 12/26/23 at 2:54 P.M., with the Director of Nursing (DON) and Administrator, they said if a resident wants to self-administer medications, this is discussed with the interdisciplinary team. The team evaluates the residents mental and physical abilities. If appropriate, the physician writes an order. No residents currently have orders to self-administer oral medications. Medications should not be left at the bed side for the resident to take. Staff should observe the resident take the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing assistants (NAs) employed by the facility were enrolled in a certification course and that NAs were certified within 4 months of hire. The sample was 9. The census was 41. Review of the facility assessment, reviewed on [DATE], showed: -Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents; -Section 5- Staff Competency Profile Guide: The Centers for Medicare and Medicaid Services pilot for facility needs assessment directs that you look at staff training/education and competencies; -Review of the assessment, showed Section 5 not included in the assessment. During an interview on 12/26/23 at 2:54 P.M., the Administrator said Section 5 of the facility assessment is addressed with the use of the onsite job competency check off list used during orientation. Review of the check off lists at this time, showed it addressed the care areas and required competencies for staff. It did not address the requirement for NAs to become certified. Review of the list of current NAs and certified nursing assistants (CNAs) employed by the facility, showed: -18 staff listed and only one of the 18 certified as a CNA; -17 NAs listed; -Of the 17 NAs, two identified as being employed for more that 4 months and not yet certified or scheduled to take the certification test: -NA B date of hire 5/28/23, enrolled in a certification class, not yet certified; -NA E date of hire 6/12/23, enrolled in a certification class, not yet certified; -Three additional NAs employed for more than a month and not enrolled in certification classes: -NA C date of hire 9/13/23 and not enrolled in a certification class; -NA D date of hire 11/6/23 and not enrolled in a certification class; -NA F date of hire 10/11/23 and not enrolled in a certification class. During an interview on 12/26/23 at 2:33 P.M., the Administrator said the facility does not have anything in writing to describe the expectation for NAs employed in regard to becoming certified. The unwritten expectation is NAs will become enrolled in a certification class within a month of hire and become certified within 4 months. MO00226505

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food at time of service was palatable and that hot food was served hot to the residents for one of one meal service observed for food taste and temperature. Residents who reside at the facility reported ongoing concerns with the food being served cold (Resident #2, Resident #4, and Resident #5). The sample was 9. The census was 41. Review of the facility's Preventing Foodborne Illness- Food Handling policy, dated July 2014, showed: -Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized; -Potentially hazardous foods held in the danger zone (41 degrees Fahrenheit (F) to 135 degrees F) for more than 4 hours if being prepared from ingredients at room temperature, or 6 hours if cooled and then cooled will be discarded; -The policy did not identify the temperature in which hot food should be at time of service. 1. Review of Resident #2's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/13/23, showed: -Cognitively intact; -Diagnoses included high blood pressure; -Eating: Setup or clean-up assistance required. During an interview on 12/26/23 at 7:20 A.M., the resident said the food is nasty and food is served ice cold. 2. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure, kidney disease, diabetes, and high cholesterol; -Eating: Setup or clean-up assistance required. During an interview on 12/26/23 at 8:35 A.M., the resident said that sometimes food is served cold. 3. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included malnutrition; -Eating: Setup or clean-up assistance required. During an interview on 12/26/23 at 9:10 A.M., the resident said he/she usually eats in his/her room. The food arrives cold. The resident pointed to his/her cream of wheat, stirred it with a spoon, and said it is so cold it is hard. Observation showed the cream of wheat appeared lumpy and thick. He/She reported the concern during the resident council meeting a couple months ago. They said they would come back with a resolution at the next meeting, but when the next meeting was held, they had not addressed it. He/She did not bring it up again because why bother. 4. Observation on 12/26/23 at 12:46 P.M., of the lunch meal service, showed the service window in the dining room opened and dietary staff began meal service for residents in the main dining room. A dietary staff stood in the window and another staff member off to the side, but outside of view, served up plates of food and set them next to the dietary staff member in the window. At any given time, three to four plates of food sat on the counter and waited for the dietary staff member to add the utensils, drinks, and sides to the meal trays. Steam was observed to rise from the food as it was placed on the counter; however, as the food made it onto a tray and taken to the dining room, steam could no longer be seen. The main dish served consisted of cheesy tortilla chips topped with a white cheese, taco meat, and lettuce. The sides consisted of black beans and cake with a caramel drizzle. A test tray was requested to be served at the end of meal service to consist of the beans and the main dish without the lettuce, to prevent the lettuce from cooling the food. At 1:06 P.M., the dietary staff in the service window said they are now prepping hall trays. Hall trays were placed on a plate and then covered with a plastic transparent lid. Some trays were placed in an enclosed cart and some on an open-air cart. The hall trays did not leave the dining area until the last resident tray was dished up. At 1:20 P.M., a test tray was provided directly from the service line and temperatures taken immediately with a digital thermometer. The main dish of chips, cheese and meat measured 127.7 degrees F taken in the center of the dish to obtain the hottest temperature. The black beans measured 109.4 degrees F. During the tasting of the food, the main dish meat and cheese in the middle of the dish felt warm and the food near the edges of the dish felt cold in the mouth. The beans tasted bland and felt cold. 5. During an interview on 12/26/23 at 2:08 P.M., when asked what the appropriate temperature is for food at time of service, the Dietary Manager said food should be at 140 degrees F while on the food line. 6. During an interview on 12/26/23 at 2:33 P.M., the Administrator said food at time of service should be served per the food borne guidelines. Food should be served at the proper temperature and have good flavor.

Based on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) form when a resident's Medicare covered services had ended for one resident (Resident #27) and to complete and notify in the proper timeframe, at least two calendar days before services were to end, the NOMNC and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident (Resident #22) out of three sampled residents. The facility census was 41. 1. Record review of Resident #22's NOMNC and SNF ABN forms showed: - The resident discharged from skilled Medicare services on 1/19/22, and remained in the facility; - The resident received and signed the forms on 1/22/22; - The facility failed to provide the NOMNC and the SNF ABN forms to the resident at least two calendar days before the skilled Medicare services ended. 2. Record review of Resident #27's SNF ABN form showed: - The resident discharged from skilled Medicare services on 1/1/22, and remained in the facility; - The resident received and signed the SNF ABN form on 12/30/21; - The resident did not receive a NOMNC form; - The facility failed to provide the NOMNC form to the resident before the skilled Medicare services ended. During an interview on 3/3/22 at 11:37 A.M., the Administrative Assistant stated he was aware of the two-day notification of the SNF ABN and NOMNC forms prior to a resident's discharge from skilled Medicare services. The facility had recently hired a new social service designee and was still a work in progress. The facility did not provide a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment to be filled out by the facility staff, within 14 days of a resident admitted to hospice. This affected one resident (Resident #26) out of a sample of one resident. The facility census was 41. 1. Record review of Resident #26's medical record showed: - The resident admitted to hospice on 10/28/21. Record review of the resident's MDS's showed: - A significant change MDS, dated [DATE], with no hospice services received; - A quarterly MDS, dated [DATE], with hospice services received; - No significant change MDS, dated within 14 days of the admission to hospice services on 10/28/21; - The facility failed to complete a significant change MDS after the resident admitted to hospice. During an interview on 3/3/22 at 12:58 P.M., the Director of Nursing (DON) said she was responsible for completing, updating, and ensuring the accuracy of the MDS's. The facility did not provide a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for one resident (Resident #9) out of 12 sampled residents and one resident (Resident #35) outside the sample. The facility census was 41. 1. Record review of Resident #9's medical record showed: - Resident did not have an order for an anticoagulant (blood thinner) medication. Record review of the resident's MDS, dated [DATE], showed the resident received an anticoagulant medication in the past seven days. 2. Record review of Resident #35's medical record showed: - The resident did not have an order for an anticoagulant medication. Record review of the resident's MDS, dated [DATE], showed the resident received an anticoagulant medication in the past seven days. During an interview on 3/2/22 at 8:35 A.M., Certified Medication Technician (CMT) B said the resident did not have an order for an anticoagulant. During an interview on 3/3/22 at 12:30 P.M., the Director of Nursing (DON) said she must have marked the MDS in error due to the resident received a daily aspirin. Record review of the facility's Resident Assessment Instrument (RAI) procedure manual, dated October 2017, showed: - Record the number of days an anticoagulant medication was received by the resident at any time during the seven-day look-back period (or since admission/entry or reentry if less than seven days); - Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here.

Based on interview and record review, the facility failed to prepare a comprehensive discharge summary for one resident (Resident #45) out of one sampled resident. The facility census was 41. 1. Record review of the facility's Discharge Summary and Plan policy, revised December 2016, showed: - When the facility anticipates a resident's discharge to a private residence or another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment; - The discharge summary will include a recapitulation (summary) of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 1. Record review of Resident #45's closed medical record showed: - The resident discharged to the community on 1/14/21; - No comprehensive discharge summary; - The facility failed to complete a comprehensive discharge summary. During an interview on 3/2/22 at 3:02 P.M., the Administrative Assistant (AA) and the Director of Nursing (DON) said Resident #45's discharge was an unplanned discharge. AA and DON stated a discharge summary should be completed upon a resident's planned discharge to home, but not necessarily on an unplanned discharge.

Based on observation, interview, and record review, the facility failed to ensure correct procedures were followed when medications were administered through a gastrostomy tube (g-tube) (a tube placed directly into the stomach) which affected one resident (Resident #26) out of two sampled residents. The facility census was 41. Record review of the facility's Administrating Medications through an Enteral Tube policy, revised 11/2018, showed: - Wash hands; - Retrieve medication; - Prepare the medication, check the label and confirm the medication name and dose with the Medication Administration Record; - Prepare the resident; - Check compatibility with feeding tube formula, if feeding would be continuous; - Verify placement of feeding tube; - If improper tube position suspected, do not administer the medication and notify the charge nurse or physician. Record review of Resident #26's Physician Order Sheet (POS), dated 3/2/22, showed: - An order to check the g-tube placement prior to each medication administration. Observation of Resident #26, on 3/2/22 at 1:00 P.M., showed: - The resident lay in bed, with the head of the bed elevated at 45 degrees; - Licensed Practical Nurse (LPN) A flushed the g-tube with 30 cubic centimeters (cc) of water; - LPN A administered the resident's lorazepam (an anti-anxiety medication) and trazadone (a medication used to decrease anxiety and increase appetite) through the g-tube; - LPN A flushed the g-tube after each medication with 30 cc's of water; - LPN A did not check the placement of the g-tube before he/she flushed the g-tube with water or administered the resident's medications. During an interview on 3/2/22 at 1:20 P.M., LPN A said the g-tube placement should be checked every four to six hours. He/she should have checked the placement of the g-tube before the tube was flushed with water or medications were administered. During an interview on 3/3/22 at 1:06 P.M., the Director of Nursing (DON) said the resident did have an order for the g-tube to be checked before medication was to be administered. The g-tube placement should have been checked before the resident's medication or flush was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #22) out of one sampled resident. The facility census was 41. Record review of the facility's End-Stage Renal Disease (ESRD), Care of a Resident policy, revised September 2010, showed: - Agreements between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed including how information will be exchanged between the facilities. 1. Record review of Resident #22's Physician Order Sheet (POS), dated March 2022, showed: - admitted to the facility on [DATE]; - Diagnosis of end stage renal disease (chronic irreversible kidney failure); - An order for dialysis three times weekly, dated 8/21/20. Record review of the resident's medical record from January 31, 2022 through March 2, 2022, showed: - No documentation of the resident's condition before and after dialysis treatments; - No documentation of communication between the facility and the dialysis center; - Out of 14 opportunities for the facility to document communication between the facility and the dialysis center, the facility missed 14 opportunities; - The facility failed to communicate with the dialysis center before and after the resident's dialysis treatments. During an interview on 3/3/21 at 9:35 A.M., Licensed Practical Nurse (LPN) A said the staff did not send any documentation or communication with the resident to dialysis. If there was anything going on with the resident, then dialysis would send something back with the resident. During an interview on 3/3/21 at 9:45 A.M., the Director of Nursing (DON) said the facility had a contract with dialysis, but did not send any communication with the resident to the dialysis center. She said if anything was pertinent, then dialysis would let them know.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure side rails (a structural support attached to the side of the bed to help prevent falls) were used only after other alternatives were attempted, failed to obtain signed informed consent with risks and benefits explained to the resident or representative, and to obtain physician orders for the use of the side rails. This affected four residents (Resident #6, #10, #26 and #39) out of 12 sampled residents and one resident (Resident #4) outside the sample. The facility census was 41. Record review of the facility's Use of Restraints policy, revised April 2017, showed: - Restraints would only be used upon the written order of a physician and after consent obtained from the resident and/or the representative (sponsor); - The order would include the specific reason for the restraint as related to the resident's medical symptom, how the restraint will be used to benefit the resident's medical symptom, the type of restraint, and the period of time for the use of the restraint. 1. Record review of Resident #4's medical record showed: - Diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture) and contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff); - No documentation of other alternatives attempted before the use of the side rails; - No documentation of signed informed consent obtained with risks and benefits explained to resident or representative; - No physician order for the side rails on Physician Order Sheet (POS), dated 3/2/22. Record review of the resident's Bed Rail assessment dated [DATE], showed: - Resident non-ambulatory; - Difficulty with balance or poor trunk control, and moving to a sitting position on the side of the bed; - Side rail placement to be bilateral. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 1/22/22, showed: - A mental status of moderate mental cognitive impairment; - Total dependence on staff for bed mobility, transferring, dressing, and bathing; - Always incontinent of bowel and bladder; - No side rails used. Observation of the resident showed: - On 2/28/22 at 12:49 P.M., the resident lay in bed with the upper and lower bed rails raised on both sides of the bed. 2. Record review of Resident #6's medical record showed: - The resident admitted on [DATE]; - Diagnoses of urinary tract infection (UTI) (an infection in the kidneys, bladder or the tube from the kidneys to the bladder), pressure ulcer (an opened sore on the body caused by a pressure source) healed, diabetes mellitus (a chronic health condition which affects how your body turns food into energy), gastrostomy (g-tube) (a tube placed directly into the stomach through the abdomen for nutrition) tube; - No documentation of other alternatives attempted before the use of the side rails; - No documentation of signed informed consent obtained with risks and benefits explained to resident or representative; - No physician order for the side rails on Physician Order Sheet (POS), dated 3/2/22. Record review of the resident's Bed Rail assessment dated [DATE], showed: - Resident non-ambulatory; - Difficulty with balance or poor trunk control, and moving to a sitting position on the side of the bed; - Resident did not express a desire to have side rails/assist bar for safety or comfort; - Side rail placement to be bilateral. Record review of the resident's quarterly MDS, dated [DATE], showed: - A mental status of severe mental cognitive impairment; - Total dependence on staff for bed mobility, transferring, dressing, feeding, and bathing; - Did not ambulate; - Always incontinent of bowel and bladder; - No side rails used. Observations of the resident from 2/28/22 at 12:32 P.M. through 3/2/22 at 8:30 A.M., showed: - The upper and lower bed rails on both sides of the bed to be raised; - The bed to be in a raised position. 3. Record review of Resident #10's medical record showed: - An admission date of 10/23/12; - Diagnoses of hypertension (high blood pressure), unspecified dementia (loss of memory) without behavioral disturbance, atherosclerosis (hardening of the arteries), shortness of breath, restlessness and agitation; - No documentation of other alternatives attempted before the use of the side rails; - No documentation of signed informed consent obtained with risks and benefits explained to resident or representative; - No physician order for the side rails on Physician Order Sheet (POS), dated 3/2/22. Record review of the resident's Bed Rail assessment dated [DATE], showed: - Resident non-ambulatory; - Difficulty with balance or poor trunk control, and moving to a sitting position on the side of the bed; - Visually challenged; - Side rail placement to be bilateral. Record review of the resident's quarterly MDS, dated [DATE], showed: - A mental status of severe mental cognitive impairment; - Total dependence on staff for bed mobility, transferring, dressing, feeding, and bathing; - Always incontinent of bladder and occasional incontinent of bowel; - No side rails used. Observations of the resident from 2/28/22 at 11:51 A.M. through 3/3/22 at 10:25 A.M., showed: - The upper and lower bed rails on both sides of the bed to be raised. 4. Record review of Resident #26's medical record showed: - An admission date of 10/26/16; - Diagnoses of chronic (long-term) pain, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), seizures (a disorder in which nerve cell activity in the brain is disturbed), muscle weakness (generalized), cerebrovascular accident (CVA) (stroke), hypertension, epilepsy (type of seizure); - No documentation of other alternatives attempted before the use of the side rails; - No documentation of signed informed consent obtained with risks and benefits explained to resident or representative; - No physician order for the side rails on Physician Order Sheet (POS), dated 3/2/22. Record review of the resident's Bed Rail Assessment, dated 11/11/21, showed: - Resident non-ambulatory; - Level of consciousness fluctuated; - Altered safety awareness due to cognitive decline; - History of falls; - Poor bed mobility; - Difficulty with balance or poor trunk control, and moving to a sitting position on the side of the bed; - Resident did not express a desire to have side rails/assist bar for safety or comfort; - Visually challenged; - Side rail placement to be bilateral. Record review of the resident's quarterly MDS, dated [DATE], showed: - A mental status of severe mental cognitive impairment; - Total dependence on staff for bed mobility, transferring, dressing, feeding, and bathing; - Always incontinent of bowel and bladder; - No side rails used. Observations of the resident from 2/28/22 at 11:45 A.M. through 3/3/22 at 10:24 A.M., showed: - The upper and lower bed rails on both sides of the bed to be raised. 5. Record review of Resident #39's medical record showed: - An admission date of 7/5/21; - Diagnoses of diabetes mellitus, multiple fractures, stroke, osteoporosis (a condition in which the bones become weak and brittle), iron deficiency anemia (low iron), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block air flow makes it difficult to breath), gastroesophageal reflux disease (GERD) (a digestive disease in which stomach acid or bile irritates the food-pipe lining), HTN and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should); - No documentation of other alternatives attempted before the use of the side rails; - No documentation of signed informed consent obtained with risks and benefits explained to resident or representative; - No physician order for the side rails on Physician Order Sheet (POS), dated 3/2/22. Record review of the resident's Bed Rail assessment dated [DATE], showed: - Altered safety awareness due to cognitive decline; - History of falls; - Poor bed mobility and difficulty moving to a sitting position on side of the bed; - Side rail placement to be bilateral. Record review of the resident's quarterly MDS, dated [DATE], showed: - Moderately impaired cognitive status; - Independent with bed mobility; - Minimal assistance and set-up with transferring, dressing, feeding, and bathing; - Frequent incontinence of bowel and bladder; - No side rails used. Observations of the resident from 2/28/22 at 1:55 P.M. through 3/3/22 at 10:26 A.M., showed: - The upper and lower bed rails on both sides of the bed to be raised. During an interview on 3/2/22 at 9:30 A.M. and 2:30 P.M., Certified Nursing Assistant (CNA) C said Resident #6's rails were up for safety. The resident didn't move much and the resident didn't use the rails. The rails were lowered for personal care for Resident #6 and #26. When care was finished, the rails were raised again. The rails were left in a raised position to prevent the resident from falling out of the bed. During an interview on 3/2/22 at 10:13 A.M., Licensed Practical Nurse (LPN) A said was not aware of the reason the side rails were raised on Resident #6 and #26. During an interview on 3/2/22 at 2:00 P.M., the Director of Nursing, (DON) said the bed side rail assessment was proof the side rails were appropriate. Resident #26 had side rails up bilaterally and were assessed on 11/11/21 for use as an enabler and had seizures. The resident was due to be reassessed in February 2022, but she was behind on completing the assessment. The resident was no longer able to use as an enabler, but had seizures and received morphine. When the reassessment would be completed, the resident would continue to use the bilateral side rails; they would not go away. DON said the care plan had been updated on 3/2/22 to show the bilateral side rails to be used and the side rails should have been care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for six residents (Resident #6, #7, #10, #26, #39 and #42) out of a sample of 12 and one resident (Resident #35) outside the sample, consistent with the resident rights that included measurable objectives and timeframes that meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The facility census was 41. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised December 2016, showed: - The care plan interventions would be derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - An explanation would be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's care plan was determined to not be practicable; - Areas of concerns would be identified during the resident's assessment and would be evaluated before interventions were added to the care plan. 1. Record review of Resident #6's medical record showed: - An admission date of 1/27/15; - Diagnoses of diabetes mellitus (a chronic health condition which affects how your body turns food into energy), gastrostomy tube (a tube directly into the stomach to provide nutrition, and pressure ulcer (skin breakdown) of the sacrum (large triangular bone at the base of the spine). Observations of the resident from 2/28/22 at 12:32 P.M. through 3/2/22 at 8:30 A.M., showed: - The upper and lower bed rails (structures added to the bed to help prevent falls) on both sides of the bed raised. Record review of the resident's comprehensive care plan, revised on 2/21/22, showed: - No specific interventions or plan of care for the use of bed rails. 2. Record review of Resident #7's medical record showed: - An admission date of 11/9/21; - Diagnoses included diabetes mellitus and atrial fibrillation (heart dysrhythmia); - A code status form signed and dated 11/16/21 for full code (perform life sustaining measures in the event of stop breathing or heart stops beating). Record review of the resident's comprehensive care plan, revised on 2/28/22, showed: - No advance directive/code status identified for full code; - No specific interventions and/or goals addressed on the care plan. Record review of the resident's comprehensive care plan, dated 1/30/22, showed: - No advance directive/code status identified; - No specific interventions and/or goals addressed on the care plan. 3. Record review of Resident #10's medical record showed: - An admission date of 10/23/12; - Diagnoses included hypertension (high blood pressure), unspecified dementia (loss of memory) without behavioral disturbance, atherosclerosis (hardening of the arteries), shortness of breath, restlessness and agitation; - Physician Order Sheet (POS), dated 3/2022, showed no physician order for the side rails; - A quarterly bed rail assessment completed on 2/1/22, with no reason for indication of use. Observations of the resident from 2/28/22 at 11:51 A.M. through 3/3/22 at 10:25 A.M., showed: - The upper and lower bed rails on both sides of the bed to be raised. Record review of the resident's comprehensive care plan, revised on 11/16/21, showed: - No specific interventions or plan of care for the use of bed rails. 4. Record review of Resident #26's medical record, showed: - An admission date of 10/26/16; - Diagnoses of chronic (long-term) pain, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), seizures (a disorder in which nerve cell activity in the brain is disturbed), muscle weakness (generalized), cerebrovascular accident (CVA)(stroke), hypertension, epilepsy (type of seizure); - A quarterly bed rail assessment dated [DATE], with no reason for indication of use; - An order for hospice, dated 10/28/21. Record review of the resident's care plan, dated 12/24/21, showed: - Side rails not addressed; - Hospice care not addressed. Observations of the resident from 2/28/22 at 11:45 A.M. through 3/3/22 at 10:24 A.M., showed: - The upper and lower bed rails on both sides of the bed to be raised. 5. Record review of Resident #35's medical record, showed: - admission date of 5/11/15; - Diagnoses of CVA, osteroarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wear down). - A quarterly bed rail assessment, dated 1/8/21, showed side rails/assist bar indicated and to serve as an enabler (to promote independence with bed mobility). Observations of the resident from 2/28/22 at 11:45 A.M. through 3/2/22 at 9:00 A.M., showed: - The upper rails on both sides of the bed to be raised. Record review of the resident's comprehensive care plan, revised on 12/1/21, showed: - No specific interventions or plan of care for the use of the bed rails. 6. Record review of Resident #39's medical record showed: - An admission date of 7/5/21; - Diagnoses of diabetes mellitus, multiple fractures, stroke, osteoporosis (a condition in which the bones become weak and brittle), iron deficiency anemia (low iron), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block air flow makes it difficult to breath), gastroesophageal reflux disease (GERD)(a digestive disease in which stomach acid or bile irritates the food-pipe lining), HTN and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should); - A quarterly bed rail assessment, dated 1/8/21, showed side rails/assist bar indicated to be used and to serve as an enabler. Observations of the resident from 2/28/22 at 1:55 P.M. through 3/3/22 at 10:26 A.M., showed: - The upper and lower bed rails on both sides of the bed to be raised. Record review of the resident's comprehensive care plan, revised on 12/8/21, showed: - No specific interventions or plan of care for the use of bed rails. During an interview on 3/1/22 at 9:30 A.M., Resident #39 said he/she used the side rails to turn from side to side. 7. Record review of Resident #42's medical record showed: - An admission date of 10/19/21; - Diagnoses included high blood pressure and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); -A code status form signed and dated 11/1/21, for full code. Record review of the resident's comprehensive care plan, dated 1/30/22, showed: - No advance directive/code status identified; - No specific interventions and/or goals addressed on the care plan. During an interview on 3/2/22 at 9:39 A.M., Certified Nursing Assistant (CNA) C said Resident #6's and #26's side rails were lowered during personal care and raised up after personal care was finished. The side rails were left raised to prevent the resident from falling out of the bed. During an interview on 03/2/22 at 10:13 A.M., Licensed Practical Nurse (LPN) A said he/she was not aware of the reason the side rails were raised on Resident #26 and Resident #6. During an interview on 3/2/22 at 11:25 A.M., the Director of Nursing (DON) said the resident beds for Resident #26 and Resident #6 had side rails per the manufacturer recommendations and family requests. Resident #26 had seizures and side rails were used for safety. The bed rail assessment was proof the side rails were appropriate. Resident #26 had bilateral side rails and was assessed on 11/11/2021. Resident #26 had been able to use the side rails as an enabler and had seizures. The resident was due to be reassessed in February 2022, but she was behind on the completion. The resident was no longer able to use the side rails as an enabler. When the reassessment would be completed, the resident would continue to use the bilateral side rails; they would not go away. She said the care plan had been updated on 3/2/22, regarding the bilateral side rails and should have been care planned. During an interview on 3/3/22 at 12:46 P.M., the DON said she expected the resident's current code status with specific interventions and goals to be addressed on the care plan to reflect the care needs of the resident. If a resident was using side rails, they should be addressed on the care with specific interventions. She was responsible for the completion of the comprehensive care plans, revision and any new problems identified for the resident. The resident's care plan should be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a current or accurate advance directive ( a written statement of a person's wishes regarding medical treatment) regarding the resuscitation status for three residents (Resident #21, #152, and #202) out of 13 sampled residents. The facility's census was 44. 1. Record review of the facility's policy titled Advance Directives, dated [DATE], showed: - Advance directives will be respected in accordance with state law and facility policy; - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so; - If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; - The Attending Physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan; - The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive; - The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS, minimum data set, a federally mandated assessment instrument completed by the facility). 2. Record review of resident #21's medical record showed: - Face sheet showed do not resuscitate (DNR); - DNR outside the hospital form dated [DATE], signed by the resident's Power of Attorney (POA; the person responsible to make decisions for the individual when the individual cannot make a decision) showed DNR; - Physician's Order Sheet (POS), dated [DATE] to [DATE], showed order start date [DATE] with no end date for Full Code (resuscitate); - Comprehensive care plan, last updated/revised [DATE], showed full code. 3. Record review of resident #152's medical record showed: - Face sheet showed no code status; - POS, dated [DATE] - [DATE], showed no code status and no order for a code status; - Cardiopulmonary Resuscitation (CPR; combines chest compressions with artificial ventilation) Directive, dated [DATE], showed wishes for CPR signed by the POA. 4. Record review of resident #202's medical record showed: - Face sheet showed no code status; - POS, dated [DATE] - [DATE], showed no code status and no order for a code status; - Comprehensive care plan, updated/revised [DATE], showed no code status; - CPR Directive, dated [DATE], showed wishes for CPR signed by the POA. 5. During an interview on [DATE] at 10:50 A.M., the Director of Nursing said she would expect there to be an order for the code status of the resident. The orders and the advance directive should match.

Based on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: a SNF will issue a SNF ABN if there is reason to believe that Part A may not cover or continue to cover your care or stay because it isn't reasonable or necessary, or is considered Custodial care) Form 10055 for two residents (Resident #21 and #23) out of two sampled current residents and one sampled closed record. The facility's census was 44. 1. Record review of Resident #21's medical record showed: - Medicare Part A (Med A) skilled services start date of 4/19/21 and end date of 5/24/21; - The facility initiated a discharge from Medicare Part A services on 5/21/21 when benefit days were not exhausted; - The facility did not issue a CMS SNF ABN Form 10055. 2. Record review of Resident #23's medical record showed: - Medicare Part A skilled services start date of 2/26/21 and end date of 5/11/21; - The facility initiated a discharge from Medicare Part A services on 5/8/21 when benefit days were not exhausted; - The facility did not issue a CMS SNF ABN Form 10055. 3. During an interview on 7/27/21 at 3:03 P.M., the Assistant Administrator said he would expect a resident or the responsible party of a resident who discharges from Med A services and remains in the facility to be provided with the SNF ABN form. 4. The facility did not provide a policy for liability/denial notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document notification in writing to the resident and/or responsible party of the reason for transfer to the hospital for two residents (Resident #21, and #34) out of 13 sampled residents and one resident (Resident #17) out of two sampled closed records. The facility's census was 44. 1. Record review of the facility's policy titled, Bed-Holds and Returns, dated March 2017, showed prior to a transfer, written information will be given to the residents and the resident representatives that explains the details of the transfer (per the Notice of Transfer). 2. Record review of Resident #17's nursing progress notes showed: - The resident to have a responsible party; - The resident transferred to a hospital on 4/19/21 and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation of notification in writing to the responsible party of the transfer. 3. Record review of Resident #21's nursing progress notes showed: - The resident to have a responsible party; - The resident transferred to a hospital on 4/10/21 and readmitted to the facility on [DATE]; - The resident transferred to a hospital on 6/7/21 and readmitted to the facility on the same day; - The resident transferred to a hospital on 6/16/21 and readmitted to the facility on the same day. Record review of the resident's medical record showed no documentation of notification in writing to the responsible party of the transfers. 4. Record review of Resident #34's nursing progress notes showed: - The resident transferred to a hospital on 3/8/21 and readmitted to the facility on [DATE]; - The resident transferred to a hospital on 5/30/21 and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation of notification in writing to the resident and/or responsible party of the transfers to the hospital. 5. During an interview on 7/27/21 at 3:03 P.M., the Assistant Administrator said he would expect the hospital transfer sheet to include the reason for transfer and to be provided to the resident and/or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident and/or the representative received a written summary of the baseline care plan (an initial plan for delivery of care and services) for three residents (Residents #50, #152, and #202) and the facility failed to complete a baseline care plan within 48 hours of admission for one resident (resident #152) out of 13 sampled residents. The facility's census was 44. 1. Record review of the facility's policy titled, Care Plans - Baseline, dated [DATE], showed: - A Baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; - The Interdisciplinary Team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social service and PASARR (preadmission screening and resident review) recommendation if applicable; - The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; - The resident and their representative will be provided a summary of the baseline care plan that included but is not limited to the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility and any updated information based on the details of the comprehensive care plan, as necessary. Record review of the facility's policy titled, Resident Participation - Assessment/Care Plans, dated [DATE], showed: - The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan; - The care planning process will: Facilitate the inclusion of the resident and/or representative, include an assessment of the resident's strengths and his or her needs, incorporate the resident's personal and cultural preferences in establishing goals of care; - Resident assessments are begun on the first day of admission and completed no later than the fourteenth day after admission. 2. Record review of Resident #50's medical record showed: - admitted on [DATE]; - Physician's Order Sheet (POS), dated [DATE] through [DATE], showed diagnosis of non-Covid (not Covid-19 virus related) acute respiratory disease (an infection of the lungs that interferes with breathing), anxiety disorder (excessive and persistent worry and fear about everyday situations), dry eye syndrome (tears do not provide adequate moisture), pneumonia (an infection of the lungs), cognitive communication deficit (difficulty using spoken languages). Record review of the resident's admission Minimum Data Set (MDS; a federally mandated assessment required to be completed by the facility), dated [DATE], showed the resident to have a diagnosis of anxiety and to be moderately cognitively impaired. Record review of the medical record showed a baseline care plan completed on [DATE]. During an interview on [DATE] at 12:21 P.M., the resident voiced concerns about his/her medication not being given correctly because the facility does not have it available. The resident said the facility did not discuss his/her care plan with him/her upon admission. Record review of the resident's nurse progress note, dated [DATE], showed the care plan was provided to the guardian. During an interview on [DATE] at 10:01 A.M.,the Public Administrator's office deputy said they do not have an electronic copy of the care plan in their record. 4. Record review of Resident #152's medical record showed: - admitted on [DATE]; - POS, dated [DATE] through [DATE], showed diagnoses of malignant neoplasm of prostate (cancer), hypertension (high blood pressure), stress incontinence (leaking urine with activity), alcohol abuse, chronic pain, type two diabetes mellitus with hyperglycemia (high blood sugar). Record review of the resident's admission MDS, dated [DATE], showed the resident to have diagnoses of cancer, diabetes, seizures, hypertension, and to be severely cognitively impaired. Record review of the medical record on [DATE] at 9:39 A.M., showed no baseline care plan completed. During an interview on [DATE] at 8:57 A.M., the resident said he/she did not know anything about a care plan. During an interview on [DATE] at 11:45 A.M., the Director of Nurses (DON) said she does the baseline care plan and usually discusses it with the family or resident but she does not document it or have them sign anything. Resident #152's baseline care plan is not complete yet as she has 21 days to complete the care plan, she could complete it now. Record review of the facility policy showed the baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. Record review of the resident's medical record on [DATE] at 2:00 P.M., showed a baseline care plan, dated [DATE], 17 days after admission. The facility did not develop a baseline care plan with 48 hours. 5. Record review of Resident #202's Face Sheet showed: - admission date [DATE]; - Diagnosis of urinary tract infection; - Emergency contact - family member. Record review of the resident's Cardiopulmonary Resuscitation (CPR; an emergency lifesaving procedure performed when the heart stops beating) Directive showed wish for CPR to be provided to resident, signed by family member, shown as Power of Attorney (POA; the authority to act for another person in specified or all legal or financial matters) dated [DATE]. Record review of the resident's comprehensive care plan, dated [DATE], showed: - Care areas with onset date [DATE] and completion date [DATE]; - Baseline care plan not provided. Record review of the resident's medical record showed no documentation that the baseline care plan was reviewed with the resident representative. 6. During an interview on [DATE] at 3:03 P.M., the DON said she would expect the baseline care plan to be discussed with the representative and a copy provided after [DATE], prior to that date the requirement was waived. She would expect it to be documented that it was discussed with the resident or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide consistent resident care for activities of daily living (ADLs) for four residents (Resident #6, #18, #45, and #46) out of 13 sampled residents. This practice could potentially affect all residents. The facility's census was 44. 1. Record review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, showed: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; - Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; - Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable; - Appropriate 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, dining (meals and snacks), and communication (speech, language, and any functional communication systems). 2. Record review of Resident #6's annual Minimum Data Sheet (MDS; a federally mandated assessment instrument required to be completed by facility staff), dated 1/21/21, showed: - Section G- Functional Status the resident requires total assistance of one for all personal care; - Section L-Oral/Dental Status the resident has inflamed, bleeding gums, loose natural teeth. Record review of the resident's quarterly MDS, dated [DATE], showed: - Section G the resident to require total assistance of one for all personal care; - Section L no documentation for dental needs. During observation and interview on 7/20/21 at 12:09 P.M., on 7/21/21 at 10:20 A.M., and on 7/22/21 at 8:45 A.M., the resident's teeth covered with thick brown substance and the gums to be red. The resident said the staff do not provide oral care. During an interview on 7/21/21 at 1:59 P.M., Certified Nurse Assistant (CNA) L said sometimes the CNAs might swab Resident #6's mouth with a wet swab but do not brush his/her teeth. The CNAs don't really do oral care during the day. During a telephone interview on 7/22/21 at 11:01 A.M., the resident's responsible party said his/her only concern with the resident's care is that the resident's teeth always seemed to be dirty and nasty. During observation and interview on 7/23/21 at 10:04 A.M., the resident's teeth covered with thick brown substance and the gums to be red. The resident said the staff have not provided oral care. The resident does not remember ever being offered dental care. During an interview on 7/23/21 at 10:50 A.M., the Director Of Nursing (DON) said she expects oral care to be provided daily for residents who need assistance. During observation and interview on 7/27/21 at 8:38 A.M., the resident's teeth covered with thick brown substance and the gums to be red. The resident said the staff have not provided oral care. 3. Record review of Resident #18's annual MDS, dated [DATE], showed: - Section G the resident to require total assistance of one for all personal care; - Section L no documentation for dental needs. Record review of the resident's quarterly MDS, dated [DATE], showed: - Section G the resident to require total assistance of one for all personal care; - Section L no documentation for dental needs. Record review of resident's Physician's Order Sheet (POS), dated 7/1/21 through 7/31/21, showed diet is nothing by mouth (NPO). Record review of the resident's comprehensive care plan, dated 5/12/21, showed staff to provide with oral care every shift and as needed. During observations on the following dates and times showed the resident's lips were dry, with peeling skin and the tongue dry with resident open mouth breathing. - On 7/20/21 at 11:00 A.M. and 3:12 P.M.; - On 7/21/21 at 9:27 A.M., 10:27 A.M. and 3:43 P.M.; - On 7/22/21 at 8:51 A.M., 11:50 A.M. and 3:50 P.M.; - On 7/23/21 at 9:00 A.M. and 12:38 P.M.; - On 7/26/21 at 11:00 A.M., 2:10 P.M. and 4:00 P.M.; - On 7/27/21 at 9:10 A.M., 11:20 A.M. and 2:45 P.M. 4. Record review of Resident #45's annual MDS, dated [DATE], showed: - Section G the resident requires total assistance of one for all personal care; - Section L no documentation for dental needs. Record review of the resident's Quarterly MDS, dated [DATE], showed: - Section G the resident requires total assistance of one for all personal care; - Section L no documentation for dental needs. During the following observations, Resident #45's teeth were covered with a dirty, thick tan substance: - On 7/20/21 at 11:30 A.M. and 3:17 P.M.; - On 7/21/21 at 9:21 A.M., 11:45 A.M. and 3:50 P.M.; - On 7/22/21 at 9:00 A.M., 1:36 P.M. and 4:05 P.M.; - On 7/23/21 at 9:10 A.M. and 11:18 A.M.; - On 7/26/21 at 11:20 A.M., 2:16 P.M. and 4:07 P.M.; - On 7/27/21 at 9:17 A.M., 11:32 A.M. and 2:32 P.M. e. 5. Record review of Resident #46's annual MDS, dated [DATE], showed: - Section G the resident requires total assistance of one for all personal care; - Section L the resident to have no natural teeth or tooth fragments. Record review of the resident's quarterly MDS, dated [DATE], showed: - Section G the resident requires total assistance of one for all personal care; - Section L no documentation for dental needs. Record review of resident's Physician's Order Sheet (POS), dated 7/1/21 through 7/31/21, showed: -Diagnoses of 2019-nCoV acute respiratory disease, essential hypertension, type 2 diabetes mellitus with hyperglycemia, cerebral infarction, unspecified dementia without behavioral disturbance, undifferentiated schizophrenia (disorder that affects a person's ability to thin, feel or behave clearly), chronic obstructive pulmonary disease (COPD), pain in unspecified joint, pseudobulbar affect (inappropriate laughing or crying due to a nervous system disorder), Parkinson's disease (disease of the central nervous system that affects movement, often including tremors), aphasia (loss of ability to understand or express speech caused by brain damage), pressure ulcer of other site stage 2, and pressure ulcer other site unspecified stage; -Diet is pureed diet with nectar thickened liquids for pleasure if resident requests three times a day. Record review of resident's comprehensive care plan, dated 4/06/21, showed provide me with oral care every shift and as needed. During the following observations, the resident's lips and tongue looked dry and the water pitcher on nightstand was empty: - On 7/21/21 at 9:25 A.M., 11:30 A.M. and 3:45 P.M.; - On 7/22/21 at 8:47 A.M., 11:53 A.M. and 3:57 P.M.; - On 7/23/21 at 9:03 A.M. and 12:42 P.M.; - On 7/26/21 at 11:08 A.M., 2:14 P.M. and 4:03 P.M.; - On 7/27/21 at 9:07 A.M., 11:25 A.M., 1:27 P.M. and 2:40 P.M. 6. During an interview on 9/23/21 at 9:05 A.M., Registered Nurse (RN) K said oral care should be performed each shift and as needed. During an interview on 9/23/21 at 9:24 A.M., CNA C said oral care should be done at least every shift. During an interview on 7/23/21 at 10:50 A.M., the DON said she expects oral care to be provided daily for residents who need assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care to prevent and promote healing of a pressure ulcer for one resident (Resident #17) out of two sampled closed records. The facility's census was 44. Record review of the facility's policy titled, Pressure Ulcers(damage to the skin and/or underlying tissue as a result of pressure)/Skin Breakdown-Clinical Protocol, dated March 2014, showed: - The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue, pain assessment, resident's mobility status, current treatments, and all active diagnoses; - The staff will examine the skin of a new admission for ulcerations or alterations in skin; - The physician will help identify factors contributing or predisposing residents to skin breakdown; - The physician will authorize pertinent orders related to wound treatments; - The physician will help staff characterize the likelihood of wound healing; - During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds; - The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Observations from 7/20/21 to 7/28/21 showed Resident #17 out of the facility due to hospitalization. Record review of Resident #17's Physician's Order Sheet, dated 7/1/21-7/31/21, showed diagnoses of Type-2 diabetes mellitus (a chronic metabolic disorder affecting blood sugar) with hyperglycemia (elevated blood sugar), acute kidney failure, hypertension (high blood pressure), dementia (loss of cognitive ability), unspecified pain, dehydration, presence of cardiac pacemaker, and urinary incontinence. Record review of the resident's Skin Integrity Assessments signed by the Director of Nursing (DON) showed: - On 4/9/21, right heel measurements 6 centimeter (cm) by 4.8 cm by 0.3 cm, heavy amount of exudate (bodily fluid of protein, cells, or debris), necrotic (death of a portion of tissue), unstageable due to slough (dead matter separated from living tissue) and/or eschar (dead matter cast off from the surface of the skin); - On 4/9/21, coccyx (small bone at the base of the spinal column) measurements 3.1 cm by 1.2 cm by 0.1 cm, light amount of exudate, granulation tissue (healing tissue), Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough); - On 4/18/21, right heel measurements 6 cm by 4.8 cm by 0.3 cm, heavy amount of exudate, necrotic tissue, unstageable due to slough and/or eschar; - On 4/18/21, coccyx wound resolved; - On 6/23/21, pressure ulcer right hip first observed, clarified with physician from buttocks to hip. No measurements. Pressure ulcer coccyx first observed 6/23/21, no measurements; - No nursing assessment dated [DATE] as noted in progress notes; - Coccyx wound measurements on 4/9/21 do not match measurements in 4/9/21 progress notes. Record review of the resident's Weekly Pressure Injury Log showed: - On 5/12/21, right heel unstageable-eschar/necrotic, measurements 7 cm by 4 cm by 0.5 cm, odor present, no drainage or culture. Left heel unstageable-eschar/necrotic, measurements 4 cm by 4.5 cm by 0.5 cm, odor and drainage present, no culture. Coccyx Stage II, measurements 3 cm by 2 cm by 0.2 cm, no odor, drainage, or culture; - The facility did not provide the weekly skin assessment for 5/19/21; - On 5/26/21, right heel unstageable-eschar/necrotic, measurements 7 cm by 4.3 cm by 0.5 cm, odor and drainage present, no culture. Left heel unstageable-eschar/necrotic, measurements 4 cm by 4 cm by 0.5 cm, odor and drainage present, no culture; - The facility did not provide the weekly skin assessment for 6/2/21; - The weekly skin assessment for 6/9/21 did not include this resident; - The facility did not provide the weekly skin assessment for 6/16/21; - On 6/23/21 (incorrectly dated 6/23/20), coccyx Stage II, measurements 2.5 cm by 2 cm by 0.1 cm, no odor or drainage present, no culture. Right heel Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle), measurements 7 cm by 4 cm by 0.5 cm, odor and drainage present, no culture. Left heel Stage IV, measurements 4 cm by 4.3 cm by 0.5 cm, odor and drainage present, no culture. Right hip Stage II, measurements 1.5 cm by 0.5 cm by 0.1 cm, odor and drainage present, no culture; - The facility did not provide the weekly skin assessment for 6/30/21. Record review of the resident's progress notes showed: - On 3/26/21, the resident admitted to the facility on contact isolation for Methicillin-resistant Staphylococcus aureus (MRSA; a bacteria that is resistant to most antibiotics) from a previous wound. Left heel wound scabbed over and right heel wound quarter sized, minimal drainage and blood noted; - On 3/30/21, the resident with shortness of breath, 2 liters oxygen administered, unable to respond to nurse and daughter; - On 3/31/21, hospital contacted and informed resident was admitted . MRSA wound swab awaiting culture from right heel. Left heel noted with unblanchable (area of tissue with redness slow to get blood supply to return) redness and wound to coccyx noted by their team; - On 4/9/21, hospital contacted for status update. Right heel culture negative for MRSA, but positive for Vancomycin-resistant Staphylococcus aureus (VRSA; a bacteria that is resistant to most antibiotics). Resident on contact precautions for previous exposure. No antibiotic noted at this time. Blood cultures negative at this time for all testing conducted. Resident returned to the facility. Coccyx wound measurements 4.5 cm by 3.2 cm. Right foot with 3.1 cm by 1.2 cm black over flap area, unstageable; - On 4/18/21, pressure ulcer to right heel noted to have large amount of serous (thin or watery) drainage. Measurements 6 cm by 4.8 cm by 0.3 cm. Doctor made aware and new order noted; - On 4/19/21, staff reported resident catheter found on side of resident's floor. Nurse observed catheter/G tube on side of bed. Nurse unable to place tube back in. New order to send resident to hospital for tube replacement; - On 4/21/21, resident returned to facility. Ulcer to right heel skin prepped and left open to air; - On 4/23/21, Resident sent to hospital from dialysis after oxygen levels lowered; - On 5/3/21, resident returned to facility. Unstageable pressure ulcers noted to bilateral heels, Stage II noted to coccyx-see nursing assessment; - On 6/23/21, Stage II pressure ulcer noted to right buttocks, physician aware, new order noted. Measurements 1.5 cm by 1.2 cm by 0. cm; - On 7/4/21, Stage II pressure ulcer to right buttocks and bilateral heels. Resident responding to name with slight moaning, has been drooling with slurred speech. New order to send to hospital; - On 7/13/21, spoke with hospital nurse, admitted for urinary tract infection (UTI) and lethargy (drowsiness). Received one unit of blood 7/12/21 for low count of 7.6, wound culture to heels positive for E coli (bacteria), Proteus (bacteria), Pseudomonas (bacteria), Faecalis (bacteria), plus one more. Antibiotic being determined. Surgical debridement to be completed at a later time; - On 7/22/21, hospital contacted, resident currently stable, wounds are actively healing, but resident has slow healing process. Record review of the resident's progress notes showed: - The resident went to dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on Tuesday/Thursday/Saturday for the dates 3/27/21 and 3/30/21; - The resident hospitalized from [DATE] through 4/9/21; - The resident went to dialysis on Monday/Wednesday/Friday for the dates 4/12/21, 4/14/21, 4/16/21, 4/19/21, 4/21/21, and 4/23/21; - The resident hospitalized from [DATE] through 5/3/21; - The resident went to dialysis on 5/27/21, 6/4/21, 6/7/21, 6/23/21, and 6/25/21; - The resident hospitalized on [DATE] to present. Record review of the resident's March 2021 Medication and Treatment Administration Record (MAR/TAR), showed no treatment orders for right heel wound or coccyx wound for four days after re-admitted from hospital to the facility on 3/26/21 through 3/30/21. Record review of the resident's April 2021 MAR/TAR, showed: - An order, dated 4/9/21, for skin prep to right heel twice daily (BID) at 8:00 A.M. and 8:00 P.M.; - On 4/14/21 at 8:00 A.M. the facility staff documented as the treatment not given due to resident unavailable and on 4/15/21 due to other reason; - An order, dated 4/18/21, for Santyl Ointment (debridement medication) 250 unit/gram (unit/gm). Cleanse open area to right heel with normal saline, apply Santyl ointment and dry dressing once daily to bilateral heels; - The facility staff documented as the treatment not given 4/22/21 due to resident unavailable. Record review of the resident's May 2021 MAR/TAR, showed: - An order, dated 4/18/21, for Santyl Ointment 250 unit/gm. Cleanse open area to right heel with normal saline, apply Santyl ointment and dry dressing once daily to bilateral heels; - The facility staff documented as the treatment not given 5/3/21 and 5/5/21 due to resident unavailable; - An order, dated 5/3/21, for Santyl Ointment 250 unit/gm. Cleanse open area to bilateral heels with normal saline, apply Santyl Ointment and dry dressing once daily to bilateral heels; - The staff documented as the treatment not given 5/10/21, 5/12/21, 5/14/21, 5/17/21, 5/19/21, 5/21/21, 5/24/21, and 5/27/21 due to resident unavailable; - No orders to care for Stage II coccyx wound. The weekly pressure injury log dated 5/12/21 documentation showed the resident had a Stage II coccyx wound. Record review of the resident's June 2021 MAR/TAR, showed: - An order, dated 5/3/21, for Santyl Ointment 250 unit/gm. Cleanse open area to bilateral heels with normal saline, apply Santyl Ointment and dry dressing once daily to bilateral heels; - The facility staff documented as the treatment not given 6/7/21, 6/11/21, 6/14/21, 6/16/21, 6/18/21, 6/21/21, and 6/28/21 due to resident unavailable, and 6/23/21 and 6/24/21 due to unable to retain; - An order, dated 6/24/21, for Collagen Matrix Fenest External Sheet (repairs tissue) 2 cm by 2 cm, cleanse pressure ulcer to right buttocks with normal saline, apply collagen dressing and secure with tape once daily; - The facility staff documented as the treatment not given 6/24/21 and 6/28/21 due to resident unavailable; - No orders to care for Stage II coccyx wound. The weekly pressure injury log dated 5/12/21 and 6/23/21 documentation showed the resident had a Stage II coccyx wound. Record review of the resident's July 2021 MAR/TAR, showed: - An order, dated 5/3/21, for Santyl Ointment 250 unit/gm. Cleanse open area to bilateral heels with normal saline, apply Santyl Ointment and dry dressing once daily to bilateral heels; - The facility staff documented as the treatment not given 7/3/21 due to resident unavailable; - An order, dated 6/24/21, for Collagen Matrix Fenest External Sheet 2 cm by 2 cm, cleanse pressure ulcer to right buttocks with normal saline, apply collagen dressing and secure with tape once daily; - The facility staff documented as the treatment not given 7/3/21 due to resident unavailable; - The facility staff continued to not obtain orders to care for coccyx wound. During an interview on 7/27/21 at 3:03 P.M., the Assistant Administrator (AA) and DON said the DON is handwriting a lot of things right now because they are getting ready to change computer systems. The DON is not putting wound care assessments in the computer, there is limited charting in the system right now. The facility stopped doing it three to six months ago, will have to look to see exactly when. When asked if the DON would expect a resident with a wound to have treatment orders for the wound, the DON said there are wounds that you don't treat, so there would not necessarily be orders. The AA said if there is a change in orders, he would expect that to be on the physician's orders.

Based on observation, interview, and record review, the facility failed to assess, develop, and implement an individualized approach to providing dementia care services for three residents (Residents #16, #45, and #46) out of 13 sampled residents. The facility's census was 44. 1. Record review of Resident #16's annual Minimum Data Set (MDS-a federally mandated assessment, required to be completed by the facility), dated 5/6/21, showed the resident to have a diagnosis of Alzheimer's (progressive mental deterioration), dementia (disorder marked by memory disorders, personality changes, and impaired reasoning), anxiety (persistent worry and fear about everyday situations), psychotic disorder (a disconnection from reality), and to be moderately cognitively impaired. Record review of the resident's Physician's Order Sheet (POS), dated 7/1/21 to 7/31/21, showed: - Diagnoses of Alzheimer's disease, dementia without behavioral disturbance, dementia with behavioral disturbance, anxiety disorder; - An order, dated 4/4/19, for Cymbalta (a medication used to treat depression) 30 milligrams (mg) once daily for dementia; - An order, dated 10/18/18, for Seroquel (a medication used to treat schizophrenia, bipolar disorder and depression) 25 mg, 1/2 tablet two times daily for vascular dementia with behavioral disturbance. Record review of the resident's medication administration record (MAR), dated 7/1/21 through 7/27/21, showed Seroquel and Cymbalta administered as ordered. Record review of the resident's comprehensive care plan, last reviewed 5/19/21, showed: - Problem: Dated 10/18/18, a history of confrontations, outbursts and violent behavior; - Approach: Dated 2/20/19, Visits as needed, medications as ordered - Seroquel as needed for diagnosis and medication management, Dated 2/25/20, Document episodes if they occur, Dated 4/20/20 the physician documented that a reduction in medications may cause an increase in symptoms, redirect as needed, validation and redirection; - Problem: a history of depression; - Approach: Dated 2/20/19, Medication as ordered - Cymbalta. The care plan failed to utilize individualized, non-pharmacological approaches to care, failed to provide current, specific interventions for confrontations, outbursts and violent behavior, and failed to provide current, specific interventions for depression to enhance Resident #16's ability to attain, or maintain the highest practicable level of functioning. Record review of the resident's progress notes, dated 1/29/21 through 6/2/21, showed no documentation of confrontations, outbursts or violent behaviors. The facility did not provide notes dated after 6/2/21. Observations showed: - On 7/20/21 at 12:42 P.M., Resident #16 to be calm, to sit in wheelchair at the dining room table, voicing that his/her legs hurt; - On 7/21/21 at 10:22 A.M., the resident to be lying in bed, calm, eyes closed; - On 7/22/21 at 8:55 A.M., the resident to be lying in bed, calm, eyes closed; - On 7/27/21 at 8:47 A.M., the resident to be eating breakfast, calm. During an interview on 7/21/21 at 1:59 P.M., Certified Nurse Assistant (CNA) L said Resident #16 sleeps a lot. 2. Record review of Resident #45's POS, dated 7/1/21 through 7/31/21, showed: - Diagnoses included unspecified dementia without behavioral disturbance; - An order, dated 9/24/20, for Namenda oral tablet 10 mg 1 tab by mouth twice daily (for dementia). Record review of the MAR, dated 7/1/21 through 7/27/21, showed Namenda administered as ordered. Record review showed no care plan for dementia and care plan last reviewed 7/5/21. 3. Review of Resident #46's POS, dated 7/1/21 through 7/31/21, showed: - Diagnoses included unspecified dementia without behavioral disturbance, major depressive disorder, undifferentiated schizophrenia (disorder that affects a person's ability to think, feel or behave clearly); -Remeron SolTab oral tablet disintegrating 15 mg 1 tab per G-tube at bedtime (for dementia) (order start date 6/30/21). Record review of the MAR, dated 7/1/21 through 7/27/21, showed Remeron administered as ordered. Record review of the resident's comprehensive care plan, dated 4/6/21, showed no care plan for depression. During an interview on 7/27/21 at 1:44 P.M., CNA C said the care plan on the computer explains how to take care of each resident. During an interview on 7/27/21 at 3:03 P.M., the Director of Nursing (DON) said she would expect there to be a care plan for antipsychotic and antidepressants medications. The facility did not provide a policy for dementia care planning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a sufficient supply of prescribed medications were available to meet the needs of two residents (Resident #46 and #50) out of 13 sampled residents. The facility's census was 44. 1. Record review of the facility's policy titled, Medication and Treatment Orders, dated July 2016, showed Drugs and biological's that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. 2. Record review of Resident #46's admission Minimum Data Set (MDS-a federally mandated assessment, required to be completed by the facility), dated 7/6/21, showed Resident #46 to have diagnoses of stroke (damage to brain from interrupted blood supply), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), hypertension (high blood pressure), diabetes mellitus (condition affecting the way the body processes blood sugar), dementia (disease causing impairment of brain functions such as memory loss and judgment), schizophrenia (disorder that affects a person's ability to think, feel or behave clearly) and chronic obstructive pulmonary disease (COPD: constriction of the airway) and to be moderately cognitively impaired. The MDS showed resident was not on a scheduled or as needed (PRN) pain medication. Record review of Resident #46's medical record showed admitted on [DATE]. Record review of the resident's Physician's Order Sheet (POS), dated 7/1/21 through 7/31/21, showed: - Diagnoses of Novel Coronavirus (2019-nCoV acute respiratory disease), type 2 diabetes mellitus with hyperglycemia, heart failure, cerebral infarction, unspecified dementia without behavioral disturbance, major depressive disorder, undifferentiated schizophrenia (disorder that affects a person's ability to think, feel or behave clearly), chronic obstructive pulmonary disease, pain in unspecified joint, pseudobulbar affect (inappropriate laughing or crying due to a nervous system disorder), abnormal weight loss, Parkinson's disease (disease of the central nervous system that affects movement, often including tremors), aphasia (loss of ability to understand or express speech caused by brain damage), constipation, pressure ulcer of other site stage 2, and pressure ulcer other site unspecified stage; - An order, dated 3/10/21, for Hydrocodone-Acetaminophen (pain medication) oral tablet 5-325 milligram (mg) per gastrostomy tube (G-tube: a surgically placed device used to give direct access to the stomach for supplemental feeding and medications) 1- 2 tabs max daily- four times a day (for pain). Record review of the resident's medication administration record (MAR), dated May 2021, showed Hydrocodone-Acetaminophen 30 missed attempts out of 124 opportunities due to medication not available. Record review of the MAR, dated June 2021, showed Hydrocodone-Acetaminophen 34 missed attempts out of 103 opportunities due to medication not available; Record review of the MAR, dated July 2021, showed Hydrocodone-Acetaminophen 38 missed attempts out of 108 opportunities due to medication not available. During an interview on 7/27/21 at 3:03 P.M., the Director of Nursing (DON) and Assistant Administrator said if medications are not available, it is ordered from the pharmacy, they have two deliveries a day so it should be delivered on the next available delivery. If the prescription requires a prescription, the facility writes an order and sends it to the pharmacy. The pharmacy calls to get a verbal or signature for the prescription to be delivered on the next delivery day. If the script is available the resident shouldn't go more than 8 hours without the medication, but if there is a lag in the script it could be longer. 3. During an interview on 7/20/21 at 1:27 P.M., Resident #50 said he/she is not getting his/her medication for his/her blood cancer. He/she is starting to feel the effects of not having it. He/she was supposed to see his/her cancer doctor on 4/14/21 but the facility didn't take him/her so now he/she can't get his/her medication. Record review of the resident's admission MDS, dated [DATE], showed Resident #50 to have a diagnosis of anxiety and to be moderately cognitively impaired. Record review of Resident #50's medical record showed admitted on [DATE]. Record review of the resident's POS, dated 7/1/21 through 7/31/21, showed: - Diagnoses of non-Covid (not Covid-19 virus related) acute respiratory disease (an infection of the lungs that interferes with breathing), anxiety disorder (excessive and persistent worry and fear about everyday situations), dry eye syndrome (tears do not provide adequate moisture), pneumonia (an infection of the lungs), cognitive communication deficit (difficulty using spoken languages); - An order, dated 6/28/21, for Imatinib mesylate (a chemotherapy medication used to treat chronic myeloid leukemia, cancer of the blood and for pneumonia in patients with severe acute respiratory syndrome SARS-Covid ) 100 mg two tablets daily to be given for a diagnosis of pneumonia. Record review of the resident's medication administration record (MAR), dated July 2021, showed: - Imatinib Mesylate to be given daily 7/1/21 through 7/11/21: - Imatinib Mesylate to be unavailable in the facility 7/12/21 - 7/15/21; - Imatinib Mesylate to be given on 7/16/21; - Imatinib Mesylate to be unavailable in the facility 7/17/21 through 7/20/21. Seven missed attempts out of 21 opportunities due to medication not available, one erroneous recorded administration on 7/26/21 when medication not to be available in facility, total eight missed attempts out of 21 opportunities. During an interview on 7/21/21 at 1:43 P.M., the Director of Nursing (DON) said the documentation of the given medication on 7/16/21 is an error and it should have been corrected as not available, she will correct it. The DON explained the medication is not covered by the resident's insurance without a prior authorization (PA). The facility was trying to get a PA for it when the resident informed them he/she receives the medication through a grant program. The DON contacted the grantor and they verified the resident's eligibility and will provide the medication at least through 2021. The medication was ordered on 7/16/21 and had just been received to the facility on 7/21/21. The resident will be re-evaluated at the end of the year for continued eligibility. The DON said the resident did not miss any appointments. During an interview on 7/22/21 at 9:52 A.M., the resident's oncologist's medical assistant (MA) said the resident has a diagnosis of chronic myeloid leukemia. The resident did miss an appointment with them on 4/14/21. In April 2021, the Grantor for the medication notified the office that the grant was going to end for non-compliance of information updates. The MA called the facility and spoke with the DON to request the information needed to continue the medication, he/she got the impression that the DON did not care and the DON did not provide the information. The MA gave the DON the information about who to call to continue the medication grant. The MA said he/she felt like he/she was talking to a wall. The MA called the responsible party (RP) who did not return the call. On 5/7/21, the MA was notified that the resident had been discontinued from the grant for non-compliance of information updates. On 7/16/21, the facility called the MA to get the information about the grant, the MA said it was a painful conversation. During an interview on 7/22/21 at 10:01 A.M., a representative at the RP's office said there is no record of any complications related to medication availability for Resident #50. During an interview on 7/27/21 at 3:03 P.M., the DON said medications are ordered from the pharmacy, the pharmacy does two deliveries a day so the medication should be delivered during the next available delivery. If the pharmacy can't get it quickly, they have a contract with another pharmacy and they can deliver anytime. The Assistant Administrator said if the medication requires a prescription and they run out of medication, we write an order and send it to the pharmacy, they call to get verbal or signature, they go ahead and fill the prescription and deliver it on the next delivery. If the script is available it shouldn't go more than eight hours, if there is a lag in the script it could be longer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Consultant Pharmacist performed a review of each resident's medical record each month, reported irregularities to the Attending Physician, Medical Director and Director of Nursing (DON) in a separate written report and the attending physician reviewed and acted on any identified irregularities and Gradual Dose Reduction (GDR) recommendations and document the action taken to address the irregularity or GDR for four residents (Residents #11, #14, #16, and #23) and failed to ensure each medication to be clinically indicated for one resident (#50) out of six sampled residents for unnecessary medications. The facility's census was 44. 1. Record review of the facility's policy titled, Medication and Treatment Orders, dated July 2016, showed: - Drug and biological orders must be recorded on the Physician's Order Sheet (POS) in the resident's chart; - Such orders are reviewed by the consultant pharmacist on a monthly basis. 2. The facility failed to provide a clear set of documentation that the Consultant Pharmacist does a complete review of all resident's medications and provides written recommendations with responses from the physician for the recommendations. 3. Record review of Resident #11's medical record showed: - admitted on [DATE]; - Diagnoses of chronic kidney disease, stage 5, dependence on renal dialysis, unspecified convulsions, major depressive disorder, type 2 diabetes mellitus (a chronic condition that affect the way the body processes blood sugar) with foot ulcer, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized anxiety disorder; - An order, dated 1/11/18, for Celexa (can treat depression) 40 mg (milligram) 1 tab by mouth every day for major depressive disorder; - An order dated, 12/4/19, for Depakote (can treat seizures and bipolar disorder, an anticonvulsant) delayed release 250 mg take 1 tablet by mouth twice a day with a 500 mg tablet for a total dose of 750 mg for bipolar disorder; - An order, dated 12/4/19, for Depakote 500 mg take 1 tablet by mouth twice a day with a 250 mg tablet for a total dose of 750 mg for bipolar disorder; - An order, dated 1/11/18, for Venlafaxine (can treat depression, generalized anxiety disorder) HCL (hydrogen chloride) ER (extended-release) 150 mg 1 tablet by mouth every day for major depressive disorder; - An order, dated 1/11/18, for Zyprexa 7.5 mg 1 tablet by mouth every day for bipolar disorder; - No documentation to show the physician reviewed the recommendation, dated 8/24/20. Record review of the Consultant Pharmacist's Medication Regimen Review listing residents reviewed with no recommendations showed no reviews for the resident in September 2020, or December 2020. A written recommendation from the pharmacist to the physician to consider gradual dose reduction on 8/24/20 for Celexa 40 mg daily since 1/11/18, Venlafaxine ER 150 mg daily since 1/11/18, and Zyprexa 7.5 mg daily since 1/11/18 with no response on pharmacist recommendation. 4. Record review of Resident #14's medical record showed: - admitted on [DATE]; - Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbances, major depressive disorder, hypertension (elevated blood pressure), abnormal weight loss, pain disorder exclusively related to psychological factors; - An order, dated 5/14/20, for Quetiapine fumarate (antipsychotic, can treat schizophrenia ,a serious mental illness that affects how a person thinks, feels, and behaves, bipolar disorder, a disorder associated with episodes of mood swings ranging from depressive lows to manic highs, and depression) 50 mg take 1 tablet by mouth once daily; - An order, dated 4/26/19, for Risperdal (antipsychotic, can treat schizophrenia, bipolar disorder, and irritability caused by autism, a serious developmental disorder that impairs the ability to communicate and interact) 0.5 mg give 1 tablet by mouth at bedtime; - An order, dated 5/1/19, for Zoloft (can treat depression, obsessive-compulsive disorder, posttraumatic stress disorder, premenstrual dysphoric, a state of unease or generalized dissatisfaction with life, disorder, social anxiety disorder, and panic disorder) 50 mg give 1 tablet by mouth daily; - No documentation to show the physician reviewed the recommendation, dated 8/24/20. Record review of the Consultant Pharmacist's Medication Regimen Review listing residents reviewed with no recommendations showed no reviews for the resident in September 2020, or December 2020. A written recommendation from the pharmacist to the physician to consider gradual dose reduction on 8/24/20 for sertraline (Zoloft) 50 mg since 5/1/19 and risperidone (Risperdal) 0.5 since 5/1/19 with no response on pharmacist recommendation. 5. Record review of Resident #16's medical record showed: - admitted [DATE]; - POS, dated 7/1/21 - 7/31/21, showed: - Diagnoses of Cerebral infarction (stroke), Alzheimer's disease (a disease that causes progressive mental deterioration), Dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Anxiety disorder (more than temporary worry or fear), Type two diabetes mellitus (an impairment in the way the body regulates and uses sugar); - An order, dated 10/18/18, for Risperdal 25 mg 1/2 tablet two times daily; - An order, dated 8/12/20, for Tramadol (used for pain) 50 mg two times daily; - An order, dated 4/4/19, for Cymbalta (used for depression) 30 mg one time daily. Record review of the Consultant Pharmacist's Medication Regimen Review listing residents reviewed with no recommendations showed no reviews for the resident in August 2020, September 2020, December 2020, or June 2021. There are no GDR attempts for Risperdal, Tramadol, or Cymbalta for more than one year. 6. Record review of Resident #50's medical record showed: - admitted on [DATE]; - The POS, dated 7/1/21 to 7/31/21, showed: - Diagnoses of non-covid acute respiratory disease, anxiety (a feeling of worry, nervousness, or unease), dry eye syndrome (tears aren't able to provide adequate lubrication for your eye), pneumonia, (an infection that inflames the air sacs in one or both lungs), cognitive communication deficit (impairment of understanding); - An order, dated 6/28/21, for Risperidone (an antipsychotic medication used to treat schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), bipolar disorder (mental disorder that causes unusual shifts in mood) and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) 0.25 milligrams (mg) two times daily for pneumonia; - An order, dated 6/28/21, for Imatinib Mesylate (a chemotherapy medication used to treat chronic myeloid leukemia) 100 mg two times daily for pneumonia, a diagnosis of pneumonia is not an indication for Imatinib Mesylate use. Record review of the Consultant Pharmacist's Medication Regimen Review listing residents reviewed with no recommendations showed reviews for the resident in April 2021, May 2021 and June 2021 and showed Resident #50 not to be included in the July 2021 report and no written recommendations. During an interview on 7/22/21 at 2:40 P.M., the DON said the Consultant Pharmacist reviews every resident's medication each month. During an interview on 7/23/21 at 8:46 A.M., the Registered Pharmacist with the facility pharmacy said they contract the monthly reviews out to an outside consulting agency. During an interview on 7/23/21 at 9:33 A.M., the Registered Pharmacist with the consulting agency said: - The medications for Resident #50 would be reviewed during his/her next review; - They use the primary diagnosis for some medications; - They only send reports for psychotic medications, unless there is a problem with the stop date on them, lab work that needs to be done, sometimes there is a delay, we make recommendations if there is an abnormal lab result; - Sometimes responses are delayed, if there isn't a response it is discussed with the DON. 7. Record review of resident #23's medical record showed: - admitted on [DATE]; - The POS, dated 7/1/21 to 7/31/21, showed: - Diagnoses of anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), major depressive disorder-recurrent (long-term loss of pleasure or interest in life), major depressive disorder-recurrent-in partial remission (symptoms of a major depressive episode are present but full criteria are not met, or there is a period without any significant symptoms lasting less than 2 months following the end of the major depressive episode); - An order, dated 6/6/17, for Seroquel (an antipsychotic medication that works by changing the actions of chemicals in the brain) 300 mg, give 1/2 tablet by mouth two times daily for major depressive disorder-recurrent. Record review of the Consultant Pharmacist's Medication Regimen Review listing residents reviewed with no recommendations showed no reviews for Resident #23 in August 2020, and September 2020, a written recommendation on 10/23/20 to reduce quetiapine (generic name for Seroquel) 500 mg with a denial marked, not signed by the physician, and no review in December 2020. During an interview on 7/27/21 at 3:03 P.M., the Director of Nursing said we send the psychiatrist the recommendation from the pharmacist and then we send the response from the psychiatrist to the pharmacist. The psychiatrist makes reductions when she agrees that they need to be made. They are documented in her notes. The pharmacist has access to our system so they can read notes.

Based on observation, record review and interview, the facility failed to ensure one resident (Resident #16) received a gradual dose reduction attempt at least annually. This failure had the potential to keep any resident on a psychoactive medication from receiving the lowest possible dosage of medication due to not monitoring if a medication is treating the target symptom (or behavior). The facility's census was 44. Record review of the facility's policy titled, Antipsychotic Medication Use, dated December 2016, showed: - Antipsychotic medications may be considered for resident with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; - Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; - The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions; - Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use; - The interdisciplinary team will complete PASRR (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate, re-evaluate the use of antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered, or discontinued, based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication; - Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident; - Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): Schizophrenia, Schizo-affective disorder, Schizophrenia disorder, Delusional disorder, Mood disorders (bipolar disorder, depression with psychotic features, and refractory major depression), Psychosis in the absence of dementia, Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g. high-dose steroids), Tourette's disorder, Huntington disease, Hiccups (not induced by other medications), or Nausea and vomiting associate with cancer or chemotherapy; - Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others AND the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions, paranoia or grandiosity, or behavioral interventions have been attempted and included in the plan of care, except in an emergency; - Antipsychotic mediation will not be used if the only symptoms are one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, inattention or indifference to surroundings, sadness or crying alone that is not related to depression or other psychiatric disorders, fidgeting, nervousness or uncooperativeness; - The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications; - The physician shall respond appropriately by changing or stopping problematic does or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Record review of Resident #16's medical record showed an admission date of 4/27/18. The Physician's Order Sheet (POS), dated 7/1/21 - 7/31/21, showed: - Diagnoses included Cerebral infarction (stroke), Alzheimer's disease (a disease that causes progressive mental deterioration), Dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Anxiety disorder (more than temporary worry or fear), Type two diabetes mellitus (an impairment in the way the body regulates and uses sugar); - An order for Risperdal (antipsychotic) 25 mg 1/2 tablet two times daily dated10/18/18; - An order for Tramadol (narcotic, works by changing the way the brain and nervous system respond to pain) 50 mg two times daily, dated 8/12/20; - An order for Cymbalta (used for depression) 30 mg one time daily, dated 4/4/19. Observations showed: - On 7/20/21 at 12:42 P.M., Resident #16 to be calm, to sit in wheelchair at the dining room table, voicing that his/her legs hurt; - On 7/21/21 at 10:22 A.M., the resident to be lying in bed, calm, eyes closed; - On 7/22/21 at 8:55 A.M., the resident to be lying in bed, calm, eyes closed; - On 7/27/21 at 8:47 A.M., the resident to be eating breakfast, calm. Record review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment, required to be completed by the facility), dated 5/6/21, showed Resident #16 with a diagnoses of Alzheimer's disease (progressive mental deterioration), Dementia (disorder marked by memory disorders, personality changes, and impaired reasoning, Anxiety (persistent worry and fear about everyday situations), and Psychotic disorder (a disconnection from reality), to be moderately cognitively impaired, no mood disorders and no behaviors. Record review of the resident's Medication Administration Record (MAR), dated 7/1/21 through 7/27/21, showed Risperdal, Tramadol and Cymbalta administered as ordered. Record review of the Consultant Pharmacist's Medication Regimen Review listing residents reviewed with no recommendations showed no GDR attempts for Risperdal, Tramadol, or Cymbalta for more than one year. Record review of the progress notes provided by the facility staff showed no GDR attempts for the Risperdal, Tramadol or Cymbalta. There were no notes addressing any previous GDR attempts and no reasoning to indicate why a GDR would not be advised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document preparation and orientation for transfer to the hospital for five residents (Resident #11, #16, #21, #34, and #37) out of 13 sampled residents and one resident (Resident #17) out of two sampled closed records. The facility's census was 44. 1. Record review of Resident #11's progress notes showed: - The resident transferred to the hospital on 6/5/21 and readmitted to the facility on the same day; - The resident transferred to the hospital on 6/8/21 and readmitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfers out of the facility. 2. Record review of Resident #16's progress notes showed the resident transferred to the hospital on 2/11/21 and readmitted to the facility on [DATE]. Record review of the resident's medical record did not show documentation which showed the resident was prepared and oriented for transfer out of the facility. 3. Record review of Resident #17's progress notes showed: - The resident transferred to the hospital on 4/19/21 and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 7/4/21 and remained in the hospital on 7/28/21. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfers out of the facility. 4. Record review of Resident #21's progress notes showed: - The resident transferred to a hospital on 4/10/21 and readmitted to the facility on [DATE]; - The resident transferred to a hospital on 6/7/21 and readmitted to the facility on the same day; - The resident transferred to a hospital on 6/16/21 and readmitted to the facility on the same day. Record review of the resident's medical record did not show documentation which showed the resident was prepared and oriented for transfers out of the facility. 5. Record review of Resident #34's progress notes showed: - The resident was transferred to the hospital on 3/9/21 and readmitted to the facility on [DATE]; - The resident was transferred to the hospital on 5/30/21 and readmitted to the facility on [DATE]; - The resident was transferred to the hospital on 7/7/21 and readmitted the same day. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfers out of the facility. 6. Record review of Resident #37's progress notes showed the resident was transferred to the hospital on 1/22/21 and readmitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. 7. During an interview on 7/27/21 at 3:03 P.M., the Assistant Administrator said he wasn't sure he would use the word oriented, but would expect that they would be informed. He understands it should be documented. 8. The facility did not provide a policy for preparation and orientation of the resident for transfer out of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and/or resident's representative of their bed hold policy at the time of transfer to the hospital for five residents (Resident #11, #16, #21, #34, and #37) out of 13 sampled residents and one resident (Resident #17) out of two sampled closed records. The facility's census was 44. 1. Record review of the facility's policy titled, Bed-Holds and Returns, dated March 2017, showed: - Prior to transfer and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy; - Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail the rights and limitation of the resident regarding bed-holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); - The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided. If there is not an available bed in that part, the resident will be given the option to take an available bed in another distinct part of the facility and return to the previous distinct part when a bed becomes available. 2. Record review of Resident #11's medical record showed: - The resident transferred to the hospital on 6/5/21 and readmitted to the facility on the same day; - The resident transferred to the hospital on 6/8/21 and readmitted to the facility on [DATE]; - The facility did not provide documentation of the bed-hold notice to the resident or the resident's representative. 3. Record review of Resident #16's medical record showed: - The resident transferred to the hospital on 2/11/21 and readmitted to the facility on [DATE]. - The facility did not provide documentation of the bed-hold notice to the resident or the resident's representative. 4. Record review of Resident #17's medical record showed: - The resident transferred to the hospital on 4/19/21 and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 7/4/21 and remained in the hospital on 7/28/21; - The facility did not provide documentation of the bed-hold notice to the resident or the resident's representative. 5. Record review of Resident #21's medical record showed: - The resident to have a responsible party; - The resident transferred to a hospital on 4/10/21 and readmitted to the facility on [DATE]; - The resident transferred to a hospital on 6/7/21 and readmitted to the facility on the same day; - The resident transferred to a hospital on 6/16/21 and readmitted to the facility on the same day; - The facility did not provide documentation of the bed-hold notice to the resident or the resident's representative. 6. Record review of Resident #34's medical record showed: - The resident transferred to the hospital on 3/9/21 and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 5/30/21 and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 7/7/21 and readmitted on the same day; - The facility did not provide documentation of the bed-hold notice to the resident or the resident's representative. 7. Record review of Resident #37's medical record showed: - The resident transferred to the hospital on 1/22/21 and readmitted to the facility on [DATE]; - The facility did not provide documentation of the bed-hold notice to the resident or the resident's representative. 8. During an interview on 7/27/21 at 3:03 P.M., the Assistant Administrator said he would expect the bed hold policy to be provided to the resident or the responsible party when they are transferred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess and document on the Minimum Data Sets (MDS; a federally mandated assessment instrument required to be completed by the facility's staff) for five residents (#6, #11, #34, #37 and #50) during the time of the individual assessments. The facility's census was 44. 1. The facility did not provide a policy for accurate MDS completion. 2. Record review of Resident #6's medical record showed: - The resident admitted on [DATE]; - Diagnoses of acute respiratory disease (a sudden condition in which breathing is difficult and the oxygen levels in the blood abruptly drop lower than normal), contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), cerebral palsy (a condition marked by impaired muscle and/or other disabilities, typically caused by damage to the brain before or at birth), and urinary tract infection (UTI; an infection in the urinary system). Record review of the resident's monthly weights showed: - admission weight on 11/18/16 to be 234 pounds (lbs); - 1/27/21 to be 244 lbs; - 2/25/21 to be 245 lbs; - 3/31/21 to be 242 lbs; - 4/2/21 to be 244 lbs; - 5/3/21 to be 245 lbs; - 6/27/21 to be 248 lbs; - No weight recorded for July, 2021. Record review of the resident's medical record showed no documentation of UTI in 2021. Record review of the resident's MDSs showed the last three assessments included a quarterly dated 10/23/20, an annual dated 1/21/21 and another quarterly on 4/23/21. Those MDSs showed: - Section G- Functional Status as total dependence with assistance of one for all personal hygiene including oral care; - Section I2300- Active Diagnoses indicated an active diagnosis of an UTI on the 1/21/21 and 4/23/21 MDS; - Section K0300- Nutritional Status indicated significant weight loss, current weight on 10/23/20 was 240 lbs. On 1/21/21 and 4/23/21 the resident's current weight was 244 lbs.; - Section L0200- Oral/Dental Status indicated no dental concerns on 10/23/20 and 4/23/21, and inflamed, bleeding gums or loose natural teeth on 1/21/21. Observations and interviews showed: - On 7/20/21 at 12:09 P.M., the resident in bed with head of bed up, feeding self, teeth covered with brown tinged scum and brown in color, gums red and inflamed; - On 7/21/21 at 10:20 A.M., on 7/22/21 at 8:45 A.M., on 7/23/21 at 10:04 A.M., and on 7/27/21 at 8:38 A.M., the resident in bed with head of bed up, teeth covered with brown tinged scum and brown in color, gums red and inflamed; - During interviews on each occasion the resident said the staff did not provide oral care. During an interview on 7/23/21 at 10:50 A.M., the Director of Nursing (DON) said Resident #6 has not had a UTI since 2018 as far as she knows. 2. Record review of Resident #11's progress notes showed: - On 2/10/21, resident ambulating in dayroom, reports that he/she became dizzy and fell. Complaint of (C/O) back pain. Dime sized abrasion to right knee, bruising noted to right knee; - On 2/23/21, resident yelling in room, found on the floor in bathroom. No injuries noted. Record review of the resident's quarterly MDS, dated [DATE], Section J1800-Health Conditions-Falls showed no falls. 3. Record review of Resident #34's progress notes showed on 3/9/21 at 6:01 A.M. loud crash heard and resident moaning. Upon further investigation, it was noted that resident was sitting on floor in front of bed. Resident stated that he/she was attempting to get up and sit in his/her chair. Resident stated that he/she wanted to go to the hospital. Resident denies pain at this time, but does state mild discomfort to right knee. Emergency Medical Services (EMS) contacted and advised that paramedics were in route. Record review of the resident's quarterly MDS, dated [DATE], Section J1800 showed no falls. 4. Record review of Resident #37's progress notes showed on 1/22/21 at 9:26 A.M., Certified Nurse Aide (CNA) reported resident had fallen in shower, nurse entered shower and found resident lying supine on back of the head with blood coming out. Resident stated the shower chair. Call out to EMS and in route to nearest hospital. Record review of the resident's quarterly MDS, dated [DATE], Section J1800 showed no falls. 5. Record review of Resident #50's medical record showed: - admitted on [DATE]; - Diagnoses of non-Covid (not Covid-19 virus related) acute respiratory disease (an infection of the lungs that interferes with breathing), anxiety (a feeling of worry, nervousness, or unease), dry eye syndrome (tears aren't able to provide adequate lubrication for your eye), pneumonia, (an infection that inflames the air sacs in one or both lungs), cognitive communication deficit (impairment of understanding); - The Physician's Order Sheet (POS), dated 7/1/21 to 7/31/21, showed an order dated 6/28/21 for Imatinib Mesylate Oral Tablet (a medication used to treat chronic myeloid leukemia, cancer of the blood) 100 milligrams, two tablets by mouth daily. Record review of the resident's MDSs showed: - admission MDS, dated [DATE], section I0100 showed no diagnosis of cancer, section O0100 showed no chemotherapy agents, - Quarterly MDS, dated [DATE], section I0100 showed no diagnosis of cancer, section O0100 showed no chemotherapy agents. During an interview on 7/20/21 at 12:21 P.M., the resident said he/she is supposed to be getting medicine for his/her blood cancer and the facility didn't get it. He/she missed an appointment on 4/14/21 to have the grant that pays for his/her medicine continued and now the facility doesn't have it. During an interview on 7/22/21 at 9:52 A.M., the nurse at the physician's office which treats the resident's cancer said the resident did miss an appointment but that is not why the medication was not continued. The medication has been provided through a grant for about a year and the facility must communicate with the grantor to continue receiving the medication. The resident has a diagnosis of chronic myeloid leukemia. 6. During an interview: - On 7/23/21 at 10:50 A.M. the DON said she would expect the MDS assessment to be completed accurately; - On 7/27/21 at 3:03 P.M. the DON said not only should the MDS be completed accurately, but care areas that no longer apply to be removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an individualized comprehensive care plan for 11 residents (Resident #6, #11, #14, #16, #18, #21, #34, #45, #46, #50, and #202) out of 13 sampled residents and one resident (Resident #17) out of two sampled closed records. The facility's census was 44. 1. Record review of Resident #6's Physician's Order Set (POS), dated 7/1/21 - 7/31/21, showed: - Diagnoses of cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth) and contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). Record review of the resident's annual Minimum Data Sheet (MDS; a federally mandated assessment instrument required to be completed by facility staff), dated 1/21/21, showed: - Section G-Functional Status (assess the need for assistance with activites of daily living ADLs): the resident to require total assistance of one for all personal care; - Section H-Bladder and Bowel (assess for incontinence or at risk for developing incontinence): the resident to be always incontinent of bowel and bladder. Record review of the resident's Quarterly MDS, dated [DATE], showed: - Section G: the resident requires total assistance of one for all personal care; - Section H: the resident always incontinent of bowel and bladder. Record review of the resident's comprehensive care plan, last reviewed 7/21/21, showed the care plan did not address the need for assistance with ADLs or personal care. 2. Record review of Resident #11's POS, dated 7/1/21 - 7/31/21, showed: - Diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (a persistent feeling of sadness and loss of interest, affects how you feel, think and behave), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities); - Celexa (antidepressant medication) 40 mg (milligram) 1 tablet by mouth every day; - Venlafaxine HCL (hydrogen chloride) ER (extended-release) (an antidepressant medication) 150 mg 1 tablet by mouth every day; - Zyprexa (an antipsychotic medication for bipolar disorder) 7.5 mg 1 tablet by mouth every day. Record review of the resident's comprehensive care plan, dated 6/6/21, showed the care plan did not address the black box warning (alert the public and health care providers to serious side effects of the medication, such as injury or death) for the medications, Celexa, Venlafaxine HCL ER, or Zyprexa. 3. Record review of Resident #14's POS, dated 7/1/21 - 7/31/21, showed: - Diagnoses of dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbances, major depressive disorder; - Quetiapine Fumarate (an antipsychotic medication) 50 mg take 1 tablet by mouth once daily; - Risperdal (an antipsychotic medication) 0.5 mg give 1 tablet by mouth at bedtime (HS); - Zoloft (an antidepressant medication) 50 mg give 1 tablet by mouth daily in morning(AM). Record review of the resident's comprehensive care plan, dated 7/12/21, showed: - The care plan did not address the black box warning for the medications, Quetiapine fumarate, Risperdal, or Zoloft; - The care plan did not address the resident's depression. 4. Record review of Resident #16's POS, dated 7/1/21 - 7/31/21, showed: - Diagnoses of Alzheimer's disease (a disease that causes progressive mental deterioration), dementia, anxiety disorder (Intense, excessive, and persistent worry and fear about everyday situations), Type two diabetes mellitus (an impairment in the way the body regulates and uses sugar); - An order, dated 2/17/21, for Novolog (a medication used for diabetes) three times a day, dosed according to blood sugar scale; - An order, dated 2/15/21, for Glucagon (a medication used to raise blood sugar) emergency injection one mg intramuscular (injected into a muscle) as needed; - An order, dated 10/18/18, for Risperdal 25 mg 1/2 tablet two times daily; - An order, dated 8/12/20, for Tramadol (pain medication) 50 mg two times daily; - An order, dated 4/4/19, for Cymbalta (an antidepressant medication) 30 mg one time daily. Record review of the resident's comprehensive care plan, last reviewed 5/19/21, showed: - The care plan did not address the resident's Type two diabetes; - The care plan did not address the resident's anxiety; - The care plan did not address the black box warning for the medications, Risperdal, Tramadol or Cymbalta. 5. Record review of Resident #17's progress notes, dated 3/26/21, showed: - The resident admitted to the facility on [DATE] with Gastrostomy (G-tube; a tube placed in the stomach for nutrition and medication administration) in place. G-tube site covered with a dry dressing with scant blood noted; - Dialysis (a process of purifying the blood of a person whose kidneys are not working normally) on Tuesday, Thursday, and Saturday, on nephro (nutritional supplement) 55 milliliters (ml) per hour, flush 100 ml every six hours, dialysis port (device used to acess the blood during dialysis) to the right side, clear dressing in place, no drainage or redness noted. Record review of the resident's POS, dated 7/1/21 through 7/31/21, showed: - An order, dated 4/11/21, for gauze dressing pad four inches (in) by four in. Cleanse G-tube site with soap and water, apply dry dressing change once weekly, daily every one day(s); - An order, dated 4/11/21, check G-tube placement prior to each medication administration four times daily; - An order, dated 6/6/21, for Glucerna (nutritional supplement) 1.5 cal oral/liquid tube feeding at 60 cubic centimeters (cc) per hour continuous. Pump may use auto flush set at 100 cc of water (H2O) every six hours three times daily (TID); - An order, dated 3/26/21, for Eliquis (an anticoagulant medication) 2.5 milligram (mg) via G-tube twice daily (BID) for diagnosis of presence of cardiac pacemaker; - No orders for dialysis care. Record review of the resident's comprehensive care plan, dated 5/19/21, showed the plan did not address the care for G-tube, anticoagulant use, or dialysis. 6. Record review of Resident #18's POS, dated 7/1/21 through 7/31/21, showed: - Diagnoses included novel coronavirus (2019-nCoV; highly contagious respiratory disease) acute respiratory disease, rash and other nonspecific skin eruption, shortness of breath, other sites of candidiasis (yeast infection), candidiasis of skin and nail; - Ipratropium-Albuterol Inhalation Solution 0.5-2.3 (3) mg/3 ml four times a day as needed for shortness of breath (order start date 6/6/2018); - Lotrimin AF External Cream 1%. Cleanse back with soap and water, pat dry, apply cream three times a day (for rash and other nonspecific skin eruption) (order start date 4/20/2021); - Nystop External Powder 100000 unit/gram. Wash under bilateral breast and axilla with soap and water, pat dry and apply power generously to side as needed (Other sites of candidiasis) (Order start date 10/23/2020). Record review of the resident's comprehensive care plan, dated 5/12/21, showed: - The care plan did not address the shortness of breath; - The care plan did not address the rash and other nonspecific skin eruption; - The care plan did not address the other sites of candidiasis. 7. Record review of Resident #21's medical record showed: - admitted [DATE]; - POS, dated 7/1/21 through 7/31/21, showed: - Diagnoses included acute respiratory disease (a sudden condition that makes breathing difficult), muscle weakness, hemiplegia following cerebral infarction (stroke with paralysis on one side), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations or states of awareness), chronic pain (long-term pain), hypertension (high blood pressure), major depressive disorder (overwhelming sadness); - An order, dated 10/19/18, for a regular diet; - An order, dated 6/6/21, for Jevity 1.5 (a nutritional supplement), to run at 55 ml/per hour between 5:00 P.M. and 6:00 A.M., (total of 13 hours at 55 ml/hr =715 ml of feeding) then off, flush at 150 ml every four hours (total of 487 ml of water flush), hold feeding if able to aspirate stomach contents greater than 60 ml during feeding; - No order for G-tube and the care or maintenance of the G-tube. Observations showed: - On 7/23/21 at 10:02 A.M., resident to lay in bed; - A mechanical feeding pump with tubing connected to the resident's G-tube; - The pump not turned on; - A 1000 ml bottle of Jevity 1.5 hung on a pole and attached into the pump; - The bottle of Jevity dated dated 7/22/21 5:00 P.M.; - 400 ml of the Jevity feeding remained in the bottle (based on the rate of the feeding and the time alloted to run the feeding, there should have been 245 ml remaining); - A 1000 ml bag for water flush hung on the pole; - A total of 600 ml remained in the bag and the bag not dated. Observations showed: - On 7/27/21 at 8:40 A.M. showed resident to lay in bed; - The mechanical feeding pump tubing not be connected to G-tube; - The feeding pump not turned on; - A 1000 ml bottle of Jevity attached to the feeding pump with 1000 ml fluid present, dated 7/26/21 at 4:15 P.M.; - A 1000 ml bag of fluid hung with 1000 ml fluid present, dated 7/26/21. During an interview on 7/22/21 at 2:40 P.M., the Director of Nursing (DON) said resident #21 had a G-tube inserted during a hospital stay in April, 2021, the resident had been alert and oriented, experienced multiple seizures, was hospitalized and returned to the facility on 4/19/21 with a G-tube in place. Record review of the resident's comprehensive care plan, last reviewed 5/19/21, showed the care plan did not address the G-tube feeding, care, or maintenance. 8. Record review of Resident #34's POS, dated 7/1/21 - 7/31/21, showed: - Diagnoses of shortness of breath, chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), and major depressive disorder, generalized anxiety disorder; - Escitalopram Oxalate (an antidepressant medication for major depressive disorder) 10 mg 1 tab by mouth every day. Record review of the resident's comprehensive care plan, dated 3/3/21, showed: - The care plan did not address the black box warning for the medication Escitalopram oxalate; - The care plan did not address the resident's depression. 9. Record review of Resident #45's POS, dated 7/1/21 through 7/31/21, showed: -Diagnoses of dysuria (painful or difficult urination), neuromuscular dysfunction of bladder unspecified (bladder dysfunction caused by neurologic damage), hematuria (blood in urine), unspecified abnormalities of gait and mobility, constipation, enlarged prostate without lower urinary tract symptoms, iron deficiency anemia (low iron in blood), hypokalemia (low potassium), essential hypertension, acute kidney failure (kidneys unable to filter waste from the blood), urinary tract infection (infection of the urinary system), unspecified viral hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation) without hepatic coma, acute tubule-interstitial nephritis (inflammation of the tubules of the kidneys), unspecified dementia without behavioral disturbance, metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), severe sepsis with septic shock (widespread infection causing organ failure and dangerously low blood pressure), abnormal weight loss, non-pressure chronic ulcer unspecified part of unspecified lower leg with unspecified severity, other seizures (sudden uncontrolled electrical disturbance in the brain), venous insufficiency (improper functioning of the vein valves in the leg causing swelling and skin changes), unspecified abdominal pain, dementia in other disease classified elsewhere without behavioral disturbances; -Keppra oral table 500 mg 1 tab by mouth twice daily (for seizures) (order started 4/14/21); -Namenda oral table 10 mg 1 tab by mouth twice daily (for dementia) (order started 9/24/20); -Tylenol oral tablet 325 mg 2 tabs by mouth every 6 hours as needed for pain (order started 5/4/20). Record review of the resident's comprehensive care plan, dated 7/5/2021, showed the care plan did not address the resident's seizures, dementia, pain, and the viral hepatitis C. 10. Record review of Resident #46's POS, dated 7/1/21 through 7/31/21, showed: - Diagnoses of 2019-nCoV acute respiratory disease, essential hypertension, type 2 diabetes mellitus with hyperglycemia, heart failure, cerebral infarction, unspecified dementia without behavioral disturbance, major depressive disorder, undifferentiated schizophrenia (disorder that affects a person's ability to think, feel or behave clearly), chronic obstructive pulmonary disease (COPD), pain in unspecified joint, pseudobulbar affect (inappropriate laughing or crying due to a nervous system disorder), abnormal weight loss, Parkinson's disease (disease of the central nervous system that affects movement, often including tremors), aphasia (loss of ability to understand or express speech caused by brain damage), hyperlipidemia (high cholesterol), constipation, hyperkalemia (high potassium), pressure ulcer of other site stage 2, and pressure ulcer other site unspecified stage; - Hydrocodone-Acetaminophen (pain medication) oral tablet 5-325 mg 1 tab per G-tube- 2 tabs max daily- four times a day (for pain) (order start date 3/10/21); - Remeron SolTab (an antidepressant medication) oral tablet disintegrating 15 mg 1 tab per G-tube at bedtime (for dementia) (order start date 6/30/21); - Seroquel (an antipsychotic medication) oral tablet 25 mg take 1 tab by mouth at 6 P.M. daily per G-Tube (for schizophrenia) (order start date 3/31/20); - Valproic Acid 250 mg/5 Ml Solution give 15 Ml via G-tube twice daily (for schizophrenia) (order start date 5/17/17); - Labs: Depakote level, complete metabolic panel, complete blood count, lipid panel, hemoglobin A1c, thyroid stimulating hormone, free thyroxine, and folic acid yearly. Record review of the resident's comprehensive care plan, dated 4/6/21, showed: - The care plan did not address the resident's depression, schizophrenia, diabetes mellitus; - The care plan for pain showed: Medication as ordered Fentanyl Patches (pain patch) (dated 3/24/19) (Resident is not on Fentanyl Patches and takes hydrocodone for pain); - The care plan addressed anxiety (Resident has no diagnosis for anxiety). 11. Record review of Resident #50's medical record showed: - admitted on [DATE]; - POS, dated 7/1/21 through 7/31/21, showed: - Diagnoses of non-Covid (not Covid-19 virus related) acute respiratory disease (an infection of the lungs that interferes with breathing), anxiety disorder (excessive and persistent worry and fear about everyday situations), dry eye syndrome (tears do not provide adequate moisture), pneumonia (an infection of the lungs), cognitive communication deficit (difficulty using spoken languages); - An order, dated 6/28/21, for Imatinib mesylate (a chemotherapy medication used to treat chronic myeloid leukemia) 100 milligrams (mg) two tablets daily to be given for a diagnosis of pneumonia. Record review of the medication administration record (MAR), dated July 2021, showed Imatinib Mesylate to be given daily 7/1/21 through 7/11/21, unavailable in the facility 7/12/21 - 7/15/21, given on 7/16/21, unavailable in the facility 7/17/21 through 7/20/21. During an interview on 7/22/21 at 9:52 A.M., the resident's oncologist's medical assistant (MA) said the resident has a diagnosis of chronic myeloid leukemia. Record review of the resident's comprehensive care plan, last reviewed on 7/22/21, showed the care plan did not address the resident's cancer or chemotherapy treatment. 12. Record review of Resident #202's progress notes showed: - On 7/13/21 at 12:42 A.M., resident observed on floor in dining hall after laying flat in w/c. Resident unable to state whether he/she hit his/her head. No trauma, redness, swelling observed; - On 7/16/21 at 4:30 P.M. resident was sitting across from the nursing station when he decided to throw himself/herself out of his/her chair according to several staff members. Resident has a small hematoma above the right eyebrow. He/she also has a resolving hematoma to the left forehead. Resident denies having any pain. Record review of the resident's comprehensive care plan, dated 7/21/21, showed the care plan did not address falls. 13. During an interview on 7/23/21 at 10:50 A.M., the Director of Nursing (DON) said if a resident has a G-tube, there should be a care plan. She would expect a resident with a fall to have a care plan with interventions. During an interview on 7/27/21 at 3:03 P.M., the DON said she would expect there to be a care plan for antipsychotics and antidepressants. When asked if she would expect there to be a care plan for cellulitis, she said if it is short term, that may not be needed, just because there is an order for treatment doesn't mean it would be on the care plan. If it is long term with a wound or several months, there should be a care plan. When asked if she would expect there to be a care plan for seizures, she said just because they have a diagnosis for seizures doesn't mean they need a care plan for seizures. If we are dealing with breakthrough seizures, yes, but they wouldn't need one just because they are on medication. A care plan should reflect how you are going to care for the patient. If they have been on medication for a long period of time and the condition is under control, She said she wouldn't do a care plan. Not all diagnoses need interventions. She would expect a care plan to be updated each time there is a seizure.

Based on observation, interview, and record review, the facility failed to revise and update comprehensive care plans with specific interventions to meet the individual needs of seven residents (Resident #11, #16, #20, #21, #34, #37, and #46) and failed to invite two residents (#23 and #34) to participate in the care planning process out of 13 sampled residents. The facility's census was 44. 1. Record review of the facility's policy titled, Change in a Resident's Condition or Status, dated December 2016, showed a significant change of condition is a major decline or improvement in the resident's status that requires interdisciplinary review and/or revision to the care plan. The facility did not provide a policy for updating care plans. 2. Observation of Resident #11 on 7/20/21, 7/21/21, 7/22/21, and 7/23/21 showed the resident in wheelchair to propel his/herself around facility. During an interview on 7/217/21 at 8:42 A.M., the resident said he/she can't use a 4-wheel roller walker. The resident fell backward with it and can't have it anymore. Therapy has to get him/her a new walker. Record review of the resident's progress notes dated 6/10/21 showed the nurse reminded the resident to use wheelchair for ambulation. Record review of the resident's comprehensive care plan, dated 6/6/21, showed: - I use a walker for ambulation - I am at risk for falls - updated 6/5/21 trip and fall with head injury; - Interventions - make sure I do not forget my walker, remind resident to stand for a few seconds; - No interventions for resident to use wheelchair. The facility did not update the care plan with new interventions to use wheelchair for ambulation. 3. During an interview on 7/20/21 at 1:15 P.M., Resident #16 said his/her legs hurt and he/she can't walk. The facility staff give him/her pain medicine. Record review of the resident's Physician's Order Sheets (POS), dated 7/1/21 - 7/31/21, showed an order for Tramadol (a medication used to treat pain) 50 mg by mouth two times a day. Record review of the resident's nurse progress notes showed a note, dated 6/2/21, the resident to be found kneeling down on floor, resident stated I was trying to get her glasses, resident denies any pain nor discomfort and refused care. Call being placed to physician, continue monitoring. Record review of the resident's comprehensive care plan, last reviewed 5/19/21, showed: - Acute and Chronic Pain, onset 5/17/18; - No new interventions after 5/17/18; - I am at risk for falls, onset 5/17/18; - No new interventions after 5/17/18. The facility did not update the care plan with new interventions for pain control and falls. 4. Record review of Resident #20's progress notes showed: - On 6/8/21, Stage II pressure ulcer noted to coccyx; - Medical Director (MD) aware, new order noted; - The pressure ulcer measured 2 centimeters (cm) x 4 cm x 0.2 cm. Record review of the resident's POS, dated 7/1/21 through 7/31/21, showed: - Order started 5/9/21 and discontinued 6/7/21, Collagen Matrix (dressing which stimulate new tissue growth) 2x2 pad. Cleanse open area to left gluteal fold with normal saline (NS), apply collagen pad and gauze, change daily; - Order started 6/9/21 and discontinued 6/30/21, Collagen Matrix 4x4. Cleanse open area to coccyx with NS, apply collagen dressing, cover with border gauze, change daily; - Order started 7/1/21 and discontinued 7/15/21, Collagen Matrix 2x2. Cleanse open areas to right and left gluteal fold with NS, apply Collagen pad and cover with gauze, change daily; - Order started 7/16/21, Collage Matrix 2x2. Cleanse open areas to right gluteal fold with NS, apply collagen pad and cover with gauze, change daily. Record review of resident's comprehensive care plan, last reviewed 5/17/21, showed: -Two at high risk for impaired skin integrity care plan areas; -High risk for impaired skin integrity onset dated 3/18/18 with interventions dated the same; -High risk for skin breakdown onset dated 11/06/18 with last intervention dated 2/21/20; -No new interventions for newly developed or healed pressure ulcers. 5. Record review of Resident #21's progress notes showed: - On 5/12/21, Resident found lying on floor next to bed, resident unable to state cause of fall. Resident very combative with staff in trying to assist back to bed, resident denies any pain or discomfort, call being placed to physician exchange, Power of Attorney (POA) will be notified, call light in reach of patient, resident refused vital signs (VS); - On 5/13/21, CNA notified this nurse patient was laying on the floor next to the bed. On assessment no apparent injuries noted, range of motion within normal limits (ROM WNL), no bruises or bleeding noted. Resident assisted back to bed with five assistance. Resident combative. Bed low and locked with call light in reach. Staff asked to do frequent checks for safety. MD and family notified. VS refused, unable to assess neuro checks. Resident combative and uncooperative. Observations showed: - On 7/20/21 at 12:40 P.M., the resident to lay in bed, gastric tube (G-tube; a tube inserted through the wall of the abdomen directly into the stomach used to give drugs and liquids, including liquid food) in place; - On 7/21/21 at 10;18 A.M., the resident to lay in bed, G-tube connected to feeding, pump not running; - On 7/22/21 at 8:56 A.M., the resident to lay in bed, G-tube in place; Record review of the resident's comprehensive care plan, last reviewed 5/19/21, showed: - I am at risk for falls, onset 11/29/16; - No new interventions after 11/29/16. - History of confrontations and repetitive bizarre stories believe that my nails can grow mushrooms if I plant my nail clippings, onset 2/28/20; - No new interventions after 2/28/20; - Regular diet, onset 3/24/19; - No new interventions after 3/24/19; - Therapeutic diet related to diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal elevated levels of glucose in the blood), onset 2/16/17; - No new interventions after 2/16/17. The facility did not update the care plan with individualized interventions for falls, combative behaviors and diet. 6. During an interview on 7/20/21 at 12:13 P.M., Resident #23 said he/she is own responsible party (RP), he/she is not invited to care plan meetings. During an interview on 7/21/21 at 1:43 P.M., the DON said the facility is not having care plan meetings with everyone right now but the care plan is reviewed in detail, especially if there are any changes, with the resident each time they are done. She does not usually document that. During an interview on 7/21/21 at 1:54 P.M., Resident #23 said the facility staff do not, and have never, invited the resident to a care plan meeting or discussed the care plan with him/her. The facility did not involve the resident to participate in the care planning process. 7. During an interview on 7/20/21 at 11:48 A.M., Resident #34 said he/she has never heard of a care plan meeting. The facility staff have never discussed the resident's medication with him/her. The facility did not involve the resident to participate in the care planning process. Record review of the Resident 34's progress notes showed: - On 3/9/21, the resident was found sitting on floor in front of bed. Resident said he/she was attempting to get up and sit in his/her chair. Mild pain in right knee, emergency medical services (EMS) were contacted; - On 7/7/21, the resident found sitting on floor with a moderate amount of blood surrounding. Laceration to right lower leg. Resident said he/she hit his/her head with noticeable lump to area. EMS here to assist resident up and to bed. Left facility enroute to hospital. Record review of the resident's comprehensive care plan, dated 3/3/21, showed: - History of falls, onset 11/20/19; - No interventions dated after 11/20/19. The facility did not update the care plan with individualized interventions for falls. 8. Record review of Resident #37's progress notes showed on 1/22/21, the resident had fallen in shower, found resident lying supine, back of head with blood coming out. Called EMS and in route to nearest hospital. Record review of the resident's comprehensive care plan, dated 6/23/21, showed: - Three fall care plan areas; - High risk for falls onset dated 6/19/18 with interventions dated the same; - I am at risk for falls onset dated 1/18/17 with interventions dated the same; - I use a walker for ambulation, I am a risk for falls onset dated 1/18/17 with interventions dated the same. - No new interventions for fall on 1/22/21 with head injury, diagnosis of subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain). The facility did not update the care plan with individualized interventions for falls. 9. Record review of Resident #46's POS, dated 7/1/21 - 7/31/21, showed an order dated, 3/10/21, for Hydrocodone (pain medication)-acetaminophen (pain and fever reducer medication) 5/325 milligram (mg) per gastrostomy tube (G-Tube) four times a day. Record review of the resident's comprehensive care plan, last reviewed 4/06/21, showed: - Problem: Chronic Pain related to medical conditions, onset 11/07/6 and edited 08/02/17; - Goal: I will voice relief of my pain or that my pain level is tolerable with current medication, dated 08/02/1; - Approach: I will report relief of pain, dated 08/02/17; - Medication as ordered Fentanyl (strong narcotic pain medicine) patches, dated 03/24/19. The facility did not update the care plan with new interventions for pain control. During an interview on 7/27/21 at 3:03 P.M., the DON said she would expect care plans to be updated with new interventions for each care area when there is a change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident care and services were provided according to acceptable standards of care for six residents (Residents #11, #18, #21, #34, #50, and #152) out of 13 sampled residents. The facility's census was 44. 1. Record review of the facility's policy titled, Medication and Treatment Orders, dated July 2016, showed orders for medications and treatments will be consistent with principles of safe and effective order writing. Record review of the facility's policy titled, Medication Orders, dated November 2014, showed: - The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; - Each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen by the physician at least every 60 days; - A current list of orders must be maintained in the clinical record of each resident; - Orders must be written and maintained in chronological order; - Physician orders/progress notes must be signed and dated every 30 days. 2. Observation on 7/27/21 at 2:12 P.M. showed Resident #11's dialysis fistula (an access made by joining an artery and vein in your arm for preparation for dialysis process) at his/her upper right arm. The site had bruises on the skin. During an interview on 7/27/21 at 2:12 P.M., the resident said he/she has a dressing on his/her dialysis site (fistula) when he/she returns from dialysis. The nurses do not check the site when he/she returns from dialysis, such as bleeding issues. The dialysis center takes care of it. Record review of the resident's Physician's Order Sheet (POS), dated 7/1/21 - 7/31/21, showed: - Diagnoses of chronic kidney disease, stage 5 (end stage) and dependence on renal dialysis; - No orders to assess the fistula after dialysis. Record review of the resident's medication administration/treatment record showed no assessment of the resident's fistula after dialysis. Record review of the facility's policy titled, End-Stage Renal Disease, Care of a Resident with, dated September 2010, showed residents with end-stage renal disease (ESRD; last stage of kidney failure and requires dialysis treatment) will be cared for according to currently recognized standard of care. Record review of [NAME] & [NAME], Inc, dated 2010, showed - After dialysis, assess the vascular access for any bleeding or hemorrhage; - Assess for patency at least every 8 hours; - Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency; - Notify the healthcare provider promptly if you suspect clotting. 3. Record review of Resident #18's POS, dated 7/1/21 through 7/31/21, showed: - admitted [DATE] with diagnoses of acute respiratory disease (an infection of the lungs that interferes with breathing), constipation, gastrostomy status (G-tube; a tube inserted through the wall of the abdomen directly into the stomach that can be used to give drugs and liquids, including liquid food); - An order, dated 11/25/19, for Jevity 1.2 (a nutritional supplement), 55 cubic centimeters (cc) per hour continuous pump, flush at 50 cc of water every hour via pump. Observation on 7/27/21 at 8:50 A.M. showed the resident lay in bed; - The mechanical feeding pump on hold; - The feeding pump set for 50 cc/hr (5 cc less than ordered, a total loss of nutrition of 120 cc/24 hour; - The Jevity bottle when first opened contains 1000 cc; - The Jevity 1.2 hung on pole attached to the mechanical feeding pump; - The Jevity bottle dated for 7/26/21 at 1:00 P.M. and contained 950 cc in bottle (the resident only received 50 cc in a 19 hour period-a total loss of nutrition of 995 cc); - The water/fluids hung on pole and attached to the mechanical feeding pump. The fluids contained 850 cc and dated 7/26/21 at 6:00 P.M. (the resident only received 150 cc of water). Record review of the resident's nurse progress notes showed the last progress note dated 6/07/21 related to the care of the resident. 4. Record review of Resident #21's POS, dated 7/1/21 through 7/31/21, showed: - admitted [DATE] with diagnoses of acute respiratory disease (a sudden condition that makes breathing difficult), hemiplegia following cerebral infarction (stroke with paralysis on one side), hypertension (high blood pressure), major depressive disorder (overwhelming sadness); - An order, dated 6/6/21, for Jevity 1.5 (a nutritional supplement), 55 cc per hour between 5:00 P.M. and 6:00 A.M., total 715 cc to be delivered, then off, flush at 150 cc every four hours, total 450 cc, hold feeding if able to aspirate stomach contents greater than 60 cc during feeding; - No order for G-tube care and maintenance. During an interview on 7/22/21 at 2:40 P.M., the Director of Nursing (DON) said resident #21 had a G-tube inserted during a hospital stay in April, 2021, the resident had been alert and oriented, experienced multiple seizures, was hospitalized and returned to the facility on 4/19/21 with a G-tube in place. Observations showed: - On 7/23/21 at 10:02 A.M., resident lay in bed, Jevity 1.5 hanging at bedside with 400 cc feeding remaining in bottle, started with 1000 cc, dated 7/22/21 5:00 P.M., 115 cc less than ordered delivered; - On 7/27/21 at 8:40 A.M., resident #21 lay in bed, Jevity bottle hanging with 1000 cc fluid present, dated 7/26/21 at 4:15 P.M., 1000 cc bag of fluid also hanging dated 7/26/21. Pump not on. During an interview on 7/27/21 at 9:01 A.M., the DON said she didn't know about the feeding, she said maybe they had to hang a new bottle. She didn't know why it is still full. During an interview on 7/27/21 9:08 A.M., RN K said he/she hung the bottle of Jevity and the bag of fluids before he/she left yesterday (7/26/21). He/she knows it was not run last night, but the night shift nurse could not tell him/her why it was not run. He/she believes they forgot it. Record review of the resident's nurse progress notes showed the last progress note dated 7/23/21 with no documentaion of reason for less than ordered Jevity delivered on that date. 5. Observation of Resident #34 on 7/20/21, 7/21/21, 7/22/21, 7/23/21 showed nasal cannula (a device used to deliver supplemental oxygen to a person in need of respiratory help) to provide supplemental oxygen at 2.5 Liters/minute. During an interview on 7/27/21 at 9:14 A.M., the Assistant Director of Nursing (ADON) said he/she would find the rate for oxygen therapy through the computer on the resident's orders. Oxygen tubing should be changed maybe every 72 hrs. It would show on the order when to change the tubing. Record review of the resident's POS, dated 7/1/21 - 7/31/21, showed: - Diagnoses of shortness of breath, chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), generalized anxiety disorder, cough; - No orders for oxygen therapy. Record review of the resident's comprehensive care plan, dated 3/3/21, showed: - COPD - oxygen as ordered; - No instructions on the care of oxygen therapy. 6. Record review of Resident #50's medical record showed: - admitted on [DATE]; - POS, dated 7/1/21 through 7/31/21, showed: - Diagnosis of anxiety disorder (excessive and persistent worry and fear about everyday situations), pneumonia (an infection of the lungs); - An order, dated 6/28/21, for Imatinib Mesylate (a chemotherapy medication used to treat chronic myeloid leukemia) 100 milligrams (mg), two tablets by mouth daily. Record review of resident #50's Medication Administration Record showed: - On 7/1/21 through 7/31/21 the Imatinib Mesylate not given; - On 7/12/21 through 7/15/21 and on 7/17/21 through 7/20/21, reason documented as the medication not given, medication not available in facility. During an interview on 7/27/21 at 1:43 P.M., the DON said the documented administration of Imatinib Mesylate on 7/16/21 is an error, the medication was not available in the facility. 7. Record review of Resident #152's admission nurse progress note, dated 7/3/21 at 3:14 P.M., showed the resident to arrive at the facility with a G-tube, a neck brace, and a condom catheter (an external urinary catheter collection device that fits over the penis like a condom). Record review of the resident's medical record showed an admission date of 7/3/21. POS dated 7/1/21 through 7/31/21 showed: - Diagnoses of malignant neoplasm of prostate (cancer), hypertension (high blood pressure), stress incontinence (leaking urine with activity), alcohol abuse, chronic pain, seizures, type two diabetes mellitus (condition that affects the way the body processes blood sugar),with hyperglycemia (high blood sugar); - An order, dated 7/4/21, Jevity 1.5 Cal/Fiber (nutritional supplement with fiber) at 60 cc per hour continuously and water 150 cc every four hours via auto pump three times a day (TID); - An order, dated 7/13/21, may use Jevity 1.2 until Jevity 1.5 is delivered to the facility; - No order for G-tube care and maintenance; - No order to administer medications via the G-tube; - No order for a neck brace use or discontinued use; - No order for condom catheter use or discontinued use; Record review of the resident's Medication Administration Record (MAR) dated 7/1/21 - 7/27/21 showed medications to be administered through the G-tube. Record review of the resident's admission MDS, dated [DATE], showed Resident #152 to have a diagnoses of cancer, diabetes, seizures, and hypertension and to be severely cognitively impaired. Observations of Resident #152 showed: - On 7/20/21 at 12:50 P.M., the resident sat near the nurse station in a wheelchair, wore a neck brace, no catheter; - On 7/27/21 at 8:45 A.M. the resident sat in a wheelchair in the dining room, the resident wore a neck brace and no catheter. During an interview on 7/20/21 at 1:00 P.M., the ADON said Resident #152 was admitted with the neck brace because he has a fracture in the first cervical vertebra (C-1), she does not think the resident has a catheter and does have a G-tube. During an interview on 7/22/21 at 4:31 P.M. the DON said Resident #152 was admitted with a condom catheter in a comatose state. The catheter has been removed because the resident is now able to walk. 8. During an interview on 7/27/21 at 3:03 P.M., the DON said she would expect all orders for medication and treatments to be followed as written, there's to be an order for oxygen use if oxygen is used, G-tube feeding administration orders to be followed, wound care orders to be followed, and she would expect orders to be updated and changed as needed. The dialysis port is assessed when the resident returns from dialysis, but it isn't documented. They look for change in condition, low blood pressure, bleeding, pain, heat, any complication. As a nurse, they should know that. There is not a daily assessment of the site. The dialysis center does an ultrasound of the resident's site monthly and a clean out every three months, so the facility staff doesn't check the thrill and bruit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. The facility's census was 44. Observation of the kitchen on 7/22/21 at 9:30 A.M. showed: - The first refrigerator along the wall to the right of the kitchen entrance had food debris in the bottom, residue running down the front of the doors, and both door seals loose at the bottom; - The freezer had food debris in the bottom and residue running down the front of the doors; - The refrigerator in the corner had food debris in the bottom and residue running down the front of the doors; - The toaster had a buildup of grime and food residue on the front and sides; - The steam table had food residue running down the front and sides; - The stove had food residue running down the front and sides; - The bottom shelf of the food prep table had a buildup of grime and food residue. Record review of the steam table temperature logs showed: - On 7/19/21, no temperatures recorded for the lunch and supper meals; - On 7/20/21 and 7/22/21, no temperatures recorded for the supper meal. During an interview on 7/22/21 at 9:45 A.M., the Dietary Supervisor (DS) said there is no kitchen cleaning schedule. The cooks should know they are supposed to deep clean on Wednesdays and Saturdays, and clean up between meal services. The DS said he/she leaves before the supper meal, but the cooks are supposed to be writing the temperatures down. During an interview on 7/27/21 at 3:03 P.M., the Assistant Administrator (AA) said he would expect the staff to know what to clean and when it needs to be cleaned, not necessarily a written schedule of who does what. He expected the DS and kitchen staff to keep all equipment clean and operational. The DS and kitchen staff should monitor and check food temperatures before the food goes out and keep a log. If the temperatures are out of range, they are to notify the DS, administration or call the Director of Nursing. Record review of the facility's policy titled, Nutrition Services, dated December 2016, showed: - Policy Statement: Store, prepare, distribute and serve food in accordance with professional standards for food service safety; - Centers for Medicaid and Medicare Services (CMS) recognizes the U.S. Food and Drug Administration's (FDS) Food Code and the Centers for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute and serve food in long term care facilities in a safe and sanitary manner.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program to include an infection surveillance program and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility's census was 44. Record review of the facility's Infection Prevention and Control Program (IPCP) showed the facility did not establish an Antibiotic Stewardship Program which includes antibiotic use protocols and a system to monitor antibiotic use. The facility did not have the following: - An infection surveillance program; - Protocols to review clinical signs and symptoms and lab reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and to identify what infection assessment tools or management algorithms are used for one or more infections; - A process for periodic review of antibiotic use by prescribing practitioners; - Protocols to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate one; - A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on lab data, and prescribing practices for the prescribing practitioners and for the Quality Assurance and Assessment (QAA) committee. The Director of Nursing (DON) provided a red binder which contained: - One sheet, dated 3/12/19, of infections, - One lab infection control detail report, dated 9/1/20-9/30/20, for a former resident's urine cultures; - One lab infection control detail report, dated 9/1/20-11/30/20, for the same former resident's urine cultures; - One sheet, titled Nursing Home Antimicrobial Stewardship Guide, dated 2021, which showed one resident with hospital acquired pseudomonas with cough, prescribed Doxycycline from 2/20/21-3/31/21, one resident with nursing home acquired cellulitis rash, prescribed cephalexin from 6/23/21-6/28/21, one resident with nursing home acquired cellulitis rash with drainage, prescribed doxycycline from 6/23/21-6/28/21, cephalexin from 3/17/21-3/24/21, cephalexin from 6/9/21-6/16/21, cipro from 4/1/21-4/8/21, and clindamycin from 5/5/21-5/15/21, and one resident with nursing home acquired leg redness from toe, prescribed cephalexin from 5/4/21-5/11/21. Infection Surveillance did not include whether the resident was on isolation precautions, prescribing clinician, medication dosage, and whether the antibiotic ordered was appropriate to treat the infection or if a change in medication was needed. During an interview on 7/27/21 at 3:03 P.M., the Assistant Administrator (AA) said they are working with the lab and pharmacy to monitor, track, and watch for infections. The AA said they still look at previous month infections at monthly meetings. The DON has a spreadsheet which shows the antibiotic, if there was a culture, and signs and symptoms being treated. The AA said they look for trends quarterly. The facility did not provide a policy for Antibiotic Stewardship.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide information and education to two residents (Resident #6 and #23) or the resident's representative, of the two types of pneumococcal vaccine (a method of preventing a specific type of lung infection (pneumonia) that is caused by the pneumococcus bacterium), and offer both pneumococcal vaccines, and failed to provide information and education and accurately document the influenza vaccine administration for four residents (#6, #20, #37, and #23) out of five residents sampled for immunization status. The facility's census was 44. 1. Record review of the facility's policy titled, Vaccination of Residents, dated 10/2019, showed: - All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated; - Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. (See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index.html for educational materials.); - Provision of such education shall be documented in the resident's medical record; - All new residents shall be assessed fro current vaccination status upon admission; - The resident or the resident's legal representative may refuse vaccines for any reasons; - If the vaccines are refused, the refusal shall be documented in the resident's medical record; - If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: site of administration, date of administration; lot number of the vaccine, expiration date, name of person administering vaccine; - Certain vaccines (influenza and pneumococcal vaccines) may be administered per the physician-approved facility protocol (standing orders) after the resident has been assessed by the physician for medical contraindications for each vaccine. The resident's attending physician must provide a separate written order for any other vaccination, and such orders shall be recorded in the resident's medical record; - Inquiries concerning this policy should be referred to the Infection Preventionist or the Administrator. 2. Record review of the facility's policy titled, Pneumococcal Vaccine, dated October 2019, showed: - All resident will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; - Prior to or upon admission, resident will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; - Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission; - Administration of pneumococcal vaccine or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 3. Record review of the facility's policy titled, Influenza Vaccine, dated October 2019, showed: - All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza; - The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents ( or residents' legal representatives); - Between October first and March 31 each year, the influenza vaccine shall be offered to residents, unless the vaccine is medically contraindicated or the resident has already been immunized; - Prior to the vaccination the resident (or legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine, provision of such education shall be documented in the resident's medical record; - The date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record; - A resident's refusal of the vaccine shall be document on the Informed Consent for Influenza Vaccine and placed in the resident's medical record; - The Infection Preventionist will maintain surveillance data on influenza vaccine coverage and reported rates of influenza among residents; - Administration of the influenza vaccine will be made in accordance with current CDC recommendations at the time of the vaccination. 4. Record review of the U.S. Department of Health and Human Services Centers for Disease Control (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: - CDC recommends two pneumococcal vaccines for adults: 13-valent pneumococcal conjugate vaccine (PCV 13, Prevnar 13) and 23-valent pneumococcal polysaccharide vaccine (PPSV 23, Pneumovax 23); - CDC recommends vaccination with PCV 13 for all adults 65 years or older and adults 19 through [AGE] years old with certain medical conditions (such as chronic heart or lung disorders, including congestive heart failure, diabetes mellitus (a chronic health condition which increases blood sugars which leads to dangerous complications), chronic obstructive pulmonary disease (COPD :a condition involving constriction of the airway and difficulty or discomfort in breathing); - CDC recommends vaccination with PPSV 23 for all adults 65 years or older and adults 19 through [AGE] years old with certain medical conditions. 5. During an interview on 7/23/21 at 10:50 A.M., the Director of Nursing (DON) said she is responsible for offering pneumonia vaccine and providing education if no records can be verified. It depends on what the doctor says if any other vaccine or screening is offered to them. 7. Record review of Resident #6's medical record showed: - The resident admitted on [DATE]; - The resident [AGE] years old; - Diagnoses of acute respiratory disease (a sudden condition in which breathing is difficult and the oxygen levels in the blood abruptly drop lower than normal), contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), acute embolism and thrombosis of deep vein (occurs when a blood clot, develops in a blood vessel and reduces the flow of blood) of low extremities bilaterally (both legs), essential hypertension (high blood pressure), cerebral palsy (a condition marked by impaired muscle and/or other disabilities, typically caused by damage to the brain before or at birth), pressure ulcer of unspecified site, stage 2 (a condition when the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful, the sore expands into deeper layers of the skin), urinary tract infection (an infection in the urinary system), hypocalcemia (low calcium), vitamin B12 deficiency anemia due to intrinsic factor deficiency (a condition in which the body does not have enough healthy red blood cells, due to a lack of vitamin B12); - The resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility's staff), dated 4/23/21, Section O, showed pneumococcal vaccine response not offered, influenza vaccine last given 10/27/20. Record review of the Immunization Record, dated 2/3/21, showed: - Staff documented the resident's pneumococcal vaccine response as not up to date, offered and declined, no reason documented; - Influenza vaccine last given 10/7/19 with a handwritten correction dated 10/27/20; - Staff did not document PCV 13 and PPSV 23 offered to the resident or representative; - Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; - Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine. 8. Review of Resident #20's medical record showed: - The resident admitted on [DATE]; - The resident [AGE] years old; - Diagnoses of stroke (damage to the brain from interruption of its blood supply), anemia, hypertension diabetes mellitus (condition that affects the way the body processes blood sugar), hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), seizure disorder (disorder in which nerve cell activity in the brain is disturbed causing seizures), benign prostatic hypertrophy (prostate gland enlargement that causes urination difficulty), abnormal weight loss, pain, disorder of skin and subcutaneous tissue unspecified, gastrostomy tube (feeding tube placed through the abdomen into the stomach), stage 2 pressure ulcer to right gluteal cleft and gastroesophageal reflux disease (condition where acid from the stomach comes up into the esophagus causing acid reflux or heartburn); - The resident's quarterly MDS, dated [DATE], Section O, showed pneumococcal vaccine response yes, influenza vaccine last given 10/27/20. Record review of the Immunization Record, dated 2/3/21, showed: - Staff documented the resident's pneumococcal vaccine response as given in 2019, type of pneumococcal vaccine not identified; - Influenza vaccine last given 10/7/19 with a handwritten correction dated 10/27/20; - Staff did not document PCV 13 and PPSV 23 offered to the resident or representative; - Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; - Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine. 9. Review of Resident #23's medical record showed: - The resident admitted on [DATE]; - The resident [AGE] years old; - Diagnoses of hypertension, cerebral infarction (stroke), major depressive disorder (depression), herpes simplex myelitis (a rare nervous system disease), pain, osteoporosis (bones become brittle and fragile), anxiety (a feeling of worry, nervousness, or unease) psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), tremor (involuntary quivering movement), insomnia (unable to sleep); - The resident's quarterly MDS, dated [DATE], Section O, showed pneumococcal vaccine response yes, influenza vaccine last given 10/27/20. Record review of the Immunization Record dated 1/21/20 showed: - Staff documented the resident's pneumococcal vaccine response as not up to date, offered and declined, no reason documented; - Influenza vaccine last given 10/7/19 with a handwritten correction dated 10/27/20; - Staff did not document PCV 13 and PPSV 23 offered to the resident or representative; - Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; - Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine. 10. Review of Resident #37's medical record showed: - The resident admitted on [DATE]; - The resident [AGE] years old; - Diagnoses of hypertension, hypothyroidism (the thyroid gland doesn't produce enough thyroid hormone), cellulitis (serious bacterial skin infection) of right lower limb, type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy (nerve damage affects the legs and feet), chronic pain, elevated prostate specific antigen (can be a sign of prostate cancer), chronic obstructive pulmonary disease (COPD); - The resident's quarterly MDS, dated [DATE], Section O, showed pneumococcal vaccine response yes, showed influenza vaccine last given 10/27/20. Record review of the Immunization Record, dated 2/3/21, showed: - Staff documented the resident's influenza vaccine last given 10/7/19 with a handwritten correction dated 10/27/20; - Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine. During an interview on 7/23/21 at 10:50 A.M., the DON said she is responsible for giving the pneumonia vaccine to residents who have not had it, she provides education. If the vaccine is needed, she orders it from the pharmacy and gives it when it arrives to the facility. The DON said if she is able to get records from where the resident comes from she uses them, it depends on what the doctor says if another vaccine is offered to the resident. The influenza vaccines are not correctly documented in the medical records, she crossed out the incorrect date and handwrote the correct date.

Based on observation, interview, and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchen, which prepared food for all residents. This practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 44. During an observation and interview in the kitchen on 7/22/21 at 9:30 A.M., the Dietary Supervisor (DS) said he/she has worked for the facility for two years, he/she isn't certified, and has never attended classes or received any formal education. Record review of the facility's current employee list, dated 7/20/21, showed a hire date of 1/10/18 for the DS. During an interview on 7/27/21 at 3:03 P.M., the Assistant Administrator (AA) said he thought the DS had until November 2021 to get certified. The AA said the DS and the Registered Dietician Consultant (RDC) are working together to make sure it happens. During an interview on 8/9/21 at 12:33 P.M., the RDC said the DS will be enrolled in a class scheduled for September to get his/her certification completed. Record review of the facility's policy titled, Nutrition Services, dated December 2016, showed: - The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment; - If a qualified dietician or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who - for designations prior to November 28, 2016, meets the following requirements no later than five years after November 28, 2016, or no later than one year after November 28, 2016 for designations after November 28, 2016 is: (A) a certified dietary manager or (B) a certified food service manager, or (C) has similar national certification for food service management and safety from a national certifying body or (D) has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning. In states that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary mangers and receives frequently scheduled consultations from a qualified dietician or other clinically qualified nutrition professional.