**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documented evidence the facility documented residents' and/or their representatives grievances and provided grievance decisions/resolutions after grievances were voiced for two residents (Resident #60 and #91) of 34 sampled residents. Review of the facility's policy titled, Grievances and Complaints Policy and Procedure, revised 12/2016, showed the following: -The facility had adopted an internal grievance procedure providing for prompt and equitable resolution of complaints/grievances of all types, including but not limited to, those alleging any discriminatory action prohibited by or in violation of patient rights, applicable state and/or federal law, internal policies, rules, enactments, guidelines, codes, regulations, or initiatives issued or enacted by any and all entities holding jurisdiction over this facility; -Depending on the nature of the complaint/grievance, there may or may not be an official form that should be completed in accordance with applicable regulations. Regardless, all complaints should be in writing, containing the name of the person filing the complaint/grievance, the address and other contact information for the person filing, the name of the patient, a description of the act/actions/problem prompting the complaint/grievance, and the remedy or relief sought; -All complaints/grievances should be filed with the facility Grievance Official immediately upon discovery of the offense and no longer than 30 days following discovery; -The Grievance Officer will investigate the complaint, and forward to governing entities as required. The investigation will afford all interested persons and their representatives an opportunity to submit evidence relevant to the complaint/grievance. The investigator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and share them only with those who have a need to know; -The Grievance Officer is responsible for all of the following with relation to filed grievances: receiving and tracking, leading and investigating, maintaining confidentiality, issuing official decisions and regulations, coordinating with state and federal agencies, preventing further violations while investigating, documenting findings; and adhering to all applicable state and federal laws and regulations. -The person making the complaint/grievance will be notified by the Grievance Officer of the findings and the resolution of the complaint/grievance. Review of the facility's Grievance Form, revised 12/2016, showed at the bottom of the form boxes to be checked by the facility or the Grievance Officer that included the following: -Grievance recorded on Grievance Log. -Decision/Investigation outcome discussed with person filing grievance on [DATE] by [initials of person who discussed outcome]; -Grievance resolved/no further action to be taken, or unable to resolve. 1. During an interview on 02/10/25, at 10:11 A.M., Family Member (FM) 2 was in Resident #60's room. FM 2 indicated one of the biggest concerns was the door coming into the unit was always buzzing and going off. FM 2 said about 90% of the time it malfunctioned and the alarm goes off. At times, it has alarmed for up to 15 minutes. The lengthy time the alarm went off was because no one could get to it right away. FM 2 indicated filing a grievance over a year ago and nothing had happened. The Social Service Director (SSD) told him/her it was brought up in a meeting, but nothing has happened to fix it. Observation on 02/11/25, at 12:45 P.M., in the memory care unit, showed an ongoing issue with the door alarm. During lunchtime, the door alarm was repeatedly sounding, and staff members were actively managing the alarm by turning it off and on to stop the noise. During an interview on 02/11/25, at 12:47 P.M., License Practical Nurse (LPN) 1 confirmed he/she was aware of the door's buzzing problem. The LPN explained the issue could be managed by being careful about how the door was closed. During an interview on 02/12/25, at 3:08 P.M., the Maintenance Man discussed the dementia unit door issue. He explained the door's magnet sometimes shifted and turned sideways. To prevent problems, staff members were instructed not to slam the door, but instead to close it gently. The Maintenance Man indicated this had been a long-standing practice at the facility, stating, I was told it has been that way, and this is what we do. He also mentioned that he had not received any complaints about noise from the door. During an interview on 02/13/25, at 10:19 A.M., the Administrator discussed concerns about a door alarm system. According to the Administrator, people sometimes caused the door alarm to malfunction by allowing the door to slam, which created a gap that prevented the alarm from triggering. The Administrator stated during his time at the facility, they had adjusted the door multiple times. The door alarm was designed to sound when the door was not closed securely. If the door closed too slowly, it might trigger the alarm. The Administrator stated he knew who complained about the door and he has had multiple conversations about the issue. When asked to review any grievances and written resolutions, the Administrator denied the survey team their request. 2. Review of the facility's policy titled, Personal Property, revised September 2012 showed the resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. Review of Resident #91's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab showed the resident was admitted to the facility on [DATE]. Review of the resident's quarterly Minimum Data Assessment (MDS), with an assessment reference date (ARD) of 12/04/24 and located in the resident's EMR under the MDS tab, showed the resident was not a candidate for a brief interview for mental status (BIMS) interview. The resident had short- and long-term memory problems. Review of of the resident's Inventory Sheet, dated 06/17/24 and located in the resident's EMR under the Misc [miscellaneous] tab, showed personal items inventoried upon admission. During an interview on 02/10/25, at 1:48 P.M., Family Member (FM) 3 said the resident had several pieces of missing clothes. The facility was responsible for doing the resident's laundry. FM 3 talked to nurses, case workers, and the Administrator about missing clothes. The resident had a dozen pants now down to four pants, no socks, fleece jacket, two blankets, and a gray hoodless jacket. FM 3 said she brought clothes for the resident and the facility was to label and add them to the rest of the resident's belongings. FM 3 said he/she had completed several grievances, and most of the grievances she never received anything back after filing them. During an interview on 02/12/25, at 4:02 P.M., the Social Services Assistant (SSA) said housekeeping labeled the clothes with a label maker. For the residents who resided on the short-term hall, at times he/she marked items with a marker. He/she said he/she did not know the process exactly to label personal items that are brought in from home. The facility would turn missing items into grievance if the items were not found. The forms the facility had were internal forms only and the person filing a grievance does not get a copy of the form. During an interview on 02/12/25, at 4:19 PM, the Social Service Director (SSD) stated the resident had a care plan meeting, and the family mentioned a fleece sweater, socks, and a couple pair of pants were missing. The family was not provided or offered to file a grievance. During an interview on 02/13/25, at 10:19 A.M., the Administrator denied the survey team the access to the grievances and/or documented resolutions.

Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications when on one resident (Resident #54), of five residents reviewed for unnecessary medication use, receive opioid pain medication without assessment of the proper pain level, without documention of non-pharmalogical interventions attempted first, and without documented monitoring for side effects. Review of the facility's policy for Medication Therapy, revised April 2007, showed the following: -Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks; -Upon or shortly after admission, and periodically thereafter the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen to identify whether there is a clear indication for treating that individual with the medication; the dosage is appropriate; the frequency of administration and duration of use are appropriate; and potential or suspected side effects are present. Review of the National Library of Medicine's website, accessed on 02/16/25, under the Bookshelf tab in book selection, State Pearls for Hydrocodone page, last update 01/29/24, showed the following: -Hydrocodone is primarily used to treat severe chronic pain that requires opioid analgesia and is not effectively treated by non-opioid alternatives; -Clinicians should vigilantly monitor patients for pain relief, constipation, respiratory depression, and other potential adverse effects; -The most common adverse effects of hydrocodone included frequent constipation and nausea; -Additional adverse effects of hydrocodone included the severe respiratory depression, shortness of breath, respiratory tract infection, hypotension (low blood pressure), bradycardia (fast heart beat), and peripheral edema (swelling), headache, chills, anxiety, sedation, insomnia, dizziness, drowsiness, fatigue, pruritus (itching), diaphoresis (excessive sweating), rash, vomiting, dyspepsia (discomfort or pain in the upper abdomen, often after eating or drinking), gastroenteritis (an inflammation of the lining of the stomach and intestines), constipation, abdominal pain, urinary tract infection, urinary retention associated with prostatic hypertrophy (a non-cancerous enlargement of the prostate gland, which is located below the bladder in men), tinnitus (a condition where a person perceives ringing, buzzing, hissing, or other noises in their ears or head, even when there is no external source of sound), sensorineural hearing loss, and secondary adrenal insufficiency. 1. Review of Resident #54's admission Record, dated 02/11/25, located in the resident's electronic medical record (EMR) under the Profile tab showed revealed the facility admitted the resident on 01/04/21 with diagnoses including chronic pain syndrome. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an assessment reference date (ARD) of 01/11/25, showed the facility assessed the resident had frequent pain, which occasionally affected his/her sleep. The resident received scheduled and as needed pain medication including an opioid. Review of the resident's Care Plan for chronic pain due to limited mobility, myopathy (a group of disorders that affect the muscles, causing weakness and other symptom), and polyneuropathies (disorders that affect multiple peripheral nerves, causing damage and dysfunction), initiated on 04/13/21, showed following interventions: -Administer medications as ordered by physician and monitor/document side effects and effectiveness each shift; -Assess pain on scale of 1 to 10 every shift; -Hydrocodone/APA had a black box warning of addiction, abuse, misuse, and life-threatening respiratory depression. Review of the resident's Administration Report, for order range 12/01/24 to 02/28/25, dated 02/12/25, showed the resident received Norco Tablet 10-325 milligrams (mg) (hydrocodone-acetaminophen), one tablet by mouth every 4 hours as needed for pain. The report showed the resident had received Norco when experiencing no pain and mild to moderate pain (scale 0 to 4) as follows: -From 12/01/24 to 12/31/24: 53 times. -From 01/01/25 to 01/31/25: 22 times. -From 02/01/25 to 02/11/25: 11 times. Review of of the resident's record showed there was no documentation that the staff offered nonpharmacological interventions for pain prior to administering Norco when the resident indicated mild to moderate pain. Staff did not document about whether the staff had been monitoring the opioid's adverse effects. During an interview on 02/11/25, at 3:42 P.M., the Director of Nursing (DON) reviewed the resident's record and said there was no documentation the opioid adverse effects were being monitored and the nonpharmacological interventions for pain were offered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to promote each resident's right to self-determination of care when staff did not provide showers as preferred and care planned for six resident (Resident #6, #7, #10, #30, #39, and #66) reviewed for showers out of 34 sampled residents This failure could lead to decreased quality of life and dignity. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Staff to document each bathing and notify the supervisor if any resident refuses the shower/tub bath; -The bathing documentation requirement included the the date and time the shower/tub bath was performed and if the resident refused the shower/tub bath, the reason; -Notify the supervisor if the resident refuses the shower/tub bath. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/2018, showed the following: -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; -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. 1. Review of Resident #10's admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the an admission date of [DATE]. Review of of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, showed the following: -The facility assessed the resident as moderately cognitively impaired; -The resident was dependent on staff to completion of the shower task. Review of the resident's Point of Care (POC) documentation showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 9:57 A.M., the resident said he/she gets one shower a week and he/she would like to get two showers a week. He/she only gets one on Monday and not the Thursday shower. The shower aide gets pulled to work on the floor instead. 2. Review of Resident #30'sadmission Record, undated, located in the resident's EMR under the Profile tab, showed an admission date of [DATE]. Review of the resident's quarterly MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident as cognitively intact; -The resident was being dependent on staff to complete showers. Review of of the resident's POC documentation showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE], -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 10:29 A.M., the resident said he/she had been at the facility about 13 months. He/she only got one shower a week and would like to get more than one shower. The facility does not two showers due to the shower aide being needed out on the floor instead. 3. Review of Resident #66's admission Record, undated and located in the resident's EMR under the Profile tab of the EMR, showed an admission date of [DATE]. Review of the resident's significant change in status MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident was cognitively intact; -The resident was dependent on staff to complete showers. Review of the resident's POC showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE] -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 10:17 A.M., the resident said he/she doesn't get his/her showers. There was one week he/she did not get a bath for one week. He/she would like to get two showers a week, but there's not enough staff to help out. One time they gave him/her a little shower. They took him/her in there and put him/her under the water, let the water fall on him/her, and then took him/her out as quick as they took him/her in. They did not wash him/her and called that a shower. 4. Review of Resident #39's admission Record, undated, located in the resident's EMR under the Profile tab, showed an admission date of [DATE]. Review of the resident's annual MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed as cognitively intact. -The resident to used a wheelchair and was dependent on staff for tub or shower transfers and to shower or bath him/herself. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit with limited mobility related to cerebrovascular accident (CVA - stroke) with hemiplegia (one-sided muscle paralysis or weakness); -Initiated [DATE], resident required dependent assistance by x 2 staff with bathing; -Initiated [DATE], resident prefers to have a whirlpool once a week and a sponge bath for his/her 2x week Tuesday/Friday. He/she prefers to have them after lunch with no set days. He/she agreed to have 2 whirlpools a week until his skin is healed. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as his care plan stated each Tuesday, Friday, and as needed. During the interview on [DATE], at 11:28 A.M., the resident said his/her last shower was about two weeks ago, with no bathing in between. He/she placed a bath request to the bath aides about two weeks ago, but no staff ever gave him/her one. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a whirlpool bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bath. -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During the interview on [DATE], at 3:35 P.M., the DON reviewed the resident's records and the monthly Documentation Surveyor Report V2 report for the resident's no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON stated that if a resident refuses to bathe, the staff should re-offer and document it. 5. Review of Resident #7's admission Record, undated, located in the resident's EMR under the Profile tab, showed an admission date of [DATE]. Revive of the resident's quarterly MDS, with an ARD of [DATE], and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed was cognitively intact; -The resident did not exhibit behavioral symptoms including rejecting care; -The resident used a wheelchair and required staff's supervision to touch assistance including verbal cues for tub or shower transfers; -The resident required substantial to maximal assistance to shower or bath him/herself. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit related to weakness; -Initiated [DATE], the resident required max assistance by 1 staff with bathing/showering 2x a week (Tues/Friday) and as necessary. -Initiated [DATE], the resident was independent with toilet transfers due to grab bar and required supervision assisting with all other transfers. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as hi/her care plan stated each Tuesday, Friday, and as needed. During an interview on [DATE], at 10:17 A.M., the resident said he/she got bathed once a week, which was not okay. He/she liked to be bathed two times a week. The resident said he/she had spoken to a social worker about his/her bathing preference. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident refused a bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not received a scheduled bath; -On [DATE], the resident received a bed bath; -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During an interview on [DATE], at 3:35 P.M., the DON reviewed the resident's records and the monthly Documentation Surveyor Report V2 report for the resident's no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON said that if a resident refuses to bathe, the staff should re-offer and document it. 6. Review of Resident #6'sadmission Record, undated, located in the resident's EMR under the Profile tab, showed an admission date of [DATE]. Review of the resident's quarterly MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident as cognitively intact; -The resident did not exhibit behavioral symptoms including rejecting care; -The resident used a wheelchair and required partial to moderate assistance for tub or shower transfer and substantial to maximal assistance for shower or bath. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit due to hereditary ataxia (a group of inherited neurological disorders characterized by progressive incoordination and loss of balance); -Initiated [DATE], provide sponge bath when a full bath or shower cannot be tolerated; -Initiated [DATE], resident was max assistance of 1 staff with bathing/showering 2 times a week Mon/Thursday and as needed. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as his/her care plan stated each Monday, Thursday, and as needed. During an interview on [DATE], at 1:39 P.M., the resident said he/she only received one bath a week instead of two times a week. The resident also said each Monday and Thursday were his/her scheduled shower days and that his/her last bath was last Thursday ([DATE]), which was the only bath of that week. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident received a shower; -On [DATE], the resident did not receive scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a shower; -On [DATE], the resident refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a shower; -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During an interview on [DATE], at 3:35 PM, the reviewed the resident's records, including the monthly Documentation Surveyor Report V2 report for the residents' no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON said that if a resident refused to bathe, the staff should re-offer and document it. 7. During an interview on [DATE],5 at 8:59 A.M., Certified Nurse Aide (CNA) 1 said his/her primary job was being a shower aide. Residents were supposed to get two showers a week unless they refuse. They wouldn't get a shower though if he/she was pulled to the floor because they were short staffed. The CNA said he/she gets pulled to the floor on average two days a week. During an interview on [DATE], at 1:34 PM, Registered Nurse (RN) 1 said the shower aides will let him/her know if a resident refuses their shower. Staff will still try to give them a second shower on the make-up days. Wednesday and Sundays are make-up shower days. If a resident repeatedly refuses, then staff will let their power of attorney know. There are not any resident who regularly refuses showers. All the residents have scheduled shower days, but sometimes staffing affects it. At times they do have to pull the shower aide to help out on the floor as an aide. During an interview on [DATE], at 12:17 PM, the DON said anytime a resident wants a shower on another day, the staff will accommodate them. The same goes if the shower aide gets pulled to the floor, staff will still give them a shower another day. During an interview on [DATE], at 2:05 PM, the Assistant Director of Nursing (ADON) said residents have two scheduled showers a week. He/she didn't know of any residents that were refusing showers. The shower aide was supposed to let the ADON know when a resident refused a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received their scheduled showers for six resident nts (Resident (R) R6, R7, R10, R30, R39, and R66) reviewed for showers out of 34 sampled residents This failure could lead to decreased quality of life and dignity. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Staff to document each bathing and notify the supervisor if any resident refuses the shower/tub bath; -The bathing documentation requirement included the the date and time the shower/tub bath was performed and if the resident refused the shower/tub bath, the reason; -Notify the supervisor if the resident refuses the shower/tub bath. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/2018, showed the followng: -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; -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. 1. Review of Resident #10's admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the an admission date of [DATE]. Review of of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, showed the following: -The facility assessed the resident as moderately cognitively impaired; -The resident was dependent on staff to completion of the shower task. Review of the residen'ts Point of Care (POC) documentation showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 9:57 A.M., the resident said he/she gets one shower a week and he/she would like to get two showers a week. He/she only gets one on Monday and not the Thursday shower. The shower aide gets pulled to work on the floor instead. 2. Review of Resident #30'sadmission Record, undated, located in the resident's EMR under the Profile tab, showed an admission date of [DATE]. Review of R30's quarterly MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident as cognitively intact; -The resident was being dependent on staff to complete showers. Review of of the resident's POC documentation showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE], -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 10:29 A.M., the resident said he/she had been at the facility about 13 months. He/she only got one shower a week and would like to get more than one shower. The facility does not two showers due to the shower aide being needed out on the floor instead. 3. Review of Resident #66's admission Record, undated and located in the resident's EMR under the Profile tab of the EMR, showed an admission date of [DATE]. Review of the resident's significant change in status MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident was cognitively intact; -The resident was dependent on staff to complete showers. Review of the resident's POC showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE] -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 10:17 A.M., the resident said he/she doesn't get his/her showers. There was one week he/she did not get a bath for one week. He/she would like to get two showers a week, but there's not enough staff to help out. One time they gave him/her a little shower. They took hium/her in there and put him/her under the water, let the water fall on him/her, and then took him/her out as quick as they took him/her in. They did not wash him/her and called that a shower. 4. Review of Resident #39's admission Record, undated, located in the resident's EMR under the Profile tab, showed an admission date of [DATE]. Review of the resident's annual MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed as cognitively intact. -The resident to used a wheelchair and was dependent on staff for tub or shower transfers and to shower or bath him/herself. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit with limited mobility related to cerebrovascular accident (CVA - stroke) with hemiplegia (one-sided muscle paralysis or weakness); -Initiated [DATE], resident required dependent assistance by x 2 staff with bathing; -Initiatiated [DATE], resident prefers to have a whirlpool once a week and a sponge bath for his/her 2x week Tuesday/Friday. He/she prefers to have them after lunch with no set days. He/she agreed to have 2 whirlpools a week until his skin is healed. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as his care plan stated each Tuesday, Friday, and as needed. During the interview on [DATE], at 11:28 A.M., the resident said his/her last shower was about two weeks ago, with no bathing in between. He/she placed a bath request to the bath aides about two weeks ago, but no staff ever gave him/her one. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident received a bed bath; -On [DATE], the reesident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a whirlpool bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident did nto receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the rsident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident refused a bath; -On [DATE], the residet received a bath. -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During the interview on [DATE], at 3:35 P.M., the DON reviewed the resident's records and the monthly Documentation Surveyor Report V2 report for the resident's no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON stated that if a resident refuses to bathe, the staff should re-offer and document it. 5. Review of Resident #7's admission Record, undated, located in the resident's EMR under the Profile tab, showed an admission date of [DATE]. Revive of the resident's quarterly MDS, with an ARD of [DATE], and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed was cognitively intact; -The resident did not exhibit behavioral symptoms including rejecting care; -The resident used a wheelchair and required staff's supervision to touch assistance including verbal cues for tub or shower transfers; -The resident required substantial to maximal assistance to shower or bath him/herself. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit related to weakness; -Initiated [DATE], the resident required max assistance by 1 staff with bathing/showering 2x a week (Tues/Friday) and as necessary. -Initiated [DATE], the resident was independent with toilet transfers due to grab bar and required supervision assisting with all other transfers. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as hi/her care plan stated each Tuesday, Friday, and as needed. During an interview on [DATE], at 10:17 A.M., the resident said he/she got bathed once a week, which was not okay. He/she liked to be bathed two times a week. The resident said he/she had spoken to a social worker about his/her bathing preference. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident refused a bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not recieve a scheduled shower; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not recieve a scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the residetn refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not received a scheduled bath; -On [DATE], the resident received a bed bath; -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During an interview on [DATE], at 3:35 P.M., the DON reviewed the resident's records and the monthly Documentation Surveyor Report V2 report for the resident's no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON said that if a resident refuses to bathe, the staff should re-offer and document it. 6. Review of Resident #6'sadmission Record, undated, located in the resident's EMR under the Profile tab, showed an admission date of [DATE]. Review of the resident's quarterly MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident as cognitively intact; -The resident did not exhibit behavioral symptoms including rejecting care; -The resident used a wheelchair and required partial to moderate assistance for tub or shower transfer and substantial to maximal assistance for shower or bath. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit due to hereditary ataxia (a group of inherited neurological disorders characterized by progressive incoordination and loss of balance); -Initiated [DATE], provide sponge bath when a full bath or shower cannot be tolerated; -Initiated [DATE], resident was max assistance of 1 staff with bathing/showering 2 times a week Mon/Thursday and as needed. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as his/her care plan stated each Monday, Thursday, and as needed. During an interview on [DATE], at 1:39 P.M., the resident said he/she only received one bath a week instead of two times a week. The resident also said each Monday and Thursday were his/her scheduled shower days and that his/her last bath was last Thursday ([DATE]), which was the only bath of that week. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident received a shower; -On [DATE], the resident did not receive scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a shower; -On [DATE], the resident refused a bath; -On [DATE], the reisdent received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident did nto receive a scheduled bath; -On [DATE], the resdient recieved a shower; -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During an interview on [DATE], at 3:35 PM, the reviewed the resident's records, including the monthly Documentation Surveyor Report V2 report for the residents' no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON said that if a resident refused to bathe, the staff should re-offer and document it. 7. During an interview on [DATE],5 at 8:59 A.M., Certified Nurse Aide (CNA) 1 said his/her primary job was being a shower aide. Residents were supposed to get two showers a week unless they refuse. They wouldn't get a shower though if he/she was pulled to the floor because they were short staffed. The CNA said he/she gets pulled to the floor on average two days a week. During an interview on [DATE], at 1:34 PM, Registered Nurse (RN) 1 said the shower aides will let him/her know if a resident refuses their shower. Staff will still try to give them a second shower on the make-up days. Wednesday and Sundays are make-up shower days. If a resident repeatedly refuses, then staff will let their power of attorney know. There are not any resideent who regularly refuses showers. All the residents have scheduled shower days, but sometimes staffing affects it. At times they do have to pull the shower aide to help out on the floor as an aide. During an interview on [DATE], at 12:17 PM, the DON said anytime a resident wants a shower on another day, the staff will accommodate them. The same goes if the shower aide gets pulled to the floor, staff will still give them a shower another day. During an interview on [DATE], at 2:05 PM, the Assistant Director of Nursing (ADON) said residents have two scheduled showers a week. He/she didn't know of any residents that were refusing showers. The shower aide was supposed to let the ADON know when a resident refused a shower.

Based on record review and interview, the facility failed administer psychotropic drugs only when medically necessary when staff failed to educate the residents and/or residents' representatives of the risks and benefits prior to starting the drugs, failed to monitor and document adequate behaviors indication to use the drugs, failed offer nonpharmacological interventions, and failed to monitor adverse side effects for antipsychotic, antidepressant, and anti-anxiety medication use for four residents (Resident #54, #60, #64, and #80) of five residents reviewed for unnecessary medication use. Review the facility's policy for Antipsychotic Medication Use, revised July 2022, showed the following: -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; -For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions; -Residents (and/or resident representatives) will be informed of the recommendations, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents (and/or representatives) may refuse medications of any kind; -The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications; -Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician. 1. Review of Resident #54's admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 01/04/21; -Diagnoses included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depressive and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an assessment reference date (ARD) of 01/11/25 and located in the resident's EMR under the MDS tab, showed the facility assessed that the resident did not exhibit mood or behavioral symptoms. The resident received antipsychotic, antianxiety, and antidepressant medication. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed psychotropic, antipsychotic, and anxiolytic [antianxiety] medications to treat/manage his/her bipolar with alteration in mood disorder, depression with anxiety, initiated 01/14/21 and revised 08/02/23, included the following interventions: -Monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications including unsteady gait, tardive dyskinesia (a chronic, involuntary movement disorder that can develop as a side effect of long-term use of certain medications, typically antipsychotic drugs), EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person initiated 08/02/23. -Administer medications as ordered by physician and monitor for side effects and effectiveness initiated on 01/14/21; -Alprazolam (used to treat anxiety disorders, panic disorders, and anxiety caused by depression) has a black box warning of risks from concomitant use with opioids. Abuse, misuse, and addiction dependence and withdrawal reactions, initiated on 08/02/23 and revised 10/26/23; -Fluxotine (antidepressant medication) had a black box warning of antidepressants increased the risk compared with placebo of suicidal thinking and behavior, initiated 06/10/22 and revised 10/26/23; -Monitor/document/report as needed adverse reactions to antidepressant therapy including change in behavior/mood/cognition, hallucinations/delusions. social isolation, suicidal thoughts, withdrawal, decline in ADL (activities of daily living) ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea and vomiting, dry mouth, dry eyes, initiated on 08/02/23. -Monitor/document/report as needed any adverse reactions to anti-anxiety therapy including drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, and blurred or double vision. Unexpected side effects included mania, hostility, rage, and aggressive or impulsive behavior, initiated on 08/02/23. -Quetiapine fumarate (atypical antipsychotic used to treat schizophrenia, bipolar disorder and depression) had a black box warning of increased mortality in elderly patients with dementia-related psychosis, initiated on 06/10/22 and revised on 10/26/23; -Resident with failed gradual dose reduction (GDR), suicidal thoughts. Clinically contradicted per psychiatric physician documentation due to bipolar disorder. Resident stated he/she felt like killing him/herself during attempted GDR. Resident is oriented, younger age for long term care placement, initiated on 08/02/23 and revised on 11/20/24; -Weekly and as needed visits with psychologist, initiated on 10/26/23 and revised 06/25/24. Review of the resident's Care Plan for risk for mood changes related to bipolar disorder, depression, and anxiety, initiated 01/14/21 and revised 12/13/23, showed the following interventions: -Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Review of the resident's record showed the staff did not care plan to include interventions of what target behaviors were being treating with the antipsychotic, antidepressant, and antianxiety mediation use. Review of the resident's Administration Report, for orders dated 12/01/24 to 02/28/25, and dated 02/12/25, showed the resident received phototropic medication by physician's order as follows: -An order, dated 12/04/22, for fluoxetine HCl capsule 40 milligram (mg), administer one capsule by mouth one time a day for depression/anxiety related to major depressive; -An order, dated 04/06/23, for alprazolam tablet 0.25 mg, administer one tablet by mouth three times a day related to generalized anxiety disorder; -An order, dated 04/06/23, for Seroquel oral tablet 300 mg, administer one tablet by mouth at bedtime related to bipolar disorder; -An order, dated 01/16/25, to observed symptoms not usual for the resident every shift for antipsychotic utilization. If observed, document in progress notes with physician and nurse practitioner notification. Review of the resident's medical record showed the facility monitored the adverse side effects for antipsychotic use; however, there was no documented evidence the facility monitored the adverse side effects for the antidepressant nor the antianxiety medication use. There was no documentation that the facility was monitoring the resident specified target behaviors for the antipsychotic, antidepressant, and antianxiety medication use and what non-pharmacological intervention were offered based on the target behaviors. There was no documentation regarding the the resident, nor was her representative being informed of the risks and benefits of her antipsychotic, antidepressant, or antianxiety medications before starting. During an interview on 02/11/25, at 3:39 P.M., the Director of Nursing (DON) said the facility did not have records documenting the daily target behaviors for the resident's psychotropic medication use. The facility only documented the exceptions for behavior motoring. If no documentation had been provided, no behavior would have been observed. The IDT (interdisciplinary team) routinely met once a week and documented the target behavior weekly, but not daily. After reviewing the resident's record, the DON said the facility combined all the adverse effects monitoring in the MAR (medication administration record) and did not have monitoring documentation by each drug class as the resident's care plan instructed. The facility's care plan for psychotropic medication use did not include interventions to monitor resident-specified target behaviors based on each drug class used. There was no consent record for the resident's psychotropic medication use. All the residents signed a consent to treat agreement upon admission, and the facility verbally notified residents or their families about the risks and benefits of the psychotropic medication. This may be documented in the progress notes, but the home does not have a standard form of consent listing the different risks and benefits of each antidepressant, antipsychotic, and antianxiety medication. 2. Review of Resident #64's admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 09/07/22; -Diagnoses included major depressive disorder, single episode, unspecified; other specified anxiety disorders; unspecified dementia; and psychotic disorder with delusions due to known physiological condition. Review of the resident's annual MDS, with an ARD of 01/08/25 and located in the resident's EMR under the MDS tab, showed the resident received antipsychotic, antidepressant, and antianxiety medications during the seven days prior to the ARD. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed a focus area for antidepressant medications with intervention to monitor for antidepressant and antianxiety medication side effects. Review of the resident's Orders, located in the EMR under the Orders tab, showed the following active orders: -Sertraline (an antidepressant), 100 mg, administer one tablet by mouth in the evening for depression related to major depressive disorder;. -Quetiapine (antipsychotic agent), 25 mg, administer one tablet by mouth at bedtime for depressive disorder; -Buspirone (an antianxiety), 10 mg, administer one tablet by mouth three times a day for anxiety related to other specified anxiety disorder; -Trazodone (an antidepressant), 50 mg, administer one tablet by mouth in the evening for depression related to major depressive disorder; -Desipramine (antidepressant), 25 mg, administer one tablet by mouth in the evening for chronic pain related to other chronic pain; -Observe symptoms not usual for the resident and if present document in progress note with physician/nurse practitioner notification every shift for antipsychotic utilization. (The Orders did not include an order for behavior monitoring or side effect monitoring for sertraline, bupropion, trazodone or desipramine.) Review of the resident's Pharmacy MRR (Medication Regimen Review)-Antidepressant, dated 11/27/24 showed the resident was prescribed multiple antidepressant medications, concomitant use could increase the risk for serotonin syndrome, and the clinical pharmacist advised to Please review and ensure adequate monitoring for adverse effects, including CNS (Central Nervous System) depression is in place if these medications are continued concomitantly. Review of the resident's MAR, dated December 2024, January 2025, and February 2025, showed staff did not document behavior monitoring or side effect monitoring for sertraline, bupropion, trazodone, or desipramine. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed no routine documentation related to behavior monitoring or side effect monitoring for antidepressant/antianxiety medications. 3. Review of Resident #60's admission Record, undated, located in the resident's EMR under the Profile tab, showed the following: -An admission date of 03/25/22; -Diagnoses included Alzheimer's Disease, anxiety disorder, and major depressive disorder. Review of the resident's quarterly MDS, with an ARD of 12/25/24 and located in the resident's EMR under the MDS tab, showed the resident had received antipsychotic and antidepressant medications, but not antianxiety medication, during the seven days prior to the ARD. Review of the resident's Care Plan, located in the resident EMR under the Care Plan tab, showed a focus area for antidepressant, antianxiety, and antipsychotic medications with the intervention to monitor for side effects and effectiveness. The Care Plan also included an intervention to monitor side effects and effectiveness PRN (as needed). Review of the resident's Orders, located in the EMR under the Orders tab, showed the following current orders: -Mirtazapine tablet (antidepressant), 15 mg, administer 2 tablet by mouth in the evening for appetite related to abnormal weight loss; -Seroquel tablet, 25 mg, administer 0.5 tablet by mouth in the evening related to major depressive disorder, recurrent, unspecified; -Sertraline tablet, 50 mg, administer 1.5 tablet by mouth in the evening related to anxiety disorder, unspecified; major depressive disorder, recurrent, unspecified; -Trazodone tablet, 50 mg, administer 1.5 tablet by mouth in the evening for insomnia related to insomnia; -Clonazepam tablet disintegrating (hypnotic agent) .5 mg, administer 1 tablet by mouth in the evening related to anxiety disorder, unspecified; -Observe symptoms not usual for the resident and if noted document in progress note with physician/nurse practitioner notification every shift for antipsychotic utilization (The Orders did not include an order for behavior monitoring or side effect monitoring for mirtazapine, sertraline, trazodone or clonazepam.) Review of the resident's MAR, dated December 2024, January 2025, and February 2025, and located in the resident's EMR under the Orders tab, showed no documentation of any behavior or side effect monitoring for mirtazapine, sertraline, trazodone, or clonazepam. Review of of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed no routine documentation related to behavior monitoring or antidepressant/antianxiety side effect monitoring. 4. Review of Resident #80's admission Record, undated, located in the resident's EMR under the Profile tab, showed the following: -admission date of 09/30/23; -Diagnoses included Alzheimer's Disease, anxiety disorder, and adjustment disorder with depressed mood, and dementia, severe, without behavioral disturbance. Review of the resident's significant change in status MDS, with an ARD of 11/13/24 and located in the resident's EMR under the MDS tab, showed the resident received antipsychotic, antianxiety, and antidepressant medications, but no hypnotic medication, during the seven days prior to the ARD. Review of the resident's Care Plan, located in the resident EMR under the Care Plan tab, showed focus areas for antidepressant, antianxiety, and antipsychotic medications with the intervention to monitor for side effects and effectiveness. The Care Plan also included an intervention to monitor for side effects and effectiveness PRN (as needed). The interventions for lorazepam included monitor for side effects and effectiveness every shift. Review of the resident's Orders, located in the EMR under the Orders tab, showed the following current orders: -Lorazepam tablet (hypnotic/antianxiety), .5 mg, administer 1 tablet by mouth three times a day related to generalized anxiety disorder; -Seroquel tablet, 25 mg, administer 25 mg by mouth in the evening for hallucinations; increased per failed attempt of GDR (gradual dose reduction)' -Duloxetine capsule delayed release sprinkle (antidepressant), 30 mg, administer 1 capsule by mouth one time a day related to visual hallucinations; -Trazodone tablet, 50 mg, administer mg by mouth at bedtime related to adjustment disorder with depressed mood' -Observe symptoms not usual for the resident and if yes document in progress note with physician/nurse practitioner notification every shift for antipsychotic utilization. (The Orders did not include an order for behavior monitoring or side effect monitoring for lorazepam, duloxetine, or trazodone.) Review of the resident's MAR, dated December 2024, January 2025 and February 2025, and located in the resident's EMR under the Orders tab, showed no behavior or side effect monitoring for lorazepam, duloxetine, or trazodone. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed no routine documentation related to behavior monitoring or antidepressant/antianxiety side effect monitoring. 5. During an interview on 02/13/25, at 2:25 P.M., the Clinical Pharmacist (Pharm D) said he/she would expect staff to monitor side effects and behaviors at least daily, particularly with residents on multiple psychotropic agents. The clinical pharmacist was unaware the facility had used PRN monitoring for psychotropic medications in the care plans. During an interview on 02/11/24, at 11:33 A.M. the Director of Nursing (DON) said behavior and side effect monitoring for psychotropic agents was documented in the MAR. During an interview on 02/11/25, at 3:39 P.M., the DON said behaviors and side effects were documented by exception or if the physician ordered specific monitoring after a medication change. The behaviors and side effects are discussed during IDT meetings.

Based on observations, interviews, and record review, the facility failed ensure storage of medication per standards of practice and in a manner that prevented possible of expired medications/supplies when staff failed to remove expired medications/supplies from one of two medication storage rooms and two of four medication carts. Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, showed the following: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. -If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observation on 02/13/25, at 9:07 A.M., with Licensed Practical Nurse (LPN) 4 of the medication cart at the nurses' station on Hall 400 showed one open box and one unopened box of Assure Prism blood glucose control solution with the expiration date of 12/07/24 were found in the first drawer of medication cart. LPN4 confirmed they were expired and removed them from the medication cart. Observation on 02/13/25, at 9:40 A.M., with LPN5 of the medication cart at the nurses' station on Hall 300 showed one open box of Assure Prism blood glucose control solution with the expiration date of 12/07/24 was found in the first drawer of the medication cart. LPN5 confirmed it was expired and removed it from the medication cart. Observation on 02/13/25, at 9:43 A.M., of the medication room at the nurses' station on Hall 300 was showed one open bottle of Docusate Sodium Liquid [stool softener laxative] that was not labeled with an open date and had an expiration date of 06/2024 was found on a shelf in the cabinet. LPN5 confirmed it was expired and removed it from the medication cart. During an interview on 02/13/25, at 9:43 A.M., LPN5 said he/she didn't know how long it had been up there, but staff don't use it. It's everyone's job to check for expired meds. Staff also have a monthly audit done when the pharmacy comes in the building. During an interview on 02/13/25, at 12:05 P.M., the Director of Nursing (DON) stated all the certified medication techs (CMT) and nurses are responsible for checking expiration dates. Our pharmacy comes in monthly and audits all the medication carts and medication rooms and removes all the expired meds too.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an effective infection control and prevention program was maintained for six residents (Resident #101, #211, #212, #215, #359, and #54) of 25 residents reviewed for infection control when the facility failed to clean and disinfect patient care equipment in between resident use. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022, showed the following: -Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Association (OSHA) Bloodborne Pathogens Standard. -Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment); -Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. 1. Review of Resident #101's admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab showed the resident was admitted to the facility on [DATE]. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an Assessment Reference Date (ARD) of 01/25/25 and located in the EMR under the MDS tab, showed the facility assessed the resident as cognitively intact. During an observation on 02/11/25, at 9:16 A.M., in the resident's room, Certified Medication Technician (CMT) 1 obtained the resident's blood pressure using a wrist cuff on the resident's right wrist. CMT1 obtained the resident's oxygen saturation (O2) using a pulse oximeter checking multiple fingers. CMT1 administered the resident's medications and left the resident's room. CMT1 set the unclean wrist cuff and pulse oximeter on top of medication cart without a barrier and moved his/her med cart to doorway of of Resident #211's room. 2. Review of Resident #211's admission Record, undated, located in the resident's EMR under the Profile tab showed the resident was admitted to the facility on [DATE]. Review of of the resident's admission MDS, with an ARD of 01/08/25, and located in the resident's EMR under the MDS tab, showed the facility assessed the resident to have a moderately cognitively impaired. During an observation on 02/11/25, at 9:24 A.M., CMT 1 picked up the unclean wrist cuff from the top of the medication cart and entered the resident's room. CMT1 obtained the resident's blood pressure using the wrist cuff on the resident's right wrist. CMT1 then obtained the resident's O2 reading using the pulse oximeter on his/her finger. CMT1 set the unclean wrist cuff and pulse oximeter on top of medication cart without a barrier and moved his/her medication cart to the doorway of Resident #212's room. 3. Review of Resident #212's admission Record, undated, located in the resident's EMR under the Profile tab revealed of the resident was admitted to the facility on [DATE]. Review of the resident's admission MDS, with an ARD of 01/28/25 and located in the resident's EMR under the MDS tab, showed the facility assessed the resident to be moderately cognitively impaired. During an observation on 02/11/25, at 9:43 A.M., CMT1 picked up the unclean wrist cuff from the top of medication cart and entered the resident's room. CMT1 obtained the resident's blood pressure using a wrist cuff on the resident's right wrist. CMT1 attempted to obtain the resident's O2 reading using the pulse oximeter on multiple fingers. CMT1 administered the resident's medications to him/her and left the resident's room. CMT1 then set the unclean wrist cuff and pulse oximeter on top of med cart without a barrier and moved her med cart to doorway of next resident's room to take vitals and administer meds too. 4. During an interview on 02/11/25, at 9:50 A.M., CMT1 said staff receive training once a month and get reminders all the time on infection control. He/she will wipe down the patient care equipment after using it on 5 to 6 residents. He/she didn't clean the wrist cuff or pulse oximeter before or after those three residents, but would have if they were on isolation or precautions. 5. During an observation on 02/13/25, at 9:07 A.M., CMT5 picked up a wrist cuff from top of the med cart and entered the Resident #212's room. CMT5 then obtained the resident's blood pressure using wrist cuff on his/her right wrist and obtained his O2 reading with the pulse oximeter he/she pulled out of his/her pocket. CMT5 administered the resident's medications to him/her, left the resident's room, set the now unclean wrist cuff and pulse oximeter on top of medication cart without a barrier, and moved the medication cart to doorway of the next resident's room to take vitals and to administer medications. 6. Review of Resident #215's admission Record, undated, located in the resident's EMR under the Profile tab showed the following: -admission date of 01/24/25; -Diagnoses included sepsis due to methicillin susceptible staphylococcus aureus (MRSA) and severe sepsis with septic shock. Review of the resident's admission MDS, with an ARD of 01/27/25 and located in the resident's EMR under the MDS tab, showed staff assessed the resident as cognitively intact. During an observation on 02/13/25, at 9:18 A.M., CMT5 donned PPE from the isolation cart outside he resident's doorway. The resident's door had signage of Contact Precautions posted to. The CMT stated, I don't know why he is on contact precautions. I believe it has something to do with his medical condition and why he is here at this facility. CMT5 picked up the wrist cuff and pulse oximeter from top of medication cart and entered the resident's room, leaving his door partially open. CMT5 obtained the resident's blood pressure using the wrist cuff on his/her right wrist and obtained his/her O2 reading with the pulse oximeter. CMT5 administered there resident's medications to him, doffed his/her PPE, set the wrist cuff on top of the medication cart without a barrier, put the pulse oximeter that he/she was holding into his/her pocket, washed his/her hands, exited the room, and closed the door. CMT5 moved the med cart to the doorway of next resident's room to take vitals and to administer medications. 7. Review of Resident #359's admission Record, undated, located in the resident's EMR under the Profile tab showed the resident was admitted to the facility on [DATE]. During an observation on 02/13/25, at 9:25 A.M., CMT5 picked up the unclean wrist cuff from the top of the medication cart and entered the resident's room. CMT5 obtained the resident's blood pressure using the wrist cuff on his/her right wrist and obtained his/her O2 reading with the pulse oximeter he/she pulled out of his/her pocket. CMT5 administered the resident's medications to him, left the resident's room, set unclean wrist cuff and pulse oximeter on top of the medication cart without a barrier, and moved her medication cart to the doorway of next resident's room to take vitals and to administer medications. 8. During an interview on 02/13/25, at 9:35 AM, CMT5 said staff are supposed to clean patient care equipment before, after, and in between each use. He/she forgot and didn't clean them between the three residents. 9. During an interview on 02/11/25, at 1:34 P.M., Registered Nurse (RN) 1 said he/she used to be the CNA program trainer and he/she always taught them to clean any type of patient care equipment with the disinfecting Sani-cloths after every use. During an interview on 02/12/25, at 10:54 A.M., the Infection Preventionist (IP) said patient care equipment should be cleaned between residents or whenever equipment is taken into a resident room. They are all trained to clean them that way and to use the cleaning wipes from the container with purple top. We have racks hanging on the walls on a couple of halls that have the cleaning wipes so they're easily accessible to staff to clean with. During an interview on 02/12/25, at 10:40 AM, the Director of Nursing (DON) said my expectation was that staff are all responsible for infection control. Staff are to use standard practice of cleaning for all patient care equipment before and after use on a resident. We task the infection control training with the IP, but staff always constantly giving everyone reminders.

Based on observations, interviews, and record review, the facility failed to ensure food items were stored in accordance with professional standards of practice for food service safety when expired foods were found in kitchen storage areas. Review of the facility's policy titled, Food Receiving and Storage, revised 10/2017, showed foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 1. Observation and interview on 02/10/25, at 9:01 A.M., alongside the Certified Director of Food Service (CDFS), showed a refrigerator in the main kitchen had an opened five-pound container of cottage cheese with a best by date of 02/01/25. The CDFS confirmed this food item was expired. Observation and interview on 02/12/25, at 9:02 A.M., alongside the CDFS, showed the dry storage room of the main kitchen had 15, 12-ounce cans of evaporated milk with best by dates of 05/02/24. The CDFS confirmed the items were expired. Observation and interview on 02/12/25, at 10:18 A.M., alongside the CDFS, showed the walk-in refrigerator in the main kitchen had unsliced ham stored in a clear plastic bag with a use-by date of 02/07/25. The CDFS confirmed the food item was expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to take steps to prevent further abuse and protect resident safety when staff failed to implement and care plan consistent and effective interventions for one resident (Resident #1) after resident-to-resident altercations with five residents (Resident #2, #3, #4, #5, and #6) resulting in continued altercations. The facility census was 99. Review of the facility's policy titled, Reporting Abuse, undated, showed the following: -The facility will not condone resident abuse by anyone, including staff members and other residents; -Physical abuse is defined as hitting, slapping, punching, kicking, etc. Review of the facility's policy titled, Preventing Resident Abuse, undated, showed the following: -Preventing resident abuse is a primary concern for the facility. It is the facility's goal to achieve and maintain an abuse-free environment; -The facility's abuse prevention program includes, assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect and assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 03/22, showed the following: -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 interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; -When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The interdisciplinary team reviews and updates the care plan:when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. 1. Review of Resident #1's face sheet (a snapshot of resident information) showed the following: -Initial admission date of 07/30/22; -Current admission date of 06/20/24; -Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbances, generalized anxiety disorder, major depressive disorder, restlessness and agitation, excoriation (skin-picking) disorder, cognitive communication deficit, and hallucinations. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/03/24, showed the following: -Severe cognitive impairment; -The resident had hallucinations and delusions; -Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred one to three days of the review period; -Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurred one to three days of the review period; -The resident was independent with transfers. Review of the resident's care plan, revised 07/31/23, showed the following: -The resident had physical (hitting) and verbal (cursing, yelling) aggressive threatening behaviors due to dementia and poor impulse control; -Staff to administer Seroquel (an antipsychotic medication) 50 milligrams, two tabs in evening and as needed; -Educate staff to be aware of beginning signs early for potential development of altercations. Review of the resident's care plan, revised 05/07/24, showed the following: -Resident had a diagnosis of dementia unspecified; -Provide the resident with a program of activities that is meaningful and of interest like watching tv and/or listening to music; -Encourage and provide opportunities for exercise, physical activity. Review of the resident's nursing notes showed the following: -On 05/24/24, at 1:38 P.M., Resident #1 slapped another resident on the right shoulder with an open hand. The residents can't recall the event. There was no redness or bruising to either resident. The residents were immediately separated. Staff initiated 15-minute checks for the aggressor. There were no visual witnesses. Review of camera footage confirmed event; -On 05/24/24, at 1:45 P.M., the resident was observed approaching another resident who was seated in a chair near the nurses' station. Resident #1 leaned in close to the other resident and started yelling at him/her, It is 144 degrees outside! Go home or you will die! Staff intervened and separated the resident without further incident; -On 05/24/24, at 2:05 P.M., resident walked toward another resident asking, Do you have a room here? When peer answered yes, Resident #1 sat down in a chair beside him/her and with a raised voice said, Well, you better go to it. Resident #1 is currently being monitored on 15-minute checks. Staff immediately separated the residents. Both residents said they felt safe. Resident #1 said mind your own business and leave me alone when asked why he/she told peer to go to their room. The resident paced in the dining room in line of sight; -On 05/25/24, at 4:30 P.M., the resident continued to be monitored due to recent incident with another resident with no aggressive or inappropriate behaviors noted or reported. Resident ambulated ad lib (at will) with rollator-style walker and continued to pace the unit. Resident has been belligerent with staff and resists redirection; -On 05/26/24, at 4:28 P.M., the resident observed on multiple occasions this shift acting in an aggressive manner towards staff, another resident, and his/her responsible party. Resident also observed pacing through unit and being belligerent with staff with each interaction. Multiple times this shift, resident has attempted to strike or actually struck staff members with his/her rollator-style walker with redirection attempts not successful. The resident's walker had a malfunction to front left wheel, causing wheel to sit at an angle without turning. This caused resident to struggle using the walker for ambulation. Several times, the resident was approached and informed of the issue with the wheel and the risk of continuing to use the walker. This nurse asked to look at the wheel to determine what the issue was several times, to which the resident responded, Just leave me the hell alone, although resident allowed this nurse to assess the walker one time. While this nurse attempted to examine malfunctioned wheel, resident shoved the walker forward, striking this nurse in the face with the frame of the walker, at which time this nurse retreated from the resident's immediate area. When this nurse called resident's responsible party to notify him/her of the resident's behaviors, the responsible party informed him/her that the resident had struck him/her with his/her walker earlier this morning while he/she was visiting. The responsible party also said he/she was agreeable to the resident having a psychiatric evaluation completed due to increased behaviors and aggressive episodes; -On 05/26/24, at 1:06 P.M., Resident #5 sat in his/her wheelchair in the hallway. Resident #1 ambulated past the resident and slapped Resident #5 in the face. Staff did not visibly witness the strike, but it was audible to several staff members. Resident #5 immediately cried out for assistance and when asked by staff what had happened, he/she said, He/She slapped me! Right in the face! I didn't even do anything to him/her! Resident #1 said Get the hell away from me! I didn't do anything to him/her! The residents were immediately separated by staff. There was no injury; -On 05/29/24, at 4:21 A.M., staff noted on 05/28/24, at 8:30 A.M., Resident #5's hair was pulled/grabbed by Resident #1. Resident #1 was heard yelling, Get out of my room. When staff responded to scene both residents were in the doorway of their shared room. Resident #1 was holding on to Resident #5's hair. The residents were separated and Resident #1 started walking towards Resident #5. In efforts to redirect resident, staff stepped in front of wheelchair and grabbed the armrest. Resident #1 attempted to ram his/her wheelchair into the staff member's legs. Resident #1 then said, Let go of me or I'll knock the hell out of you. Resident #5 was questioned about incident and said, I was just trying to get by and he/she grabbed a hold of my hair and kept telling me to move. I told him/her to let go of me and she/he said he/she wasn't going to. I'm afraid he/she's going to do it again and if he/she does I'm going to get him/her back next time. What's wrong with him/her? Do you think he/she's missing something from his/her diet? Resident #1 said Yeah, I pulled him/her hair because he/she was in my way. I'll do it to you too. Get away from me and stop bothering me. Staff escorted Resident #5 to the nurses' station for one-on-one supervision until room change. Resident #5 denied any pain or discomfort. Staff implemented 15-minute checks Resident #1 until he/she's in bed for the night. Hot rack charting in place related to several resident-to-resident altercations where this resident was the aggressor. Resident remains on 15-minute checks until in bed for the night. A one time only dose of Seroquel 25 mg administered per physician. The resident's pacing/wandering has decreased. -On 05/29/24, at 9:30 A.M., during one-on-one monitoring for safety with a CNA, resident abruptly struck the face of a facility nursing aide student several times. Resident denied recollection of event when questioned; -On 05/29/24, at 9:23 A.M., the Director of Nursing (DON) said he/she spoke with Resident #1's responsible party regarding the resident's violent behavior and verbal threats towards peers and staff that required continual observation and one-on-one cares. As a result of these events and for the safety and well-being of all parties on the Memory Care Unit (MCU), an emergency discharge notice had been prepared and the facility would discharge the resident to his/her place of residence on this date. The resident's responsible party verbalized his/her understanding. The DON acknowledged that this may present a difficult circumstance for him/her to navigate considering the amount of time for preparation. The on-call provider was informed of increased behaviors and aggressive actions and a new order for a psychiatric evaluation was given. New order noted and carried out. Resident transported to hospital via ambulance without further incident at approximately 4:00 P.M.; -On 5/29/24, at 4:58 P.M., staff noted at 9:00 A.M., the physician was contacted that there was an incident of unknown origin with suspicion of resident-to-resident altercation. A witness said he/she saw Resident #6 being shooed out of Resident #1's room. Resident #1 was pushing a wheelchair into Resident #6 in a herding fashion. Resident #6 said He/She's trying to kill me. When asked if he/she was okay, Resident #6 showed new hematomas (is an abnormal collection of blood outside of a blood vessel or significant bruising) on his/her hands and said he/she beat me. Resident #1 said I better not talk about it. Go away. A skin assessment was completed on Resident #6 with a hematoma found on left hand, middle finger, wrapping to webbing of fingers and a hematoma on dorsum (back) of his/her right hand. Residents were immediately separated. A CNA is to stay with Resident #1 for one-on-one supervision; -On 05/29/24, at 12:19 P.M., staff noted the resident was discharged from the facility at 11:42 A.M., in the custody of his/her responsible party; -On 06/14/24, at 1:03 P.M., the Social Services Director (SSD) documented Resident #1's family appealed the decision that was made to do an emergency discharge. Resident #1 had hurt many residents in the MCU. The physician and staff had tried everything to help him/her not cause physical harm to other residents, but he/she continued to hurt residents and staff. The last time he/she physically hurt a resident, the decision had to made to do an emergency discharge. The DON and unit nurse had to make the decision he/she could no longer stay or come back to keeping other residents safe. SSD sent a response to the State why the facility did not feel it in the best interest for the safety of our other residents to have her come back. SSD sent the same letter to the Ombudsman and his/her responsible party; -On 06/20/24, at 3:59 P.M., the resident was admitted to the facility. Review of the resident's care plan showed staff update the care plan regarding any additional monitoring to protect other residents when the resident readmitted to the facility. Review of the resident's nursing notes showed the following: -On 06/21/24, at 3:00 P.M., staff noted the resident was alert and oriented to self only and verbalized needs to staff without difficulty. The resident paced the memory care unit and denied pain or discomfort. No aggression or inappropriate behaviors observed or reported at this time; -On 06/22/24, at 8:29 P.M., the resident paced laps on unit, opened residents' doors and leaving them open, which caused other residents' distress. Staff was unable to redirect the resident; -On 06/22/24, at 8:55 P.M., staff entered another resident's room and found Resident #1 in the room. Resident #1 was informed it was not his/her room and he/she walked towards the door. Resident #1 told him/her, I'm going to hit the hell out of you one of these days, and walked out of the room; -On 06/22/24, at 9:55 P.M., a certified nurse aide (CNA) redirected the resident out of the wrong room and resident said, move out of my way or I'm going to pounce you; -On 06/23/24, at 5:28 P.M., staff heard raised voices from down the hall. Upon investigation he/she found a resident in a wheelchair in the door to her room with Resident #1 attempting to pull the other resident's wheelchair out of the room while he/she said, you are in my room. Staff separated the residents and Resident #1 was informed where his/her room was. Resident #1 than went to his/her room and sat down on the bed. When interviewed regarding what occurred Resident #1 did not provide any new information that had not been provided by the other resident during the interview. Staff implemented immediate Intervention of residents separated and 15-minute location monitoring initiated for Resident #1; Review of the resident's care plan showed staff did not care plan regarding the resident's behaviors since admission or new interventions to protect other residents. Review of the resident's nursing notes showed the following: -On 06/23/24, at 10:18 P.M., a CNA reported that, Resident #1 was in Resident #2's room again. When he/she got to room Resident #2's room, Resident #2 was in his/her wheelchair in the doorway to his/her room. Resident #2 reported that Resident #1, pushed me out. He/she asked Resident #2 if Resident #1 had pushed him/her wheelchair or his/her body. Resident #2 rubbed his/her left forearm and said, with my body. The nurse entered the room and found Resident #1 sitting on Resident #2's bed. He/she Instructed Resident #1 to stand and leave the room because it is not his/her room. Resident #1 stood and walked out of the room with his/her wheeled walker. He/She took a few steps and started to turn around and come back. The nurse stopped the walker with his/her hand and the resident struck the nurse's right arm with an open hand and walked away. A physical assessment completed on both residents with no signs or symptoms of injury. Staff initiated 15-minute monitoring Resident #1. Staff notified the on-call provider for both residents and family/responsible party for both residents. Immediate intervention of Resident #1 removed from Resident #2's room and instructed not to return. Resident #2 was brought to the nurses' station and continued 15-minute checks on both residents. (Staff previously documents 15-checks implemented earlier on 06/23/24.) Review of the resident's care plan showed staff did not care plan regarding the resident's behaviors since admission or new interventions to protect other residents. Review of the resident's nursing notes showed the following: -On 06/24/24, at 5:50 A.M., staff noted hot rack charting related to two incidents in which this resident was the physical aggressor against another resident, the same resident both times. Resident rested well overnight in his/her bed with no further episodes of anxiety or aggression; -On 06/24/24, at 3:21 P.M., staff noted hot rack charting related to two incidents in which this resident was the physical aggressor. Resident is on 15-minute checks and walked with his/her walker around the unit. Resident ate breakfast and lunch. The resident is adjusting, but he/she was not friendly; -On 06/25/24 at 3:54 P.M., staff noted hot rack charting related to resident being physically aggressive with another resident. Resident is irritable when spoken too, however, he/ she was not aggressive towards resident nor staff this shift; -On 06/26/24, at 1:38 P.M., staff noted hot rack charting with continued to monitor for aggressive behavior with no such behavior noted or reported at this time. Resident ambulates ad lib with rollator-style walker and continuously paces the MCU; -On 06/26/24, at 1:35 P.M., staff noted Resident #1 was readmitted to MCU with a current order for Seroquel 25 mg twice daily. The resident continues to pick skin, trying to shoo bump others with his/her walker, yell out, speak rudely to staff, and aggressive/agitated with peers. There were two additional resident-to-resident altercations since being readmitted to memory care unit. Current interventions included sertraline (antidepressant), Depakote (antiepileptic than can be used as a mood stabilizer), participated in group activities parallel to others in group setting, one-on-one activities, and snacks. Interdisciplinary Plan to continue to monitor behaviors and intervene as needed. The physician does not feel resident is appropriate for gradual dose reduction of medication this time due to extent of skin picking, refusal of cares, and verbal threats towards others. (Staff did not address the 15-minute checks previously implemented.) Review of the resident's care plan, revised 06/27/24, showed the following: -Staff will continue to monitor the resident for aggression, location, and potential aggression toward others; -Staff to redirect resident from area where others are at risk; -Resident will not be involved in further altercations; -Staff to redirect resident from others that he/she has been known to have altercations previously. Review of the resident's nursing notes showed the following: -On 06/30/24, while in the dining room, the aides heard a resident call out for assistance on the other side of the dining room. Upon investigating, a resident said Resident #1 struck her. The residents were immediately separated. Resident #1 denied having struck the other and told this nurse, Go to hell. Staff notified administrative on-call and reviewed camera footage. Review of the footage showed Resident #1 was ambulating and attempting to go around the other resident, who was seated in his/her wheelchair. Resident #1 was unable to go around the other resident and attempted to move the other resident's wheelchair. A verbal altercation took place between the two residents and Resident #1 struck the other resident on the right shoulder with an open hand four times. The other resident began calling for help and Resident #1 walked away. Following the incident, a physical assessment attempted on Resident #1. Resident #1 was noncompliant and refused to allow this nurse to perform a physical assessment. Staff initiated 15-minute checks for location monitoring for Resident #1. Staff reported incident to on-call physician and the resident's responsible party; -On 07/01/24, at 12:54 P.M., staff noted on 06/30/24, at 8:43 A.M., while in the dining room, the aides heard a resident call out for assistance on the other side of the dining room. Upon investigating, a resident said Resident #1 struck him/her. Staff immediately separated the residents. Resident #1 denied having struck the other and told this nurse, Go to hell. Staff notified administrative on-call and reviewed camera footage. Review of the footage showed Resident #1 was ambulating and attempting to go around the other resident, who was seated in his/her wheelchair. Resident #1 was unable to go around the other resident and attempted to move the other resident's wheelchair verbal altercation took place between the two residents and Resident #1 struck the other resident on the right shoulder with an open hand four times, the other resident began calling for help and Resident #1 walked away. Following the incident, a physical assessment attempted on Resident #1. Resident #1 was noncompliant and refused to allow this nurse to perform a physical assessment. Staff initiated 15-minute checks for location monitoring for Resident #1. The incident reported on-call physician and the residents responsible party. Long term intervention of staff will monitor Resident #1's location at all times when he/she ambulates in close proximity of any other residents. Staff will be especially aware when the resident is in close location of residents who present as weaker, or more confused. The resident has been observed targeting this type of resident when he/she is agitated or anxious. Staff will add to care plan that staff will monitor the resident's location at all times when he/she ambulates in close proximity of any other residents and will be especially aware when he/she is in close location of residents who present as weaker, or more confused. The resident had been observed targeting this type of resident when he/she is agitated or anxious. Staff delivered a 30-day exit notice to resident and representative due to unsafe behaviors. Review of the resident's care plan, revised 07/01/24, showed the following -The resident had a resident-to-resident altercation; -The resident will not cause injury or receive injury from resident-to-resident altercations; -Physical assessment attempted and resident was noncompliant and refused; -Staff initiated 15-minute location monitoring from 8:45 A.M. to 5:45 A.M.; -Staff gave the resident's responsible party a 30-day exit notice due to unsafe behaviors; -Staff to monitor the resident's location at all times when he/she ambulates in close proximity of any other residents, Staff will be especially aware when he/she is in close location of residents who present as weaker, or more confused. The resident has been observed targeting this type of resident when he/she is agitated. Review of the resident's nursing notes showed the following: -On 07/02/24, at 9:44 A.M., staff noted hot rack charting related to medication change with no adverse reaction noted. Resident walks with his/her walker and has kept far away from other residents. Staff will continue to monitor; -On 07/02/24, at 10:23 P.M., staff noted hot rack charting related to resident being physically aggressive with another resident as well as recent start of Depakote. No adverse reaction to Depakote. No inappropriate behavior with any residents. Resident did refuse to allow vital signs to be obtained; -On 07/03/24, at 5:39 P.M., staff noted he/she was approached by a CNA who said a resident reported to him/her that he/she was struck by Resident #1. When interviewed, the other resident said that he/she was struck in the back while sitting in him/her wheelchair. Upon camera review, Resident #1 was observed to shake his/her hand at the other resident and then struck the other resident in the right shoulder. Immediate intervention was residents immediately separated. Resident #1 refused to allow a physical assessment. Staff initiated 15-minute location monitoring Resident #1; -On 07/04/24, at 3:29 A.M., staff noted hot rack charting related to recent start of Depakote and also for having an incident in which resident was physically aggressive with another resident. Resident #1 has not been aggressive with any residents; however, he/she was verbally aggressive with staff and staff were unable to redirect. Resident paced in hallway until 10:00 P.M. when he/she went to bed. Resident has rested well overnight; -On 07/04/24, at 10:38 A.M., staff noted on 07/03/24, at 4:15 P.M., the nurse was approached by a CNA who said a resident reported to him/her that he/she was struck by Resident #1. When interviewed, the other resident said he/she was struck in the back while sitting in his/her wheelchair. Upon camera review, Resident #1 was observed to shake his/her hand at the other resident and then struck the other resident in the right shoulder. Staff initiated 15-minute location monitoring for Resident #1. Staff notified Resident #1's responsible party of the incident. Resident's physician notified of incident. Long tem intervention of Resident #1 again placed on 15 minute locator monitoring. Staff is [NAME] about resident location and behavior. The facility continued with active attempt to find more compatible placement for resident. Staff added to the care plan resident again placed on 15 minute locator monitoring. Staff is [NAME] about resident location and behavior. Staff to continue with active attempt to find more compatible placement for resident. -On 07/04/24, at 11:32 A.M., staff noted said hot rack charting of continue to monitor for adverse effects of recent medication change with no adverse effects observed at this time. Resident #1 remained on 15-minute location monitoring due to recent altercation with another resident. Resident continued to pace the MCU with no aggressive behaviors noted at this time. Review of the resident's care plan, revised 07/04/24, showed the following: -Resident #1 was again placed on 15-minute locator monitoring; -Staff is [NAME] about resident location and behavior; -The facility continued to actively attempt to find more compatible placement for the resident. Review of the resident's nursing notes showed the following: -On 07/05/24, at 7:52 P.M., staff noted a dietary aide brought resident to the nurses' desk and said, He/She's trying to jump him/her. Upon review of cameras Resident #1 viewed standing aggressively over peer as peer is trying to get away in his/her wheelchair. The resident followed him/her using a wheeled walker. Resident #1 viewed striking him/her right forearm in the dining room. Immediate intervention of residents separated and new order for Zyprexa (antipsychotic medication) received and Seroquel increased to three times daily. Staff will monitor the resident closely and redirected when necessary; -On 07/06/24, at 12:05 A.M., staff noted the resident continued on hot rack charting for increase in Seroquel and new orders for Zyprexa and Depakote. The resident also continued on monitoring for aggression towards peers. The resident as viewed persistently going after peer as peer was attempting to get away and pacing hallways circling around to posture to peer as he/she passed. Staff monitors closely to keep residents separate. Will continue to monitor for changes in condition; -On 07/06/24, at 2:15 P.M., staff noted hot rack charting of resident continued to be monitored for adverse effects of recent medication changes. The resident was observed to pace the MCU continuously. Several times this shift, resident has entered into another resident's room and became belligerent with the room's occupant and staff when attempts to redirect resident to his/her own room are attempted. Staff notified administration and on-call provider of continued aggressive behavior. The nurse was instructed by administration to contact a psychiatric facility regarding possible transfer to that facility. The nurse was informed by the psychiatric facility that facility has placement available, and that the facility required medical clearance prior to admission, which could be performed at the hospital. Staff notified on-call provider of continuing aggressive behaviors and received new order to send resident to the hospital. Review of the resident's care plan, revised 07/07/24, showed the following: -Resident #1 has episodes of verbal and physical aggression including: yelling, cursing, verbally threatening, and physically hitting peers and staff; -The resident will have no increase in episodes of verbal/physical aggressive behavior this next review period; -Resident to remain separated from targeted resident with 15-minute location monitor until bedtime; -Staff to supervise for further indicators of aggression. Review of the resident's physician orders sheets, dated June 2024 and July 2024, showed staff did not document any specific behavior monitoring in place. 2. Review of Resident #2's face sheet showed the following: -admission date of 03/08/22; -Diagnoses included dementia, generalized anxiety disorder, and major depressive disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -The resident displayed no behaviors in the assessment period; -The resident required substantial assistance for transfers. Review of the resident's care plan, updated 12/11/23, showed the following: -The resident had impaired cognitive function/dementia or impaired thought processes; -Staff to use positive approach techniques including approach the resident from the front, use a wave and extend hand, then approach, modify hand position to engage the hand under hand technique, move to the side of the resident, and stay at eye level; -Present just one thought, idea question, or command at a time. Review of the resident's nurses' notes showed the following: -On 06/23/23, at 4:49 P.M., staff heard raised voices from down the hall. Upon investigation the nurse found a resident in a wheelchair in the door to his/her room with Resident #1 attempting to pull the other resident's wheelchair out of the room while he/she said, you are in my room. Resident #2 said He/She hit me. He/She threw water at me. He/She hit me with water, not her hand. If he/she had hit me with his/her hand, I would've hit her back; -On 06/23/24, at 10:18 P.M.,staff noted a CNA reported Resident #1 is in Resident #2's room again. When he/she got to room Resident #2's room, Resident #2 was in his/her wheelchair in the doorway to his/her room. Resident #2 reported that Resident #1, pushed me out. He/she asked Resident #2 if Resident #1 had pushed him/her wheelchair or his/her body. Resident #2 rubbed his/her left forearm and said, with my body. LPN E entered the room and found Resident #1 sitting on Resident #2's bed. He/she Instructed Resident #1 to stand and leave the room because it is not his/her room. Resident #1 stood and walked out of the room with his/her wheeled walker. He/She took a few steps and started to turn around and come back. The nurse stopped the walker with his/her hand and Resident #1 struck LPN E's right arm with an open hand and walked away. A physical assessment was completed on both residents with no signs or symptoms of injury. Staff initiated 15-minute [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to one resident (Resident #42) and failed to consistently provide oral care assistance for one resident (Resident #91), with known dental issues, out of a sample of 24 residents. The facility had a census of 93. Review of the facility's policy titled, Activities of Daily Living (ADLs - dressing, grooming, bathing, eating, and toileting), Supporting, revised March 2018, showed the following: -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; -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). 1. Review of the facility's policy titled, Bath,Shower/Tub, revised February 2018, showed the following: -The purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -If the resident refused the shower/tub bath, document the reason why and the intervention taken; -Notify the supervisor if the resident refused the shower/tub bath. Review of Resident #42's face sheet (admission data) showed the following: -admission date of 10/08/21; -Diagnoses included anxiety disorder, reduced mobility, and major depressive disorder. Review of the resident's annual Minimum Data Set (MDS - a federally required assessment completed by facility staff), dated 09/09/23, showed the following: -Cognitive skills intact; -No behaviors; -No rejection of care; -Dependent on staff for shower/bath. Review of the resident's care plan, revised on 09/06/23, showed the following: -The resident has an ADL self-care performance deficit with limited physical mobility, alteration in musculoskeletal status related to muscle weakness, foot drop, and muscle wasting atrophy (decrease in size of an organ or tissue); -The resident prefers shower during the daytime hours with no specified preferred day of the week; -Staff to provide sponge bath when a full bath or shower cannot be tolerated; -The resident is dependent assistance of one staff. Review of the resident's September 2023 shower documentation showed the resident received a shower on the following days: -On 09/01/23; -On 09/11/23 (10 days after the prior shower); -On 09/12/23; -On 09/19/23 (7 days after the prior shower); -On 09/29/23 (10 days after prior shower). Review of the resident's October 2023 shower documentation showed the resident received a shower on the following days: -On 10/14/23 (15 days after prior shower); -On 10/27/23 (13 days after prior shower); -On 10/28/23. Review of the resident's November 2023 shower documentation showed the resident received a shower on the following days: -On 11/12/23 (15 days after prior shower); -On 11/21/23 (whirlpool) (9 days after prior shower). Review of the resident's progress notes, dated 08/18/23 through 11/29/23, showed staff did not document any refusal by the resident's of scheduled showers. During an interview on 11/30/23, at 9:12 A.M., the resident said the following: -He/she keeps track of his/her received showers on his/her phone; -The resident normally receives showers on Tuesday and Friday; -He/she refused a shower once awhile ago, but had not refused since then; -The last shower he/she received was on 11/12/23; -Not getting a regular shower made the resident feel dirty; -He/she would like to have a shower on the scheduled days; -He/she would like a shower at least once per week. During an interview on 11/30/23, at 10:05 A.M., Licensed Practical Nurse (LPN) E said the following: -Staff have not told him/her the resident refuses showers; -He/she has known the resident for sometime and he/she did not refuse showers. The resident may request another time for a shower, but not refuse; -He/she assigns an aide when he/she is the charge nurse on the 400 hall; -Staff should notify the charge nurse if a resident refuses a shower; -The nurse should talk with the resident and ask if a different time of day would be better for the shower; -The nurse aides complete a shower sheet and enter the shower in the computer; -The aides should document in the computer if a resident refused or received a shower. During an interview on 11/30/23, at 10:36 A.M., Certified Nurse Aide (CNA) V said the following: -The resident will refuse a shower if it is close to an activity time; -Staff had a shower list; -Aides documented completed showers in the computer; -Aides completed the shower sheets located at the nurses desk; -Nurses reviewed the shower sheets for skin issues; -Aides should report to the nurse if a resident refuses a shower and enter a note in the computer; -Staff should offer a resident a shower again on the next scheduled day if refuses. During an interview on 11/30/23, at 10:54 A.M., CNA W said the following: -The resident did not typically refuse showers; -Staff assigned the aides showers in the morning; -The nurses made the shower assignments; -If a resident refused a shower, aides should offer the resident a shower a few more times that day; -Staff should document on the shower sheet, computer and tell the nurse if a resident refuses. During an interview on 12/01/23 at 12:17 P.M., the Assistant Director of Nursing (ADON) said the following: -The aides give residents showers based on the shower books which show the days; -Weekends are make up days for residents who refuse; -She audits showers and refusals every few days; -Staff should document showers in the computer; -She checks the shower sheets weekly and documents the showers staff did not chart in the computer; -Aides come back later to the resident on the same day if a resident refuses a shower; -Aides should document if a resident refuses a shower and notify the nurse; -Nurses should document in the progress notes if a resident refuses a shower. During an interview on 12/01/23, at 1:11 P.M., the Director of Nursing (DON) said the following: -The resident did not refuse showers and has never complained about showers; -Staff give showers according to resident preference; -Staff should document in the computer if a resident refuses a shower. During an interview on 12/01/23, at 12:30 P.M., the Administrator said the following: -The resident is habitual with his/her refusal of showers; -Staff checked daily for showers; -Staff should attempt to reschedule if a resident refuses a shower; -Shower schedule is twice per week. 2. Review of the facility's Routine Dental Care policy, revised April 2007, showed the following: -The nursing care staff will conduct ongoing oral health assessments to assure that each resident receives adequate oral hygiene. -The facility's routine dental care includes, but is not limited to an initial evaluation of the resident's dental needs; daily dental and oral hygiene plan of care; and preventive care and treatment. Review of Resident #91's face sheet showed the following: -Initial admission on [DATE] and readmitted to the facility on [DATE]; -Diagnoses included dysphagia following cerebral infarction (difficulty swallowing after a stroke), cachexia (condition causing muscles to waste away), muscle weakness (generalized), muscle wasting, and atrophy (wasting or thinning of muscle mass). Review of the resident's current care plan, revised on 11/20/23, showed the following: -The resident had his/her own teeth that were broken and with cavities and gum inflammation; -The resident required extensive assist of one staff with personal hygiene and oral care; -Discuss oral health concerns with resident/responsible party. Observation and interview with the resident on 11/27/23, at 2:25 P.M., showed the resident had missing, broken, and discolored teeth. The resident said he/she knew he/she had dental issues, but at that time he/she experienced no mouth or gum pain. The resident said he/she ate most meals in his/her room, in bed. During an interview on 11/30/23, at 10:36 A.M., CNA V said the following: -Aides assisted residents with oral care in the morning and as needed. Aides documented it in the electronic medical record; -He/she assisted residents with oral care if they needed it or if their mouth was dirty; -He/she usually worked on another hall, but had cared for Resident #91 in the past. He/she had not assisted the resident with oral care today (11/30/23). During an interview on 11/30/23, at 10:54 A.M., CNA W said the following: -Aides assisted residents with oral care when they assisted residents up in the morning; -He/she also asked residents if they needed assistance with oral care; -If a resident stayed in bed, he/she tried to assist that resident with oral care after meals; -Staff documented oral care in electronic medical record along with other activities of daily living; -He/she had not personally assisted Resident #91 with oral care, but would if the resident asked. During an interview on 11/30/23, at 12:17 P.M., CNA X said the following: -Staff assisted residents with oral care when staff got residents up in the morning; -Staff documented providing oral care in the electronic medical record; -Oral care consisted of cleaning residents' dentures or brushing their teeth with toothpaste; -The CNA did not usually work on Resident #91's hall and had not assisted him/her with oral care including today (11/30/23). During an interview on 11/30/23, at 12:37 P.M., LPN C said the following: -Staff assisted residents with oral care in the morning or after meals; -Oral care consisted of cleaning dentures, brushing teeth, and flossing; -Resident #91's teeth were not in good condition, but they did not affect the resident's eating. Review of the resident's electronic health records (EHR), dated 11/01/23 to 11/30/23, showed staff documented they provided oral care to the resident two to three times daily. The documentation did not specify the type of oral care provided. During an interview on 12/01/23, at 8:44 A.M., the resident said the following: -Staff assisted him/her with oral care once or twice per week at his/her request. They did not provide oral care every day. -He/she could brush his/her own teeth, but needed staff to give him/her the supplies. During an interview on 12/1/23, at 11:30 A.M., Registered Nurse (RN) H said the following: -Staff assisted residents with oral care every morning and after meals and was part of regular care; -If a resident refused oral care, the aides notified the nurse; -Staff documented oral care and any refusals in the electronic medical record. During an interview on 12/01/23, at 11:45 A.M., LPN E said that following: -The aides assisted residents with oral care every shift and documented it in the electronic medical record; -Oral care consisted of brushing teeth and dentures, making sure no food remained in the mouth between meals, and keeping the mouth clean; -Resident #91's teeth were in poor condition. During an interview on 12/01/23, at 1:11 P.M., the DON said the following: -Aides or nurses could assist residents with oral care; -Staff should assist resident with oral care before and after meals; -Oral care included denture care, checking the mouth for pocketing, brushing teeth in the morning and evening, and per residents' preferences; -Staff documented oral care in electronic medical record; -Resident #19's teeth were in poor condition, staff should assist him/.her with oral care. During an interview on 12/1/23, at 2:48 P.M., the Administrator said staff should assist residents daily with oral care.

Based on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed-hold policy for one resident (Resident #94) who was transferred out to the hospital. A sample of three residents' closed records was selected for review in a facility with a census of 93. Review of the facility's policy titled Bed-Hold Charge, undated, showed the following: -In the absence of the resident from the facility, a daily bed-hold charge will be made until the personal effects of the resident are removed from the facility or a stop bed-hold agreement is signed; -Bed-hold provisions vary according to whether the resident is private or medicare, or medicaid for hospital/therapeutic leave so long as the facility occupancy rate is 97% or higher in accordance with state regulations, up to a maximum of 12 therapeutic leave days in a six month period; -If the resident's insurance covers the bed-hold period, the resident will not be billed separately for the amount covered. 1. Record review of Resident #94's face sheet (admission data) showed the following: -admission date of 10/17/23; -Diagnoses included acute kidney failure and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Review of the resident's physician order dated 10/18/23, at 9:28 A.M., showed an order to transfer the resident to the hospital for a behavioral evaluation. Review of the resident's progress notes showed the following: -On 10/18/23, at 10:29 A.M., a nurse documented the Assistant Director of Nursing (ADON) messaged nursing staff to send the resident back to the hospital for behaviors. The resident left the facility with emergency medical services at 11:50 A.M.; -On 10/18/2023, at 5:35 P.M., social service staff documented the resident's current placement was less then 24 hours and the resident was transferred back out to the hospital. Review of the resident's medical record showed staff did not document providing documentation of the bed hold policy to the resident or resident's representative at discharge to the hospital. During an interview on 12/01/23, at 12:14 P.M., the Business Office Manager (BOM) said the following: -She is responsible for sending the bed hold policy to the resident and/or representative; -She reviews discharges every morning; -She did not send the bed hold policy for the resident; -The facility had a lot of admissions and discharges for the month of October 2023 and she missed it; -She prints a copy of the bed hold policy and mails it to the resident or to the guardian. During an interview on 12/01/23, at 12:30 P.M., the Administrator said the BOM is responsible for sending the bed hold policy and should have sent it to the resident's responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to verify a resident's code status and failed to provide basic life support timely, including cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped), for one resident (Resident #95) of a sample of two residents who was found unresponsive. The facility census was 93. Review of the facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation, revised 02/2018, showed the following: -If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/Basic Life Support (BLS) shall initiate CPR unless the resident is a known that a Do Not Resuscitate (DNR - order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g., rigor mortis)); -If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR; -If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives; -If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. Instruct a staff member to activate the emergency response system (code) and call 911. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. 1. Review of Resident #95's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of [DATE]; -The resident was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive); -The resident had a responsible party; -Diagnoses included epilepsy (a brain disorder that causes recurring, unprovoked seizures), depression, anxiety, and dementia. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated [DATE], showed the following: -The resident had severe cognitive impairment; Review of the resident's care plan, revised [DATE], showed the following: -The resident lacked capacity to understand and make decisions regarding healthcare due to dementia and had the following Advance Directives and Durable Power of Attorney for health care decisions. The resident would have healthcare decisions made for him/her in accordance with any written advance directives if known and in accordance with the resident's best interests. Arrange for care plan conference with healthcare providers and resident's healthcare surrogate or healthcare agent to review the resident's current status and to make healthcare decisions at least quarterly and more often as needed; -The resident's code status was full code. If the resident's heart stops beating or the resident stops breathing, CPR would be initiated per the resident's/responsible party's wishes. Check to make sure that full code was listed as the resident's code status on the resident's profile/face sheet. Provide opportunity for the resident to discuss feelings and to ask questions related to end of life decisions as needed. Review code status with the resident/responsible party quarterly or as needed. Review of the resident's Physician's Order Sheet (POS), dated 10/2023, showed the following: -An order, dated [DATE], for CPR full code. Review of the resident's physician's progress note dated [DATE], at 5:56 A.M., showed the following: -Resident had been at baseline for 2:30 A.M. rounds. At approximately 5:15 A.M., certified nursing assistants (CNA) went into the resident's room to do morning cares and the resident was unresponsive. This nurse went in to assess the resident and noted that he/she was pale, skin cold to the touch and not breathing. The resident was noted to be deceased by two nurses listening for heart and lung sounds. While preparing to notify family, it was noted that the resident was a full code. Compressions were initiated at 5:25 A.M. Staff called Emergency Medical Services (EMS) and the resident was declared deceased at 5:30 A.M. by EMS. Staff notified the resident's family member, the resident's Nurse Practitioner, and Director of Nursing (DON). During an interview on [DATE], at 2:09 P.M., CNA F said the following: -He/she started work on [DATE], at approximately 6:15 A.M., and was told in report that the resident bled out in their sleep and passed away around 6:01 A.M. The CNA who gave him/her report said they walked into the room, saw blood everywhere and started CPR. During an interview on [DATE], at 2:41 P.M., Licensed Practical Nurse (LPN) G said the following: -When he/she assessed the resident after the resident was found unresponsive, he/she believed there was no chance of resuscitation because the resident was cold to the touch, blue, and had started to become stiff; -He/she asked a CNA to grab his/her stethoscope and another nurse was walking by the room at the time. He/she and the other nurse listened to the resident and the resident had no pulse and was not breathing; -He/she went and looked at the resident's chart approximately five minutes after the resident was found unresponsive and noticed the resident was full code and the other nurse then started compressions and he/she called 911; -The nurse started compressions because legally they were required to since the resident was a full code; -He/she did exactly what he/she was supposed to because there was absolutely no chance of reviving the resident. During an interview on [DATE], at 9:52 A.M., the DON said the following: -The resident was full code; -The nurse should have verified the resident's code status prior to verifying signs of life; -The nurse did not check the resident's code status until ten minutes after the resident was found unresponsive. The nurse should have checked the resident's code status immediately; -He/she was responsible for ensuring staff know the proper procedure when a resident was found unresponsive. During an interview on [DATE], at 12:23 P.M., LPN A said he/she found the resident's code status in the electronic medical documentation program (EMR). During an interview on [DATE], at 8:38 A.M., Nursing Assistant (NA) B said he/she looked in EMR to verify a resident's code status. During an interview on [DATE], at 8:57 A.M., LPN C said he/she verified a resident's code status by looking in the EMR. During an interview on [DATE], at 2:00 P.M., the Activities Assistant said the following: -If he/she found a resident unresponsive, he/she checked their pulse, yelled for a nurse and if the resident was full code, started compressions until someone told him/her different; -He/she verified a resident's code status in the EMR. During an interview on [DATE], at 2:03 P.M., Certified Medication Technician (CMT) D said the following: -If a resident was unresponsive, he/she immediately notified the nurse and checked the resident's code status; -If the resident was full code, he/she grabbed the crash cart and followed the nurse's instructions from there. During an interview on [DATE], at 2:05 P.M., LPN E said the following: -If a CNA or CMT found a resident unresponsive, they should notify the charge nurse; -The charge nurse verified the resident's code status and assessed the resident for a pulse and if the resident was breathing; -The charge nurse instructed another staff member to notify EMS and started compressions if the resident's code status was full code and was not breathing or had no pulse; -He/she verified a resident's code status in the EMR. During an interview on [DATE], at 2:09 P.M., CNA F said the following: -He/she knew a resident's code status by asking the charge nurse; -If a resident was unresponsive, he/she called for the charge nurse, verified code status, and started CPR. During an interview on [DATE], at 2:41 P.M., LPN G said the following: -If a CNA found a resident unresponsive, they notified the nurse immediately; -The nurse assessed the resident, verified the code status as soon as possible, and, if the resident was full code, started CPR. During an interview of [DATE], at 8:37 A.M., Registered Nurse (RN) H said the following: -If a CNA or CMT found a resident unresponsive, they activated the emergency response and notified the nurse; -Any nursing staff could check the resident's code status in the EMR and someone should check the code status while the nurse assessed the resident with a stethoscope; -If the resident was full code, staff grabbed the crash cart and started compressions and breaths while another staff member called 911; -Facility nurses could not declare a resident deceased , but EMS could; -If a resident, who was full code, was cold, blue in color and started to get stiff, he/she still started compressions until EMS pronounced the resident deceased . During an interview on [DATE], at 9:52 A.M., the DON said the following: -If a CNA or CMT found a resident unresponsive, they called for help and initiated CPR if the resident was full code; -The charge nurse or CMT verified code status immediately; -If a resident was full code, nursing staff should start CPR even if the resident was cold, blue in color and starting to become stiff; -Staff should call 911, and any staff member could do this; -CPR should not be stopped until EMS took over. During an interview on [DATE], at 11:36 A.M., the Administrator said the following: -If staff found a resident unresponsive, they should immediately check the resident's code status and if the resident was full code, start CPR while another staff called 911.

Based on interview and record review, the facility failed to communicate and collaborate, consistent with professional standards of practice, with the dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) center for one resident (Resident #73), out of a sample of two residents, when staff did not consistently send and receive communication with the dialysis facility regarding each dialysis session. The facility census was 93. Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with, revised October 2010, showed the following: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The facility will ensure that residents who require dialysis receive such services, consistent with professional standards of proactive, the comprehensive person-centered care plan, and the resident's goals and preferences; -Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented and how information will be exchanged between the facilities. 1. Review of Resident #73's face sheet (a document that gives a patient's information at a quick glance) showed the following: - admission date of 06/13/22; - Diagnoses included acute kidney failure, edema (swelling), diabetes, and depression. Review of the resident's Physician Order Sheet (POS), showed the following: -An order, dated 06/19/23, to complete nursing communication with dialysis assessment Tuesday, Thursday, and Saturday (send copy with patient to be completed by dialysis). One time a day every Tuesday, Thursday, and Saturday for pre dialysis and in the afternoon every Tuesday, Thursday, Saturday for post dialysis. Review of the resident's care plan, revised 10/06/23, showed the following: -Monitor resident for adverse reactions from dialysis and notify nurse; -Dialysis assessment communication form to be completed prior to dialysis and upon returns as ordered by the MD (medical director); -Resident to attend all of his/her dialysis appointments. Review of the resident's nursing shared communication with dialysis assessment (electronic file), showed the nursing staff did not complete the communication with dialysis assessments from 08/22/23 through 12/01/23. During an interview on 11/30/23, at 10:16 A.M., Certified Nursing Assistant (CNA) I said social services handles dialysis communications. During an interview on 11/30/23, at 10:43 A.M., the RN/Clinical Instructor said the following: -Social services sets up transportation for residents to receive dialysis; -The shared communication with dialysis form is on the electric file and filled out by the nurses, printed, and sent with the resident to dialysis; -Sometimes dialysis fills out the rest of the communication form and returns it with the resident; -The completed form goes in the screen box at the nurse's desk; -Where the form goes after picked up from the screen box, he/she did not know; -The communication form is important so the nurse knows how the resident did at dialysis and if there are any concerns. During an interview conducted on 11/30/23, at 10:46 A.M., Licensed Practical Nurse (LPN) E said the following: -The dialysis communication form is paper and sent with the resident when going to dialysis; -The dialysis communication form goes in the screen box at the nurse's desk, when the resident returns to the facility, -The purpose of the form is for the facility and the provider to share information regarding the residents care. During an interview on 11/30/23, at 11:46 A.M., the Assistant Director of Nursing (ADON) said the following: -The resident should take the communication form with them to dialysis; -Very seldom does the dialysis center return the communication form; -They had difficulty getting the form back from dialysis; -The communication form goes in the screen basket at the nurses' desk when returned; -The ADON collects the forms every 24 to 48 hours; -The ADON scans the returned communication form into the resident's electronic file; -The resident goes to dialysis four to five days a week because he/she is not always able to receive dialysis; -The nursing staff hears about the resident's dialysis treatment by word of mouth from the transport driver; -The ADON has asked for communication forms from the dialysis center and has not received them; -If the resident is not able to receive dialysis, the nurse should document that in the residents nurse notes. During an interview on 11/30/23, at 2:56 P.M., the transport driver said the following: -The driver has been providing transportation for the resident consistently for two years; -The nurses do not send any document/form with the resident when he/she goes to dialysis; -When the dialysis center runs test they will send the residents results back with the resident to give to the nursing staff; -The dialysis center calls the facility routinely to keep the facility up to date on the residents care. During an interview conducted on 11/30/23, at 3:49 P.M., the Director of Nursing (DON) said the following: -The nurse should send the resident with the dialysis communication form along with a medication list when requested; -The dialysis center has not been returning the communication form; -The nurse should communicate new orders through phone call or fax; -The charge nurse should complete the communication with dialysis form, print the form, and send with the resident; -If the communication with dialysis form is not received when the resident returns from dialysis, the charge nurse should call the dialysis center for verbal report and document that information in the residents nursing notes; -The ADON scans the completed communication with dialysis form into the resident's electronic chart, then put in the screening basket at the nurse's desk; -Social Services is responsible for scheduling transportation to dialysis for the resident. During an interview on 12/01/23, at 12:30 P.M., the Administrator said the following: -The expectation of dialysis is out of his scope; -The electronic medical record has a communication tool; -They should be able to print out the communication with dialysis form and send with the resident.

Based on interviews and record review, the facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible abuse involving five residents (Resident #3, Resident #25, Resident #50, Resident #66, and Resident #82) out of 24 sampled residents. The facility census was 93. Review of the facility's policy titled Abuse Prevention Program, revised December 2016, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; -Investigate and report any allegations of abuse within timeframe as required by federal requirements. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: -Two hours if the alleged violation involves abuse or has resulted in serious bodily injury. 1. Review of Resident #'82's face sheet (admission data) showed the following: -admission date of 11/18/22 and readmission of 03/19/23; -Diagnoses included unspecified dementia, mild with agitation, anxiety disorder, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/13/23, showed the following: -Moderately impaired cognitive skills; -The resident had no behaviors. Review of the resident's care plan, dated 11/23/23, showed the following: -The resident has impaired cognitive function/dementia, or impaired thought processes; -Provide the resident with a homelike, therapeutic environment. Review of the resident's progress note dated 11/27/23, at 6:56 P.M., showed Licensed Practical Nurse (LPN) J documented the resident reported another resident touched his/her butt and ran his/her hand up his/her leg. Upon follow up by this nurse, resident recants statement and states he/she did not touch him/her inappropriately. The resident did not feel threatened, violated, sexually abused, just annoyed by his/her presence. LPN J educated the resident on appropriate ways to communicate emotions and needs. The facility will educate nursing staff to intervene when necessary when both residents are in common areas at the same time. During an interview on 11/28/23, at 4:19 P.M., LPN J said last night, on 11/27/23, the resident told him/her another resident (Resident #3) slapped his/her butt and groped his/her leg. LPN J reported this to the Director of Nursing (DON) immediately. The DON reviewed the facility cameras and found the resident was in the dining room and Resident #3 braised the back of Resident #82's knee with his/her fingertips. LPN J asked Resident #82 and told him/her staff reviewed the cameras and it showed Resident #3 braised back of his/her leg. Resident #82 said Resident #3 drives him/her crazy and did not think the resident touched his/her butt. LPN J said he/she would consider this an allegation of abuse. The facility staff reviewed the cameras to determine if this incident happened. During an interview on 11/28/23, at 8:50 P.M., LPN K said he/she heard in the nursing report that Resident #82 said Resident #3 came up behind him/her and grabbed his/her butt and ran his/her hand down the back of his/her leg. Facility staff reviewed the facility cameras and asked Resident #82 again about the incident and Resident #82 said it did not happen like that. LPN K said this is the only time he/she has heard about Resident #3 being inappropriate. During an interview on 11/29/23, at 9:08 A.M., the resident was in his/her room and appeared in no distress. The resident said he/she stood up at the nurses' station and Resident #3 walked by him/her. He/she thinks Resident #3 touched his/her leg. During an interview on 11/28/23, at 4:49 P.M., Certified Medication Technician (CMT) L said Resident #82 said this morning at around 6:00 A.M., when he/she came on shift, that Resident #3 was a hand full. Resident #82 said the resident hit him/her on the butt and he/she let everyone know. CMT L said the nurses said it is an increased behavior. He/she would consider this an allegation of sexual abuse due to Resident #3 touched Resident #82 without consent. During an interview on 11/28/23, at 5:10 P.M., Registered Nurse (RN) M said when he/she came on shift this morning, he/she heard from the charge nurse who had floated that there had been an allegation, but once the investigation was initiated and completed last night, Resident #82 said Resident #3 tried to smack his/her butt. During an interview on 11/30/23, at 12:19 P.M., the Administrator said the following: -The resident recanted the statement. Staff reviewed the facility cameras with no physical touching; -He would consider this an allegation of abuse; -The nurse followed up with the resident who said he/she was annoyed with the resident; -The resident is high functioning and he trusts the resident. The resident said nothing happened; -He has a two hour window to report an allegation of abuse to the state and did not report this allegation due to the resident said it did not happen. Review of DHSS records showed the facility did not self-report the allegation of possible abuse prior to 11/30/23. 2. Review of Resident #3's face sheet showed the following: -admission date of 09/04/19; -Diagnoses included Alzheimer's disease, anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Review of the resident's care plan, revised 09/05/23, showed the following: -The resident has impaired cognitive function/dementia; -The resident uses psychotropic medications to treat and manage his/her depression with psychotic with delusions diagnosis; -The resident uses anti-anxiety medication due to dementia with behavioral and psychotic disorder with anxiety. Review of the resident's annual MDS assessment, dated 09/07/23, showed the following: -Severely impaired cognitive skills; -Physical behavior symptoms toward others marked occurred four to six days, but less daily; -Other behaviors symptoms not directed toward others, but less daily. During an interview on 11/28/23, at 8:57 P.M., Certified Nurse Aide (CNA) O said the following: -The resident follows the residents and tries to play with their butts; -The resident is in a wheelchair and follows other residents; -He/she did not observe the resident touch other residents inappropriately, but has heard other residents say 'he/she tried to touch my butt. During an interview on 11/28/23, at 4:10 P.M., CNA P said the following: -Last week, the resident groped a person's butt last week. A family member came up and said the resident was inappropriate; -A couple of weeks ago, a CNA reported the resident touched Resident #25's butt; -RN M said he/she would check into it. During interviews on 11/28/23, at 4:49 P.M., and on 11/29/23, at 9:44 A.M., CMT L said the following: -The resident likes to follow residents of the opposite sex; -He/she sees the resident touch a resident's butt once per week and reports it to the charge nurse; -The resident purposely goes and pinches residents' butts with a grin on his/her face; -He/she reports the incidents to the nurses each time who say to watch the resident and keep away from other residents. Review of the resident's record showed staff did not document reporting these allegations of possible abuse. Review of DHSS records showed the facility did not self-report the allegations of possible abuse prior to 11/30/23. 3. Review of Resident #50's face sheet showed the following: -admission date of 08/19/19; -Diagnoses included Alzheimer's disease, unspecified dementia, and cognitive communication deficit. Review of the resident's quarterly MDS assessment, dated 11/20/23, showed the following: -Severely impaired cognitive skills; -No behaviors. Review of the resident's care plan, revised 11/17/23, showed the following: -The resident had impaired cognitive function/dementia or impaired thought process; -Staff to cue, reorient, and supervise the resident as needed. During an interview on 11/29/23, at 2:16 P.M., Staff Person U said Resident #3 touched the resident's breast last week. He/she reported the incident to a nurse who no longer works at the facility. He/she did not report this incident to the DON or Administrator. During an interview on 11/30/23, at 12:19 P.M., the DON said she did not hear reports of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear reports of this allegation of abuse. Review of the resident's record showed staff did not document reporting this allegation of possible abuse. Review of DHSS records showed the facility did not document reporting this allegation of abuse prior to 11/30/23. 4. Review of Resident #25's face sheet showed the following: -admission date of 10/23/23; -Diagnoses included unspecified dementia and anxiety disorder. Review of the resident's admission MDS assessment, dated 10/29/23, showed the following: -Severely impaired cognitive skills; -Physical behaviors directed toward others - one to three days; -Verbal behaviors directed toward others - one to three days; -Wandering occurred one to three days. Review of the resident's care plan, dated 11/07/23, showed the resident had impaired cognitive function/dementia or impaired thought processes. During interviews on 11/29/23, at 09:44 A.M. and 12:50 P.M., CMT L said the following: -On 11/12/23, at 11:30 A.M. the resident came over to Resident #66's dining room table and Resident #66 touched Resident #25's nipple and twisted it. The resident jerked his/her arm up and stepped back. Resident #66 grabbed the resident's wrist and pulled Resident #25 toward him/her. CMT L intervened and separated the residents; -CMT L reported this incident to two different nurses; -One nurse said he/she did not want to hear it because he/she did not want to chart on it; -CMT L did not report this incident to the DON and Administrator and should have reported it to administration staff; -No other staff witnessed the incident between the residents. During an interview on 11/29/23, at 9:19 A.M., CNA F said the following: -CNA O reported in the nursing report a week ago that staff found Resident #25 naked on top of Resident #3's in his/her bed; -He/she has not observed the incidents; -A charge nurse said this incident is already charted and documented. Record review of the resident's record showed staff did not document an incident of resident found in another resident's bed naked. During an interview on 11/29/23, at 10:54 A.M., LPN Q said he/she heard the resident strips off his/her clothes and walks down the hall. He/she heard staff found the resident in one of the resident's beds undressed, but did not remember what room. During an interview on 11/30/23, at 9:45 A.M., CMT D said he/she was told the resident was pulled out of Resident #3's bed. He/she thinks there was an instance where Resident #3 did not have any clothes on, but the residents were just laying there two or three weeks ago and nothing inappropriate. During an interview on 11/30/23, at 12:19 P.M. the DON said she did not hear of reports of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear reports of this allegation of abuse. Review of the resident's record showed staff did not document reporting these allegations of possible abuse. Review of DHSS records showed the facility did not self-report the allegations of possible abuse prior to 11/30/23. 5. Review of Resident #66's face sheet showed the following: -admission date of 10/09/21; -Diagnoses included Alzheimer and major depressive disorder. Review of the resident's annual MDS assessment, dated 10/07/23, showed the following: -Severely impaired cognitive skills; -No behaviors. Review of the resident's care plan, reviewed 07/17/23. showed the following: -Impaired cognitive function/dementia with impaired thought process related to Alzheimer's disease; -Use positive approach technique. During an interview on 11/29/23, at 9:44 A.M., CMT L said the resident touched Resident #25's nipple and twisted it on 11/12/23, at 11:30 A.M., and he/she reported it to two different nurses. During an interview on 11/30/23, at 12:19 P.M., the DON said she did not hear of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear reports of this allegation of abuse. Review of the resident's record showed staff did not document reporting this allegation of possible abuse. Review of DHSS records showed the facility did not self-report the allegation of possible abuse prior to 11/30/23. 6. During an interview on 11/28/23, at 4:10 P.M. CNA P said the following: -Types of abuse include physical, mental, emotional, and sexual; -Staff should report to the charge nurse immediately an allegation of abuse; -The facility should call the state within two hours with an allegation of abuse. 7. During an interview on 11/28/23, at 4:19 P.M., LPN J said the following: -Types of abuse include physical, mental and sexual; -Staff should report to the DON and Administrator immediately of an allegation of abuse; -The facility should call the state within two hours with an allegation of abuse. 8. During an interview on 11/28/23, at 4:49 P.M., CMT L said the following: -Types of abuse include verbal, physical, and sexual which could include inappropriate touching; -Staff should report to the charge nurse immediately of an allegation of abuse; -The facility should call the state under two hours with an allegation of abuse; -Nurses should notify the DON or on-call nurse with an allegation of abuse; -Nursing staff pass on in nursing report of allegations of abuse. 9. During an interview on 11/28/23, at 5:10 P.M., RN M said the following: -Types of abuse staff should monitor include physical, resident to resident abuse, staff to resident abuse, sexual, emotional and verbal; -Staff should separate the individuals with any allegation of abuse if observed or reported; -Staff should call the administration immediately of an allegation of abuse; -The facility should report to the state within two hours of an allegation of abuse. 10. During an interview on 11/29/23, at 9:19 A.M., CNA F said the following: -Types of abuse include sexual, physical, and resident-to-resident abuse; -Staff should separate residents from each other if abuse is observed or reported; -Staff should report to the charge nurse immediately of an allegation of abuse; -The facility should report to the state within two hours of an allegation of abuse. 11. During an interview on 11/29/23, at 10:54 A.M., LPN Q said the following: -Types of abuse include verbal, physical, sexual which is inappropriate touching; -Staff should separate the residents if abuse is observed or reported and notify the administrator as soon as possible; -The facility should notify the state within two hours of an allegation of abuse. 12. During an interview on 11/30/23, at 12:19 P.M., the DON said the following: -Types of abuse include neglect, misappropriation, physical, emotional, mental and sexual; -She expects staff to report to the charge nurse, DON, and Administrator immediately with an allegation of abuse; -There is a checklist in a folder at each nurses station regarding abuse; -The facility should notify the state in two hours with an allegation of abuse; -The facility encourages all disciplines to report immediately to the charge nurse if resident behaviors of touching other residents inappropriately. 13. During an interview on 11/30/23, at 12:19 P.M., the Administrator said the following: -Types of abuse include neglect, misappropriation, physical, emotional, mental, and sexual; -The facility should notify the state in two hours with an allegation of abuse. MO00228139, MO00228141, MO00228142, MO00228143 and MO00228171

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations of possible abuse were thoroughly and timely investigated when staff failed to document investigations of alleged abuse involving five residents (Resident #3, Resident #25, Resident #40, Resident #66 and Resident #82) out of a sample of 24 residents. The facility census was 93. Review of the facility's policy titled Abuse Prevention Program, revised December 2016, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; -Administration will protect residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; -Administration will identify and assess all possible incidents of abuse; -Administration will investigate and report any allegations of abuse within timeframe as required by federal requirements; -Administration will protect residents during abuse investigations. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017 showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 1. Review of Resident #'82's face sheet (admission data) showed the following: -admission date of 11/18/22 and readmission date of 03/19/23; -Diagnoses included unspecified dementia, mild with agitation, anxiety disorder and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/13/23, showed the following: -Moderately impaired cognitive skills; -The resident had no behaviors. Review of the resident's care plan, 11/23/23 , showed dementia and impaired thought. Review of the resident's progress note dated 11/27/23, at 6:56 P.M., showed Licensed Practical Nurse (LPN) J documented the resident reported another resident touched his/her butt and ran his/her hand up his/her leg. Upon follow up by this nurse, resident recants statement and states he/she did not touch him/her inappropriately, the resident did not feel threatened, violated, sexually abused, just annoyed by his/her presence. LPN J educated the resident on appropriate ways to communicate emotions and needs. The facility will educate nursing staff to intervene when necessary when both residents are in common areas at the same time. During an interview on 11/28/23, at 4:19 P.M., LPN J said last night, on 11/27/23, the resident told him/her Resident #3 slapped his/her butt and groped his/her leg. LPN J reported this to the Director of Nursing (DON) immediately. The DON reviewed the facility cameras and found the resident was in the dining room and Resident #3 braised the back of Resident #82's knee with his/her fingertips. LPN J asked Resident #82 and told him/her staff reviewed the cameras and it showed Resident #3 braised back of his/her leg. Resident #82 said Resident #3 drives him/her crazy and did not think the resident touched his/her butt. LPN J said would consider this an allegation of abuse. The facility staff reviewed the cameras to determine if this incident happened. During an interview on 11/28/23, at 8:50 P.M., LPN K said he/she heard in the nursing report that Resident #82 said Resident #3 came up behind him/her and grabbed his/her butt and ran his/her hand down the back of his/her leg. Facility staff reviewed the facility cameras and asked Resident #82 again about the incident and Resident #82 said it did not happen like that. During an interview on 11/29/23, at 9:08 A.M., the resident said he/she stood up at the nurses' station and Resident #3 walked by him/her. He/she thinks Resident #3 touched his/her leg. During an interview on 11/28/23, at 4:49 P.M., Certified Medication Technician (CMT) L said Resident #82 said this morning at around 6:00 A.M., when he/she came on shift, that Resident #3 was a hand full. Resident #82 said the resident hit him/her on the butt and he/she let everyone know. CMT L said the nurses said it is an increased behavior. He/she would consider this an allegation of sexual abuse due to Resident #3 touched Resident #82 without consent. During an interview on 11/28/23, at 5:10 P.M., Registered Nurse (RN) M said when he/she came on shift this morning, he/she heard from the charge nurse who had floated that there had been an allegation, but once the investigation was initiated and completed last night, Resident #82 said Resident #3 tried to smack his/her butt. During an interview on 11/30/23, at 12:19 P.M., the DON said staff followed up with one more alert resident who said they felt safe. During an interview on 11/30/23, at 12:19 P.M., the Administrator said the following: -The resident recanted the statement. Staff reviewed the facility cameras with no physical touching; -He would consider this an allegation of abuse; -The nurse followed up with the resident who said he/she was annoyed with the resident; -The resident is high functioning and he trusts the resident. The resident said nothing happened. Review of DHSS records showed the facility did not provide copy of an investigation of the allegation prior to 11/30/23. 2. Review of Resident #3's face sheet showed the following: -admitted on [DATE]; -Diagnoses included Alzheimer's disease, anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Review of the resident's annual MDS assessment, dated 09/07/23, showed the following: -Severely impaired cognitive skills; -Physical behavior symptoms toward others marked occurred four to six days, but less daily; -Other behaviors symptoms not directed toward others, but less daily. Review of the resident's care plan, revised 08/02/23 showed the following: -The resident has impaired cognitive function/dementia; -The resident uses psychotropic medications to treat and manage his/her depression with psychotic with delusions diagnosis; -The resident uses anti-anxiety medication due to dementia with behavioral and psychotic disorder with anxiety. During a phone interview on 11/28/23, at 8:57 P.M., Certified Nurse Aide (CNA) O said the following: -The resident follows the residents and tries to play with their butts; -The resident is in a wheelchair and follows other residents; -He/she did not observe the resident touch other residents inappropriately, but has heard other residents say he/she tried to touch his/her butt. During an interview on 11/28/23, at 4:10 P.M., CNA P said the following: -Last week, the resident groped a person's butt last week. A family member came up and said the resident was inappropriate; -A couple of weeks ago, the CNA reported the resident touched Resident #25's butt; -RN M said he/she would check into it. During interviews on 11/28/23, at 4:49 P.M., and on 11/29/23, at 9:44 A.M., CMT L said the following: -The resident likes residents of the opposite sex and follows them; -He/she sees the resident touch a resident's butt once per week and reports it to the charge nurse; -The resident purposely goes and pinches residents' butts with a grin on his/her face; -He/she reports the incidents to the nurses each time who say to watch the resident and keep away from other residents. During an interview on 11/30/23, at 12:19 P.M., the DON said staff followed up with one more alert resident who said they felt safe. Review of DHSS records showed the facility did not provide copy of investigation of the allegation prior to 11/30/23. 3. Review of Resident #50's face sheet showed the following: -admitted on [DATE]; -Diagnoses included Alzheimer's disease, unspecified dementia and cognitive communication deficit. Review of the resident's quarterly MDS assessment, dated 11/20/23, showed the following: -Severely impaired cognitive skills; -No behaviors. Review of the resident's care plan, revised 11/17/23, showed the following: -The resident has impaired cognitive function/dementia or impaired thought process; -Staff to cue, reorient, and supervise the resident as needed. During an interview on 11/29/23, at 2:16 P.M., Staff Person U said the Resident #3 touched the resident's breast last week. He/she reported the incident to a nurse who no longer worked at the facility. He/she did not report this incident to the DON or Administrator. During an interview on 11/30/23, at 12:19 P.M., the DON said she did not hear or investigation reports of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear or investigate reports of this allegation of abuse. Review of DHSS records showed the facility did not provide copy of investigation of the allegation prior to 11/30/23. 4. Review of Resident #25's face sheet showed the following: -admitted on [DATE]; -Diagnoses included unspecified dementia and anxiety disorder. Review of the resident's admission MDS assessment, dated 10/29/23, showed the following: -Severely impaired cognitive skills; -Physical behaviors directed toward others - one to three days; -Verbal behaviors directed toward others - one to three days; -Wandering occurred one to three days. Review of the resident's care plan, dated 11/07/23, showed the resident has impaired cognitive function/dementia or impaired thought processes. During interviews on 11/29/23, at 9:44 A.M. and 12:50 P.M., CMT L said the following: -On 11/12/23, at 11:30 A.M., the resident came over to Resident #66's dining room table. Resident #66 touched Resident #25's nipple and twisted it. The resident jerked his/her arm up and stepped back. Resident #66 grabbed the resident's wrist and pulled Resident #25 toward him/her. CMT L intervened and separated the residents; -CMT L reported this incident to two different nurses; -One nurse said he/she did not want to hear it because he/she did not want to chart on it; -CMT L did not report this incident to the DON and Administrator and should have reported it to administration staff; -No other staff witnessed the incident between the residents. During an interview on 11/29/23,at 9:19 A.M., CNA F said the following: -CNA O reported in the nursing report a week ago that staff found Resident #25 naked on top of Resident #3's in his/her bed; -He/she has not observed the incidents; -A charge nurse said this incident is already charted and documented. Review of the resident record showed staff did not document regarding resident found in another resident's bed naked. During an interview on 11/29/23, at 10:54 A.M., LPN Q said he/she heard the resident strips off his/her clothes and walks down the hall. He/she heard staff found the resident in one of the resident's beds undressed, but did not remember what room. During an interview on 11/30/23, at 9:45 A.M., CMT D said he/she was told the resident was pulled out of Resident #3's bed. He/she thinks there was an instance where Resident #3 did not have any clothes on, but the residents were just laying there two or three weeks ago and nothing inappropriate. During an interview on 11/30/23, at 12:19 P.M., the DON said she did not hear or investigate the reports of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear or investigate the reports of this allegation of abuse. Review of DHSS records showed the facility did not provide copy of investigation of the allegation prior to 11/30/23. 5. Review of Resident #66's face sheet showed the following: admission date of 10/09/21; Diagnoses included Alzheimer and major depressive disorder. Review of the resident's annual MDS assessment, dated 10/07/23, showed the following: -Severely impaired cognitive skills; -No behaviors. Review of the resident's care plan, reviewed 07/17/23. showed the following: -Impaired cognitive function/dementia with impaired thought process related to Alzheimer's disease; -Use positive approach technique. During an interview on 11/29/23, at 9:44 A.M., CMT L said the resident touched Resident #25's nipple and twisted it on 11/12/23, at 11:30 A.M., and he/she reported it to two different nurses. During an interview on 11/30/23 at 12:19 P.M., the DON said she did not hear or investigate of this allegation of abuse. During an interview on 11/30/23 at 12:19 P.M., the Administrator said he did not hear or investigate this this allegation of abuse. Review of DHSS records showed the facility did not provide copy of investigation of the allegation. prior to 11/30/23. 6. During an interview on 11/28/23, at 4:19 P.M., LPN J said the charge nurse initially starts the abuse investigation. The DON and Administrator review the facility cameras and investigate. 7. During an interview on 11/28/23, at 5:10 P.M. RN M said the following: -The DON or Administrator immediately starts an abuse investigation; -Staff should investigate the allegation of abuse until resolved or further actions. 8. During an interview on 11/30/23, at 12:19 P.M., the DON said the following: -There is a checklist in a folder at each nurses station regarding abuse; -The charge nurse initiates an assessment of the resident; -The interdisciplinary team approach interviews the resident, other staff members, and witnesses. 9. During an interview on 11/30/23, at 12:19 P.M., the Administrator said the following: -The charge nurse initiates an assessment of the resident; -The interdisciplinary team approach interviews the resident, other staff members, and witnesses. MO00228139, MO00228141, MO00228142, MO00228143 and MO00228171

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed maintain an effective infection control program when staff failed to properly dispose of used Personal Protective Equipment (PPE - gloves, gowns and masks) and failed to don the appropriate PPE when entering isolation rooms with residents positive with Coronavirus Disease 2019 (COVID-19); when staff failed to implement source control when the facility had resident positive for COVID-19; and when staff failed to separate and appropriately handle hall trays and cleaning supplies removed from isolation rooms with residents positive with COVID-19. The facility census was 93. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, showed the following: -The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency; -Healthcare facilities should have a plan for how SARS-CoV-2 (COVID-19) exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed; -Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking. sneezing, or coughing. Masks and respirators also offer varying levels of protection to the wearer. People, particularly those at high risk for severe illness, should wear the most protective mask or respirator they can that fits well and that they will wear consistently; -Source control options for health care personnel (HCP) include a NIOSH approved particulate respirator with N95 filters (a safety device that covers the nose and mouth and helps protect the wearer from breathing in some hazardous substances. An N95 mask protects a person from breathing in 95% of small particles in the air) or higher; a respirator approved under standards used in other countries that are similar to NIOSH approved N95 filtering face piece respirators; a barrier face covering that meets ASTM F3502-21 requirements including workplace Performance and Workplace Performance Plus masks; OR a well-fitting facemask; -When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment, they should be removed and discarded after the patient care encounter and a new one should be donned; -Source control is recommended more broadly in the following circumstances: by those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or facility-wide or, based on a facility risk assessment, targeted toward higher risk areas (e.g., emergency departments. Urgent care) or patient populations (e.g., when caring for patients with moderate to severe immunocompromised) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission; or have otherwise had source control recommended by public health authorities (e.g., in guidance for the community when COVID-19 hospital admission levels are high). Review of the facility's policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, dated 04/2022, showed the following: -The facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility; -This policy is based on current recommendations for standard precautions and transmission-based precautions, environmental cleaning, and social distancing for COVID-19; -While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including hand hygiene, respiratory hygiene, appropriate use of PPE, transmission-based precautions (where indicated), monitoring and reporting of respiratory infections, environmental cleaning (with EPA-registered disinfectants approved for use against SARS-CoV-2), and laundry practices; -To address asymptomatic and pre-symptomatic transmission, universal source control is being implemented when there is a COVID-19 outbreak in the facility, otherwise facemasks are optional for staff, residents, and visitors. Anyone entering the facility is required to have a face covering regardless of symptoms. Cloth face coverings are appropriate for visitors and residents. Cloth face coverings for source control are not considered PPE. Staff should wear a facemask at all times when in the facility if facility is in an outbreak status; -Standard precautions are utilized when caring for all residents. Review of the facility's policy titled Personal Protective Equipment, revised 10/2018, showed the following: -Personal protective equipment appropriate to specific task requirements is available at all times; -Personal protective equipment provided to personnel includes, but is not necessarily limited to, gowns/aprons/lab coats (disposable, cloth, and/or plastic), gloves (sterile, non-sterile, heavy-duty and/or puncture-resistant), masks, and eye wear (goggles and/or face shields); -Not all tasks involve the same risk of exposure, or the same kind or extent of protection. The type of PPE required for a task is based on the type of transmission-based precaution, the fluid or tissue to which there is a potential exposure, the likelihood of exposure, the potential volume of material, the probable route of exposure, and the overall working conditions and job requirements; -A supply of protective clothing and equipment is maintained at each nurses' station. PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed; -Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals. Review of the facility's policy titled Personal Protective Equipment - Using Face Masks, revised 09/2010, showed the following: -Objectives are to prevent transmission of infectious agents through the air, protect the wearer from inhaling droplets, prevent transmission of some infections that are spread by direct contact with mucous membranes, prevent the splashing of blood or body fluids into the mouth or nose, and prevent exposure to viruses from blood or body fluids; -Put the mask on before entering the room and after cleaning hands. -Be sure that face mask covers the nose and mouth while performing treatment or services for the patient; -Before changing a face mask, wash hands. -Do not remove the mask while performing treatment or services for the patient; -Follow established handwashing techniques; -Use a mask when providing treatment or services to a patient who has a communicable respiratory infection and when providing treatment or services to a patient and the use of a mask is indicated. -Obtain a mask, wash your hands, remove the mask from its container (Note: if gowning procedures are necessary, put the mask on before putting on gown.), place the mask over the nose and mouth and avoid any unnecessary handling of the mask; -Removing the mask: wash hands, remove the mask from the face, discard the mask into the designated waste receptacle inside the room, and wash hands. Review of the facility's sign for the sequence for donning and doffing personal protective equipment (PPE) showed the following: -The type of PPE used will vary based on the level of precautions required; e.g., standard and contact, droplet or airborne infection isolation; -Sequence for donning PPE is as follows: Gown - cover torso from neck to knees, arms to end of wrists and wrap around the back. Fasten in back of neck and waist. Mask or respirator - secure ties or elastic bands at middle of head and neck. Fit flexible band to nose bridge. Fit snug to face and below chin. Fit-check respirator. Goggles or face shield - place over face and eyes and adjust to fit. Gloves - extend to cover wrist of isolation gown; -Use safe work practices to protect self and limit the spread of contamination. Keep hands away from face, limit surfaces touched, change gloves when torn or heavily contaminated, and perform hand hygiene; -Sequence for removing personal protective equipment. Except for respirator, remove PPE at doorway or in anteroom (a small room between areas of contamination and treatment areas). Remove respirator after leaving patient room and closing door. Gloves - the outside of gloves is contaminated; grasp outside of glove with opposite gloved hand and peel off. Hold removed glove with gloved hand. Slide fingers of ungloved hand under remaining glove at wrist. Peel glove off over first glove. Discard gloves in waste container. Goggles or face shield - the outside of goggles or face shield is contaminated. To remove, handle by head band or ear pieces. Place in designated receptacle for reprocessing or in waste container. Gown - gown front and sleeves are contaminated. Unfasten ties. Pull away from neck and shoulders, touching inside of gown only. Turn gown inside out. Fold or roll into a bundle and discard. Mask or respirator - Front of mask/respirator is contaminated, do not touch. Grasp bottom, then top ties or elastics and remove. Discard in waste container; -Perform hand hygiene immediately after removing all PPE. Review of a sign placed on COVID-19 isolation rooms for droplet precautions showed everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry or remove face protection before room exit. Review of the facility's policy titled Coronavirus Disease (COVID-19) - Cleaning and Disinfecting, revised 09/2022, showed the following: -Standard cleaning and disinfection practices in accordance with the Centers for Disease Control and Prevention, measures are implemented when areas, material or equipment have likely been contaminated by a person with COVID-19; -Management of laundry, food service utensils, and medical waste are performed in accordance with routine procedures; -Once the resident has been discharged or transferred, staff, including environmental services personnel, should refrain from entering the vacated room without all recommended PPE until 24 hours has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use. 1. Observations on 11/28/23, at 8:32 A.M., showed the following: -Nursing Assistant (NA) N donned a surgical mask and gloves and entered isolation room [ROOM NUMBER] with a food tray; -NA N exited the room, doffed the gloves and mask and laid them on the PPE cart outside isolation room [ROOM NUMBER]; -He/she did not perform hand hygiene, donned new gloves, and surgical mask only, picked the soiled mask and gloves up off the PPE cart and entered room [ROOM NUMBER] to throw the soiled mask and gloves into the red bagged trash inside this room; -He/she continued into room [ROOM NUMBER] without removing the newly soiled gloves, performing hand hygiene or donning clean gloves; -He/she did not don a gown, eye protection, or N95 mask when entering room [ROOM NUMBER] or 322; -He/she exited room [ROOM NUMBER] carrying a hall tray and wearing the surgical mask and gloves and placed the tray on the hall cart; -He/she then doffed the surgical mask and gloves, used his/her elbow to open the door of room [ROOM NUMBER], placed the gloves and mask in the trash inside room [ROOM NUMBER] and performed hand hygiene. Observation on 11/28/23, at 12:23 P.M., showed the following: -NA N donned a gown, gloves, and surgical mask, and entered room [ROOM NUMBER]. He/she did not don a N95 mask or eye protection; -He/she later donned a gown, gloves and surgical mask and entered room [ROOM NUMBER]. He/she did not don a N95 or eye protection; -LPN C donned a gown, gloves, and N95 mask, and entered room [ROOM NUMBER]. He/she did not don eye protection. Observation on 12/01/23, at 10:16 A.M., showed the Housekeeping Supervisor exited room [ROOM NUMBER], which was a COVID-19 isolation room. He wore his gloves out of the room, touched the door handle, door frame and an empty cardboard box. He grabbed a red bag and placed it in the empty box, opened the door to room [ROOM NUMBER] again, and placed the box with a red bag inside the room. He then continued to walk down the hallway wearing the same gloves. During an interview on 11/29/23, at 8:57 A.M., Licensed Practical Nurse (LPN) C said the following: -Before entering a COVID-19 isolation room, he/she performed hand hygiene, donned a gown, gloves, goggles and N95 mask; -When he/she exited, he/she doffed all of the PPE and placed in the trash inside the room, performed hand hygiene and donned a new mask. During an interview on 11/30/23, at 12:11 P.M., Registered Nurse (RN) H said the following: -When staff entered an isolation room, they should put on a gown, mask and gloves and when they exit they should remove the PPE in the room, place in red bag and sanitize their hands; -Staff should not place used PPE on the PPE cart because it would contaminate all that is on the cart and bringing the used PPE out into the hallway could spread the virus. During an interview on 12/01/23, at 9:05 A.M., the Infection Preventionist (IP) said the following: -When staff enter a COVID-19 isolation room they should sanitize their hands, don gown, gloves, N95 mask and eye protection and when they exit they should doff the PPE, place in red bag in the resident's room, and sanitize their hands; -Staff should not enter COVID-19 isolation room only wearing surgical mask and should not doff the mask and gloves, exit the room and place the dirty PPE on the PPE cart. If the room they exited did not have a red bag for PPE, they should place in a regular trash bag, tie it up and leave in the room until they get the proper red bag receptacle in that room. During an interview on 12/01/23, at 9:52 A.M., the Director of Nursing (DON) said the following: -When staff entered a COVID-19 isolation room, they should wear a N95 mask, eye protection, gown and gloves and when they exited the room they should doff the PPE before they leave the room and sanitize their hands; -Staff should not enter those rooms wearing just a surgical mask and gloves; -Staff should not place a dirty mask and gloves after exiting an isolation room on top of the PPE cart because that would cause cross contamination. If they did not have what they needed in the isolation room, they could activate the call light and request the item or double bag the dirty PPE and leave in the room until they could get a red bag receptacle into the room. During an interview on 12/01/23, at 11:36 A.M., the Administrator said the following: -When entering COVID-19 isolation rooms, staff should don N95 mask, gown, and gloves and they should doff before leaving the room and place the PPE in the trash inside the room; -Staff should not exit isolation room and place dirty mask and gloves on PPE cart. This could spread the infection. 2. Observation and interview on 11/27/23, at 8:40 A.M., showed the following: -The administrator said the facility had three residents who tested positive for COVID-19 on two separate areas of the facility; -No staff wore face masks for source control in any area of the facility. Observations on 11/27/23, from 8:40 A.M. to 4:15 P.M., showed no staff wore face masks for source control on the two areas or halls where the COVID-19 positive residents resided. During an interview on 11/28/23, at 11:55 A.M., Administrative Assistant BB said the following: -When a resident tested positive for COVID-19, staff moved the resident to another area of the facility and placed them in isolation; -When visitors entered the facility, he/she would let them know if the facility had COVID-19 positive residents; -Source control depended on the number of residents who tested positive for COVID-19; -If a resident had COVID-19, staff and visitors were encouraged to wear masks in those rooms; -Last week, the Administrative Assistant asked the infection preventionist (IP) for more training regarding the facility's COVID-19 protocol. The IP told him/her he would provide that education the following week. During an observation interview on 11/28/23, at 12:00 P.M., Certified Medication Technician (CMT) Z said the following: -The CMT stood near the dining room preparing medications for administration. The CMT was not wearing a face mask; -The facility currently had five people who tested positive for COVID-19. The five residents resided on two different areas of the facility; -Staff did not wear masks for source control until the facility was in outbreak status which occurred when multiple residents, residing on all halls, tested positive. During an interview on 11/28/23, at 12:05 P.M., CMT AA said the following: -The CMT stood near the dining room preparing medications for administration. The CMT was not wearing a face mask; -Staff wore face masks in the halls for source control when administrative staff told them to. Observation on 11/28/23, at 3:05 P.M., showed the following: -The barrier doors separating the foyer from the resident care areas were closed. On the door hung a sign with the image of a red stop sign that gave the following information/instructions: Droplet Precautions: Everyone must clean their hands, including when entering and when leaving the room. Make sure eyes, nose, and mouth are fully covered; -A small white three drawer storage cart sat to the side of the barrier doors. It contained gloves and masks for staff to apply before entering the resident care areas. Observation and interview on 11/28/23, at 3:07 P.M., showed the following: -The Dietary Manager (DM) wore a surgical type face mask which covered his/her nose and mouth; -The DM said, while in a care plan meeting, she received a message on the secured messaging app that directed staff to wear face masks any time they worked on the two areas COVID-19 positive residents resided. The DM did not know what prompted the change from not wearing masks to wearing masks. Observation and interview on 11/28/23, at 3:08 P.M., showed the following: -The Activity Director (AD) wore a surgical type face mask which covered his/her nose and mouth; -The AD said about an hour ago, the IP told her to wear a face mask when she worked in the resident care areas where COVID-19 positive residents resided; -The AD did not know what prompted the change. Observation and interview on 11/28/23, at 3:10 P.M., showed the following: -LPN Q sat at the nurses' station in one of the resident care areas. The LPN did not have a face mask covering his/her mouth or nose. When asked about his/her mask, the LPN said he/she just returned from outside and forgot to put it on. The LPN found his/her surgical type face mask and put it on; -The LPN said, about an hour ago, the IP told staff to wear face masks when working in the COVID-19 positive areas. The new directive occurred due to the number of COVID-19 positive residents residing in the facility. The facility now had five residents who tested positive. Observation and interview on 11/28/23, at 3:12 P.M., showed the following: -LPN Y sat at the nurses' station in one of the resident care areas. The LPN wore a surgical type face mask that covered his/her nose and mouth; -The LPN said the facility now had five COVID-19 positive residents and one resident in the hospital with pneumonia caused by COVID-19. During an interview on 11/29/23, at 8:57 A.M., LPN C said he/she considered a COVID-19 outbreak when the facility had multiple residents on multiple units positive for COVID-19. During an interview on 12/01/23 at 1:11 P.M., the DON said the following: -When a facility had two or more residents test positive for COVID-19, the facility was considered in outbreak status. The CDC recommendations included staff wearing face masks as source control when a facility had an outbreak of COVID-19; -The facility administration did not implement source control for the two resident areas where COVID-19 positive residents resided because the residents resided in controlled areas; -A few months ago, the facility had positive Covid-19 residents, but the infection was contained to the locked unit; -When the unit was out of outbreak status, the facility had a resident who resided on another area, test positive. Staff moved that resident to another area attempting to cluster any COVID-19 positive residents to a specific area; -Over the holiday weekend, two residents who resided on the non-specific area, tested positive. One resident refused to move to another area of the facility. Staff determined moving the second resident to another area of the facility would be detrimental to his/her psychosocial well-being. Both of those residents resided in private rooms; -On 11/28/23, another resident tested positive. At that time, the facility decided since they could not cluster the residents to a specific area, they would require all staff to wear face masks in those two resident care areas; -Staff should wear masks if there was a facility acquired COVID-19 positive resident, but Administration did not advise staff to wear masks when the first resident tested positive for Covid-19. During an interview on 12/01/23, at 2:48 P.M., the Administrator said according to the CDC, masking was recommended for source control, but it was just a recommendation. Since the first residents who tested positive were moved to specific area, they did not implement source control; -Staff were not wearing masks for source control until 11/28/23 when another resident (the fifth) tested positive. 3. Observation on 11/28/23, at 8:32 A.M., showed the following: -NA N exited COVID-19 isolation room [ROOM NUMBER] and placed the resident's hall tray on the hall tray cart. The hall tray was not placed inside a bag and had no separation from the other hall tray already on the cart. The NA pushed the cart to the end of the hall and left it in the hallway by room [ROOM NUMBER]; -The hall tray contained regular silverware, cups, plate and plate cover, not disposable items. During an interview on 11/29/23, at 8:38 A.M., NA B said the following: -When he/she removed a hall tray from a COVID-19 isolation room, he/she placed the tray in a red bag so the kitchen staff knew how to handle the trays; -Staff should not bring trays out of COVID-19 isolation rooms not bagged because this could spread the virus to other residents and staff. Observation on 11/28/23, at 12:40 P.M., showed the following: -A housekeeper exited room [ROOM NUMBER] while wearing N95 mask, gown, and gloves. The housekeeper threw a rag into his/her cart and placed trash from the room into the trash receptacle on his/her cart; -He/she removed a broom and dust pan from the cart and reentered room [ROOM NUMBER]. The resident could be heard coughing while the housekeeper was in the room cleaning; -He/she exited the room again wearing the PPE and placed the broom and dust pan back on the cart; -He/she obtained the mop and mop pad and reentered the room; -He/she exited the room again and doffed the PPE before he/she exited and placed the mop back on the cart and the mop pad inside the cart; -He/she placed a wet floor sign on the name plate to the room, pushed the cart approximately 50 foot down the hallway and then performed hand hygiene; -He/she did not sanitize the broom, mop or the dustpan. During an interview on 11/29/23, at 8:57 A.M., LPN C said the following: -When staff took a hall tray out of a COVID-19 isolation room, they should red bag it so the kitchen staff know the tray came from an isolation room; -Staff should not place hall trays from COVID-19 isolation rooms on the hall cart, not red bagged, because this could spread the COVID-19 virus. During an interview on 11/29/23, at 10:00 A.M., Dietary Aide (DA) T said the following: -He/she waited until all of the dishes were washed before he/she ran the COVID-19 isolation trays through the dishwasher and wore gloves when handling these trays due to COVID-19 being contagious. Observation on 11/30/23, at 11:13 A.M., showed the door to a COVID-19 positive resident's room was open. Inside the room, the housekeeping supervisor cleaned the floor with a microfiber broom. He continued to use the broom to clean the floor outside of the room, in front of the isolation cart. He then dragged the microfiber broom head along the floor to the empty room next door. During an interview on 11/30/23, at 12:03 P.M., DA R said he/she knew a tray came from a COVID-19 isolation room if the tray was red bagged. During an interview on 11/30/23, at 12:11 P.M., Registered Nurse (RN) H said the following: -Staff should place hall trays from COVID-19 isolation rooms in a regular trash bag to prevent the spread of the virus; -The bag let kitchen staff know the tray was contaminated; -Staff should not place hall trays from isolation rooms on the cart uncovered and pushed to the end of the hall because this could spread the virus. During an interview on 12/01/23, at 8:37 A.M., RN H said the following: -When housekeeping cleaned a COVID-19 isolation room, they should place the mop pad in a bag before they leave the room. They should not mop out into the hallway and drag the mop down the hallway because this could spread the virus. During an interview on 12/01/23, at 8:48 A.M., the DM said the following: -Staff should put hall trays from COVID-19 isolation rooms in a bag. The bag can be red or clear; -When staff placed trays in bags, his/her staff knew how to handle them; -Kitchen staff waited until all dishes were washed before handling the isolation room trays. The staff put on gloves while they handled the trays to protect themselves; -After they washed the trays from the COVID-19 isolation rooms, they drained the dishwasher, sanitized the dishwasher and then drained the dishwasher again; -If nursing staff did not place the trays in bags, his/her staff did not know they came from an isolation room and could wash them with the other dishes. This could cause cross contamination and possibly spread the virus to kitchen staff or other residents; -He/she was responsible for ensuring kitchen staff knew how to handle hall trays from COVID-19 isolation rooms and the DON or Administrator was responsible for ensuring other staff knew the process. During an interview on 12/01/23, at 8:56 A.M., Housekeeper S said the following: -When he/she cleaned a COVID-19 isolation room, he/she put on a gown, gloves and N95 mask. He/she could not go in and out of the room so he/she took what he/she needed to clean the room inside and closed the door; -When he/she was done cleaning, he/she placed the rag and mop head used in the laundry in the room. If he/she brought the mop head out, he/she placed in a yellow bag prior to placing it in his/her cart; -He/she took all the PPE off inside the room and placed in the red bag trash inside the room; -Staff should not throw the used mop pad or rag inside the cart without placing them in a bag; -Staff should sanitize the broom and mop when they left an isolation room as well; -Staff should not mop inside an isolation room and then mop outside the room and drag the mop down the hallway. This could cross contaminate and make others sick; -Staff should not wear gloves outside the room and should sanitize their hands before they touch anything when they leave an isolation room. They should not push their cart down the hall and then sanitize their hands. During an interview on 12/01/23, at 9:05 A.M., the IP said the following: -When staff took hall trays out of a COVID-19 isolation room, they should be bagged in either a red or clear trash bag; -Staff should not bring the hall tray out not bagged, place it on the hall tray cart and push it down the hall. This could cause cross contamination and dietary would not know which trays came from an isolation room; -He/she, the DON, and staff development were responsible for ensuring staff knew proper infection control techniques; -When housekeeping cleaned a resident's room, they should not go in and out of the room multiple times; -Housekeeping should leave their mop pad and rag to clean the room in the COVID-19 laundry in the resident's room. They should not bring these out of the room, not bagged and just throw in their cart no bagged; -Housekeepers should not mop inside the room, then continue to mop outside the room and then drag the mop down the hallway. This could contaminate the hallway and other staff could carry the virus to other residents' rooms; -He/she, staff education coordinator, and the Housekeeping Supervisor were responsible for ensuring housekeeping staff knew proper infection control. During an interview on 12/01/23, at 9:44 A.M., the Housekeeping Supervisor said the following: -When housekeeping staff entered a COVID-19 isolation room, they don a gown, gloves and N95 mask. They grab all of the cleaning supplies they need and enter the room and stay in the room until the room was cleaned; -When they finish, they place the mop pad and rags in a bag, place it outside the door along with their mop, broom and cleaning supplies. They doff the PPE inside the room and place in the trash and then sanitize their hands; -Once outside the room, they sanitize the mop, broom and cleaning supplies and placed the bagged rags and mop pads into their cart. They should do this to not contaminate anything else; -Staff should not exit these rooms with their gloves on, should not throw their rag and mop pad in their cart not bagged and should not mop from inside the room out into the hallway and then drag the mop down the hall. This could cause an outbreak; -He/she was responsible for ensure housekeeping staff knew the proper infection procedures. During an interview on 12/01/23, at 9:52 A.M., the DON said the following: -Staff should double bag hall trays when they bring them out of COVID-19 isolation rooms. They should place them in a red bag and not just an ordinary trash bag; -Staff should not bring a hall tray out of a COVID-19 isolation room not bagged, place it on the hall tray cart and push it down to the end of the hall. This could spread the virus; -The kitchen staff knew the precautions to use if the hall tray was red bagged and if the hall tray was not bagged, the virus could spread to staff and other residents; -He/she was responsible for ensuring nursing staff knew how to handle hall trays from COVID-19 isolation rooms and the charge nurse should oversee this as well; -When housekeeping cleaned a COVID-19 isolation room, they should don a gown, N95 mask, gloves and eye protection and follow their cleaning protocol; -Housekeeping staff should not bring the mop pad and rags out of the room and throw them in their cart unless they were double bagged in yellow bags; -Housekeeping staff should not wear gloves outside the isolation rooms and should not mop the floor of the isolation room, then out in the hall and then drag the mop down the hall. This could cause cross contamination; -The Housekeeping Supervisor was responsible for ensuring housekeeping staff knew proper infection control protocols and the IP and DON ensured the Housekeeping Supervisor knew proper infection control techniques. During an interview on 12/01/23, at 11:36 A.M., the Administrator said

Based on interview and record review, the facility failed ensure staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when the staff failed to document routine offers of bathing or showering and failed to address resident's preferences for shower/baths in the resident's care plan for one resident (Resident #1). The facility had a census of 94. Review of the facility's policy titled Bath, Shower/Tub, revised February 2018, showed the following: -The purpose of the procedure is to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident skin; -Staff should document the date and time the bath was performed; -Staff should document the name and title of the individual(s) who assisted the resident with the bath; -Staff should document how the resident tolerated the bath; -Staff should document if the resident refused the bath, and what interventions were taken by staff; -Staff should notify the supervisor if the resident refuses the bath; -Report other information in accordance with facility policy and professional standards of practice; (The policy did not address the frequency for bathing or care planning resident's bathing preference.) 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 03/24/23; -Diagnoses included stroke and retention of urine. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/28/23, showed the following information: -Moderately impaired cognition; -Required extensive assistance with dressing, toilet use, and personal hygiene; -Dependent on staff for bed mobility and transfers; -Used a wheelchair for mobility; -Had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid); -Totally dependent on staff for bathing. Review of the resident's care plan, updated 04/18/23, showed the following: -The resident had difficulty caring for himself/herself due to a history of stroke, and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in his/her legs. (Staff did not care plan the resident's preference for how often to have a bath or shower. Staff did not care plan how many staff were required to assist with bathing or showers.) Review of the resident's electronic bathing record showed the following: -On 04/17/23 staff recorded assisting the resident with a bed bath (24 days after the resident was admitted to the facility); -On 04/20/23, staff recorded not applicable under type of bathing; -On 05/01/23, staff recorded not applicable under type of bathing; -On 05/04/23, staff recorded not applicable under type of bathing; -On 05/15/23, staff recorded not applicable under type of bathing; -On 05/17/23, staff recorded assisting the resident with a shower (one month after the last documented shower). During an interview on 08/01/23, at 9:47 A.M., Certified Nurse Assistant (CNA) A said there is a shower and bathing schedule made for all residents. Most residents get two baths or showers a week and CNAs electronically record when a resident has a shower or bath. During an interview on 08/01/23, at 9:5 A.M., Licensed Practical Nurse (LPN) B said he/she had not heard any recent concerns about residents not receiving sufficient baths or showers. He/she said each resident usually gets two showers or baths per week. During an interview on 08/01/23, at 2:38 P.M., the Director of Nursing (DON) said the following: -Residents are scheduled to have a bath or shower at least two times per week; -Staff can record the showers electronically on the kiosks/electronic bathing record, or sometimes on paper bath sheets; -For residents who refuse a bath at a certain time, staff should retry and re-approach the resident at a different time; -She was unable to say what occurred when staff put not applicable on the electronic bath records for the resident for the dates of 04/20/23 through 05/15/23. She could not say whether a bath had been offered or refused. She said staff should not be recording not applicable, as it has no indication as to what occurred. Review showed the facility did not provide paper bath sheets for the resident. During an interview on 08/01/23, at 4:27 P.M., the Administrator said staff should not be recording not applicable, because it has no meaning as to whether a bath was even offered to a resident. MO00218005

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to obtain timely catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care orders, failed to obtain an order and document an indwelling catheter change, and failed to obtain a timely urine specimen when a resident had symptoms of a urinary tract infection and contact the physician on the delay for one resident (Resident #1). The facility also failed to follow physician's orders when staff inserted a different sized catheter than ordered for two residents (Resident #1 and #2). The facility's census was 94. Review of the facility's catheter procedure, revised October 2010, showed the following: -Staff should verify there there is an order for the procedure; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -Equipment necessary for the procedure included a catheter tray, size (of the catheter) specified in the order; -Document the date and time the procedure was performed, who performed the procedure, all assessment data collected during the procedure (color, clarity, character), the size of the catheter inserted and the amount of fluid used to insert the balloon, in the resident's record; -Notify the physician of any abnormalities. Review of the facility's agreement for portable imaging services, dated 11/03/20, showed the provider will provide courier service at a mutually agreed upon time daily (Sunday through Saturday) to pick up specimens from the facility. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 03/24/23; -Diagnoses included stroke and retention of urine. Review of the resident's March 2023 through July 2023 Physician Order Sheet (POS) showed an order, dated 03/27/23, for indwelling catheter output every shift. (Staff did not obtain orders regarding catheter care). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/28/23, showed the following information: -Moderately impaired cognition; -Required extensive assistance with dressing, toilet use, and personal hygiene; -Dependent on staff for bed mobility and transfers; -Used a wheelchair for mobility; -Had an indwelling catheter; -Received an antibiotic five out of the last seven days. Review of the resident's March 2023 through July 2023 POS showed the following: -An order, dated 03/29/23 (to start 4/24/23), to change the resident's 16 French (fr - diameter of the catheter)/10 cubic centimeters (cc - the size of the balloon) indwelling catheter, on the evening shift, every month on the 24th; -An order, dated 03/29/23, may flush catheter with sterile water (water that is free of all microorganisms) as needed (PRN) every 8 hours for indwelling catheter care. Review of the resident's care plan, updated 04/18/23, showed the following: -The resident was dependent on staff for toilet use; -Monitor and document intake and output as per facility policy; -Monitor for signs of discomfort with urination and frequency; -Change catheter monthly; -The resident had a diagnosis of urinary retention. (Staff did not care plan catheter care.) Review of the resident's April 2023 Treatment Administration Record (TAR) showed the following: -An order, dated 03/29/23, to change the resident's 16fr/10cc catheter every month on the 24th; -On 04/24/23, a nurse documented changing the resident's catheter. Review of the resident's physician assistant (PA) progress note, dated 04/27/23, showed the following: -The resident reported significant catheter pain. The resident said the catheter needed changed; -The resident's indwelling catheter currently had no output (at approximately noon). Aides reported they had not emptied it this day; -The PA asked nursing to reposition/replace the catheter. The nurse received approximately 400 cc of urine output when replaced. Staff will send urine for UA due to very cloudy with foul odor. Review of the resident's March 2023 through July 2023 POS showed the following: -An order, dated 04/27/23, for a urinalysis with reflex laboratory testing performed subsequent to initial test results to culture and sensitivity (C&S-a culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) one time for urinary tract infection (UTI). Review showed the staff did not document regarding obtaining the first specimen and reason for delay. Review of the resident's progress note dated 05/01/23, at 10:05 A.M., showed a nurse documented the PA reordered the UA with reflex to culture due to the laboratory did not collect the previous specimen. Review of the resident's March 2023 through July 2023 POS showed an order, dated 05/01/23, for a urinalysis with reflex to culture for UTI (four days after the initial order). Review of the resident's progress note dated 05/01/23, at 9:48 P.M., showed a nurse documented the resident said it felt like his/her catheter was not working right. The nurse attempted to flush the catheter without any luck. The nurse changed the indwelling catheter and used an 18fr/10cc catheter. The resident's urine was very thick, cloudy and had a foul odor. (The resident's physician's order was for a 16fr/10cc catheter.) Staff did not document obtaining the second specimen. Review of the resident's UA results, dated 05/02/23, and C&S results, dated 05/05/23, showed the following: -The resident's urine contained blood, leukocytes (a specific type of white blood cell), white blood cells, red blood cells and bacteria (the reference range of each of the findings was negative/not present) ; -The C&S showed the presence of Proteus mirabelis (bacterium that is a frequent cause of catheter-associated urinary tract infections) greater than 100,000 colony forming units (cfu)/milliliter (ml) (estimates the number of microbial cells (bacteria, fungi, viruses etc.) in a specimen) (cultures with greater than 100,000 cfu/ml of one type of bacteria usually indicate infection) Review of the resident's May 2023 TAR showed the following: -An order, dated 03/29/23, to change the resident's 16fr/10cc catheter every month on the 24th (the order did not include a PRN order); -On 05/25/23, a nurse documented changing the resident's catheter (the nurse did not document changing the resident's catheter on 05/01/23 as noted in the nurses' notes). Review of the resident's March 2023 through July 2023 POS showed an order, dated 06/19/23, for indwelling catheter care every shift and as needed with soap and water or wipes for infection control. During an interview on 08/01/23, at 11:25 A.M., the Assistant Director of Nursing, Long-Term Care (ADON-LTC), said she was the admitting nurse for the resident when the resident first came to the facility. She remembers that the resident would sometimes have a urinary tract infections (UTI), which were treated. The resident would sometimes have discomfort with his/her catheter. At that time, staff would flush the catheter and that would usually relieve the discomfort. If there were still problems, staff would change (replace) the catheter, and that would usually provide the resident with relief. During interviews on 08/01/23, at 2:38 P.M. and 4:48 P.M., and on 08/03/23, at 1:13 P.M., the Director of Nursing (DON) said the following: -The resident admitted to the facility with a catheter. He/she did not admit with specific catheter size or frequency orders due to a pending urology appointment. When the resident returned from that appointment (on 03/29/23), he/she had recommendations from the urologist that included frequency of catheter changes and to flush the catheter as needed; -The facility contracted with a laboratory company. A technician picked up urine specimens Monday through Friday; -The DON did not think staff changed the resident's catheter on 04/27/23. The nurse did not document the change in the resident's progress notes or TAR. Staff did not have to change a catheter to obtain a urine sample; -The DON did not know why the laboratory technician did not pick up the resident's urine specimen on 4/28/23. The nurse contacted the PA when he/she noticed the laboratory did not pick up the previous specimen (05/01/23). Staff would not need to contact the PA or physician sooner since a technician only picked up Monday through Friday. If the resident's condition was unstable, the facility would send the resident to the hospital if they could not wait until the next business day for pick up; -The nurse who changed the resident's catheter on 05/01/23 should have documented the change in the resident's TAR. If the resident did not have a PRN order to change his/her catheter, the nurse should have called the physician to obtain an order. If he/she could not obtain the correct size of catheter, he/she should have contacted the physician. The nurse should not have used a non-ordered size of catheter. 2. Review of Resident #2's face sheet showed the following information: -admission date of 4/26/21; -Diagnoses included congestive heart failure (inability of the heart to pump blood and oxygen to all necessary areas of the body), difficulty walking, and disorders of the bladder and urinary tract. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Total dependence on staff for toileting and personal hygiene; -Had an indwelling catheter Review of the resident's POS, dated August 2023, showed the following: -An order, dated 03/23/23, for supra pubic catheter (catheter enters the bladder directly through the abdomen) 16fr/10cc balloon. Change catheter PRN (as needed) for leakage obstruction or patient removal. Observation on 08/01/23, at 12:30 P.M., of the resident's suprapubic catheter showed showed the resident had a catheter in use with the size 16fr with a 5 cc balloon. During an interview on 08/01/23, at 12:40 P.M., the ADON-LTC said she didn't know why the resident had a catheter size that was different from what was ordered by the doctor. She said, if the facility does not have the correct-sized catheter, they can usually ask another facility for one the correct size and obtain it the same day. If that still isn't possible, the facility can go and buy the correct size. She said staff should not use a catheter for a resident that is not the same size as the one in the physician's order. 3. During an interview on 08/01/23, at 9:47 A.M., Certified Nurse Aide (CNA) A said CNAs are trained on catheter care and cleaning, but catheters are only changed by nurses. 4. During an interview on 08/01/23, at 9:55 A.M., Licensed Practicing Nurse (LPN) B said once an order for a UA is given by the doctor, one of the nurses should be obtaining a urine sample (specimen) as soon as possible. Then the lab would be contacted for pick up, if they were not already scheduled to come to the facility. 5. During interviews on 08/01/23, at 2:38 P.M. and 4:48 P.M., and on 08/03/23, at 1:13 P.M., the Director of Nursing (DON) said the following: -All residents should have orders upon admission for catheter care at least every shift and as needed, and to monitor output every shift as needed; -Although past standards of care recommended catheter changes every month, that changed and now catheter changes occurred according to physician orders and based on the specific needs of the resident; -The physician ordered the size of the catheter and staff should follow physician's orders related to size and frequency. -Staff documented changing a resident's catheter on the TAR and in the resident's progress notes. All catheter change orders should include a PRN order in case the catheter became clogged or dislodged; -The resident admitted to the facility with a catheter. He/she did not admit with specific catheter size or frequency orders due to a pending urology appointment. When the resident returned from that appointment (on 03/29/23), he/she had recommendations from the urologist that included frequency of catheter changes and to flush the catheter as needed; -The facility contracted with a laboratory company. A technician picked up urine specimens Monday through Friday. -The DON did not think staff changed the resident's catheter on 04/27/23. The nurse did not document the change in the resident's progress notes or TAR. Staff did not have to change a catheter to obtain a urine sample; -The DON did not know why the laboratory technician did not pick up the resident's urine specimen on 4/28/23. The nurse contacted the PA when he/she noticed the laboratory did not pick up the previous specimen (05/01/23). Staff would not need to contact the PA or physician sooner since a technician only picked up Monday through Friday. If the resident's condition was unstable, the facility would send the resident to the hospital if they could not wait until the next business day for pick up; -The nurse who changed the resident's catheter on 05/01/23 should have documented the change in the resident's TAR. If the resident did not have a PRN order to change his/her catheter, the nurse should have called the physician to obtain an order. If he/she could not obtain the correct size of catheter, he/she should have contacted the physician. The nurse should not have used a non-ordered size of catheter. 6. During an interview conducted on 8/1/23, at 4:48 P.M., the Administrator said staff should follow physician's orders. MO00218005

Based on interview and record review, the facility failed to obtain a timely ultrasound and notify the physician when a stat (emergent) ultrasound imaging was delayed for one resident (Resident #1) who complained of abdominal tenderness. The facility's census was 94. Review of the facility's agreement for portable imaging services, dated 11/03/20, showed the following: -The imaging provider shall provide a qualified technologist who shall perform non-stat (routine) imaging exams as requested. Every effort will be made to complete routine exams the same day ordered. If the provider is unable to complete a routine exam the day it is ordered, the facility will be notified and the exam will be performed the next day; -The provider shall be available 24 hours a day, seven days a week, for stat requests. Stat services provided for critical situations requiring rapid results. The facility agrees that stat orders are provided for critical situations requiring rapid results. The facility should use its best efforts to limit stat orders to urgent situations where the absence of an order could reasonably be believed to place the patient's health in serious jeopardy or result in serious bodily impairment or dysfunction. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 03/24/23; -Diagnoses included stroke, retention of urine, and esophageal reflex disease (acid reflux). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/28/23, showed the following information: -Moderately impaired cognition; -Required extensive assistance with dressing, toilet use, and personal hygiene; -Dependent on staff for bed mobility and transfers; -Used a wheelchair for mobility. Review of the resident's physician assistant (PA) progress note, dated 04/27/23, showed the following: -The resident admitted to lower abdominal pain and reported continued nausea and vomiting. The resident denied that it was worse during any specific time of the day, possibly worse prior to meals; -Therapy reported they were trying to get him/her out of bed more. The resident continues to vomit when he/she was moved or frequently during therapy; -The source of the resident's nausea and vomiting was unknown. Medications were changed and recent laboratory tests were normal. The resident complained of right upper abdominal tenderness. Facility will obtain an abdominal ultrasound. The resident said anti-nausea medication helped. Review of the resident's March 2023 through July 2023 physician order sheet (POS) showed an order, dated 04/27/23, for an abdominal ultrasound stat for complaints of abdominal pain. Review of the resident's abdominal ultrasound results, dated/completed 05/01/23, showed gallstones were seen. Review of the resident's progress notes showed staff did not document regarding the ordered ultrasound, including contacting the physician when the stat order was delayed and completed four days after ordered as stat imaging. During an interview on 08/01/23, at 11:25 A.M., Assistant Director of Nursing, Long-Term Care (ADON-LTC) said she was the admitting nurse for the resident at the time the resident first came to the facility. She was in charge of reviewing admission orders and make sure they were in the facility system. She could not remember any orders for the resident to have an order for an ultrasound. During interviews on 08/01/23, at 4:25 P.M., and on 08/03/23, at 1:13 P.M., the Director of Nursing (DON) said the following: -The facility contracted with a laboratory and imaging company; -When a physician or physician's assistant ordered imaging, such as an ultrasound, the nurse entered the order into the resident's electronic medical record and into the imaging company's system. The technician then will usually notify the staff of his/her estimated arrival time; -After entering the order, the facility staff are at the mercy of the imaging technician; -When a physician ordered stat services the timeliness of the completion depended on the type of order. If the physician ordered an intervention that staff had immediate access to, they completed it immediately. If the physician ordered blood tests, they were usually obtained within a few hours. In regards to imaging services, those stat orders depended on when the imaging company sent a technician; -Facility staff entered the resident's ultrasound as stat. The facility staff do not have control when the imaging company will arrive to the facility to complete the ultrasound; -The nurses did not contact the physician regarding the delay because the providers know of the issues with the imaging company, and they anticipate the delay; -If a resident needed imaging quicker than the imaging company could provide, such as a change in condition, the staff would notify the physician and send the resident to the hospital. During an interview on 08/01/23, at 4:48 P.M., the Administrator said staff should follow physician's orders. MO00218005

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of abuse involving two residents (Resident #1 and Resident #2) to the State Survey Agency (Department of Health and Senior Services -DHSS) within two hours of staff becoming aware of the receiving the allegation. The facility census was 104. The Administrator and Director of Nursing (DON) were notified on 12/18/2022, at approximately 1:30 P.M., of the Past Non-Compliance which occurred on 12/18/2022, early morning. Facility staff notified Department of Health and Senior Services (DHSS) of the noncompliance, and started an investigation, in-serviced the facility staff involved in reporting timely, and started doing daily chart checks. The checks will continue to be done daily indefinitely. The noncompliance was corrected on 12/21/2022. Record review of the facility's policy titled Abuse Investigating and Reporting, dated July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. 1. Record review of Resident #1's face sheet showed the following: -An admission date of 3/3/2022; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder, and generalized anxiety disorder. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/4/2022, showed the following: -The resident was severely cognitively impaired; -He/she had physical behaviors toward others four to six days of the evaluation period. Record review of the resident's care plan, updated 12/6/2022, showed the following: -The resident exhibits behavioral indicators of anxiety and agitation related to Alzheimer's disease. Record review of the resident's nursing note dated 12/18/2022, at 2:05 P.M., showed the following: -When the nurse came in this morning, an aide informed the nurse that Resident #1 and Resident #2 were hitting each other with their fists. Resident #1 stated Resident #2 was in his/her bed and would not get out and when he/she tried to get him/her out, he/she hit me. The nurse did a head to toe assessment and no new marks were noted at the time of the assessment. 2. Record review of Resident #2's face sheet showed the following: -An admission date of 12/8/2022; -Diagnoses included Alzheimer's disease, and right femur (thigh bone) fracture. Record review of the resident's admission MDS, dated [DATE], showed the following: -The resident was severely cognitively impaired; -He/she had exhibited no physical behaviors towards others. Record review of the resident's care plan, dated 12/21/2022, showed the following: -Resident had impaired cognitive function or impaired thought processes; -Staff to use a positive approach to cares, cue, reorient, and supervise as needed. Record review of the resident's nursing notes, dated 12/18/2022, at 2:43 P.M., showed the following: -When the nurse came in this morning, aide informed nurse that Resident #2 and Resident #1 were hitting each other with their fists. Residents were separated. Head to toe assessment done and no new marks noted. The physician was notified at 2:34 P.M. The responsible party was notified at 2:34 P.M. 3. During an interview on 1/10/2023, at 10:36 A.M., Licensed Practical Nurse (LPN) A said when he/she got to work on the morning of 12/18/2022, for the morning shift, he/she was told by Certified Nursing Assistant (CNA) B that Resident #1 and Resident #2 had an altercation early that morning, just as the evening shift was ending. The CNA said Resident #2 was in Resident #1's bed, and Resident #1 was upset and was trying to get Resident #2 out of his/her bed. The residents threw water and Resident #1 said Resident #2 punched him/her in the eye. LPN A said he/she told the Director of Nursing (DON) as soon as he/she found out. All allegations of abuse are to be reported within two hours. The bruising was not evident on Resident #1 until later that morning. 4. During an interview on 1/10/2023, at 10:45 A.M., Certified Medication Technician (CMT) C said if there is an allegation of abuse, staff should report to DHSS within two hours. 5. During an interview on 1/10/2023, at 10:50 A.M., CMT D said any allegation of abuse should be reported to DHSS and the police within two hours. 6. During an interview on 1/10/2023, at 11:00 A.M., LPN E said all allegations of abuse should be reported to DHSS within two hours. 7. During an interview on 1/10/2023, at 11:20 A.M., LPN F said any allegation of abuse should be reported within two hours. 8. During an interview on 1/10/2023, at 2:20 P.M., the Director of Nursing (DON) and Administrator said the resident to resident incident occurred on 12/18/2022, between 5:00 A.M., and 6:00 A.M. The incident was reported to the DON as just having water thrown, but later when they were told there was hitting involved, it was reported to DHSS. It is expected that staff report everything immediately so DHSS can be notified within two hours. The resident had been separated when the incident occurred, and 15 minute checks started. A skin assessment was done and no bruising was noted initially. The bruising on Resident #1 was not found until close to noon. 9. Record review of DHSS reports show the facility notified DHSS of the allegation of abuse on 12/18/2022 at 1:36 P.M. (approximately 7 1/2 hours after staff became aware of the abuse. MO00211374

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards as possible when staff did not maintain water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in occupied resident room sinks which put the residents at increased risk for burns caused by scalding. The facility census was 113. Record review of the American Burn Association website, updated 2002, showed hot water causes third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters: -In 1 second at 156 degrees F; -In 2 seconds at 149 degrees F; -In 5 seconds at 140 degrees F; -In 15 seconds at 133 degrees F; -In 1 minute at 127 degrees F. -Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Record review of the facility policy, titled Safety of Water Temperatures, dated December 2009, showed the following: -Tap water in the facility shall be kept within a temperature range to prevent scalding of residents; -Water heaters that service resident rooms, bathrooms, common areas, and tub/shower area shall be set to temperatures of no more than 120 degrees F or the maximum allowable temperature per state regulation; -Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in the maintenance logs; -Maintenance staff shall conduct periodic tap water temperature checks and record the water temperature in a safety log; -If at any time water temperatures feel excessive to the touch, staff will report this finding to the immediate supervisor. 1. Record review of the facility's Weekly Water Temperature Logs, dated 8/1/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 123.4 degrees F in room [ROOM NUMBER]; -The water temperature was 120.2 degrees F in room [ROOM NUMBER]; -The water temperature was 120.6 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 8/8/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 122.5 degrees F in room [ROOM NUMBER]; -The water temperature was 124.4 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 8/15/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 120.7 degrees F in room [ROOM NUMBER]; -the water temperature was 123.8 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 8/23/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 125.6 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 8/29/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 124.8 degrees F in room [ROOM NUMBER]; -The water temperature was 123.4 degrees F in room [ROOM NUMBER]; -The water temperature was 120.2 degrees F in room [ROOM NUMBER]; -The water temperature was 123.1 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 9/6/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 121.0 degrees F in room [ROOM NUMBER]; -The water temperature was 128.6 degrees F in room [ROOM NUMBER]; -The water temperature was 120.2 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 9/12/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 122.0 degrees F in room [ROOM NUMBER]; -The water temperature was 120.4 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 9/19/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 122.2 degrees F in room [ROOM NUMBER]; -The water temperature was 120.6 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 9/26/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 120.0 degrees F in room [ROOM NUMBER]; -The water temperature was 123.3 degrees F in room [ROOM NUMBER]; -The water temperature was 120.4 degrees F in room [ROOM NUMBER]; -The water temperature was 125.1 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 10/24/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 123.4 degrees F in room [ROOM NUMBER]; -The water temperature was 124.7 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 10/31/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 125.1 degrees F in room [ROOM NUMBER]; -The water temperature was 120.2 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 10/31/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 125.1 degrees F in room [ROOM NUMBER]; -The water temperature was 120.2 degrees F in room [ROOM NUMBER]. Record review of the facility's Weekly Water Temperature Logs, dated 11/21/2022, showed the following: -The water temperature was set to 140 degrees F in hot water heaters #1, #2, and #3; -The water temperature was 127.2 degrees F in room [ROOM NUMBER]. 2. Observations on 12/1/2022, at 10:45 A.M., showed the following -The water temperatures at the sink In room [ROOM NUMBER] was 123.7 F. 3. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admission date of 7/29/2022; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and chronic kidney disease. Record review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 11/4/2022, showed the following: -The resident was moderately cognitively impaired; -He/she was independent with transfers, toileting, and personal hygiene. Record review of Resident #1's care plan, dated 8/4/2022, showed the following: -Resident #1 had impaired cognitive function or impaired thought processes. Record review of Resident #2's face sheet showed the following: -admission date of 7/26/2022; -Diagnoses included cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit), muscle wasting, and a history of falling. Record review of Resident #2's quarterly MDS, dated [DATE], showed the following: -The resident was mildly cognitively impaired; -He/she was independent with transfers, toileting, and personal hygiene. Record review of Resident #2's care plan, dated 8/22/2022, showed the following: -The resident needed no assist with activities of daily living (ADLs- dressing, grooming, bathing, eating, and toileting). Observations on 12/1/2022, at 10:45 A.M., showed the water temperature in Resident #1 and #2's room measured 123.7 degrees F. 4. Record review of Resident #3's face sheet showed the following: -admission date of 8/20/2021; -Diagnoses included cognitive communication deficit. Record review of the resident's annual MDS, dated [DATE], showed the following: -The resident was mildly cognitively impaired; -He/she was independent with transferring, and required limited assistance with personal hygiene and toilet use. Record review of the resident's care plan, dated 8/9/2022, showed the following: -The resident required one person's assist with showering personal hygiene, and toileting. Observations on 12/1/2022, at 10:47 A.M., showed the water temperature in the resident's room measured 126.7 F. 5. Record review of Resident #4's face sheet showed the following: -admission date of 6/28/2022; -Diagnoses included Alzheimer's disease and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy (nerve damage caused by diabetes). Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was moderately cognitively impaired; -He/she required assist of one person with transfers, toileting, and hygiene. Record review of the resident's care plan, dated 10/4/2022, showed the following: -The resident had diabetes and to avoid exposure to extreme heat or cold. Observations on 12/1/2022, at 11:15 A.M., showed the water temperature in the resident's room measured 129.7 F. 6. Record review of Resident #5's face sheet showed the following: -admission date of 5/13/2019; -Diagnoses included Alzheimer's disease. Record review of Resident #5's quarterly MDS, dated [DATE], showed the following: -The resident was moderately cognitively impaired; -He/she required one person assist for transfers, toileting, and hygiene. Record review of Resident #5's care plan, dated 6/24/2022, showed the following: -Resident #5 had an ADL self-care deficit related to poor memory and judgment. The resident is able to move independently. Record review of Resident #6's face sheet showed the following: -admission date of 11/7/2022; -Diagnoses included Alzheimer's disease and non-Hodgkin's lymphoma (a cancer that starts in the lymphatic system). Record review of Resident #6's admission MDS, dated [DATE], showed the following: -The resident was severely cognitively impaired; -He/she required one person assist for transfers, toileting, and hygiene. Record review of Resident #6's care plan, dated 11/7/2022, showed the following: -Resident #6 required limited assistance of one for showers, grooming and toileting. Observations on 12/1/2022, at 11:50 A.M., showed the water temperature in Resident #5 and Resident #6's room measured 129.5 F. 7. Record review of Resident #7's face sheet showed the following: -admission date of 4/15/2021; -Diagnoses included Alzheimer's disease. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was severely cognitively impaired; -He/she is able to transfer independently between locations in his/her room; -He/she required one person assist for toileting, and hygiene. Record review of the resident's care plan, dated 7/28/2022, showed the following: -The resident required extensive assist by one staff for bathing and showering. Staff should use short, simple instructions such as hold the wash cloth in your hand, put soap on the wash cloth, wash your face, to promote independence; -The resident is able to transfer him/herself with limited assist. Observations on 12/1/2022, at 11:52 A.M., showed the water temperature in the resident's room measured 127.8 F. 8. Record review of Resident #8's face sheet showed the following: -admission date of 10/27/2021; -Diagnoses included dementia and metabolic encephalopathy (a problem in the brain caused by chemical imbalances, usually caused by an illness or organs not working as well as they should). Record review of Resident #8's annual MDS, dated [DATE], showed the following: -The resident was severely cognitively impaired; -He/she required one person assist for bathing, toileting, and hygiene. Record review of Resident #8's care plan, dated 7/28/2022, showed the following: -Resident #8 required limited assist of one for showering and toileting. Record review of Resident #9's face sheet showed the following: -admission date of 7/30/2022; -Diagnoses included dementia, anxiety, and depression. Record review of Resident #9's quarterly MDS, dated [DATE], showed the following: -The resident was severely cognitively impaired; -He/she required supervision with transfers, bathing, and hygiene. Record review of Resident #9's care plan, dated 8/15/2022, showed the following: -Resident #9 had an ADL self-care deficit related to fatigue, impaired balance, and required one staff for showering, dressing, and toileting. Observations on 12/1/2022, at 2:50 P.M., showed the water temperature in Resident #8 and Resident #9's room measured 132.6 degrees F. 9. During an interview on 12/1/2022, at 1:35 P.M., Certified Nursing Assistant (CNA) A said he/she sees maintenance checking resident room water temperatures frequently. 10. During an interview on 12/1/2022, at 1:45 P.M., Licensed Practical Nurse (LPN) B said he/she has had some residents complain about the water temperature being too hot. When that happens, he/she mixes the water with cold water to cool it. 11. During an interview on 12/2/2022, at 8:30 A.M., the Maintenance Director said he checks room water temperatures weekly. If the temperature if too high or too low in multiple rooms on the hall, he checks the water heater for that hall. If it is just one room that the temperature is off, he checks the valve on that particular faucet in the room. The readings are documented in a log book and the repairs are documented in a daily planner book. 12. During interviews on 12/1/2022, at 3:05 P.M., and 12/2/2022, at 11:55 A.M., the Administrator said he expects water temperatures to be tested weekly and the results to be documented. The temperatures should range between 105 F and 120 F. He expects staff to make adjustments if the water temperatures do not fall in range, and if the water is too hot or cold document the adjustments. It is not acceptable for the water to be too hot. MO00209307

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to treat one resident (Resident #202) in a manner that promoted dignity and respect when staff did not verify the resident's Coronavirus Disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome, Coronavirus 2 (SARS-CoV-2)) vaccination status prior to admitting the resident to the COVID-19 quarantine hall when the resident voiced he/she did not wish to be placed on the quarantine hall if avoidable. The facility's census was 104. According to the Center for Disease Control (CDC) regarding COVID-19, people are considered fully vaccinated two weeks after their second dose in a two-dose series, such as the Pfizer or Moderna vaccines, or two weeks after a single-dose vaccine, such as Johnson & Johnson's [NAME] vaccine. Record review of the CDC's Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination, dated 4/27/21, showed the following: -Quarantine is no longer recommended for residents who are being admitted to a post-acute care facility if they are fully vaccinated and have not had prolonged close contact with someone with SARS-CoV-2 infection in the prior 14 days. Record review of the facility's COVID-19 Infection Prevention and Control Measures Policy, dated April 2020, included the following information: -This facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility; -This policy is based on current recommendations for standard precautions and transmission based precautions, environmental cleaning and social distancing for COVID-19; -Signage on the use of specific Personal Protective Equipment (PPE-disposable gowns, gloves, face shields, goggles, facemasks and/or respirators) (for staff) is posted in appropriate locations in the facility (outside of resident's room). (The policy provided by the facility did not include information related to procedures for newly admitted residents.) 1. Record review of Resident #202's face sheet (a document that gives a resident's information at a quick glance) showed staff admitted the resident to the facility, from a hospital, on 5/19/21. His/her diagnoses included diabetes with foot ulcer and abnormalities of gait (a person's manner of walking) and mobility. Record review of the resident's hospital discharge instructions, dated [DATE], showed the resident reported he/she received one Moderna COVID-19 SARS-CoV-2 vaccination shot on 3/16/21. Record review of the resident's nursing admission assessment and care plan, dated 5/19/21, showed the resident was cognitively intact. Record review of the resident's physician order, dated 5/19/21, showed an order for isolation/droplet precautions (used to prevent the spread of pathogens that are passed through respiratory secretions and do not survive for long in transit. These droplets are relatively large particles that cannot travel though the air very far. They are transmitted through coughing, sneezing, and talking). Record review of the resident's care plan showed the following information: -Initiated on 5/20/21: The resident had the potential to develop a respiratory infection due to the COVID-19 pandemic. Instruct the resident to wear a facemask when staff enters the room or the resident leaves the room; -Initiated on 5/20/21: The resident was at risk for an alteration in psychosocial well-being due to restriction/limitation on visitation due to COVID-19. Provide opportunities for expression of feelings related to situational stressor. Provide the resident with the opportunity to ask questions and receive updated information and education as needed. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 5/22/21, showed the resident was cognitively intact. Observation on 5/24/21, at approximately 12:00 P.M., showed the resident resided in a room located on the facility's COVID-19 quarantine hall. A table, positioned near the first room on the quarantine hall, had various PPE supplies available. Signage on the resident's door alerted staff of the resident's quarantine status. Observations throughout the survey, 5/24/21 to 5/28/21 and 6/1/21 to 6/2/21, showed the facility had a designated hallway for quarantined residents (for newly admitted residents whose COVID-19 status was unknown and were not fully vaccinated per the CDC's definition). The quarantine hall included rooms 315 to 323. Staff placed a table with, various supplies, including hand sanitizer, gloves, disposable gowns and masks, near the first quarantine room (315). Next to the supply table, staff placed two red trash cans with lids for discarded disposable gowns and gloves. Signs adorned each resident's room door that directed staff and visitors to clean their hands then apply gloves, gown and a mask, before entering the room. The sign also directed staff to dedicate resident specific supplies/equipment or use disposable equipment to each room. Observation and interview conducted on 5/25/21, at 3:08 P.M., showed the following: -The resident resided in a room located on the COVID-19 quarantine hall; -The resident said he/she did not know why he/she had to be in a quarantine room. Prior to his/her admission to the facility, he/she received both COVID-19 vaccines at a local pharmacy. He/she was fully vaccinated as he/she received the second vaccine about a month ago. He/she asked staff why he/she had to be in quarantine, but staff did not answer or could not provide him/her with a reason. The resident said he/she could provide the pharmacy name if that would help get him/her out of quarantine. During an interview 5/26/21, at 10:51 A.M., the facility's Infection Control Preventionist (ICP) said a resident's hospital discharge paperwork, under immunization, should indicate if a resident had one or both, COVID-19 vaccine(s). If a resident said he/she had the COVID-19 vaccine and the hospital paperwork did not include any specifics, he would contact the hospital or pharmacy where the resident said he/she received the vaccine. During an interview on 5/27/21, at 1:30 P.M., the resident said the following: -He/she received both of his/her vaccines. He/she could not remember the exact dates, but he/she received one then exactly one month later received the second vaccine. The resident provided the pharmacy's phone number and pharmacist's name to verify he/she received both COVID-19 vaccines; -He/she told any staff who entered his/her room that he/she was fully vaccinated. Staff did not respond to his/her statement; -No staff asked him/her if, when, or where he/she received one or both vaccines; -When staff entered his/her room, they often left his/her quickly because the gown and mask they had to wear made them hot. During an interview on 5/27/21, at 2:15 P.M., a pharmacist at a local pharmacy said he/she administered both vaccines to the resident. The first on 3/16/21 and the second on 4/16/21 (the resident was fully vaccinated as of 5/1/21). During an interview on 5/27/21, at 2:36 P.M., Therapy Aide (TA) FF said this morning, before the resident used therapy equipment in the hallway, he/she asked the resident to put on a mask. The resident said it was ridiculous (to be in quarantine) because he/she had both of his/her vaccines, but the resident complied. The therapist did not ask the resident any specific information about his/her vaccination status. They (the therapy staff) just did as they were told (regarding residents who were in quarantine). During an interview conducted on 5/28/21, at 10:45 A.M., Speech Therapist S said if a resident was not vaccinated prior to admission to the facility, nursing staff would assign the resident a room on the COVID-19 quarantine hall. During an interview conducted on 5/28/21, at 12:00 P.M., LPN E said prior to admission, the admissions coordinator/marketer obtains the resident's COVID-19 vaccination history. Residents admitted to the facility who had not received both vaccinations stay on the quarantine hall for 14 days. If the LPN read in the resident's hospital discharge record that he/she received one or both vaccinations for COVID-19, he/she would talk to the Assistant Director of Nursing (ADON). A fully vaccinated resident should not be in quarantine. During an interview on 5/28/21, at 12:42 P.M., the ICP said the following: -If a resident was fully vaccinated for COVID-19, he/she did not require 14-day quarantine. Prior to admission to the facility, several staff review the potential resident's hospital records, including his/her immunizations and physician's order. Although the ADON completed most of the admission paperwork, the Director of Nursing (DON), and both MDS coordinators also review the potential resident's records. The staff mostly reviewed the paperwork separately but they did talk about admissions as a group. Sometimes they discussed a resident's COVID-19 vaccination status, but not always. The Director of Nursing (DON) and ADON discussed each new admission and decided which room to admit the resident to. If a resident's hospital discharge paperwork indicated the resident received one or both vaccinations, he would either contact the hospital or talk to the resident, if he/she was lucid, for more information; -According to the resident's hospital records, the resident reported he/she received the Moderna vaccine on 3/16/21. The ICP did not verify the resident received his/her first COVID-19 vaccine, but he talked to him/her yesterday (5/27/21) and he/she was looking forward to receiving his/her second COVID-19 vaccine. The ICP said he usually documented the conversations he had with residents, but this time he did not; -The ICP did not verify COVID-19 vaccination status with lucid residents. He typically verified vaccines with the pharmacy. but did not verify the resident's vaccination with the pharmacy. The ADON would actually verify that. The resident did not tell the ICP he/she was fully vaccinated. During an interview on 5/28/21, at 1:17 P.M., the ADON said the following: -Facility staff admitted residents to the quarantine hall for 14 days if the resident was not fully vaccinated at the time of admission. Before the resident admitted to the facility, she reviewed the resident's hospital referral or discharge summary to determine a resident's vaccination status. If a resident's hospital record indicated the resident had one or both COVID-19 vaccines, then, on admission, staff asked the resident for his/her vaccination card, but lot of times, residents' families brought the resident's vaccination card to the facility. If a resident did not have a vaccination card, staff would attempt to find out where the resident received his/her vaccinations. Staff would call the resident's family and ask them, or ask the resident if the resident was alert and oriented. If the resident could not provide details of where and when he/she received the vaccinations, for facility staff to verify, they erred on the side of caution and placed the resident in quarantine. The ICP verified some residents' vaccinations, but she verified the majority of them. -The ADON thought the resident received only one (Moderna) COVID-19 vaccine. She tried contacting the resident's family member to verify the resident's vaccination, but she could not get a hold of him/her. She did not talk to the resident when he/she admitted , but she would not have trusted the resident's memory because when she first admitted she was a little confused. She also had not talked to or assessed the resident since the resident admitted , but she should have checked on him/her. No one told the ADON the resident was fully vaccinated. After the ADON reviewed the resident's admission assessment (during the interview on 5/28/21), she said the resident was alert and oriented and was cognitively intact. Record review of the resident's progress notes dated 5/28/21, at 6:34 P.M., showed a nurse documented the resident reported today that he/she received both COVID-19 vaccines. The facility's infection control nurse called the pharmacy and verified the resident received both vaccines. During an interview on 6/2/21, beginning at 11:39 A.M., the DON said before a resident admitted to the facility, she and the ADON reviewed the resident's hospital discharge paperwork, most of the time the paperwork included information regarding the resident's COVID-19 vaccination status. If a resident was not fully vaccinated before admission, staff admitted the resident to the COVID-19 quarantine hall for 14 days. The DON and ADON relied on the hospital's records for a resident's vaccination status. Upon admission, staff could ask the resident, but residents were not always the best historians. If staff had a question about a resident's vaccination status, staff would investigate further. If the hospital discharge paperwork showed the resident reported he/she had a COVID-19 vaccination, he/she assumed hospital personnel verified the resident's vaccination status by requesting their vaccination card. He/she hoped hospital personnel verified the resident received a reported vaccination. During an interview on 6/2/21, beginning at 11:39 A.M., the corporate nurse said staff had to depend on or trust the hospital for the information they provided to the facility.

Based on observation, interview, and record review, the facility staff failed to obtain timely treatment orders for new pressure sores, failed to document completing the treatment as ordered once order was received, and failed to complete a timely full assessment of the pressure sores for one resident (Resident #87) who developed two newly identified pressure sores. The facility's census was 104. Record review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries, revision dated July 2017, included the following: -Assess the resident on admission and repeat weekly and upon any changes in condition; -Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Identify any signs of developing pressure injuries (i.e., nonblanchable (stays red when pushed indicating poor blood flow) reddening of the skin); -Inspect pressure points (i.e., sacrum (the triangular-shaped bone at the base of the spine), heels, buttocks, coccyx (tailbone), elbows etc.); -Wash skin after any episodes of incontinence, using a pH balanced skin cleanser; -Moisturize dry skin daily; -Reposition resident as indicated on the care plan; -Evaluate, report, and document potential changes in the skin; -Review the interventions and strategies for effectiveness on an ongoing basis. 1. Record review of Resident #87's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 02/10/21; -Diagnoses included bimalleolar (ankle area) fracture, muscle wasting and atrophy, dysphagia (difficulty swallowing), and Vancomycin-Resistant Enterococci (VRE - a type of bacteria that have developed resistance to many antibiotics). Record review of the resident's care plan, updated 05/26/21, showed the following: -Resident has potential impairment to skin integrity due to impaired mobility; -Follow facility policy/protocols for the prevention/treatment of skin breakdown; -Identify/document potential causative factors and eliminate/resolve where possible; -Resident requires extensive staff assistance of one to turn and reposition in bed; -Air mattress to bed; -Monitor/document/report as needed any changes in skin status including appearance, color, wound healing, signs/symptoms of infection, wound size (length by width by depth), and stage; -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/28/21, showed the following: -Severe cognitive impairment; -Extensive staff assistance required for bed mobility, transfers, dressing, toileting and personal hygiene; -A wheelchair used for mobility; -Incontinence of bladder and bowel; -Indwelling catheter (a hollow, partially flexible tube maintained within the bladder for the purpose of continuous drainage of urine); -Identified as at risk for developing pressure ulcers; -No pressure ulcers; -Pressure reducing device for chair and bed; -Turning/repositioning program. Record review on 5/25/21 of the resident's undated care plan located in the resident's room, inside the closet door, showed the following: -Follow facility policies/protocols for the prevention/treatment of skin breakdown; -Extensive assistance required with bed mobility, transfers, dressing, toileting and personal hygiene. Observation and interviews on 05/25/21, at 10:29 A.M., showed Licensed Practical Nurse (LPN) AA (wound care nurse) and Certified Nurse Assistant (CNA) H entered the resident's room for incontinence care. During the incontinence care, the resident's buttocks were reddened and each buttock had a vertical pressure ulcers, approximately 1.5 centimeter (cm) by 3.0 cm oblong in shape, with a small amount of light pink drainage on the resident's incontinence brief. LPN AA and CNA H said the skin tears on both buttocks were new. LPN AA patted the pressure ulcers with gauze and applied barrier cream. During an interview on 05/25/21, at 11:09 A.M., LPN AA said the residents' skin tears looked like shearing (a form of pressure, occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage). He/She would notify the Assistant Director of Nursing (ADON) to evaluate them. Barrier cream is used on the skin tears until orders are received. Record review of the residents' physician's medication and treatment orders, dated 05/26/21, showed staff did not obtain a a treatment order for the resident's buttock pressure ulcers. Record review of the resident's 12-Hour Nursing Skilled Charting, dated 05/26/21, showed staff did not obtain a treatment order for the resident's buttock pressure ulcers or address the resident's pressure ulcers. Record review of the residents' physician's medication and treatment orders, dated 05/27/21, showed staff did not obtain a treatment order for the resident's buttock pressure ulcers. Record review of the resident's 12-Hour Nursing Skilled Charting, dated 05/27/21, showed staff did not obtain a treatment order for the resident's buttock pressure ulcers or address the resident's pressure ulcers. Observations on 05/28/21, at 10:40 A.M., showed LPN E and CNA BB performed the resident's catheter care, incontinence care, and wound care. During the incontinence care, the resident's buttocks showed no change. LPN E applied Cavilon skin barrier (a no sting long lasting barrier film used as a skin protection film for damaged skin or those with skin at risk of damage) to both pressure ulcers. During an interview on 05/28/21, at 10:50 A.M., LPN E said the resident is turned every two hours by a CNA. Staff notify the Assistant Director of Nursing (ADON) when a pressure ulcer is identified to evaluate the pressure ulcer. The ADON comes up with a plan and contacts the resident's physician with the findings. It takes about 30 minutes to get a treatment order. During an interview on 05/28/21, at approximately 3:00 P.M., LPN E said he/she did get an order for the resident's bilateral buttock pressure ulcers, but did not have time to enter the order in the resident's chart. Record review of the resident's physician's medication and treatment orders, dated 05/28/21, showed staff did not obtain an order for the resident's buttock pressure ulcers. Record review of the resident's 12-Hour Nursing Skilled Charting, dated 05/28/21, showed staff did not obtain a treatment order for the resident's buttock pressure ulcers or address the resident's pressure ulcers. Record review of the resident's physician's order, dated 05/29/21, showed direction for staff to apply Triad (a sterile wound treatment that maintains a moist environment and absorbs moderate levels of wound exudate) two times a day to both buttocks. Record review of the resident's 12-Hour Nursing Skilled Charting, dated 05/29/21, showed staff did not address the resident's buttock pressure ulcers. Record review of the resident's treatment administration record (TAR), dated 05/30/21, showed staff provided the Triad treatment once. Staff did not document a second ordered treatment completed. Record review of the resident's 12-Hour Nursing Skilled Charting, dated 05/30/21, showed staff did not address the resident's buttock pressure ulcers. Record review of the resident's TAR, dated 05/31/21, showed staff did not document completing the Triad treatment/dressing changes are ordered. Record review of the resident's 12-Hour Nursing Skilled Charting, dated 05/31/21, showed staff did not address the resident's buttock pressure ulcers. During an interview on 06/01/21, at approximately 9:30 AM, following wound care to the resident's lower legs, Registered Nurse (RN) F said the resident did not have any pressure ulcers on his/her buttocks. During observation and interview on 06/01/21, at approximately 9:50 A.M., RN F entered the resident's room to evaluate the residents' buttocks. He/She said the resident did have pressure ulcers on both buttocks. The staff did not notify him/her of the pressure ulcers so he/she could complete the skin and wound evaluation. When the CNA or bath aide find pressure ulcers they notify the charge nurse. The charge nurse notifies the ADON. The ADON notifies him/her to complete a skin and wound evaluation. After the evaluation, the ADON determines a plan for treatment. The ADON notifies the resident's physician of the pressure ulcer and the proposed treatment. The physician would approve the treatment or change it. Record review of the resident's TAR, dated 06/01/21, showed staff did not document completing ordered Triad treatment. Record review of the resident's form titled Skin and Wound Evaluation, dated 06/01/21, showed staff documented the following: -A stage II (partial-thickness skin loss with exposed dermis) right buttock pressure ulcer which measured 0.7 length and 0.7 cm width with serosanguineous (fresh bloody exudate that appears when skin is breached) drainage. The depth of the pressure ulcer noted as not applicable; -The left buttock showed a new Stage II pressure ulcer which measured 1.8 cm length and 1.4 cm with serosanguineous drainage. The depth of the pressure ulcer noted as not applicable. MO00182633, MO00182769 and MO00172442

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to obtain physician's orders related to the use of as needed use of oxygen, and failed to update a resident's care plan to reflect the use of as needed oxygen, for one resident (Resident #43). The facility census was 104. Record review of the facility's Oxygen Administration Policy, dated October 2010, showed the facility must verify a physician's order for this procedure, review the resident's care plan for any needs of the resident, and assemble the equipment and supplies as needed. 1. Record review of Resident #43's medical record showed the following: -admitted to the facility on [DATE]; -Diagnoses included of chronic rhinitis (sneezing or a congested, drippy nose) and heart failure (when heart muscle doesn't pump blood as well as it should). Record review of the resident's progress note dated 4/15/21, at 1:50 A.M., showed the physician ordered a chest xray and electrocardiogram (EKG - a test that measures the electrical activity of the heartbeat) due to shortness of breath and chest pain. The resident had an episode of decreased blood oxygen saturation below 90% (normal blood oxygen saturation levels range from 95 to 100 percent; values under 90 percent are considered low). Record review of the resident's progress note dated 4/15/21, at 4:05 A.M., showed the following: -Resident blood oxygen level was was in high 70's. Staff administered oxygen at two liters per minute (LPN); -Blood oxygen level returned to low 90's; -Resident remains on oxygen to maintain oxygenation greater than 90%. Record review of the resident's quarterly Minimum Data Seta (MDS - a federally mandated comprehensive assessment instrument completed by staff), dated 4/16/21 showed the resident had shortness of breath or trouble breathing at rest. Record review of resident's April 2021 and May 2021 physician order sheet (POS) showed no orders related to oxygen usage. Record review of the resident's April 2021 and May 2021 medication administration record (MAR) and treatment administration record (TAR) showed no orders regarding oxygen usage. Record review of the resident's care plan, last updated of 1/11/21, showed the following: -The resident had congestive heart failure and to check breath sounds and monitor/document for labored breathing. (Staff did not address the resident's oxygen use.) Observation on 5/25/21, at 8:41 A.M., showed the resident's oxygen concentrator on 2.5 LPM and humidifier dated 4/22/21. Observation on 5/25/21, at 2:07 P.M., showed the resident's oxygen concentrator on 2.5 LPM and humidifier dated 4/22/21. Observation on 5/26/21, at 2:47 P.M., showed the resident's oxygen concentrator in the resident's room, but was not turned on. The humidifier was dated 4/22/21. During an interview on 5/26/21, at 2:50 P.M., Certified Nursing Assistant (CNA) FF said the following: -The nurses hand out duty sheets and that is how he/she knows which residents are on oxygen. He/she can also look in the computer and on the care plan; -The resident is on oxygen as needed; -The resident has his/her oxygen on in the morning and he/she will take it off of the resident in the mornings. During an interview on 5/26/21, at 3:12 P.M., CNA GG said the following: -The nurse will inform the aides who is on oxygen and they can get the information from the physician's orders or from the care plan; -The resident is on oxygen as needed; -When the CNA gets there in the morning he/she will check vitals. If the the resident's oxygen is low, he/she will put the resident's oxygen on and let the nurse know; -CNA's tells the nurse and they will get water for the oxygen machine. The resident hardly uses his/hers so the water will last a long time; -The last time he/she put on the oxygen for the resident was last Friday (5/21/21). The resident's blood oxygen level was 93%. He/she put the oxygen on the resident and the blood oxygen level went up. During an interview on 5/24/21, at 9:12 A.M., Licensed Practical Nurse (LPN) EE said the following: -They have to contact the physician and give the physician information to get an oxygen order; -After the nurse gets the order, the nurse should put the order in the computer under the patient profile; -The same steps are followed for an as needed order; -The resident does not have an order for oxygen; -The LPN has never used oxygen on the resident because his/her oxygen is never low; -If staff is using oxygen on the resident, there needs to be an order; -If resident doesn't have an order for oxygen, it shouldn't be in the room. During an interview on 5/27/21, at 9:42 A.M., CNA X said the following: -The care plan will show if residents need oxygen and what it should be set on; -The care plan should address if a resident uses oxygen and the care plan is in the closet taped on the door; -If there are new orders, the nurse will tell the CNAs and what the LPM needs to be on; -If the resident's blood oxygen level goes below 92%, the oxygen will go on; -The resident receives oxygen as needed and has a concentrator in his/her room; -The last time the CNA saw the resident with oxygen on was a couple of weeks ago and it was on all day. During an interview on 6/1/21, at 12:11 P.M., LPN A said the following: -The nurse is responsible for getting an order for oxygen. Staff can also try to get the resident to take deeper breaths, cough or reposition them; -In an emergency situation, staff might use a standing order for that moment, but staff have to get an order if there is continuous usage; -Oxygen should be taken out of the room if used for an emergency and not needed routinely; -The facility will usually get an oxygen order and an order to change the humidifier and hose every week; -If a resident had a concentrator in his/her room dated 4/22/21, there should be an order for it; -If the LPN gets an order for oxygen, he/she will pass that onto the next shift and make sure the order is put in the care plan; -The nurse should have received the order or taken the concentrator out of the room. During an interview on 6/1/21, at 12:24 P.M., the Director of Nursing (DON) said the following: -If there is an issue in the middle of the night, there is a standing order for two LPM of oxygen below 90% and if there if there is shortness of breath, contact the doctor; -The nurse working with that resident is responsible for getting orders from the doctor; -If there is a concentrator in the room, there should be an order if the resident is using it or it should be taken out of the room; -The facility will get an order to change the humidifier and tubing once a week; -If staff are using oxygen on the resident, they should have orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent when staff made two errors out of 27 opportunities, resulting in an error rate of 7.4 percent affecting one residents (Resident #54). The facility's census was 104. Record review of the facility's Documentation of Medication Administration policy, dated April 2007, showed the facility shall maintain a medication administration record to document all medications administered, as well as reason(s) why a medication was withheld, not administered, or refused (as applicable). 1. Record review of Resident #54's face sheet (a document that gives a resident's information at a quick glance) showed the following: -Diagnoses included heart failure (a chronic condition in which the heart does not pump blood as well as it should), irritable bowel syndrome without diarrhea (an intestinal disorder causing pain in the belly, gas, and constipation), and gastrointestinal hemorrhage (bleeding in the gastrointestinal tract). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 4/22/21, showed the following: -Moderate cognitive impairment; -admitted on [DATE]. Record review of the resident's physician order sheets showed the following orders: -Floraster (medication for irritable bowel syndrome), 250 milligrams (mg) capsule, one capsule, by mouth, two times per day, order dated 9/16/20; -Cetirizine Hydrochloride (HCl) (medication for allergies), 5 mg tablet, one tablet, by mouth, give in the evening, order dated 9/2/20. Observation on 5/27/21, at 4:16 P.M., showed Licensed Practical Nurse (LPN) A prepared the resident's medications for administration. LPN A was unable to locate the bottle of Floraster. At 4:25 P.M., LPN A noticed he/she had missed some of the resident's medications. LPN A removed a bottle of cetirizine HCl to prepare administration and noticed the bottle was empty. LPN A informed resident two of the medications were unavailable at that time and he/she would attempt to locate new bottles to administer after completing other residents' medication administration. Record review of the resident's medication administration record, dated 5/27/21, showed staff did not administer the physician ordered Floraster and cetirizine HCl due to being unavailable. Record review of resident's nursing notes, dated 5/27/21, showed staff did not document notifying the physician of the medication being unavailable. During an interview on 6/1/21, at 5:03 P.M., LPN A said he/she checked the facility supply closet and was unable to locate the missing medications. LPN A said he/she marked the MAR as medication unavailable and informed the central supply person the need to order more of the medications. He/she did not notify the physician of the two medications not being given due to unavailability. He/she said the physician should have been notified, but he/she had forgot to. During an interview on 6/1/21, at 4:58 P.M., Certified Medication Technician (CMT) C said if a resident's medication was unavailable he/she would ask the nurse to check the emergency kit or central supply closet to see if there were available medications and then administer. If an over the counter medication is needing refilled, he/she would let the central supply staff) know by filling out a paper saying what was needed and put under the central supply door. CMT C said sometimes central supply staff purchase the over the counter medications locally if supply ran out before the order was received. CMT C said to order a refill for prescription medications he/she would make sure pharmacy was notified then check to see if the medication had been reordered. Any medication not available should be reported to the nurse and the physician. During an interview on 6/2/21, at 11:05 A.M., the Director of Nursing (DON) said nursing staff who notice medications or other supplies running low during administration would be responsible for requesting a refill. Scheduled medications ordered through the pharmacy are requested for refill through a reorder tab in the electronic medical record system. The DON, Assistant Director of Nursing (ADON), and central supply staff person would check supplies randomly to see if anything was low and notify central supply of anything that needed to be restocked. Central supply, who is responsible for ordering all over the counter medications, would be notified by either phone call, told during morning meeting, or given a written list. The DON said if a medication is unavailable to administer, the nursing staff should attempt to locate the medication from another area. If the medication was not found in either the emergency kit, the supply closet, or another medication cart, the nursing staff would then report it to the charge nurse, who would report it the physician, the DON as well as central supply.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess the resident's dental condition and determine if the resident wished to receive dental services for one resident (Resident #85). The facility census was 104. Record review of the facility's Dental Services Policy, revised December 2016, showed the following: -Routine and emergency dental services are available to meet the resident's oral health need as in accordance with the resident's assessment and plan of care; -Routine and 24-hour emergency dental services are provided to residents through a contract agreement with a licensed dentist that comes to the facility as needed, referral to the resident's personal dentist, referral to community dentist, or referral to other health care organizations that provide dental services; -A list of community dentists available to provide dental services to residents is available from social services; -Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. 1. Record review of Resident #85's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), dysphagia (the medical term for swallowing difficulties), and oropharyngeal phase (term that describes swallowing problems occurring in the mouth and/or the throat). Record review of the resident's Nursing Admission/readmission Assessment and Care Plan, dated 4/29/21, showed the following: -Resident cognitively intact; -Required setup or cleanup assist for eating and oral hygiene; -The resident had his/her own teeth; -No documentation of dental issues; -No chewing or swallowing problems. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 5/2/21, showed the following: -Cognitively intact; -Independent with eating; -Coughing or choking during meals or when swallowing medications; -Complains of difficulty or pain with swallowing; -No dental issues. Record review of the resident's current care plan showed the following: -Independent with oral care; -Nutritional problem or potential nutritional problem due to increased nutrient needs related to diagnosis of C-diff (a germ that causes severe diarrhea and colitis (an inflammation of the colon)) and multiple pressure ulcers; -No mention of dental issues. Record review of the the resident's Dietary Profile, dated 5/3/21, showed the following: -Resident did not have his/her own teeth; -Resident had both upper and lower dentures; -Had problems chewing; -Currently received a mechanical soft diet (food made easier to chew and swallow by using machines), but resident does not like it per Dietary Manager (DM) and DM will keep his tray card updated. Observation and interview on 5/24/21, at 4:20 P.M., showed the following: -The resident had several broken natural teeth; -The resident did not have dentures; -The resident said he/she had his/her own teeth. He/she occasionally had mouth/gum pain, but not at that time. The resident had not talked to anyone about his/her teeth and no one asked him/her about his/her dental health. The resident would like to talk to someone about setting up a dental appointment. During an interview on 5/27/21, at 12:59 P.M., Registered Nurse (RN) I said the following: -Nursing does a total body assessment and nursing admission assessment; -Nursing has resident open his/her mouth and inspect for missing teeth, upper/lower dentures, oral mucosa (a mucous membrane), assess pain, and look for broken teeth, abscesses (a swollen area within body tissue, containing an accumulation of pus), bleeding or anything abnormal; -If issues are identified, nursing calls the physician to get a dental evaluation and treatment order; -Nursing obtains a physician's order whether the resident is at the facility long term or for short term rehabilitation; -Nursing communicates the order to the person responsible for making appointments. During an interview on 5/27/21, at 1:49 P.M., Speech Language Pathologist (SLP) S said the following: -If the resident is skilled, the nurse lets him/her know the resident is having difficulty with chewing; -The rehab director attends morning meeting and that is where therapy receives information on the long term care residents; -He/she looks at the resident's information from the hospital such as the history and physical and if they have had a swallow study completed; -He/she assesses the resident's dentition for missing or broken teeth, partials or dentures; -If a resident complains of mouth pain due to missing or broken teeth or ill-fitting dentures, he/she notifies the physician and talks to family about the resident's dental care. During an interview on 5/28/21, at 10:06 A.M., Certified Nurse Aide (CNA) O said the following: -He/she knows a resident is having issues with their teeth if the resident communicates this to him/her; -If the resident cannot communicate, he/she can tell by if they resident is not eating as much; -He/she checks the resident's mouth, cleans the resident's teeth, and if the resident shows pain, he/she reports this to the charge nurse. During an interview on 5/28/21, at 11:06 A.M., Licensed Practical Nurse (LPN) E said the following: -The charge nurse does a head to toe assessment when a resident is admitted and charts that; -He/she asks the resident if they have dentures; -He/she has resident open their mouth and he/she looks for sores, thrush, chipped or broken teeth and pain and documents the findings on the admission assessment. He she does not believe there is a place on the assessment to make a note; -If the resident has sores or other issues, he/she reports this to the Assistant Director of Nursing (ADON), Director of Nursing (DON), or weekend supervisor and they will get orders to send to a physician; -The ADON, DON, or weekend supervisor should contact the resident's physician and get orders to send the resident to the dentist; -The ADON sets up the appointments and coordinates the transportation; -He/she did not know if the resident had his/her own teeth or had dentures; -The resident is independent and has not complained of any pain; -If the resident did complain of pain, he/she would assess the resident, report to the ADON, and have him/her get an order for a referral to a dentist; -He/she would document the findings in a nurse's note. During an interview on 5/28/21, at 1:17 P.M., the ADON said the following: -If the resident is alert and orientated, he/she visualizes the resident's mouth and asks the resident if he/she has their own teeth or dentures. If the resident has altered mental status, he/she can see through conversation and visually if the resident has issues; -The CNAs do night oral care with the residents and if something is wrong he/she should report it to the charge nurse; -He/she knows the facility has a lot of dental appointments on the long term side and on the rehab side they are usually on top of this; -If an issue is reported to the charge nurse, he/she calls family to find out if it is an ongoing issue and if the resident follows dentist before calling the physician. He/she can ask resident if alert and orientated and call family if the resident is not. The nurse visualizes the resident's mouth and documents it in the resident's chart; -The nurse asks the physician for an assessment and gets an order for the resident to be evaluated and treated; -During nursing stand up, the facility goes over new orders and he/she notifies the long term care social worker if there is an order for dental services; -The long term care social worker finds out if the resident has a dentist and checks the residents insurance. If the social worker knows the resident has a dentist then the transport person is notified and he/she sets up an appointment with the resident's dentist; -The long term care social worker documents this in the social services notes and the transport person tells the ADON and he/she documents the appointment in the residents chart as an order. During an interview on 6/1/21, at 12:03 P.M., the Dietary Manager said the following: -He/she asks residents if they have their own teeth and he/she looks in their mouth. If the resident is not able to communicate he/she asks the nurse about their teeth; -He/she does not believe the resident has his/her own teeth and he/she assessed the resident. During an interview on 6/2/21, at 11:32 A.M., LPN L said the following: -When he/she assesses dental for the MDS and care plan he/she actually looks in the residents mouth if the resident will allow it; -If the resident will not allow it, he/she contacts the resident's family and asks them about the resident's dental status; -When he/she assesses the resident, he/she is looking for upper and lower dentures, partials, condition of the mouth, gums and teeth and looks for sores and broken teeth -He/she documents his/her findings in the resident's care plan and MDS; -If he/she finds issues he/she contacts social services to get a dental consult and documents this in a nurse's progress note. During an interview on 6/2/21, at 11:39 A.M., the DON said the following: -Initially the nurse assesses a resident from head to toe and asks the resident if he/she has dentures; -The head to toe assessment is documented in the admission assessment by the nurse; -If the resident does not have dentures, the nurse has the resident open their mouth and looks for dental issues and sores; -If a resident has broken teeth, the nurse should document this on the admission assessment; -If the resident has dental issues, the nurse should document this in a nurse's note that the DON reviews every day; -He/she and the ADON make sure the nurse completes all areas on the admission assessment. -If the resident's teeth are broken and it is noted, he/she tells social services and they ask the resident if they have a dentist and want to go to the dentist; -The facility has a nurse in a social services role; -If the resident is on rehab, he/she tells social services and the social worker verifies the resident's payer source and finds a dentist that takes the residents insurance if the resident does not have a dentist. Transport takes the resident to the dentist; -The MDS coordinator is to go down and visually assess the resident's mouth on the five day assessment. The MDS coordinator is to do a head to toe assessment like the initial assessment; -Dietary will not examine the resident's teeth, but can see if they are broken and can ask the nurse about it. They document their findings on the resident's dentition; -He/she does not know anything about the resident's teeth.

Based on observation, record review, and interview, the facility staff failed to ensure approved recipes were followed when preparing pureed foods to ensure residents received the correct consistency and correct amount of calories and nutrients. The facility census was 104. Record review of the facility's Pureed Diet Policy, no date, showed the following: -The purred diet is a modification in consistency of a regular or any therapeutic diet providing foods of smooth semi-liquid or semi-solid consistency requiring no mastication prior to swallowing; -Often individuals on pureed diet texture are nutritionally compromised; -Preparation of the pureed diet should maximize flavor appeal and nutrient density. 1. Observation on 5/58/21, at 10:38 A.M., showed the following: -There were two residents on pureed diets; -Dietary Aide (DA) T made chicken broth. He/she did not measure out the powdered broth. He/she poured some powdered chicken broth out in a measuring cup and added water. The amount of powder chicken broth in the measuring cup was unclear due to the powder being uneven in the cup; -DA T made the vegetable broth. He/she placed some solid vegetable broth in the measuring cup without measuring the vegetable broth in a measure cup and added water. The DA did not measure the amount of vegetable broth solid that was used; -DA T put six pieces of catfish in the blender without measuring the weight and added the premixed chicken broth and blended the catfish; -DA T did not have the recipe book out for purees; -The recipe book for purees was laying on the table eight feet away from the blender with cups and books located on top of the recipe book; -DA T pureed the green beans that were in a pan and bread without referring to the recipe book. During an interview on 5/28/21, at 10:38 A.M., DA T said the following: -He/she does not measure food, he/she guesses and doesn't know if it is the right amount of food; -He/she looked at the recipe book this morning; -Doesn't measure food in scoops before pureeing; -He/she never brings the puree recipe book to the area where he/she blends the food; -He/she does not use scoops to measure out the food to be pureed and just went by pieces of catfish. During an interview on 5/28/21, at 2:42 P.M., the Dietary Manager said the following: -She expects her staff to follow the recipe book and follow exactly how much product they are to puree; -She wants them to put a little extra in when they are blending because residents will get the correct amount of protein; -She expects her staff to have the recipe book out and using the correct scoops to measure the food; -She wants them to use milk or broth and not plain water for liquid. She expects them to measure out the correct amount of broth to get the correct mixture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents from misappropriation of property when staff discovered missing doses of controlled medications, that were in the possession of the facility, for three residents (Resident #2, #5, and #303). The facility census was 104. Record review of the facility's policy titled, Controlled Substances, revised on December 2012, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Individuals must sign the designated controlled substance record; -If the count is correct, an individual resident controlled substance record must be made for each resident who will by receiving a controlled substance. Do not enter more than one prescription per page. This record must contain name of the resident, name and strength of the medication, quantity received, number on hand, name of physician, prescription number, name of issuing pharmacy, date and time received, time of administration, signature of person receiving medication, and signature of nurse administering medication; -Controlled substances must be stored in the medication room in a locked container, separate from containers for non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents; -All keys to controlled substance containers shall be on a single key ring that is different from any other keys; -The charge nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back up keys for all medication storage area including keys to controlled substance containers; -Nursing staff must count controlled medications at the end of each shift. The nursing coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services; -The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties, and shall give the administrator a written report of such findings. Record review of the facility policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, showed the following: -All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated; -Residents have the right to be free from theft and/or misappropriation of personal property; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent; -The facility will implement policies that strictly prohibit, and pursue to the full extent of the law, staff or employee theft or misappropriation of resident property; -The facility will promptly respond to and investigate complaints of theft or misappropriation of property; -The facility will train staff to report misappropriation of resident property; -When an incident of theft and/or misappropriation of resident property is reported, the administrator will appoint a staff member to investigate the incident; -Should an alleged or suspected case of staff misappropriation of resident property by reported, the facility administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: state licensing and certification agency, resident representative, law enforcement official, and attending physician; -Employees who have been accused of misappropriation of resident property shall be removed from resident care areas or suspending pending the results of the investigation; -The results of the investigation will be reported to the facility administrator within 5 days of the reported incident; -The administrator will report the results to Department Heath Senior Services (DHSS) within 5 days on the incident. 1. During an interview on 5/27/21, at 9:24 A.M., the Director of Nursing (DON) said the following: -On the evening of 3/31/21, Resident #5 requested a dose of oxycodone (narcotic pain medication used to treat moderate to severe pain) for pain; -The nurse on duty, Licensed Practical Nurse (LPN) AA, looked for, but could not locate the resident's card of oxycodone and then notified the current DON (who was working as the Assistant Director of Nursing (ADON) at that time) of the situation; -The current DON said she went to the nurses' station to search for the missing medication; -Staff used a narcotic book with bound pages to track resident narcotic quantities; -Staff were to log/document all controlled medications into the narcotic book, a nurse should sign for each dose administered, and the on-coming and off-going nurses were supposed to count all the narcotics between each shift; -Once a card of medication was empty, the staff would fold the narcotic sheet over (in half, long-ways, with the count side concealed) and write an explanation on the back of the resident's narcotic sheet as to what happened to the medication; -While looking for the missing card of medicine, the current DON noticed several pages of narcotic count sheets were folded over with remaining doses on the page, with no explanation written on the back of the pages; -Once the medication was gone and the sheet was folded over, the nurses no longer had to view the page during count, but several pages were folded over with remaining doses of medications listed; -After reviewing the narcotic books and the controlled medications for the entire building, the DON discovered three residents (Resident #2, #5, and #303) with missing controlled medications; -These missing narcotic count pages for these three residents were folded over with no explanation on the back of the page and the front of the pages showed multiple doses remained in the cards for each resident; -After discovering this issue, the current DON notified administration, the residents' physicians, the residents, their responsible parties, the police department, and DHSS. Record review of the facility's investigation for missing narcotics, dated 3/31/21, completed by the facility DON, showed the following: -Facility staff notified the physician and the medical director of the issue on 3/31/21; -The DON interviewed all nurses on the process for passing narcotics and what to do with missing narcotics; -The DON reviewed the records of all residents with missing narcotics and compared the narcotic count sheets to the treatment administration record (TAR). 2. Record review of Resident #2's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of stroke, major depression, type 2 diabetes mellitus with diabetic polyneuropathy (damage of the peripheral nerves), spondylosis (degeneration of the spine), and a past surgical fusion of the cervical (neck) spine. Record review of the resident's March 2021 nurses' treatment administration record (TAR), showed the following: -An order, dated 11/27/19, for oxycodone hydrochloride (HCl) (an opioid medication used to treat moderate to severe pain) 10 milligrams (mg) tablets. Staff to administer one 10 mg tablet by mouth every six hours as needed for pain, not to exceed 40 mg in 24 hours. During an interview on 6/9/21, at 4:15 P.M., a pharmacist from the dispensing pharmacy said the pharmacy delivered 30 tablets of oxycodone 10 mg to the facility on 2/20/21. Record review of the resident's narcotic count sheet showed the following: -A page for the resident's oxycodone 10 mg with directions to administer one tablet every six hours as needed for pain; -The final entry on the narcotic count sheet showed on 3/22/21, at 7:30 P.M., a nurse signed administration of the medication, leaving a remaining balance of 15 tablets on the count sheet. During an interview on 5/27/21, at 9:24 A.M., the DON said the following: -On 4/1/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's remaining 15 tablets of oxycodone 10 mg listed on the count sheet were missing. 3. Record review of Resident #5's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of peripheral vascular disease (PVD - a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), chronic venous ulcer (open lesion of the skin and subcutaneous tissue of the lower leg, often occurring in the lower leg around the medial ankle) to left lower leg, type 2 diabetes mellitus, major depressive disorder, peripheral neuropathy (a result of damage to the nerves outside of the brain and spinal cord (peripheral nerves) that often causes weakness, numbness and pain, usually in hands and feet), lymphedema (refers to swelling that generally occurs in one of the arms or legs), and spondylosis with radiculopathy (pinch nerve), lumbar region (lower back). Record review of the resident's March 2021 nurse TAR showed the following: -An order, dated 8/29/20, for morphine sulfate (an opioid pain medication) 30 mg extended release (ER). Staff to give one tablet by mouth two times per day for pain. During an interview on 6/9/21, at 4:15 P.M., the pharmacist from the dispensing pharmacy said the pharmacy delivered 60 tablets of morphine sulfate 30 mg ER to the facility on 2/13/21. Record review of the resident's narcotic count sheet showed: -A page for the resident's morphine sulfate tablet 30 mg extended release (ER) with directions to administer one tablet two times per day; -The final entry on the narcotic count sheet showed on 3/12/21, at 8:00 P.M., a nurse signed administration of the medication leaving a remaining balance of five tablets on the count sheet. During an interview on 5/27/21, at 9:24 A.M., the DON said the following: -On 4/1/21, while reviewing this resident's narcotic count sheets and searching for the medication, the facility staff discovered the resident's remaining five tablets of morphine sulfate 30 mg ER listed on the count sheet were missing. 4. Record review of Resident #303's face sheet showed: -admitted to the facility on [DATE]; -Diagnoses of prostate cancer, paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), bipolar disorder(a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and intervertebral disc degeneration (the wearing down of the rubbery cushion between disc in the spine), lumbar region. Record review of the resident's March 2021 nurse TAR showed the following: -An order, with a start date of 12/14/20 and an end date of 3/5/21, for oxycodone HCl 10 mg, staff to administer one tablet by mouth every four hours as needed for pain; -An order, with a start date of 3/5/21 and an end date of 3/10/21, for oxycodone HCl 10 mg by mouth every four hours for pain and discomfort. During an interview on 6/9/21, at 4:15 P.M., the pharmacist from the dispensing pharmacy said the pharmacy delivered 28 tablets of oxycodone to the facility on 2/21/21. Record review of the resident's oxycodone narcotic count sheets showed: -A page for the resident's oxycodone HCl 10 mg tablets with directions to administer one tablet every four hours as needed for pain; -The final entry on the narcotic count sheet showed on 2/26/21, at 4 P.M., a nurse signed administration of the medication leaving a remaining balance of 15 tablets on the count sheet. Record review of the resident's March 2021 nurse TAR showed: -An order, dated 3/6/21, for OxyContin ER (a long-acting form of oxycodone) 60 mg, staff to administer one tablet by mouth every 12 hours for pain management. During an interview on 6/9/21, at 4:15 P.M., a pharmacist from the dispensing pharmacy said the pharmacy delivered 28 tablets of OxyContin ER 60 mg to the facility on 3/7/21. Record review of the resident's OxyContin (a long-acting form of oxycodone) narcotic count record showed: -A page for the resident's OxyContin ER 60 mg with directions to administer one tablet every 12 hours; -The final entry on the narcotic count sheet showed on 3/12/21, at 8:00 A.M., a nurse signed administration of the medication leaving a remaining balance of 19 tablets on the count sheet. Record review of the resident's physician order sheet, dated 2/23/21, showed the following: -An order for lorazepam (an anti-anxiety medication) 0.5 mg, staff to administer one tablet every six hours as needed for anxiety. During an interview on 6/9/21, at 4:15 P.M., a pharmacist from the dispensing pharmacy said the pharmacy delivered 26 tablets of Lorazepam 0.5 mg to the facility on 3/5/21. Record review of the resident's lorazepam narcotic count sheet showed: -A page for the resident's lorazepam 0.5 mg tablets with directions to administer one tablet every six hours as needed; -The final entry on the narcotic count sheet showed on 3/8/21, at 4:00 P.M., a nurse signed administration of the medication leaving a remaining balance of 22 tablets on the count sheet. During an interview on 5/27/21, at 9:24 A.M., the DON said the following: -On 4/1/21, facility staff reviewed this resident's narcotic count sheets and searched for the medications; -The facility staff were unable to find the resident's remaining 15 tablets of oxycodone 10 mg listed on the count sheet; -The facility staff were unable to find the resident's remaining 19 tablets of OxyContin ER 60 mg listed on the count sheet; -The facility staff were unable to find the resident's remaining 22 tablets of lorazepam listed on the count sheet. 5. During an interview on 5/26/21, at 3:35 P.M., Licensed Practical Nurse (LPN) AA said the following: -If a narcotic is discontinued or a resident is discharged , the DON removes the remaining narcotics for that resident from the cart, folds the count sheet page in half, and documents the reason for removal of the medication on the back of the count sheet. Once this occurs, the nurses do not unfold and view the page during narcotic count between each shift; -Nurses should not fold a count page over if a resident has remaining doses of the medication in the cart; -On 3/31/21, the LPN attempted to administer an oxycodone 10 mg tablet to Resident #2, but could not find the resident's medication; -The nurse then looked through the narcotic book and found the narcotic count page for this medication folded over and the front of the page showed 15 remaining doses. -The nurse observed the DON had not documented removal of the medication on the back of the narcotic count sheet, but instead the sheet was blank on the back; -The nurse again searched for the medication, but was unable to find the card of medicine; -The nurse immediately notified the DON and ADON of the situation and they began an investigation; -The nurse pulled a dose of the medication from the emergency kit and administered the medication to the resident. During an interview on 6/02/21, at 1:06 P.M., the administrator said the following: -The DON had kept him informed of the missing narcotics; -More oversight was implemented for the missing narcotics; -He expects staff to follow proper procedures regarding narcotics; -He would expect the nurses to complete a narcotic count at each shift change and/or when the next charge nurse takes over. MO00183509 and MO00183541

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #95's face sheet showed the following: -readmitted to the facility on [DATE]; -Diagnoses included fracture (broken) and displacement of the resident's left femur (thigh bone). Record review of the resident's Nursing Admission/readmission Assessment, dated 5/4/21, showed the following: -The resident had 2+ edema (swelling with moderate pitting, when pushed, indentation subsides rapidly) to his/her left lower leg; -Cognitively intact; -Substantial/maximal assistance needed for transfers and bed mobility; -Lower extremity range of motion impairment on one side; -Partial loss of voluntary movement in legs and feet. No side specified; -Non-weight bearing. No side specified. Record review of the resident's physician order, dated 5/4/21, showed the following: -No bearing weight on the resident's left leg; -May perform range of motion (ROM) as tolerated. Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required moderate assistance for mobility. Record review of the resident's current care plan showed the following: -Non-weight bearing to left lower extremity. (Staff did not care plan or develop/implement interventions for the resident's edematous (swelling caused by excess fluid trapped in your body's tissues) left leg.) Observation on 5/25/21, at 9:50 A.M., showed the following: -The resident propelled his/her wheelchair towards the therapy department; -The resident's left lower leg was significantly larger than the right lower extremity. His/her left bare foot rested on the edge of the foot rest of the wheelchair. His/her left leg and foot was visibly swollen. The skin on his/her left foot was dark pink/light purple and shiny, with dry patches of flaking skin. Observation and interview on 5/25/21, at 11:30 A.M., showed the resident sat in his/her wheelchair with his/her left lower leg in a dependent position. His/her left lower leg was swollen and the skin shiny and flaky. The resident said hospital staff told him/her it could take a long time before the swelling in his/her leg to decrease. The resident pointed to his/her left leg and said it was two to three times larger than the right and felt heavy. He/she could move his/her left leg, but not a lot. He/she had a recliner in his/her room, but did not sit in it often. Then resident sat in his/her wheelchair most of the day. The resident did not elevate his/her while in his/her wheelchair. Staff had to assist him/her to transfer, they did not ask if he/she wanted to sit in the recliner and he/she did not ask them to assist him/her. The recliner would help the swelling in his/her leg. Observation and interview on 5/27/21, at 10:50 A.M., showed the resident moved to a room on a different hall. He/she sat in his/her wheelchair with his/her left foot positioned on the foot rest, in the dependent position. A bandage covered his/her left heel. The top of the resident's foot and toes were very swollen and the skin was dark pink/light purple with flaky patches. The resident's left leg was visibly larger than the right. The resident did not have a recliner in his/her room. The resident said he/she did not ask staff for a recliner, but it would be more comfortable and would help with the swelling in his/her leg. Observation and interview on 5/28/21, at 9:49 A.M., showed the resident sat in his/her wheelchair with his/her left foot positioned on the foot rest, in the dependent position. A bandage covered his/her left heel. The top of the resident's foot and toes were very swollen and the skin was dark pink/light purple with flaky patches. The resident's left leg was visibly larger than the right. The resident said his/her left foot hurt last night. Because his/her leg was swollen (in the dependent position), it pushed hard on the foot rest and it hurt after sitting in the wheelchair all day. Observation on 6/1/21, at 11:32 A.M., showed the resident sat in his/her wheelchair talking with visitors. His/her left foot/heel was positioned on the foot rest. The foot rest was in the dependent position. The resident's left leg and foot was visibly larger than the right. During an interview on 6/1/21, at 12:10 P.M., CNA G said the following: -If a resident had swelling in his/her legs or feet, staff elevated his/her arms or legs with pillows. -The resident's left leg was swollen. When the resident resided on the therapy hall, he/she elevated the resident's left leg when the resident was in bed. The foot pedal on the resident's wheelchair lifted up so he/she tried to put a pillow under the resident's left lower leg to help elevate it. When the resident's left leg was really swollen, he/she did not want to get up out of bed. The resident did not have a recliner in his/her room on 400 hall, but he/she did not have one on the 300 hall. He/she used it once in a while. -If a resident asked him/her for a recliner, he/she would tell the charge nurse, ask maintenance or the DON. Observation on 6/1/21, at 12:38 P.M., showed the resident sat at the dining room table with his/her left heel resting on the foot rest, in the dependent position, with a sock covering his/her left foot. The resident's left leg was visibly larger than his/her right lower leg. During an interview on 6/1/21, at 12:41 P.M., LPN A said the following: -If a resident's leg was swollen, interventions included elevating the resident's feet and if there is no change, he/she contacted the physician for a diuretic (medication that increased the amount of water and salt expelled from the body as urine) for the resident. When the resident laid bed, he/she raised the foot of the bed and propped up the resident's legs with pillows. The resident could also sit in a recliner or elevate his/her feet on the wheelchair's foot rest. -Nursing encouraged the resident to lay in bed with his/her feet propped up on pillows. Nurses initiated interventions. LPN A did not initiate any specific interventions related to the resident's edema. The nurses assessed the resident's edema every shift; -LPN A said he/she could get a recliner for the resident and rearrange the resident's room to make the recliner fit; -The resident usually does not stay up all day on his/her shift. During an interview on 6/2/21, at 9:31 A.M., Physical Therapy Aide (PTA) Y said the following: -Therapy assisted nursing with recommendations for positioning if the resident received therapy services; -Interventions for edema included elevated leg rests, propping up the affected extremity (leg) on pillows when in bed, and sitting in a recliner; -Therapy and nursing discussed and educated each other on their intervention recommendations; -Therapy staff gave the resident elevating leg rests on 5/12/21 (for the edema in his/her leg); -If a resident did not have a recliner in his/her room, therapy could recommend one; -The resident did not have a recliner in his/her room but when the resident attended therapy today, the PTA would look into it for him/her. Observation on 6/2/21, at 10:18 A.M., showed the resident sat in his/her wheelchair in his/her room. His/her left foot was positioned on the wheelchair's foot rest in the dependent position. The resident's left lower leg and foot appeared significantly bigger than his/her right lower leg and foot. Observation on 6/2/21, at 10:29 A.M., showed LPN Z entered the resident's room to change the dressing on the resident's left foot. The resident's left leg and foot was visibly swollen around the brace. When the LPN removed the ankle brace, the resident's leg showed a significant indention from the brace with swollen tissue around the indention. During an interview on 6/2/21, at 10:45 A.M., LPN Z said the following: -All nursing staff could initiate and implement interventions for edema including elevating the affected extremity (arm or leg). If a resident developed edema, the nurse notified the physician and initiated interventions; -The resident had significant edema in his/her left lower leg and foot. He/she did not know why the nurses did not implement specific interventions for the resident's edema. During an interview on 6/2/21, at 11:39 A.M., the DON said the following: -Interventions for edema depended on the cause of the edema but could include a chair that elevated the resident's feet, transferring the resident to bed between meals, and propping up the affected extremity when in bed; -Interventions for edema should be on the care plan; -The charge nurse should initiate interventions and document the interventions in a progress note; -When the charge nurse initiated new interventions, he/she let the on-duty staff know of the interventions and during shift report, communicate the newly initiated interventions; -Nursing could suggest a recliner for a resident if the resident wanted one, but they could not force the resident to elevate his/her feet; -If a resident refused any interventions, staff should document the refusal in the progress note; -The DON did not know anything specific about the resident's edema. Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #7) received the necessary care and treatment for his/her contractured (a permanent tightening of the muscles, preventing normal movement of the joints) hand when staff failed to document notification of the physician of changes in the condition of the resident's left hand, failed to follow therapy recommendations and obtain orders to monitor consistently placing a carrot (an orthotic device placed in the hand to protect the skin from moisture, pressure, and the risk of fingernail puncture) in the resident's contractured hand, and failed to notify therapy of a physician's order to evaluate and treat the resident's left hand. The facility failed to document a complete and accurate bowel assessment including history of, or currently experiencing bout of loose stools, failed to obtain antidiarrheal medication in a timely manner, and failed to notify the physician of the delay of ordered medication for one resident (Resident #202) with a history of Crohn's disease (a type of inflammatory bowel disease (IBD) that causes inflammation of the digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition). The facility failed to identify, develop, and implement interventions for the care of one resident's (Resident #95) edematous (swollen with an excessive accumulation of fluid) left leg. The facility census was 104. 1. Record review of the facility's protocol titled, Functional Impairment, revised March 2018, showed the following: -Upon admission, whenever a significant change occurs, and periodically during a resident's stay, the physician and staff will assess the resident's function along with their physical condition; -The staff and physician will identify residents with potential for significant improvement in function or significant decline in function, including the ability to perform activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -The physician will identify and document the impact of medical conditions on function and identify resident's potential to benefit from rehabilitative services such as physical and occupational therapy; -The staff and physician will collaborate to identify a rehabilitative or restorative care plan to help improve function and quality of life and meet a residents's goals and needs and attain other desired outcomes such as discharge to the community; -Based on a review of available information (including results of the evaluation) the physician will determine if a resident meets the criteria for skilled therapy services; -The physician will order any therapy services; -The staff will monitor and document the resident's function and will discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care. Record review of the facility's policy titled, Requests for Therapy Services, revised April 2007, showed the following: -Therapy services must be ordered by the resident's physician; -A physician's order must be obtained prior to requesting therapy services; -Once an order is obtained, the Director of Nursing (DON) shall forward the request to the therapist. Record review of Resident #7's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/4/20, showed the following: -admitted to the facility on [DATE]; -Severe cognitive impairment; -Diagnoses included Alzheimer's disease, muscle wasting, and atrophy (wasting away); -Functional limitation in range of motion (ROM) impairment on one side to upper and lower extremities; -Required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Record review of the resident's occupational therapy plan of care, dated 10/14/20, showed the following: -Current level of function: the resident demonstrated no passive range of motion (PROM - when someone physically moves or stretches a part of your body) to the left upper extremity (LUE) with contractures forming in digit flexion (fingers); -Goal: the resident will increase LUE digits extension with carrot and/or splint; -Discharge plan: long term care with restorative nursing program (RNP). Record review of the resident's occupational therapy (OT) daily treatment notes showed the following: -On 10/14/20, recent referral to therapy for LUE contracture causing decline in ADLs; -On 10/15/20, left fingers extension, passive range of motion (PROM) completed to the left hand, order to cleanse palm of left hand due to contracted joints; -On 10/16/20, PROM to LUE and placed carrot in left hand; -On 10/19/20, when completing digit extension to insert carrot noted bleeding, at which time the treatment was ceased and the resident was taken to the nurse for assessment. Record review of the resident's medical record showed staff did not document on 10/19/20 regarding the resident's bleeding hand. Record review of the resident's occupational therapy (OT) daily treatment notes showed the following: -On 10/22/20, PROM completed on LUE. Discussed with nursing the importance of donning (wearing) the carrot; -On 11/5/20, PROM completed on LUE digit extensions, inserted carrot, and discussed with nursing on condition of resident contracture on digit extension condition. Record review of the resident's OT Progress and Discharge summary, dated [DATE], showed the following: -The resident will increase left upper extremity extension with carrot and/or splint, goal met; -Discharge plan: long-term care. Record review of the resident's physician orders, dated November 2020, showed no order for the left hand carrot. Record review of the resident's progress notes, dated 1/5/21, showed the following: -The resident had redness, swelling, warmth, and increased pain to his/her left hand; -The resident's physician evaluated the resident's hand; -The physician ordered Doxycycline (an antibiotic) 100 milligrams (mg) two times per day for seven days; -The physician ordered occupational therapy to evaluate and treat the resident, new hand splint required. Record review of the resident's occupational therapy documentation showed no evaluation or documentation following the physician's order on 1/5/21. Record review of the resident's orthopedic surgeon office visit, dated 1/12/21, showed the following: -Resident presents with a left hand deformity; -Resident symptoms began three to four years prior; -Received occupational therapy at the facility in the past, but they were unable to extend his/her fingers out of the palm which has resulted in some hygiene difficulties; -The physician was unable to extend the resident's left finger due to spasticity (abnormal muscle tightness); -Suspect the resident may have had a stroke in the past with subsequent left sided hemiparesis (partial paralysis on one side of the body), therefore will refer to neurology for further work up; -Discussed possible treatments plans with resident's family member. Record review of resident's progress notes, dated 1/28/21, showed the following: -The nurse attempted the resident's left hand treatment; -The nurse soaked the left hand in warm water and soap; -The nurse could not open the resident's hand; -The nurse used a toothette (a sponge used for oral care) to cleanse the hand; -The nurse noted purulent (containing pus) drainage from the hand and open areas under the resident's clenched fingers; -The nurse washed the resident's hand with water, and attempted to dry using Inter Dry (an absorbent material that [NAME] moisture from the skin) and left it in place for two hours; -The nurse administered Tylenol to the resident for pain. (The nurse did not document notification of the physician of the change in the resident's hand condition.) Record review of the resident's care plan, revised on 3/8/21, showed the following: -The resident has a left hand contracture; -The resident will remain free from of injuries or complications related to the contracture; -Anticipate and meet the resident's needs; -Be sure the call light is within reach and respond promptly to all requests for assistance; -Clean the resident's left hand daily; -Monitor for fatigue; -Plan activities during optimal times when pain and stiffness is abated; -Monitor, document, and report as needed signs and symptoms or complications related to arthritis: joint pain, stiffness, swelling, decline in mobility, decline in self care ability, contracture formation, joint shape changes, crepitus (creaking with joint movement), and pain after exercise. Record review of the resident's physician order, dated 5/26/21, showed the following: -Staff to clean the resident's left hand with soap and water twice per day and place gauze between the resident's fingers. Observation on 6/1/21, at 9:35 A.M., showed the following: -The resident lay on his/her bed; -The resident's left fingers were folded closed into a fist with his/her fingers tight against the palm of his/her hand; -The resident had a bandage, dated 6/1/21 on the base of his/her thumb; -The resident's fingernails were trimmed short; -The resident did not have a carrot or other device in place in his/her hand; -The resident did not have gauze between his/her fingers. During an interview on 6/1/21, at 9:35 A.M., Restorative Nurse Assistant (RNA) II said the following: -He/she believed the resident's left thumb bandage covered a cut caused from the resident's fingernails. During an interview on 6/1/21, at 10:00 A.M., Licensed Practical Nurse (LPN) Z said the following: -The current physician order directs the nurses to clean the contractured hand with normal saline (NS) and dry with gauze; -In the past, staff placed a carrot in the resident's hand, but staff became unable to open the resident's fingers enough to place the carrot in the resident's hand; -Therapy tried to insert the carrot, but they felt it was detrimental to the resident, so the carrot was discontinued. Observation and interview on 6/1/21, at 10:15 A.M., showed: -LPN Z removed the bandage from the resident's left thumb exposing a linear scab at the base of his/her left thumb, approximately one-half inch in length; -LPN Z said the cut to the resident's left thumb may have been caused from the resident's fingernails, which staff recently trimmed. During interviews on 6/1/21, at 11:45 A.M. and 2:10 P.M., Occupational Therapist (OT) HH said the following: -Therapy worked with the resident in October and November of 2020 and provided therapy to the resident's left contractured hand during that time; -When therapy discharged the resident in November of 2020, he/she asked nursing to obtain a physician's order to place a carrot orthotic in the resident's left contractured hand to help prevent the resident's contracture from worsening; -He/she was originally going to recommend the resident be placed on restorative therapy after the discharge from skilled therapy in November 2020, but decided it was too dangerous for the resident to be treated by a restorative therapy aide due to the severity of the contracture, and instead a skilled nurse needed to place the carrot in the resident's contractured hand; -The resident needed something in his/her hand to prevent the resident's fingernails from digging into his/her palm and the carrot would help prevent increased contracture and further injury; -The OT placed several carrots in the resident's room in his/her bedside table; -The OT educated nurses on the use of the carrot and documented the need to place the carrot on a communication board (dry erase board) in the resident's room to place the carrot in the resident's left hand daily; -On several occasions, he/she observed the resident without the carrot in his/her hand after discharge from therapy services in November 2020; -He/she did not recall notifying anyone of nursing's failure to place the carrot as directed in the resident's hand; -In January of 2021, the OT was asked by the nursing department to look at the resident for possible therapy due to the resident's contractured hand; -When the therapist looked at the resident's left hand in January, 2021, the resident's palm had an open area with bloody drainage caused from the resident's fingernails digging into his/her palm and the contracture had worsened; -He/she did not feel it was safe for the resident to have therapy on his/her hand at that time due to the open area and drainage from the resident's palm; -The OT informed the nursing department that the resident needed medical intervention due to the hand's condition before therapy could be resumed; -The OT did not believe he/she documented what occurred in January of 2021; -He/she was unaware of an order from the physician on 1/5/21 to evaluate and treat the resident's left hand; -If nursing had notified therapy of the physician's order to evaluate and treat, he/she would have conducted a full evaluation and documented the findings or would have communicated to the physician, if the evaluation was not possible; -The OT said he/she believed an outside physician was currently treating the resident's hand contracture. During an interview on 6/1/21, at 12:30 P.M., the Director or Rehabilitation (DOR) said the following: -The resident received occupational therapy (OT) services from 10/14/20 until 11/10/20; -Upon discharge, the OT recommended nursing should place a carrot in the resident's left contractured hand; -When therapy requires a physician ordered treatment for a resident, the normal process is for therapy to ask the nursing department to contact the physician for the order. During an interview on 6/1/21, at 12:35 P.M., LPN Z said the following: -If therapy wanted nurses to place a carrot in the resident's contractured hand, then therapy should have obtained a physician's order for the treatment; -Therapy had not asked the nursing department to obtain physician orders in the past; -The nurse said he/she believed the resident had a carrot in his/her room, but nurses did not have a physician's order to place the carrot in the resident's hand; -The nurse said, to her knowledge, nursing staff did not place the carrot in the resident's hand. During an interview on 6/1/21, at 2:35 P.M., Certified Medication Technician (CMT) C said the following : -Nurses asked the CMT to place the carrot in the resident's left hand in the past, but the CMT was unsure which nurses; -He/she attempted several times to place a carrot in the resident's left contractured hand, but the resident would remove the carrot with his/her right hand; -The resident would verbally express pain, by saying, Ouch, when staff would attempt to place the carrot, therefore the CMT stopped attempting to place the carrot in the resident's contractured hand; -The CMT attempted to administer pain medication, such as Tylenol, to the resident prior to placing the carrot, but the resident still complained of pain; -The CMT said he/she informed nurses when the resident did not tolerate the carrot, but was unsure which nurses he/she informed. During an interview on 6/1/21, at 2:40 P.M., Certified Nurse Aide (CNA) CC said the following: -In the past, CNAs would place the carrot in the resident's left hand in the morning while assisting the resident with morning cares; -Some days, the resident's left hand hurt too much and he/she could not tolerate the carrot; -The CNA said, the aides knew to place the carrot in the resident's hand because of the communication board in the resident's room directing them to do so; -The CNA said, a few months ago, resident's hand became infected and the staff stopped using the carrot. During an interview on 6/1/21, at 3:55 P.M., the Director of Nursing (DON) said the following: -Therapy should notify the nurse if a resident needs a physician's order for an (orthotic) device; -Nursing is responsible for obtaining physician orders for treatment and placing orders on the treatment administration record (TAR); -The DON did not remember therapy directing nursing to obtain an order for the resident to have a hand carrot; -Staff told the DON on several occasions that the resident removed the carrot whenever staff placed the device in the resident's hand; -The DON directed nurses to notify the resident's physician and responsible party of the resident's refusals and document in the progress notes; -The DON said staff should have documented the resident's non-compliance in the progress notes; -The DON said, on one occasion, the placement of the carrot caused the resident's hand to start bleeding and the DON notified the physician, but the DON was unsure when this occurred; -If a resident needs a therapy evaluation, the DON would communicate that information to the director of rehabilitation during the morning meeting (held daily Monday to Friday); -In January 2021, after the physician recommended therapy, the therapy department said the could not do anything for the resident's hand because the hand was too contractured and they could not open the resident's hand; -The DON said she believed the resident's family was currently taking the resident to an outside specialist for treatment. During an interview on 6/02/21, at 1:06 P.M., the administrator said the following: -In the past, staff encouraged the resident to have the carrot or brace in his/her hand; -The therapy department is involved in the staff morning meetings; -Staff should communicate if a resident needs a new carrot; -The resident has never had a carrot in his/her hand since October 2019. 2. Record review of Resident #202's face sheet (a document that gives a resident's information at a quick glance) showed the following: -Staff admitted the resident to the facility on 5/19/21; -His/her diagnoses included diarrhea, and abnormalities of gait (a person's manner of walking) and mobility. Record review of the resident's hospital discharge information, dated 5/19/21, showed the following: -Diagnoses included diarrhea, unspecified. -A physician's order for Lomotil (medication used to treat diarrhea), one tablet, four times a day as needed for diarrhea/loose stool; -The resident's clostridium difficile (C. diff - a germ (bacterium) that causes severe diarrhea and colitis (an inflammation of the colon)) laboratory results, dated 5/19/21, were negative (no bacteria detected). Record review of the resident's progress note dated 5/19/21, at 7:21 P.M., showed a nurse documented the resident admitted to the facility this evening via transport van from a hospital. The resident was alert and oriented. He/she said he/she had diarrhea. The resident tested negative for C. diff today (5/19/21). The resident had an active order for as needed Lomotil. Record review of the resident's nursing admission assessment and care plan, dated 5/19/21, showed the following information: -Cognitively intact; -Continent of bowel; -Bowel pattern: normal, formed stool, rarely/never depended on laxatives; -Had a bowel movement two to three times a week. Record review of the resident's physician order summary report showed the following: -On 5/19/21, an order for Florastor (a probiotic (good bacteria touted to help maintain digestive health and boost the immune system) supplement that may be effective in treating symptoms of Crohn's disease), 250 milligrams (mg) by mouth every morning; -On 5/19/21, an order for Lomotil 2.5 mg/0.025 mg, one tablet by mouth every six hours as needed for diarrhea. (The resident's orders did not show any additional antidiarrheal medication). Record review of the resident's care plan, initiated on 5/20/21, showed the resident had self-care deficit and required extensive assistance with bed mobility, personal hygiene and transfers. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance with bed mobility, transfers, walking, dressing, personal hygiene, and bathing; -Required limited assistance for toileting; -Continent of bowel; -No documented diagnosis of Crohn's disease or inflammatory bowel disease. Record review of the resident's skilled nursing notes showed a nurse documented the following bowel/gastrointestinal (GI- referring collectively to the stomach and small and large intestines section) assessment: -On 5/22/21, at 10:34 P.M., the resident was continent of bowel with bowel sounds present (diarrhea was not checked indicating the resident did not have diarrhea); -On 5/23/21, at 10:34 A.M., the resident was continent of bowel with bowel sounds present (diarrhea was not checked indicating the resident did not have diarrhea); -On 5/23/21, at 10:22 P.M., the resident was continent of bowel with bowel sounds present (diarrhea was not checked indicating the resident did not have diarrhea). Record review of the resident's care plan, initiated on 5/23/21, showed the following: -The resident had diarrhea; -The resident will have reduced episodes of diarrhea through the review date; -Administer anti-diarrheal medications as ordered; -Monitor and document for any precipitating factors; -Prevent factors that increase risk or episodes of diarrhea; -Monitor and document for pain and discomfort. Record review of the resident's skilled nursing notes showed a nurse documented the following bowel/GI assessment: -On 5/24/21, at 10:22 A.M., the resident was continent of bowel with bowel sounds present (diarrhea was not checked indicating the resident did not have diarrhea); -On 5/24/21, at 9:47 P.M., the resident was continent of bowel with bowel sounds present (diarrhea was not checked indicating the resident did not have diarrhea); -On 5/25/21, at 12:27 P.M., the resident was continent of bowel. During an interview conducted on 5/25/21, at 2:22 P.M., the resident said he/she had been experiencing a lot of diarrhea (since before admission to the facility and now). He/she had eight to ten loose stools a day. He/she needed antidiarrheal medication at least in the morning and at night. He/she talked to a nurse practitioner (NP) who said she would order something, but when the resident asked staff about the medication, staff did not know what medication the resident was talking about. The resident said he/she would never get the diarrhea resolved unless he/she received routine medicine. Record review of the resident's skilled nursing notes showed a nurse documented the following bowel/GI assessment: -On 5/25/21, at 7:27 P.M., the resident was continent of bowel with bowel sounds present (diarrhea was not checked indicating the[TRUNCATED]

Based on interview and record review, the facility failed to ensure all controlled drugs were reconciled periodically per standards of practice when staff failed to ensure outgoing and incoming nurses counted narcotics during shift change on two of three units in the facility. The facility census was 104. Record review of the facility's policy titled, Controlled Substances, revised on December 2012, showed the following: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Individuals must sign the designated controlled substance record; -If the count is correct, an individual resident controlled substance record must be made for each resident who will by receiving a controlled substance. Do not enter more than one prescription per page. This record must contain: name of the resident, name and strength of the medication, quantity received, number on hand, name of physician, prescription number, name of issuing pharmacy, date and time received, time of administration, signature of person receiving medication, and signature of nurse administering medication; -Controlled substances must be stored in the medication room in a locked container, separate from containers for non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents; -All keys to controlled substance containers shall be on a single key ring that is different from any other keys; -The charge nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back up keys for all medication storage area including keys to controlled substance containers; -Nursing staff must count controlled medications at the end of each shift. The nursing coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services; -The director of nursing services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties, and shall give the administrator a written report of such findings. Record review of the facility's Controlled Drug Count nurse signature page, located in the front of each controlled drug book, showed the following: -Count all controlled drugs accessible to medication nurse at each shift change; -The form contained spaces for the following information: date, time, outgoing nurse's signature, incoming nurse's signature, and count ok (yes or no). 1. Record review of the 200 hall controlled drug count (nurse signature page), dated 2/26/21 to 3/16/21, showed nurses failed to sign the count form on the following dates and times: -On 2/28/21, at 6:00 P.M., the outgoing nurse failed to sign; -On 3/01/21, at 6:00 A.M., the incoming nurse failed to sign; -On 3/01/21, at 6:00 P.M., the outgoing nurse failed to sign; -On 3/02/21, at 6:00 A.M., the incoming nurse failed to sign; -On 3/02/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 3/03/21, at 6:00 A.M., the incoming nurse failed to sign; -On 3/03/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 3/10/21, at 6:00 P.M., the incoming nurse failed to sign; -On 3/11/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 3/12/21, at 6:00 A.M., the incoming nurse failed to sign; -On 3/12/21, at 12:00 P.M., the outgoing nurse failed to sign. Record review of the 200 hall controlled drug count nurse signature page, dated 3/17/21 to 4/07/21, showed nurses failed to sign the count form on the following dates and times: -On 3/18/21, at 6:00 A.M., the incoming nurse failed to sign; -On 3/18/21, at 6:00 P.M., the outgoing nurse failed to sign; -On 3/19/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 3/20/21, at 6:00 A.M., the incoming nurse failed to sign; -On 3/20/21, at 6:00 P.M., the outgoing nurse failed to sign; -On 3/22/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 3/23/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 3/26/21, all outgoing and incoming nurses failed to sign; -On 3/27/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 3/28/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 4/03/21, at 6:00 A.M., the incoming nurse failed to sign; -On 4/04/21, all outgoing and incoming nurses failed to sign; -On 4/05/21, at 6:00 P.M., the outgoing nurse failed to sign; -On 4/06/21, at 12:00 P.M., the outgoing nurse failed to sign; Record review of the 200 hall controlled drug count nurse signature page, dated 4/07/21 to 4/23/21, showed nurses failed to sign the count form on the following dates and times: -On 4/08/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/09/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/10/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/11/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/14/21, at 9:00 P.M., the outgoing nurse failed to sign; -On 4/17/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/21/21, at 6:00 P.M., the incoming and outgoing nurse failed to sign; -On 4/22/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/22/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/23/21, at 6:00 A.M., the outgoing nurse failed to sign. Record review of the 200 hall controlled drug count nurse signature page, dated 4/23/21 to 5/10/21, showed nurses failed to sign the count form on the following dates and times: -On 4/24/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/24/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 4/26/21, at 6:00 A.M., the incoming nurse failed to sign; -On 4/28/21, at 6:00 A.M., the incoming nurse failed to sign; -On 4/29/21, at 6:30 A.M., the outgoing nurse failed to sign; -On 4/30/21, at 6:00 P.M., the incoming and outgoing nurse failed to sign; -On 5/01/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/03/21, at 8:30 P.M., the incoming nurse failed to sign; -On 5/04/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/09/21, at 6:00 A.M., the incoming nurse failed to sign; -On 5/09/21, at 8:15 P.M., the incoming nurse failed to sign; -On 5/10/21, at 5:45 P.M., the outgoing nurse failed to sign. Record review of the 200 hall controlled drug count nurse signature page, dated 5/11/21 to 5/27/21, showed nurses failed to sign the count form on the following dates and times: -On 5/14/21, at 6:00 A.M., the incoming nurse failed to sign; -On 5/14/21, at 6:00 P.M., the outgoing and incoming nurses failed to sign; -On 5/15/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/17/21, at 6:00 A.M., the incoming nurse failed to sign; -On 5/18/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/20/21, at 12:00 P.M., the outgoing nurse failed to sign; -On 5/22/21, at 6:00 A.M., the incoming nurse failed to sign and no other nurse signed on 5/22/21; -On 5/23/21, all incoming and outgoing nurses failed to sign. 2. Record review of the 400 hall controlled drug count nurse signature page, dated 4/1/21 to 4/25/21, showed nurses failed to sign the count form on the following dates and times: -On 4/01/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/01/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/02/21, all outgoing and incoming nurses failed to sign; -On 4/03/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/06/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/07/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/07/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/10/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/10/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/11/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/11/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/13/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/15/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/15/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/17/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/21/21, all outgoing and incoming nurses failed to sign; -On 4/22/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/23/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/24/21, at 6:00 P.M., the incoming nurse failed to sign; -On 4/25/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/25/21, at 6:00 P.M., the incoming nurse failed to sign. Record review of the 400 hall controlled drug count nurse signature page, dated 4/27/21 to 5/18/21, showed nurses failed to sign the count form on the following dates and times: -On 4/27/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 4/30/21, at 6:00 P.M., the incoming nurse failed to sign; -On 5/01/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/04/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/05/21, all outgoing and incoming nurse failed to sign; -On 5/06/21, at 6:00 A.M., the outgoing and incoming nurse failed to sign; -On 5/06/21, at 6:00 P.M., the outgoing nurse failed to sign; -On 5/07/21, at 6:00 A.M., the incoming nurse failed to sign; -On 5/07/21, at 6:00 P.M., the outgoing nurse failed to sign; -On 5/08/21, at 6:00 P.M., the incoming nurse failed to sign; -On 5/09/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/09/21, at 6:00 P.M., the incoming nurse failed to sign; -On 5/10/21, at 6:00 P.M., the incoming nurse failed to sign; -On 5/12/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/12/21, at 6:00 P.M., the incoming nurse failed to sign; -On 5/13/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/13/21, at 6:00 P.M., the incoming nurse failed to sign; -On 5/14/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/14/21, at 6:00 P.M., the incoming nurse failed to sign; -On 5/15/21, at 6:00 A.M., the incoming and outgoing nurses failed to sign; -On 5/15/21, at 6:00 P.M., the outgoing nurse failed to sign; -On 5/16/21, at 6:00 A.M., the incoming nurse failed to sign; -On 5/17/21, at 6:00 A.M., the incoming nurse failed to sign; -On 5/18/21, at 6:00 P.M., the outgoing nurse failed to sign. Record review of the 400 hall controlled drug count nurse signature page, dated 5/19/21 to 5/27/21, showed nurses failed to sign the count form on the following dates and times: -On 5/19/21, at 6:00 A.M., the outgoing nurse failed to sign -On 5/19/21, at 6:00 P.M., the outgoing and incoming nurses failed to sign; -On 5/21/21, at 6:00 P.M., the incoming nurse failed to sign; -On 5/22/21, at 6:00 A.M., the outgoing nurse failed to sign; -On 5/26/21, at 6:00 P.M., the outgoing nurse failed to sign. 3. During an interview on 5/27/21, at 3:00 P.M., Licensed Practical Nurse (LPN) EE said the following: -He/she counts all narcotics on his/her assigned unit at the beginning and end of each shift with the outgoing and incoming nurses; -On the morning of Monday, 5/24/21, he/she worked the 200 hall and a nurse from one of the other units came over to drop off the keys for the narcotic box; -LPN EE informed the other nurse that they needed to count the control medications and while counting, LPN EE noticed the the weekend staff had failed sign the narcotics count book on 5/22/21 and 5/23/21; -LPN EE said he/she notified the Director of Nursing of this situation; -LPN EE said, at times, 200 Hall does not have a night nurse on the weekends and the nurses from the other units are responsible for coming over to 200 hall to count the narcotics at shift change; -LPN EE said, he/she thinks the narcotics are not always counted during the times when there is no nurse assigned to 200 hall. During an interview on 5/27/21, at 4:00 P.M., the Director of Nursing (DON) said the following: -She expected nurses to count all controlled medications and sign the controlled medication book signature page, located on each unit, at every change of shift; -If the facility does not have a nurse assigned to the 200 hall at night, then the 300 hall nurse is responsible for both the 200 and 300 halls; -The 300 hall nurse should come to the 200 hall and count all controlled drugs with the outgoing 200 hall nurse that evening and then count again with the incoming 200 hall nurse the next morning; -All nurses should sign the narcotic count book signature page after counting; -On Monday, 5/24/21, a nurse showed the DON the gaps on the narcotic count signature page and prior to that the DON was unaware of the problem. During an interview on 6/02/21,at 1:06 P.M., the administrator said the following: -He expected staff to follow proper procedures regarding narcotics; -He expected the nurses to complete a narcotic count at each shift change and/or when the next charge nurse takes over.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review staff failed to ensure staff performed hand hygiene when leaving rooms or the hall, failed to sanitize equipment used by multiple residents after possible contamination, and failed to ensure trash cans holding potentially hazardous gloves and gowns were properly covered on the Coronavirus Disease 2019 (COVID-19) (an infectious disease caused by severe acute respiratory syndrome, Coronavirus 2 (SARS-CoV-2)) quarantine hall. Additionally, the facility failed to develop a complete program for the prevention of the growth of Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella). The facility's census was 104. 1. Record review of the facility's Policies and Practices - Infection Control, revised October 2018, showed the objectives of the facility's infection control policies and practices are to: -Prevent, detect, investigate, and control infections in the facility; -Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; -Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Record review of the facility's Infection Control Guidelines for All Nursing Procedures, revised August 2012, showed: -Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents; after removing gloves; when there is likely exposure to spores (i.e. C. Difficile or Bacillus anthraces) (Note: Alcohol-Based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30-60 seconds with soap and water or 2% chlorhexidine gluconate.); -In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: after contact with objects (e.g., medical equipment in the immediate vicinity of the resident); and after removing gloves. Record review of the facility's policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, dated April 2020, showed the following: -The facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility; -While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including hand hygiene, respiratory hygiene, appropriate use of PPE, transmission-based precaution where indicated, surveillance and reporting of respiratory infections, environmental cleaning with EPS-registered disinfectants approved for use against SARS-CoV-2 and laundry practices; -For a resident with an undiagnosed respiratory infection, standard, contact and droplet precautions (i.e. facemask, gloves, isolation gown) with eye protection are implemented unless the suspected diagnosis requires airborne precautions; -For a resident on contact precautions: staff don gloves and isolation gown before contact with the resident and/or his/her environment; -For a resident on droplet precautions staff don a facemask within six feet of a resident; -For a resident on airborne precautions staff don an N95 or higher level respirator mask prior to room entry of a resident room; -For a resident with known or suspected COVID-19, suspected of being defined as a known exposure to COVID-19 or symptoms of COVID-19, staff don prior to entering the units or resident room gloves, isolation gown, eye protection and an N95 or higher-level respirator if available (a facemask is an acceptable alternative if a respirator is not available); and resident is placed in a private room with a dedicated bathroom (if available) and close the door; or resident is cohorted per national, state, or local public health authority recommendations. Staff doff gloves prior to exiting the room and perform hand hygiene. Staff doff gowns prior to exiting the designated unit or as needed if contamination is suspected; -Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitoring equipment) are used, or if not available, then equipment is cleaned and disinfected according to manufactures' instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident; -Signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (e.g., outside of resident's room, wing, unit or facility-wide). Observations throughout the survey, 5/24/21-5/28/21 and 6/1/21-6/2/21, showed the facility had a designated hallway for quarantined residents. The quarantine hall included rooms 315 to 323. Staff placed a table with, various supplies, including hand sanitizer, gloves, disposable gowns and masks, near the first quarantine room (315). Next to the supply table, staff placed two red biohazard trashcans with lids for discarded gowns and gloves. Signs adorned each resident's room door that directed staff and visitors to clean their hands then apply gloves, gown, and a mask, before entering the room. The sign also directed staff to dedicate resident specific supplies/equipment or use disposable equipment to each room. Observations on 5/25/21, beginning at 2:59 P.M., showed the following: -Licensed Practical Nurse (LPN) E exited room [ROOM NUMBER] (located on the facility's COVID-19 quarantine hall due to possible COVID exposure prior to admission), removed his/her gloves and gown, and placed them in the red trash cans near the PPE supply table; -The LPN applied new gloves, without washing or sanitizing his/her hands, and removed the red bag from one of the trash cans. The second red trashcan did not have a red bag liner. The LPN asked a staff member to bring him/her some red liners; -At 3:00 P.M., the LPN removed his/her gloves, took his/her phone out of his/her pocket and made a phone call while carrying one red bag down the hall. The LPN did not sanitize or wash his/her hands after he/she removed his/her gloves; -The LPN left both red trashcan lids on the floor. The red trashcan that did not have a red bag liner was overflowing with discarded disposable gowns and gloves; -The LPN returned to the quarantine hall, donned a disposable gown, and entered room [ROOM NUMBER]. The LPN did not apply gloves prior to entering the resident's room; -When he/she exited the room, he/she removed the gown and placed it in uncovered overly-full red trashcan. Both trashcan lids remained on the floor. The LPN did not sanitize his/her hands or wash his/her hands after he/she exited the resident's room; -The LPN stood at nurses' station, removed a computer from a cart and took it to the nurses' station; -At 3:13 P.M., one of the red trash cans remained empty without a red bag liner, the discarded disposable gowns and gloves spilled over the top of the second red trashcan (without a liner). Both trashcan lids remained on the floor; -At 3:18 P.M., the LPN emptied the contents of the red unlined trashcan into a red bag liner and carried the bag down the hall; -At 3:20 P.M., the LPN placed a new red bag liner in each red trashcan then covered the trashcan with the lid. Observations on 5/27/21, on the facility's COVID-19 quarantine hall showed the following: -At 1:25 P.M., a portable vital sign machine (a machine that included attachments that measured blood pressure, heart rate and in some models, blood oxygen levels) was plugged into a wall outlet near the nurses' station, its blood pressure cuff laid on the floor; -At 1:38 P.M., Certified Nurse Aide (CNA) G picked up the blood pressure cuff from the floor and placed it in a tray on the vital sign cart. The CNA did not sanitize or clean the blood pressure cuff before placing it in the cart; -At 1:42 P.M., the vital sign machine and cart, with the potentially contaminated blood pressure cuff, remained at nurses' station. CNA G donned a disposable gown, performed hand hygiene and entered room [ROOM NUMBER]. The CNA did not apply gloves prior to entering the resident's room. (The resident was on quarantine due to possible exposure prior to admission.) When he/she exited room [ROOM NUMBER], he/she entered room [ROOM NUMBER], wearing the same gown. (The resident was on quarantine due to possible exposure prior to admission.) After exiting room [ROOM NUMBER]. He/she removed the gown and placed it in the red trashcan located near the supply table. The CNA did not perform hand hygiene after removing the gown. He/she walked to nurses' station and touched multiple surfaces. He/she knocked the same blood pressure cuff off of the vitals cart onto the floor, picked it up, and placed it back on the vitals cart; -At 2:22 P.M., therapy staff wheeled the vital sign cart from the nurses' station to room [ROOM NUMBER]. The therapy staff member placed the blood pressure cuff on the resident, without cleaning or sanitizing it. During an interview on 6/2/21, at 11:01 A.M., LPN N said the following: -The facility did not have a designated vital sign cart for the quarantine hall; -Staff should sanitize the vital sign cart with sani-wipes (a germicidal disposable wipe) after each resident. If blood pressure cuff laid on the floor, staff sanitized it before using it on a resident. During an interview on 6/2/21, at 11:39 A.M., the Director of Nursing (DON) said the following: -Each resident who resided on the COVID-19 quarantine hall, should have his/her own designated disposable blood pressure cuff, stethoscope, oxygen sensor and dedicated glucometer (an instrument for measuring the concentration of glucose in the blood) if applicable. Observation on 5/27/21, at 1:25 P.M., showed used disposable gowns hung over the sides of both red biohazard trash cans located at the table at the entrance of the COVID-19 isolation hall. Observations on 5/27/21, at 1:42 P.M., showed the following: -CNA G donned a disposable gown, performed hand hygiene and entered room [ROOM NUMBER] (on the quarantine hall due to possible exposure prior to admission); -CNA G exited room [ROOM NUMBER] then, without sanitizing or washing his/her hands, entered another room [ROOM NUMBER] (on the quarantine hall due to possible exposure prior to admission); -The CNA exited the second resident's room, removed his/her gown and placed it in the red trashcan. He/she walked to nurse's station and touched multiple surfaces. The CNA did not wash or sanitize his/her hands after removing his/her disposable gown and before touching other surfaces. During an interview on 6/2/21, at 11:39 A.M., the DON said the following: -Staff should wear a KN95 mask (type of respirator) and disposable gown when entering residents' rooms on the quarantine hall. Staff should probably wear gloves, as well, if they may come into contact with any bodily fluid; -After exiting a resident's quarantine room, staff should remove their disposable gown then their gloves, and place them in a biohazard container then wash their hands. Staff could wash their hands at the sink behind the nurses' station or in the bathroom; -Staff could use hand sanitizer while still in the resident's room, but she also wanted them to wash their hands after they left the room. During an interview on 6/2/21, at 11:01 A.M., LPN N said the following: -Nursing staff removed and discarded the red trashcan bags. The trashcan lid should close properly. Gowns should not hang out of the red trash cans. Observation on 6/2/21, at 11:15 A.M., showed discarded disposable gowns hanging out of the red trash cans located on the facility's COVID-19 quarantine hall. Staff had over-filled the trash cans and lids did not completely close. During an interview on 6/2/21, at 11:39 A.M., the DON said the following: -Staff who worked on the quarantine hall should empty the red trash cans before they get too full. -Disposable gowns should not hang out of the red trash cans and the lids should completely close. 3. According to the Centers for Disease Control (CDC) Toolkit for Legionella (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) bacteria (officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective. Record review of the facility's undated policy titled Reduce Risk of Growth and Spread of Legionella, showed the following: -The facility would follow guidelines detailed in the CDC Toolkit for Legionella; -The facility will conduct a facility risk assessment where legionella could grow and spread in facility water; -The facility will implement a water management problem that includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Facility procedures for investigation and control of Legionnaire's Disease (a type of pneumonia caused by legionella bacteria. The bacteria spreads through mist, such as air-conditioning units for large buildings. Adults over [AGE] years of age and people with weak immune systems or chronic lung disease, are most at risk. Those who develop symptoms may experience cough, fever, chills, shortness of breath, muscle aches, headaches, and diarrhea); -Facility procedures for long term control measures; -Facility procedures for legionella written control scheme; -Facility procedures for legionella water management plan. During an interview on 5/26/21, at 3:35 P.M., the maintenance director said the following: -He was not aware of any procedures or policies related to reducing legionella growth and spread in the building; -When shown the facility policy for preventing legionella growth, the maintenance director said he was completely unfamiliar with the policy; -He was not checking any part of the facility, in any manner, for risk and conditions related to legionella prevention or growth. During an interview on 5/26/21, at 4:01 P.M., the administrator said the following: -He was unaware of any steps ever taken, by any staff, to enact or follow the CDC Toolkit for Legionella or follow the facility policy Reduce Risk of Growth and Spread of Legionella.