**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to facilitate and support each resident's right to self-determination when staff failed to provide baths/showers to two residents (Resident #46 and #49) as requested and care planned. A sample of 27 residents was reviewed in a facility census with a census of 101. Review showed the facility did not provide a policy related to showers/bathing of residents. 1. Review of Resident #46's face sheet (brief information sheet about the resident) showed the following: -admission date of 10/03/22; -Diagnoses include: cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), systemic lupus erythematosus (SLE - an autoimmune disease, the immune system of the body mistakenly attacks healthy tissue), cognitive communication deficit, and congestive heart failure (CHF - condition in which the heart cannot pump enough blood to the body's other organs). Review of the resident's care plan, last reviewed on 03/08/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance related to weakness and non-ambulatory status; -Staff should offer two baths/showers per week and as needed; -Resident required extensive assistance of one staff for bathing/showering. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/04/24, showed the following: -Moderate cognitive impairment; -Required partial to moderate assistance with showering/bathing; -Independent with transfers. Review of the resident's ADL sheet titled Bathing Monday & Thursday & PRN (as needed), dated 06/01/24 to 07/29/24, showed staff documented the following: -On 06/05/24, the resident received a shower; -On 06/12/24, the resident received a shower (seven days after the previous shower); -On 06/19/24, the resident received a shower (seven days after the previous shower); -On 06/24/24, the resident received a shower; -On 07/08/24, the resident received a shower (14 days after the previous shower); -On 07/18/24, the resident received a shower (10 days after the previous shower); -On 07/29/24, the resident received a shower (11 days after the previous shower). Observation and interview on 07/23/24, at 1:15 P.M., showed the resident said he/she would like showers more often. He/she only get a shower once per week. He/she felt dirty and tired when not clean. He/she was scheduled for showers on Monday and Thursdays. He/she said when received, showers twice week was good enough, but that once per week was not enough. The resident's hair was uncombed and dull. 2. Review of Resident #49's face sheet showed the following: -admission date of 05/20/22; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), dependence on wheelchair, acquired absence of right leg and left leg above the knee (limb was amputated), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic respiratory failure a with hypoxia (condition not have enough oxygen in the tissues in the body), and obstructive and reflux uropathy (urine cannot drain through the urinary tract, and may back up into the kidneys). Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Required substantial to maximal assistance with showering/bathing; -Dependent on staff for transfers. Review of the resident's care plan, last reviewed 07/18/24, showed the following: -The resident had an ADL self-care performance deficit related to bilateral above the knee amputation; -The resident preferred bathing/showering on Monday, Thursday, and as needed; -The resident required extensive assistance of one staff for bathing/showering; -The resident required extensive assistance of two staff for bed mobility; -The resident required mechanical lift, Hoyer, with two staff assistance for transfers. Review of the resident's ADL sheet, titled Bathing Monday & Thursday & PRN, dated 06/01/24 to 07/29/24, showed staff documented the following: -On 06/11/24, the resident received a bed bath (at least 11 days after the previous bath/shower); -On 06/13/24, the resident received a shower; -On 06/25/24, the resident received a shower (12 days after the previous shower); -On 07/24/24, the resident received a shower (one month after the previous shower); -On 07/28/24, the resident received a bed bath. Observations and interview on 07/23/24, at 11:16 A.M., showed the resident said he/she had not had any shower or bed bath since 07/03/24, when came off hospice. The resident's hair had a greasy, oily, and dull appearance. The resident said he/she needed a shower. He/she felt crusty, dirty, nasty, and smelled without a shower. The resident said he/she had agreed to a full shower one to two times per month because he/she did not tolerate the Hoyer lift (mechanical device with a sling attached to lift and transfer a non-ambulatory resident) well with skin issues on the back side. He/she thought at one time the physician ordered for him/her to receive bathing/shower five times per week, but he/she would settle for twice per week. During an interview on 07/26/24, at 12:30 P.M., Certified Nurse Aide (CNA) S said residents on hospice services should be offered showers from the facility staff as well. The resident just came off hospice and the resident's hospice staff was great about getting him/her cleaned. The resident took two showers per month and the rest of the time had bed baths. He/she did not provide showers last week as the resident was still on hospice. 3. During an interview on 07/26/24, at 10:25 A.M., Licensed Practical Nurse (LPN) G said that showers are done by shower aides with the schedule they had. He/she had not seen any residents not appear clean or heard of no shower for weeks. 4. During an interview on 07/26/24, at 12:30 P.M., CNA S said that he/she had a shower list and that residents should be offered two showers per week. Some residents only take one per week. 5. During an interview on 07/26/24, at 2:20 P.M., the Director of Nursing (DON) said staff should offer two showers/baths per week, even if on hospice service. Staff should communicate in report if a resident was no longer on hospice although nothing should change because staff should already be offering two shower/baths per week. Residents should not have to wait 20 days to have a shower/bath. 6. During an interview on 07/26/24, at 3:00 P.M., the Administrator said staff should offer residents showers/baths two times per week even if on hospice. Residents should not have to wait three weeks for shower.

Based on observation, interview, and record review, the facility failed to ensure each resident's personal privacy was protected when staff failed to shut the door for one resident (Resident #6) while providing personal care exposing him/her to anyone passing the room. The facility census was 101. Review of the facility's policy titled Dignity, last revised in February 2021, showed the following information: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents' private space and property are respected at all times; -Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of the Resident #6's face sheet showed the following information: -admission date of 04/18/18; -Diagnoses include diabetes, obesity, Alzheimer's disease, chronic kidney disease, and major depressive disorder. Review of the resident's quarterly Minimum Data Sheet (MDS - a federally mandated assessment tool filled out by facility staff), dated 05/01/24, showed the following information: -Moderate cognitive impairment; -Dependent on staff for all personal cares and mobility; -Incontinent of bowel and bladder. Review of the resident's care plan, last revised on 10/17/22, showed extensive assist of two staff required for personal care. Observation on 07/25/24, at 10:37 A.M., showed the resident's room door open with the the resident's unclothed back of his/her body visible from the hall. The resident was laying on his/her left side facing toward Certified Nursing Assistant (CNA) E. The resident was undressed from the waist down. CNA said oh, sorry, I should have pulled this. CNA E left the side of the resident and pulled the curtain to provide privacy. CNA E said he/she was performing incontinence care and had just finishing up. During an interview on 07/26/24, at 9:15 A.M., the resident said he/she did not particularly like his/her whole body shown to the hall, but his/her roommate likes the door open, so it is often left open during care. During an interview on 07/26/24, at 9:39 A.M., Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) F said a resident's bare body should never be seen from the hallway. Staff should provide privacy for the resident prior to providing care. The resident's roommate has claustrophobia (a fear of confined spaces), so he/she does not like the door to be closed often. But, in that case, staff should still pull the privacy curtain. During an interview on 07/26/24, at 9:50 A. M., Licensed Practical Nurse (LPN) G said he/she expected staff to provide privacy during care by closing the curtain around them. There should never be any instance when walking down the hall should you see an unclothed resident. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said it is never acceptable to be able to see an exposed resident from the hallway. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and Administrator agreed and said that residents' doors and curtains should not be open while incontinent care is being performed.

Based on observation, interview, and record review, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) prior to or upon admission to the facility for one resident (Resident #14). The facility census was 101. Review of the facility's policy titled admission Criteria, dated March 2019, showed the following information: -All new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders per the PASARR process; -The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a mental disorders, intellectual disabilities, or related disorders; -If the level I screen indicates that the individual may meet the criteria for a mental disorders, intellectual disabilities, or related disorders, he/she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process; -Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he/she needs, and whether placement in the facility is appropriate; -The state PASARR representative provides a copy of the report to the facility; The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation; -Once a decision is made, the state PASARR representative, the potential resident, and his/her representative are notified. 1. Review of Resident #14's face sheet (brief overview of resident information) showed the following information: -admission date of 08/09/09; -Diagnoses include dysphagia (difficulty swallowing), intellectual disabilities, cognitive communication deficit, visual loss in both eyes, and dementia. Review of the resident's care plan, last revised on 05/12/21, showed the following information: -Required extensive assistance with two staff for toileting, mobility, dressing, and transfers related to intellectual disabilities; -Visual and hearing disablement; -Lacked capacity to understand and make decisions regarding healthcare. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 05/25/24, showed the following information: -Resident rarely or never understood; -Substantial to maximum assist from staff for personal care and mobility; -Incontinent of bowel and bladder. Review of the resident's record on 07/23/24, at 2:28 P.M., showed no Level I or II PASARR completed. During observation and interview on 07/25/24, at 12:43 P.M., the MDS Coordinator said she is responsible for PASARR's. Level I PASARR's are completed at the hospital prior to admission to the facility. If the resident comes from home, then the facility will complete it. A Level II is only completed if the resident has had a recent behavioral, psychiatric, or impatient stay at the hospital. If a resident does require a level II, the facility contacts Bock Associates and they will come and complete it for the facility. She does not believe this resident would trigger a Level II. The resident has been at the facility for a long time, so he/she should have a completed PASARR. The MDS Coordinator reviewed the resident's electronic medical record (EMR) and said she could not find one. The MDS Coordinator said the Medical Records Nurse might have record of his/her PASARR in paper form. During an interview on 07/26/24, at 1:42 P.M., the Medical Records Director said they were unable to find the resident's PASARR in the facility's records due to him/her being at the facility so long. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and Administrator said, a PASARR Level I should be completed prior to admission to the facility. If they don't have one, the MDS Nurse is responsible for completing them. The resident hasn't had any behavioral admissions, so they do not believe he/she would require a Level II, but he/she should at least have had a Level I completed.

Based on observation, interview, and record review, the facility failed to ensure all residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene when staff failed to provide peri-care and change urine soaked items for one resident (Resident #42). The facility census was 101. Review of the facility's policy titled Urinary Incontinence- Clinical Protocol, last revised April 2018, showed staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. Review showed the facility did not provide a policy regarding incontinent care and/or performing incontinent care. 1. Review of the Resident #42's face sheet (brief look at resident information) showed the following information: -admission date of 04/20/18; -Diagnoses include chronic kidney disease, overactive bladder, muscle wasting and atrophy (loss of muscle tissue, size, and strength), and diabetes mellitus. Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff), dated 06/25/24, showed the following information: -admission date of 04/20/18; -Cognitively intact; -Dependent on staff for mobility; -Substantial to maximum assistance from staff needed for personal hygiene; -Incontinent of bladder. Review of the resident's care plan, last revised on 07/24/24, showed the following information: -Frequent bladder incontinence; -Staff to check as required for incontinence. Staff to wash, rinse, and dry perineum (sensitive skin between genitals). Staff to change clothing as needed after incontinence episodes; -Staff to monitor for signs and symptoms of infection; -At times resident refused to allow staff to change him/her. Puddles of urine have been under his/her chair and resident remains non-compliant with allowing staff to change him/her. Observation on 07/24/24, at 3:37 P.M., showed the following: -The resident sat in his/her wheelchair in his/her room with the call light on. He/she said they were waiting for staff to return to provide care. -Certified Nursing Assistant (CNA) I entered the room at 3:40 P.M. and said he/she would be performing care as soon as he/she found some help. At 3:48 P.M., CNA I , CNA H, and the Assistant Director Of Nursing (ADON) entered the room. CNA I, CNA H, and ADON donned (put on) gowns. At 3:50 P.M., CNA J knocked on the resident's door and entered with a Hoyer lift (mechanical lift). -CNA I and CNA H donned gloves. CNA I obtained the Hoyer lift and positioned it in front of the resident. CNA I and CNA H both obtained Hoyer sling (sling that goes under the resident and hooks to the lift) straps from under the resident and hooked them up to the lift. CNA I operated the Hoyer lift and lifted the resident into the air, while CNA H guided the resident's legs. While aides were doing so, urine was seen on the resident's wheelchair pad that he/she was sitting on and dripping onto the floor from the point of the resident's wheelchair to the bed. -Once the resident was over the top of the bed, CNA I lowered the lift and resident onto the bed with CNA H guiding. CNA I and CNA H unlatched the Hoyer sling from the lift. The ADON prepped brief and laid it on the bed for the aides and then obtained a towel and began cleaning up urine spill on the floor with his/her shoe. -CNA H and CNA I pulled down the resident's pants and took off the resident's shoes. CNA I and CNA H pulled down the resident's dirty brief and exposed the resident. CNA I doffed (took off) gloves and donned new gloves. CNA I handed wipes to CNA H. CNA H wiped under the resident's pannus (excess skin and fat that hang down from the stomach) and down each side of the residents' inner thighs with the same wipe change. The CNAs did not provide peri-care (washing of genitals and anal area). The resident then rolled toward CNA H and CNA I wiped the resident's bottom three times with one wipe. -With no hand hygiene or glove change, CNA I obtained and placed a clean brief under the resident. The wet Hoyer sling was not changed and remained under the resident. Resident rolled toward CNA I and CNA H, pulled out that side of the resident's brief. Resident rolled back onto his/her back. CNA H and CNA I latch the clean brief around the resident and asked the resident if he/she would like them to change his/her pants. The resident said no. CNA H and CNA I did not tell the resident that his/her pants were urine soaked. CNA I and CNA H pulled the residents pants back up. -CNA H and CNA I doffed gloves. CNA H washed hands and CNA I did not. CNA I obtained the Hoyer lift and put it over the top of the resident. CNA I and CNA H latched the Hoyer sling to the Hoyer lift. CNA I operated the Hoyer lift, while CNA H guided the residents' legs. CNA H locked the resident's wheelchair, and CNA I lowered the Hoyer lift and resident down onto the urine-soaked pad in the wheelchair. Before unhooking the resident from the lift, the surveyor asked the aides if they had checked to see if the pad in the resident's wheelchair was urine-soaked. Both aides did not check and unhooked the Hoyer sling from the lift. During an interview on 07/26/24, at 9:39 A.M., CNA/Certified Medication Tech (CMT) F said to provide incontinent care staff must, provide privacy, gather all necessary supplies, and perform hand hygiene and don gloves prior. Staff should let the resident know what they are going to be doing. Staff would cleanse front to back, one side of the privates at a time, then down the middle at the end. One wipe per swipe. At the end of that care, staff may apply barrier cream then put the residents' clothes/brief back on. Staff should wash your hands and don clean gloves before and after care, and anytime they go from a dirty surface to a clean one. It would never be acceptable to not change out soiled clothing/linens. During an interview on 07/26/24, at 9:50 A. M., Licensed Practical Nurse (LPN) G said for incontinent care, he/she expected staff to wash their hands, don gloves, remove any dirty items, take off gloves, wash hands, and don new gloves prior to starting care. After cleansing, staff should change wash their hands, don new gloves, then move onto the resident's backside, one wipe per swipe. It is never acceptable to not change out soiled clothing/linens. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said that staff should always wash their hands, especially when going from a dirty surface to a clean one. Staff should also not leave a resident in soiled clothing or linens. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and the Administrator said there should be two staff for providing incontinent care. Hand hygiene should be performed, the curtain should be pulled, and staff should explain what they are doing. The staff should don gloves and proceed to performing care. One staff member should assist with getting the resident positioned. The second staff should pull down the resident's brief and obtain three wipes. One wipe per side, and one wipe for the middle, utilizing one wipe per swipe. After that, staff should doff their dirty gloves, perform hand hygiene, and don clean gloves, otherwise everything is contaminated. Staff should make sure all linens and clothing being put back on the resident are clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that one resident's (Resident #46) code status (type of emergent treatment a person would or would not receive if their heart or breathing were to stop) matched throughout the medical record out of a sample of 27 residents. The facility census was 101. Review of the facility policy titled Advance Directives, dated [DATE], showed the following information: -Advance directives will be respected in accordance with state law and facility policy; -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so; -Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members or legal representative, about the existence of any written advance directives; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive; -The Interdisciplinary Team will conduct ongoing review of the resident's decision-making capacity and communicate significant changes to the resident's legal representative. Such changes will be documented in the care plan and medical record; -Changes or revocations of a directive must be submitted in writing to the administrator. The care plan team will be informed of such changes so that appropriate changes can be made in the resident assessment and care plan. 1. Review of Resident #46's face sheet (brief information sheet about the resident), current as of [DATE], showed the following: -admission date on [DATE]; -Diagnoses included cerebral infarction (stroke), altered mental status, chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure with hypoxia (condition that results in the inability to effectively exchange carbon dioxide and oxygen, and induces chronically low oxygen levels or chronically high carbon dioxide levels), and systemic lupus erythematosus (SLE - an autoimmune disease. In this disease, the immune system of the body mistakenly attacks healthy tissue); -Code status of do not resuscitate (DNR - if a person's heart or breathing stops the healthcare team will not try to restart it). Review of the resident's care plan, last revision on [DATE], showed the following: -Code status is full code (the resident wished to receive cardiopulmonary resuscitation (CPR - an emergency life-saving procedure completed when someone's breathing or heartbeat has stopped); -Staff should make sure that the full code is listed as the resident's code status on the resident profile/face sheet; -Staff should provide opportunity for the resident to discuss feeling and ask questions related to end of life decision as needed; -Staff should review code status with the resident/responsible party quarterly or as needed. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated [DATE], showed resident cognitively intact. Review of the resident's Social Services - Assessment and Note, dated [DATE], showed the following: -Quarterly assessment; -Code status of full code; -Code status care plan if the resident's heart stops beating or the resident stops breathing CPR will be initiated per the resident's/responsible party's wishes; -Check to make sure that full code is listed as the resident's code status on the resident profile/face sheet; -Review code status with the resident/responsible party quarterly and as needed. Review of the resident's physician's order sheet, active as of [DATE], showed an order dated, [DATE], for DNR. During an interview and observation on [DATE], at 3:00 P.M., the resident said that he/she would want CPR started if his/her heart or breathing stopped. The care plan inside the resident's closet door showed resident as full code. During an interview on [DATE], at 3:40 P.M., Certified Nurse Aide (CNA) N said that a resident's code status could be found on the top of the screen in the electronic medical record (EMR) and in the resident's closet care plans. During an interview on [DATE], at 9:05 A.M., CNA B said that resident code status was located in the EMR and in each resident's closet care plan. The information should match. During an interview on [DATE], at 9:15 A.M., Certified Medication Technician (CMT) M said staff could locate a resident's code status by looking in the EMR and inside a resident's closet door. He/she said the information should match and thought someone checked that monthly. During an interview on [DATE], at 3:55 P.M., Licensed Practical Nurse (LPN) L said that code status for residents can be found on the resident's face sheet in the EMR, as well as in the resident's closets, and this information should match. During an interview on [DATE], at 10:08 A.M., LPN U said he/she would look in the EMR for a resident's code status. During an interview on [DATE], at 10:25 A.M., LPN G said that resident code status was located in the EMR on the face sheet, medication administration record, and the physician orders. The information was also located inside the resident closets on a posted paper care plan. The information should match. He/she was unsure who audits charts for accuracy. During an interview on [DATE], at 10:35 A.M., Registered Nurse (RN) D said that resident code status could be found in the resident medical record and on the care plan posted in residents' closets. The information should match and he/she thought that social services audited for accuracy. During an interview on [DATE], at 10:15 A.M., the Social Service Director (SSD) said the staff would notify him/her when a code status should be changed in the care plan. He/she did not have access to enter information on the face sheet. He/she thought the Administrator audited the charts. During an interview on [DATE], at 2:08 P.M., the admission Coordinator said that he/she reviewed initial admission code status with residents. When a resident returned from the hospital the nursing staff reviewed if any changes have been made. The nursing staff should audit to ensure the code status is accurate and matched throughout chart. During an interview on [DATE], at 2:20 P.M., Director of Nursing (DON) said resident code status should match throughout the chart. The admission nurse entered the code status information and then the next day on match back the orders should all be checked. (Match back is the chart audit 24 hours after orders are entered.) The resident's care plan and outside hospital orders should all match. When a resident leaves and returns from the hospital the nurses should ensure and update information and ensure it all matches throughout the record. At times the hospital might make someone a DNR at hospital even though the resident has not signed the DNR form. The closet care plan should be updated and accurate, however, it is a guide. Staff should always verify the electronic record. Usually, social services ensured that charts were accurate when doing the quarterly care plan updates. During an interview on [DATE], at 3:00 P.M., the Administrator said that the admission nurses should enter resident code status and then there is a match back to ensure orders match. Code status audits are done every three months with care plan meetings and in-between as needed. The information can be located on the top banner of the EMR, in physician orders, signed documents, and care plan. Staff should notify nurses changes in care plan or EMR are needed. Any nurse can make changes to the care plan, as well as social services. All resident code status should match through their chart. Social Services Director completes quarterly care plan. Inaccuracies should be caught during match back even on readmission from hospital.

Based on observation, record review, and interview, the facility failed to ensure catheter (a sterile tube inserted into the bladder to drain urine) use per standard of practice when one resident's medical record (Resident #47) failed to have a diagnosis to show why the resident had a catheter. The facility census was 101. Review of the facility policy Catheter Care, Urinary, revised, August 2022, showed the following information: -To prevent urinary catheter associated complications, including urinary tract infections (UTI's) staff will review the resident's care plan to assess for any special needs and review and document the clinical indications for catheter use prior to inserting. 1. Review of Resident #47's face sheet (a brief look at the residents personal, incoming information), showed the following information: -admission date of 05/22/24 -Diagnoses included kidney complications. Review of the resident's progress note dated 05/22/24, at 5:18 P.M., showed the resident arrived to facility with a catheter in place. (Staff did not document the diagnosis that warranted the catheter use.) Review of the resident's admissions Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 05/31/24, showed the following information: -Cognitively moderately impaired; -Resident required a catheter; -Diagnoses showed resident has had UTI's. (The MDS did not show a diagnosis associated with need of a catheter.) Review of the resident's physician's orders, dated 07/07/24, showed the following information: -An order, dated 05/26/24, for Foley catheter output documented every shift for health maintenance. (The order did not include the diagnosis that warranted the catheter use.) -An order, dated 06/03/24, for foley catheter to be changed 22nd of every month and as needed. (The order did not include the diagnosis that warranted the catheter use.) -An order, dated 06/03/24, for Foley cath care every shift and as needed. (The order did not include the diagnosis that warranted the catheter use.) Review of the resident's care plan, dated 07/07/24, showed the following information: -The resident had an indwelling catheter; -The resident will be/remain free from catheter-related trauma; -The resident will show no signs or symptoms of urinary infection; -Monitor and document intake and output as per facility policy; -Monitor for signs and symptoms of discomfort on urination and frequency; -Monitor/document for pain/discomfort due to catheter. (Staff did not care plan the diagnosis that warranted the catheter use.) Review of the resident's July 2024 Treatment Administration Record (TAR) showed staff did not document the diagnosis that warranted the catheter use. Review of the resident's progress note dated 07/22/23, at 10:19 A.M. showed catheter changed per physician orders. (Staff did not document the diagnosis that warranted the catheter use.) During an interview on 07/30/24, at 11:15 A.M., the Infection Control Nurse said there should be a diagnosis as to why a resident would require a catheter. Someone should have questioned why there was no diagnosis for the catheter. During an interview on 07/30/24, at 1:35 P.M., the Admissions Coordinator said the following: -He/she usually made sure the diagnoses are included in the physician's orders; -A resident requiring a catheter should definitely have a diagnosis as to why they would need it. During an interview on 07/30/24, at 2:10 P.M., the Director of Nursing (DON) and Administrator said the following: -There should be a diagnosis for why the resident would need a catheter; -This is important because physician orders come from diagnosis' and must be followed.

Based on observation, interview, and record review, the facility failed to ensure respiratory care consistent with standards of practice when staff failed to obtain a physician's order for staff to administer continuous positive airway pressure machine (CPAP - machine used to deliver constant and steady air pressure while sleeping) for the treatment for obstructive sleep apnea (breathing repeatedly stops and starts during sleep) at bedtime as care planned for one resident (Resident #49) with a CPAP machine at bedside. The facility census was 101. Review of the facility policy titled CPAP Support, dated March 2015, showed the following information: -Purpose to provide the spontaneously breathing resident with continuous airway pressure machine with or without supplemental oxygen; to improve oxygenation in residents with respiratory insufficiency, obstructive sleep apnea or restrictive/obstructive lung disease; and to promote resident comfort and safety; -Review the physician's order to determine the oxygen concentration and the pressure for the CPAP machine; -Review and follow the manufacturer's instructions for CPAP machine setup and oxygen delivery; -Document in the resident's medical record the time CPAP therapy was started and the duration of therapy; the mode and settings for the CPAP; and how the resident tolerated the treatment. 1. Review of Resident #49's face sheet showed the following: -admission date 05/20/22; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), acquired absence of right leg and left leg above the knee (limb was amputated), congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), and chronic respiratory failure a with hypoxia (condition not have enough oxygen in the tissues in the body). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 07/07/24, showed the following: -Cognitively intact; -Use of supplemental oxygen; -Staff did not mark use of CPAP treatment. Review of the resident's care plan, last reviewed 07/18/24, showed the following: -The resident had altered respiratory status/difficulty breathing related to sleep apnea; -Staff should apply auto titrating CPAP at 9-15 cwp (centimeters of water pressure (setting to be ordered by the physician)) with heated humidifier; -Staff should monitor, document, and report abnormal breathing pattern to the physician. Review of the resident's June 2024 and July 2024 Treatment Administration Record (TAR) and Medication Administration Record (MAR) showed no order for CPAP placement, pressure setting, or monitoring. Review of the resident's physician order sheet, current as of 07/26/24, showed no order for application or use of CPAP therapy at bedtime. During observation and interview on 07/23/24, at 11:14 A.M., showed the resident's CPAP was on the bedside table. The resident said that the CPAP mask was not always applied by staff at night or machine turned on. The resident said he/she falls asleep and forgets to tell the staff and did not want to bother staff. He/she said that he/she would use the CPAP if staff helped him/her at night. During an interview on 07/25/24, at 3:45 P.M., Licensed Practical Nurse (LPN) L said that CPAP treatment would populate on the nursing TAR during the night shift. The resident did not want his/her CPAP on at night. He/she thought the resident's family took the CPAP out of the room. During an interview on 07/26/24, at 10:08 A.M., LPN U said that the nursing TAR showed what treatments are required for each resident during the shift. He/she did not know if CPAP was on the TAR. During an interview on 07/26/24, at 10:35 A.M., Registered Nurse (RN) D said that treatments and medications populate on the MAR and TAR for each resident. He/she would expect there was an order for a resident with CPAP therapy. During an interview on 07/26/24, at 2:20 P.M., the Director of Nursing (DON) said that the nurses are responsible for CPAP treatment for residents and there should be an order for use. The CPAP should be in the care plan and there should be an order for nurses to apply the CPAP including the pressure settings. The nurses could communicate with aides for CPAP application. During an interview on 07/26/24, at 3:00 P.M., the Administrator said there should be an order for all treatments, including CPAP therapy. The nurses were responsible to ensure the CPAP was started for the resident.

Based on observation, record review, and interview, the staff failed to ensure correct installation and maintenance of all bed rails when the bed rails of one resident (Resident #49) could be moved by the resident back and forth several inches in each direction. The facility had a census of 101. Review showed the facility failed to provide a policy regarding side rail use, installation, and monitoring. 1. Review of Resident #49's face sheet showed the following: -admission date of 05/20/22; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), dependence on wheelchair, acquired absence of right leg and left leg above the knee (limb was amputated), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic respiratory failure a with hypoxia (condition not have enough oxygen in the tissues in the body), and obstructive and reflux uropathy (urine cannot drain through the urinary tract, and may back up into the kidneys). Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/07/24, showed the following: -Cognitively intact; -Required substantial to maximal assistance with showering/bathing; -Dependent on staff for transfers. Review of the resident's care plan, last reviewed 07/18/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to bilateral above the knee amputation; -The resident had enable bars (side rails) to left upper and right upper sides of bed to increase bed mobility and assist with positioning during staff assisted ADLs due to bilateral below the knee amputations; -The resident was informed of risks and benefits of enable bars and consent form signed by resident; -Side rail assessment performed to ensure appropriateness of halo bars for resident; -Side rail zone measurements every monthly and with every significant change; -Assessment of side rail use dated 4/4/23. Observation and interview on 07/25/24, at 10:53 A.M., showed the following: -The resident seated upright in bed with bilateral (both sides) half side rails on the bed; -The resident said that the right-side rail was very loose and that he/she used the bed rail throughout the day to move him/herself in the bed; -The resident grabbed the right-side rail and pulled with the rail several inches back and forth and side to side when he/she pulled on the rail. The resident said that he/she had notified staff of the rail being this loose. During an interview on 07/26/24, at 11:10 A.M., the Maintenance Director said the following: -He installed enabler bars when notified that therapy had done an evaluation. He checked the measurements, ensured they are installed tightly and securely, and educated the resident on the use of the bar. He checked monthly to ensure nothing was loose or broken; -He visually inspected all bed rails every month, but did not keep a log of this check. -Staff should notify maintenance of items in need of repair or write on the maintenance log at the nursing station. During an interview on 07/26/24, at 2:20 P.M., Director of Nursing (DON) said the following: -Side rail assessments should be reviewed by all management teams; -The maintenance staff should monitor for measurements and safety quarterly or when changes in resident condition; -Staff should notify maintenance if there is something wrong with the bed rail so it can be fixed quickly. During an interview on 07/26/24, at 11:46 A.M., the Administrator said that the Maintenance Director was given a list of all side rails once per month to ensure they were intact and not loose. There was nothing other than a check mark for this check. All items should be repaired any time found or notified loose. Staff should notify maintenance of any needed repairs or damage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that the medication error rate was not 5 percent or greater when the facility failed to prime (removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly) an insulin pen for one resident (Resident #74) and when staff crushed and mixed three medications and administered via percutaneous endoscopic gastrostomy (PEG - a tube that is surgically placed into the stomach through a small incision in the abdomen) for one resident (Resident #254). This resulted in four errors out of 28 opportunities during the observed during medication pass resulting in a 14% error rate. The facility census was 101. 1. Review of manufacturer's instructions regarding NovoLog (rapid acting insulin) FlexPens, last revised on March 2008, showed the pen should be primed before each injection. The pen should be primed by the following steps: -Turn the dose selector to select two units; -Hold the pen with the needle pointing up. Tap the cartridge gently with finger a few times to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero. -A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times; -If there is not a drop of insulin after six times, do not use the pen. Review of Resident #74's face sheet (brief look at resident information) showed the following information: -admission date of 04/15/24 -Diagnoses include type two diabetes, obesity, dependency on renal dialysis (procedure that removes wastes and excess fluid from the blood when the kidneys are no longer able to do so), high blood pressure, and heart failure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/04/24, showed the following information: -Cognitively intact; -Insulin injections received seven days a week. Review of the resident's care plan, last revised on 04/12/22, showed the resident to receive diabetic medications as ordered by the doctor. Staff to monitor and document any side effects and/or effectiveness. Review of the resident's physician order sheet, dated 07/30/24, showed the following: -Novolog FlexPen Subcutaneous Solution Pen - injector 100 units (U)/milliliter (ml). Administer insulin subcutaneously (under the skin) before meals per sliding scale; -If blood sugar is 181 milligrams (mg)/ deciliter (dL) to 200 mg/dL, administer 2 units of insulin; -If blood sugar is 201 mg/dL to 250 mg/dL, administer 4 units of insulin; -If blood sugar is 251 mg/dL to 300 mg/dL, administer 6 units of insulin; -If blood sugar is 301 mg/dL to 350 mg/dL, administer 8 units of insulin; -If blood sugar is 351 mg/dL to 400 mg/dL, administer 10 units of insulin; -If blood sugar is 401 mg/dL or higher, administer 2 units of insulin. Observation on 07/29/24, at 11:52 A.M., showed Licensed Practical Nurse (LPN) T performed an accucheck (finger stick blood test to determine level of sugar) with the result of 206 mg/dL. The LPN said the resident required 4 units of sliding scale Novolog. He/she wiped the insulin pen with an alcohol swab and attached the needle. Without first priming the insulin pen, the LPN set the dial to 4 and administered the insulin to the resident. During an interview on 07/29/24, at 1:40 P.M., LPN T said he/she only primes the insulin pens for the first initial use,. He/she does not prime insulin pens otherwise. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said insulin pens should be primed with at least two to four units prior to each administration. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and Administrator said the expectation of staff is to prime the insulin pens prior to each administration. 2. Review of the facility's policy Administering Medications through an Enteral Tube, dated November 2018, showed the following information: -Verify there is a physician's medication order for this procedure; -Review the resident's care plan to assess for any special needs; -Administer each medication separately and flush between medications; -Do not crush or split medications for administration through an enteral tube unless first checking with the pharmacy; -Tablets that must be crushed prior to administration through an enteral tube require a specific order related to crushing. Review of Resident #254's face sheet showed the following information: -admission date of 03/19/24; -Diagnoses include chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), respiratory failure, encephalopathy (brain disease that alters brain function or structure), and dysphagia (difficulty swallowing). Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -51% of calories received are through parenteral (administered or occurring elsewhere in the body than the mouth) or tube feeding; -Takes antianxiety (medications that are used to treat anxiety disorders), antidepressants (medications that are used to treat depressive disorders), anticoagulants (medications that prevent and treat blood clots), opioids (pain reducing medications), and hypoglycemics (a group of drugs that help lower blood sugar levels). Review of the resident's care plan, last revised on 07/24/24, showed the resident has a nothing by mouth (NPO) status with medications and feedings of formula and water enterally. Review of the resident's Physician Order Sheet (POS), dated 07/30/24, showed the following: -Diltiazem (antihypertensive drug that treats high blood pressure) HCI (added salt to help the medication dissolve or be absorbed in the bloodstream) 90 mg tablet, give one tablet via g-tube three times a day; -Gabapentin (anticonvulsant that treats pain and nerve pain and seizures) 100 mg capsule, give one capsule via peg-tube three times a day; -Oxycodone (narcotic that treats moderate to severe pain) HCI 5 mg tablet, give one tablet via peg-tube every four hours as needed. (There was not an order for staff to administer combine medications when administering by the peg-tube.) Observation on 07/24/24, at 1:09 P.M., showed LPN T obtained diltiazem from the medication card, crushed it, then placed it into a medication cup. LPN T obtained gabapentin from the medication card and emptied the capsule into the same medication cup with the diltiazem. LPN T obtained oxycodone from the medication card, crushed it, then placed the medication into the same medication cup with the diltiazem and gabapentin. All medications emptied into a bigger cup and LPN T added 30 ml's of water into the cup and poured it into the resident's peg-tubing via a 60 milliliter (ml) syringe. During an interview on 07/26/24, at 9:50 A. M., LPN G said the expectation for administering medications through a peg-tub would be to crush the medications, pour them together, add water, and administer. There should be a physician order to crush the medications and mix them. LPN G looked in the resident's electronic medical record (EMR) and said the resident did not have an order for this. In the case of not having an order, he/she would first flush the peg-tube with water, keep the medications in separate cups, administer one medication, flush again, and repeat the process until all medications are given. During an interview on 07/26/24, at 9:39 A.M., Certified Nursing Assistant/Medication Technician (CNA/CMT) F said some medications can be crushed and/or mixed while others cannot. Staff must obtain a physician's order to be able to crush or mix any medications. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said she believes there are standing orders to crush medications for by mouth administrations. If the administration is through a peg tube, that order should be in the record. During an interview on 07/25/24, at 12:37 P.M., the DON said the resident's doctor does not have any standing orders. Staff must call the physician for all orders. During an interview on 07/30/24, at 1:08 P.M., the Medical Director said he does not have any standing orders. The staff must call him for any orders needed. He expected staff to follow his orders and they need to clear it with him before they mix any medications together to administer. During an interview on 07/30/24, at 1:33 P.M., the DON and Administrator agreed that the expectation and best practice for medication administration through a peg-tube would be to flush with water, give one medication, then flush again. That process was to be continued until all medications were administered. There should be a physician's order if the staff were giving medications any other way.

Based on observation, record review, and interview, the facility staff failed to ensure all resident's were free from significant medication errors when staff failed to prime (removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly, failure to do so may result in giving the resident too much or too little insulin) an insulin pen for one resident (Resident #74). The facility census was 101. Review of manufacturer's instructions regarding NovoLog (rapid acting insulin) FlexPens, last revised on March 2008, showed the pen should be primed before each injection. The pen should be primed by the following steps: -Turn the dose selector to select two units; -Hold the pen with the needle pointing up. Tap the cartridge gently with finger a few times to make any air bubbles collect at the top of the cartridge; -Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero. -A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times; -If there is not a drop of insulin after six times, do not use the pen. 1. Review of Resident #74's face sheet (brief look at resident information) showed the following information: -admission date of 04/15/24 -Diagnoses include type two diabetes, obesity, dependency on renal dialysis (procedure that removes wastes and excess fluid from the blood when the kidneys are no longer able to do so), high blood pressure, and heart failure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/04/24, showed the following information: -Cognitively intact; -Insulin injections received seven days a week. Review of the resident's care plan, last revised on 04/12/22, showed the resident to receive diabetic medications as ordered by the doctor. Staff to monitor and document any side effects and/or effectiveness. Review of the resident's physician order sheet, dated 07/30/24, showed the following: -Novolog FlexPen Subcutaneous Solution Pen - injector 100 units (U)/milliliter (ml). Administer insulin subcutaneously (under the skin) before meals per sliding scale; -If blood sugar is 181 milligrams (mg)/ deciliter (dL) to 200 mg/dL, administer 2 units of insulin; -If blood sugar is 201 mg/dL to 250 mg/dL, administer 4 units of insulin; -If blood sugar is 251 mg/dL to 300 mg/dL, administer 6 units of insulin; -If blood sugar is 301 mg/dL to 350 mg/dL, administer 8 units of insulin; -If blood sugar is 351 mg/dL to 400 mg/dL, administer 10 units of insulin; -If blood sugar is 401 mg/dL or higher, administer 2 units of insulin. Observation on 07/29/24, at 11:52 A.M., showed Licensed Practical Nurse (LPN) T performed an accucheck (fingerstick blood test to determine level of sugar) with the result of 206 mg/dL. The LPN said the resident required 4 units of sliding scale Novolog. He/she wiped the insulin pen with an alcohol swab and attached the needle. Without first priming the insulin pen, the LPN set the dial to 4 and administered the insulin to the resident. During an interview on 07/29/24, at 1:40 P.M., LPN T said he/she only primes the insulin pens for the first initial use,. He/she does not prime insulin pens otherwise. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said insulin pens should be primed with at least two to four units prior to each administration. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and Administrator said the expectation of staff is to prime the insulin pens prior to each administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat all residents with dignity and respect when staff used an inappropriate tone of voice and a public location to discuss concerns with one resident (Residents #22) and when one staff member (Certified Nurse Aide (CNA) A) cursed and used a disrespectful name in the presence of a resident, transferred a resident in a rough manner, and tossed a draw sheet while assisting a resident for one resident (Resident #19). The facility census was 101. A sample of 27 residents was reviewed; the facility census was 101. Review of a facility's policy titled Dignity, revised 02/2021, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -Honor resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay; -Individual needs and preferences of the resident are identified through the assessment process; -Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice. Review of the facility policy titled Resident Rights, dated December 2016, showed the following: -Federal and state laws guarantee certain basic right to all residents of this facility; -These rights include the resident's right to be treated with respect, kindness, and dignity. 1. Review of Resident #22's face sheet (gives basic profile information) showed the following: -admission date of 10/04/20; -Diagnoses included multiple sclerosis (MS - disease causing nerve damage which disrupts communication between the brain and the body; may result in impaired movement, vision loss, pain, and fatigue), muscle wasting and weakness, left femur (leg) fracture, diabetes, muscle spasm and pain of lower back, anemia (low red blood cell count), depressive disorder, urinary incontinence, high blood pressure, history of mini-stroke, and generalized anxiety disorder. Observation on 07/23/24, at 4:40 P.M., showed the resident sat in his/her power chair in the facility's library room. The library was approximately 10 feet by 8 feet in size with a large windows on adjacent sides that allowed visibility into the room. The room's door was closed. Certified Nursing Assistant (CNA) K, CNA N, and CNA O sat in chairs surrounding the resident. Licensed Practical Nurse (LPN) L stood approximately three feet in front of the resident, leaning into him/her. The LPN shook his/her splayed hands out to his/her front/sides and loudly demanded, What do you want us to do?! CNA K came out of the room and went to talk to Assistant Director of Nursing (ADON) R. The ADON entered the library at that time and began talking to the resident. During an interview on 07/23/24, at 4:55 P.M., the resident said during the event in the library, he/she was frustrated, saying We weren't getting anywhere! It was just a 'he said/she said' argument. The staff wasn't listening to me, and they said I wasn't hearing them! The resident said following a disagreement with the CNAs in his/her room, the nurse said they would go to the library to discuss the situation. The resident said he/she was upset, so he/she went into the room of another resident to briefly talk to them. While in that room, the door accidentally closed, and the resident was unable to re-open it due to his/her power chair. LPN P knocked on the door and loudly called out, Come on, we're waiting on you! During an interview on 07/25/24, at 9:37 A.M., the resident said he/she felt like the four staff were ganging up on me during the discussion in the library on 07/23/24. The resident said he/she felt intimated. During an interview on 07/24/24, at 3:50 P.M., CNA N said the group discussion in the library was due to a disagreement between the resident and aides regarding the prioritizing/timing of residents' cares, resulting in the resident telling all of the aides to just leave the room. LPN L came and took the CNAs and resident into the library. During the conversation, CNA K told CNA N the discussion wasn't productive and left the room to get ADON R. CNA N said LPN L and the resident was trying to work it out, but it was just a 'he said/she said' argument. CNA N said he/she wasn't comfortable with the situation and thought management should have been involved. During an interview on 07/24/24, at 4:05 P.M., CNA O said he/she, CNA K, and CNA N had a disagreement with the resident regarding the prioritizing of residents' cares. When the aides said they didn't want to argue about it, the resident told them all to leave his/her room. LPN L suggested they all go to the library to avoid talking in front of the resident's roommate. CNA O said the aides didn't really talk much, LPN L and then later ADON R, did the talking. The resident was a bit upset, insisting I needed to lay down, but you kept taking care of everyone else! The staff was explaining the need to prioritize care. CNA K went to get ADON R, who sat down across from the resident to explain the aides' actions. CNA K and CNA N apologized to the resident, who then allowed them to assist him/her to bed without telling them to leave. During an interview on 07/25/24, at 4:05 P.M., LPN L said staff should help residents maintain their dignity and a dignified appearance. The LPN said on 07/24/24, at around 4:00 P.M., he/she sent staff to put the resident in bed. When the aides reported to LPN L that the resident had sent them all out of the room, LPN L went to the resident, who was then out in the hall, and asked him/her the reason. The resident said it was because they told her they weren't going to put up with my talking about another resident's care. LPN L said he/she wanted to talk about what was said and how the resident interpreted it. LPN L started to take the three staff into the resident's room to discuss the situation, but the resident didn't want to talk in front of the roommate. LPN L suggested they go to the library. The LPN said nobody raised their voices, and the staff wasn't trying to intimidate the resident by all of them being present. LPN L said he/she suggested the library because the resident likes it in there. The LPN said he/she had not noticed that the discussion was audible and visible to anyone who was in the front lobby area and maybe he/she should have better managed the issue by talking to the resident one-to-one instead of with all of the aides there. During an interview on 07/26/24, at 2:22 P.M., the Director of Nursing (DON) said staff should treat residents in a dignified manner. If there is a need to discuss a resident's concerns, needs, or a situation regarding the aides, the charge nurse, not a group of staff, should remove the aides from the situation and speak calmly with the resident one-to-one. During an interview on 07/26, 24, at 3:00 P.M., the Administrator said staff should not stand over a resident or have a group of staff confronting the resident to discuss a disagreement; that might be appear to be undignified and possibly intimidating to the resident. Appropriate staff (the charge nurse, DON or Administrator) should meet with the resident one-to-one to de-escalate the situation. 2. Review of Resident #19's face sheet showed the following: -admission date of 04/22/22; -Diagnoses included multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without behavioral disturbance, Alzheimer's disease with late onset (progressive disease that destroys memory and other important mental functions) , generalized anxiety disorder, and age-related physical debility (the state of being weak in health or body). Review of the resident's care plan, last updated 02/05/24, showed the following: -The resident lacked the capacity to understand and make decision regarding healthcare; -The resident has an ADL self-care performance deficit; -The resident required extensive assistance of one staff for toilet use; -The resident required substantial/maximum assistance by two staff for all transfers; -The resident had limited physical mobility; -The resident was totally dependent on one staff for locomotion using wheelchair; -Staff should provide supportive care and assistance with mobility as needed; -When resident became agitated staff to interview before agitation escalated; guide away from source of distress; and engage calmly in conversation. If response was aggressive, staff should walk calmly away and approach later; -The resident had impaired cognitive function/dementia or impaired thought process, -Staff should engage in conversation about a pleasant topic before initiating care; -Staff should use positive approach techniques including approach resident from the front and use a wave and extend your hand for a handshake. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 07/04/24, showed the following: -Severe cognitive impairment; -Resident required substantial/maximal assistance for toileting hygiene; -Resident required partial/moderate assistance for dressing; -Resident required use of a wheelchair for mobility. Review of the resident's nursing progress note dated 07/21/24, at 3:19 P.M., showed during the course of the day, there was an alleged incident of verbal abuse from a staff member. Statements were gathered and the event was reported to the Director of Nursing (DON) and Administrator. Staff informed physician, family member, and on-call nurse for hospice. The staff member was released from duty pending the investigation. Nurse completed head to toe assessment with no finding. The resident was alert to self only and could not make any statement about the incident. Review of the interview statement, dated 07/22/24, completed by the Administrator and an Assistant Director of Nursing (ADON) with CNA B, showed the following: -CNA B went to the shower room. CNA A and the resident were already present. The resident was screaming help. CNA A stood the resident up and CNA B pulled down the resident's pants. CNA A pivot transferred the resident to the toilet by throwing him/her. The Administrator and ADON asked CNA B to demonstrate the transfer. From CNA B's description, the resident was not thrown, but transferred in a rough manner. -CNA A then left to collect a fresh brief and pants. While CNA A was gone the resident stated, I'm not getting a shower. CNA B reassured the resident that he/she was only getting cleaned up. -CNA B put the brief and pants around the resident's leg. CNA A stood the resident up. The resident had another bowel movement. CNA B cleaned the resident up again. -CNA C entered the room. CNA A pivot transferred the resident back to the chair. During the transfer CNA A said to the resident, you sound like a fucking [NAME] goat. After the transfer, CNA B took the foot pedals back to the room. CNA B went to the charge nurse and reported the incident. Review of the written statement, dated 7/21/24, completed by CNA A showed the following: -While working with CNA B, they took the resident to the shower room to change his/her brief. CNA C came in to talk with CNA B. The resident was yelling, and CNA A said to both co-workers that the resident sounded like a [NAME] goat. CNA B and CNA A then stood the resident and pulled up his/her pants. CNA A took the resident to his/her room. -CNA C and CNA A both were in the resident room when CNA A transferred the resident. When CNA A pulled the blankets down, he/she tossed the stained pull sheet out in the hallway, covered the resident up, and pushed the wheelchair to the hallway. During an interview on 07/25/24, at 1:23 P.M., CNA A said the following: -The resident was upset in the hallway and was trying to climb out of his/her chair. The resident was crying loud pitch noises which was not his/her normal. The resident said he/she wanted to go to bed. He/she took the resident to the big bathroom in the hallway, toileted the resident, and then took the resident back to his/her room and transferred to him/hr to bed. CNA A said that he/she tossed the dirty pull sheet to the hallway. He/she did not put another draw sheet because the resident was anxious; -In the shower room, he/she said to another co-worker that when the resident was crying he/she sounded like a baby [NAME] goat. The aide said this to the coworker in a low voice. The resident was in the room, but was hard of hearing. CNA A said that he/she should not have done that. The aide said he/she was not rough with transfer; -CNA A said that he/she was going to lay down the resident, but knew he/she needed changed first. The resident was a two-person transfer to the toilet, the aide said that he/she assisted the resident to stand up and CNA B pulled up the resident's pants. CNA A pivoted the resident and sat him/her back down, this was not rough or hard. Review of the written statement, dated 07/21/24, completed by CNA B showed the following: -CNA A took the resident in the main shower room on 300 hall. CNA A picked the resident up and threw him/her on the stool. CNA A said I am mad. CNA B said okay, I'm sorry. CNA A went and got the resident's pants. CNA A stood the resident up and CNA B wiped the resident. CNA C was in the room now. As they were cleaning the resident CNA A said I'm going to start calling you a fucking goat. Then he/she threw the resident in his/her chair. CNA A was cussing about Registered Nurse (RN) D and saying this is not how you treat your aides; -CNA A is frequently rude to residents and always cussing. During an interview on 07/26/24, at 9:05 A.M., CNA B said he/she did not feel CNA A mean to intentionally do anything to the resident, he/she was having a bad day. Review of the written statement, dated 07/21/24, completed by CNA C showed the following: -When CNA C walked into the shower room, CNA C was looking for CNA B and was told that was where he/she was. -When CNA C walked in CNA B was cleaning up the resident and CNA A said the resident sounded like a fucking goat. -CNA C grabbed the chair and CNA A put the resident in the chair roughly. CNA C then followed CNA A and CNA B to the resident's room. CNA B left and CNA A started to put the resident into bed and he/she proceeded to throw the dirty pull sheet out into the hallway. During an interview on 07/26/24, at 8:50 A.M., CNA C said the following: -On Sunday, 07/21/24, he/she walked into the shower room and two aides were giving care to the resident. CNA A was holding up the resident and CNA B was cleaning the resident. He/she moved the wheelchair closer and asked what the resident was yelling about. CNA A looked at the resident and said you shit yourself. CNA A then pivoted the resident to the wheelchair, but instead of sitting the resident into the wheelchair, he/she just dropped the resident into the wheelchair and the resident had a rough landing. CNA A grabbed the wheelchair to take back to his/her room. -The resident said something about not being clean or not being done. CNA A was argumentative, so CNA C said let's just get the resident back to his/her room for now. CNA B left the room. CNA C and CNA A went into the resident room. -As the staff got the resident into his/her bed there was a stain or dirty mark on the draw sheet, CNA A threw the sheet out into the hallway. CNA A said the resident sounded like a fucking [NAME] goat. He/she was looking at the resident when he/she said this. During an interview on 07/23/24, at 3:50 P.M., the resident's roommate, Resident #67, said CNA A was rude and hateful. Resident #67 said he/she asked CNA A for wash rags and towels and the aide told the resident that he/she did not have time for that. During an interview on 07/24/24, at 3:15 P.M., Resident #17 said that he/she had seen CNA A be rude and rough with the resident. During an interview on 07/24/24, at 12:10 P.M., CNA K said he/she had worked with CNA A and had seen CNA A have a rude tone and attitude to staff and residents. During an interview on 07/25/24, at 1:43 P.M., RN D said the following: -CNA B and CNA C reported to him/her that the resident was transferred roughly and verbal abuse occurred, including general cursing. He/she then contacted the DON and was told to escort CNA A out of the building. He/she completed a full assessment on the resident. He/she asked questions of the resident with no response. The resident was at his/her baseline and was not fearful. The RN contacted the family and the physician and hospice and no new orders were received. The RN had witnessed CNA A's attitude but not to any one person; -he RN said that Resident #17 mentioned that he/she had witnessed CNA A move the resident roughly before; -The RN said he/she would tell the DON if any resident stated that staff were rude. During an interview on 07/25/24, at 3:45 P.M., LPN L said that it was not appropriate for staff to call resident names even to each other. During an interview on 07/26/24, at 9:15 A.M., CMT M said it was not appropriate for staff to call any resident disrespectful names while standing over the resident or with the resident in the room. If needed, staff should talk to co-worker in a private area. During an interview on 07/25/24, at 2:03 P.M., the DON said the following: -Was made aware of allegation of abuse when CNA B sent a text; -The DON called RN D and he/she said the aides just came to him/her and he/she went to make sure the resident was safe; -It was not appropriate to call a resident a [NAME] goat, even if not talking to the resident; -Staff should not talk over residents to talk each other and should not call residents derogatory names. This was not dignified behavior. During an interview on 07/26/24, at 3:00 P.M., the Administrator said the following: -Was notified on Sunday, 07/21/24, of an incident and then came into the building and took some staff interviews; -It is not appropriate for staff to call residents disrespectful names. The residents have rights and they have names. MO00239286

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a clean, safe, and comfortable homelike environment for all residents when when staff failed to repair a stained ceiling, and failed to keep the floor free from debris for one resident (Resident #70); when staff failed to repair wall damage for one resident (Resident #30); and when staff failed to maintain wall outlets for one resident (Resident #49). The facility census was 101. Review of the facility policy titled Homelike Environment, dated February 2021, showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; -The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary and orderly environment. 1. Review of Resident #70's face sheet (brief information sheet about the resident) showed the following: -admission date of 03/02/24; -Diagnoses included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) affecting left non-dominant side, spondylosis of thoracolumbar region (natural wearing down in the mid-back), repeated falls, and generalized anxiety disorder. Review of the resident's care plan, last updated 04/02/24, showed the resident had an activities of daily living (ADL) self-care performance deficit related to weakness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 05/27/24, showed the resident cognitively intact and use of manual wheelchair. Observation and interview on 07/25/24, at 11:03 A.M., showed the following: -The resident said there was trash under the bed and under the recliner that the housekeeping staff would not clean up. There were also several stains on the ceiling; -Observation showed multiple pieces of trash and debris, including food crumbs, medication cups, paper, tissue, under the resident's bed and behind the bedside recliner; -Observation showed stained area on the ceiling directly above the resident's bed approximate 6-inch diameter stain with a black ring, pink ring, and brown discoloration in the stain; -Observation showed two stained appearance spots around smoke detector above the resident's dresser area that were brown discoloration in appearance and extended around the smoke detector about two inches round; -The resident said that the stains and trash were bothersome and made him/her feel that the room was dirty. Review of the Maintenance Request Log at the 300 hall nurses' station showed the following: -On 05/26/24, leak by the smoke detector. The entry was initialed by someone other than the current Maintenance Director; -No entry documented regarding ceiling damage above the bed. 2. Review of Resident #30's face sheet showed the following information: -admission date of 01/20/23; -Diagnoses included anemia (low red blood cell count), paraplegia (loss of muscle function in the lower half of the body), left above-knee amputation (AKA) with phantom limb pain, high blood pressure, obstructive uropathy (causes impaired urinary elimination), chronic obstructive pulmonary disease (COPD - breathing disorder), and respiratory failure. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Utilized a motorized wheelchair; -Dependent on staff for transfers between chair/bed. Review of the resident's care plan, last updated 05/23/24, showed the resident had capacity to understand and make decisions and resident has limited physical mobility related to left above the knee amputation and right leg brace for foot drop; Observation and interview on 07/24/24, at 12:50 P.M., showed the following: -The resident pointed out wall damage to the corner of the wall next to the closet. He/she said staff had driven his/her power chair into it on occasion, knocking off the clear plastic protective covering and leaving the metal drywall corner bracket revealed. Observation at the time of the interview confirmed the damage. -The resident said the peeled portion of the wall/wallpaper above his/her bed looked like (the shape of) a pregnant woman. I needed to move my plant over there to cover it up! Observations at the time of the interview confirmed the peeling wall paper. -The resident said the new maintenance staff was working hard to make repairs that had been needed for quite a while. Review of the Maintenance Request Log at the 300 hall nurses' station showed the no entries documented regarding wall damage. 3. During an interview on 07/26/24, at 9:05 A.M., Certified Nursing Assistant (CNA) B said that if he/she had any environment concerns, he/she would notify the maintenance staff, and there was a maintenance log at the nursing station that information could be added to. He/she had not been told by any residents of environment concerns. He/she had seen holes and tears in the walls of various resident rooms. 4. During an interview on 07/26/24, at 9:15 A.M., Certified Medication Technician (CMT) M said that any environment concerns should be written on the maintenance log that was located on the 100/200 hall nurse desk. He/she was not aware of any residents with complaints of room repairs needed. 5. During an interview on 07/26/24, at 10:25 A.M., Licensed Practical Nurse (LPN) G said that staff should notify the maintenance staff any time concerns in any resident rooms or common areas. He/she was not aware of any resident room concerns. 6. During an interview on 07/26/24, at 10:35 A.M., Registered Nurse (RN) D said that staff should notify the maintenance staff of damage in resident rooms. He/she was not aware of stained ceiling or resident rooms not cleaned. 7. During an interview on 07/26/24, at 11:10 A.M., the Maintenance Director said staff should write any maintenance concerns on the log at the nurses' stations, or they could verbally notify him. He was currently trying to fix holes in walls, closets, and doors, and would assist with the current process involving new floors in the 400 hall. He was aware of some large holes in various rooms, but not aware of any damage on the 300 hall at that time. 8. During an interview on 07/26/24, at 3:00 P.M., the Administrator said that resident rooms should not have large holes in walls, doors, or closets. The rooms should not have stained ceilings. The maintenance staff was trying to catch up on facility repairs. Staff should notify the Maintenance Director for repairs or damage to resident rooms. 9. Review showed the facility did not provide a policy regarding electrical outlet monitoring. Review of Resident #49's face sheet showed the following: -admission date of 05/20/22; -Diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), dependence on wheelchair, acquired absence of right leg and left leg above the knee (limb was amputated), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic respiratory failure a with hypoxia (condition not have enough oxygen in the tissues in the body), and obstructive and reflux uropathy (urine cannot drain through the urinary tract, and may back up into the kidneys). Review of the resident's significant change in status Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 07/07/24, showed the following: -Cognitively intact; -Required substantial to maximal assistance with showering/bathing; -Dependent on staff for transfers. Review of the resident's care plan, last reviewed 07/18/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to bilateral above the knee amputation. Observation and interview on 07/25/24, at 10:53 A.M., showed the following: -The resident said the electrical outlet behind the small bedside table in his/her room was significantly loose. He/she said that no plug would remain plugged in without being propped up by the bedside table. The resident said he/she cannot plug his/her cell phone into the outlet because it will not stay plugged in. He/she said that he/she had notified staff several times; -Observation of the outlet showed the resident's CPAP machine (continuous positive airway pressure - machine that uses mild air pressure to keep breathing airways open while sleeping) plugged into the outlet with most of the silver prongs visible and loosely hanging into the outlet. The back of the bedside table was touching the electrical cord. During interview on 07/26/24, at 11:10 A.M., Maintenance Director said the following: -He checked electrical outlets for receptacle retention tests and was not aware of any outlets that are loose at this time; -Staff should notify maintenance of items in need of repair or write on the maintenance log at the nursing station; -Plugs should not be hanging out of the wall or propped up by furniture. During an interview on 07/26/24, at 2:20 P.M., the DON said outlets should not have furniture propping up plugs and staff should notify maintenance for repair. During an interview on 07/26/24, at 11:46 A.M., the Administrator said plugs should not be supported by furniture to stay in the outlet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly store all drugs in locked compartments when three medication carts were observed unlocked while unattended by staff. The facility census was 101. Review showed the facility did not provide a policy pertaining to storage of medication. 1. Observation on 07/26/24, at 11:30 A.M., showed Licensed Practical Nurse (LPN) U positioned a medication cart in the hallway outside a resident's room. The cart was facing the resident's doorway and adjacent wall, approximately two feet away. The LPN dispensed the resident's medications, did not lock the cart, and entered the resident's room to administer the medications. The Assistant Director of Nursing (ADON) R approached the cart and depressed the lock. Observation on 07/29/24, at 1:42 P.M., showed a medication cart positioned with its back against the half-wall of the nurses' station, facing a resident lounge area. Two unidentified residents were in the lounge area, and two staff passed down the hall pushing residents in wheelchairs. The cart was not attended by staff and was not locked. The Director of Nursing (DON) approached the cart and depressed the lock. Observation on 07/24/24, at 1:02 P.M., showed a medication cart positioned against the wall facing toward resident room [ROOM NUMBER] and left unattended. The medication cart contained several cards of medication. Several residents and staff, including housekeeping and LPN T passed by the cart. At 1:04 P.M., Certified Mediation Technician (CMT) V came out of room [ROOM NUMBER] and locked the medication cart. During an interview on 07/26/24, at 9:39 A.M., Certified Nursing Assistant/ Certified Medication Technician (CNA/CMT) F said that medication carts should be locked when staff are not present. During an interview on 07/30/24, at 12:15 P.M. the Admissions Nurse said all medication carts should be locked when staff is walking away from them. During an interview on 07/30/24, at 1:33 P.M., with the Administrator, Director of Nursing (DON), Clinical Nurse Consultant, and Director of Operations, the DON said staff should lock the medication carts when they are not with the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to maintain proper infection control when administering medication for two residents (Residents #254 and #8) and failed to properly disinfect glucometers (medical device for determining glucose in the blood) during tests performed for three residents (Residents #74, #22, and #14). The facility census was 101. 1. Review of the facility policy titled Administering Oral Medications, dated October 2010, showed staff should not touch medications with their hands. Review of Resident #254's face sheet (gives basic profile information), showed the following information: -admission date of 03/19/24; -Diagnoses included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), respiratory failure, encephalopathy (brain disease that alters brain function or structure), and dysphagia (difficulty swallowing). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 06/08/24, showed the following information: -Cognitively intact; -Takes antianxiety (medications that are used to treat anxiety disorders), antidepressants (medications that are used to treat depressive disorders), anticoagulants (medications that prevent and treat blood clots), opioids (pain reducing medications), and hypoglycemics (a group of drugs that help lower blood sugar levels). Review of the resident's physician order sheet, dated 07/30/24, showed the following: -Diltiazem (antihypertensive drug that treats high blood pressure) HCI (added salt to help the medication dissolve or be absorbed in the bloodstream) 90 milligram (mg) tablet, give one tablet via g-tube (tube used for medication nutrition when resident cannot do so by mouth) three times a day; -Gabapentin (anticonvulsant that treats pain and nerve pain and seizures) 100 mg capsule, give one capsule via peg-tube (g-tube) three times a day; -Oxycodone (narcotic that treats moderate to severe pain) HCI 5 mg tablet, give one tablet via peg-tube every four hours as needed. Observation on 07/24/24, at 1:09 P.M., showed Licensed Practical Nurse (LPN) T obtained diltiazem from the medication card, crushed it, then placed it into a medication cup. LPN T obtained gabapentin from the medication card and emptied the capsule into the same medication cup as diltiazem. LPN T obtained oxycodone from the medication card, crushed it, then placed the medication into the same medication cup as the diltiazem and gabapentin. LPN T emptied all medications into a bigger cup and added 30 milliliters (ml) of water into the cup. After adding water to the cup LPN swirled the medication. The medication continued to have some clumping of medications. LPN T took his/her gloved finger and stirred the medications. LPN T apologized and said he/she did not have a spoon with him/her. LPN T then poured the medications into the resident's peg-tubing via a 60 ml syringe. During an interview on 07/26/24, at 9:39 A.M., Certified Nursing Assistant/Medication Technician (CNA/CMT) F said it was not acceptable to stir medications with one's fingers, gloved or not. During an interview on 07/26/24, at 9:50 A.M., LPN G said that he/she would not stick his/her finger in medications to stir them. The expectation is to use a spoon. He/she would consider stirring medications with a finger, gloved or not as cross contamination and an infection control issue. During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said it is not acceptable to stir medications with one's finger, gloved or not. During an interview on 07/30/24, at 1:33 P.M., the Director of Nursing (DON) and Administrator said it would not be acceptable for staff to stir medications with their fingers. 2. Review of Resident #8's face sheet showed the following: -admission date of 10/11/22; -Diagnoses included anemia, congestive heart failure (CHF - inability for heart to pump blood to the body as needed), renal insufficiency (kidney issues), pain, dementia, high cholesterol, and thyroid disorder. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severely impaired cognition; -Received antipsychotic and antiplatelet (helps prevent blood clots) medications on a routine basis. Review of the resident's care plan, last updated 07/24/24, showed the following: -Resident has congestive heart failure. Administer cardiac medications as ordered; -Resident has impaired cognitive function/dementia or impaired thought processes. Administer medications as ordered; -Resident uses psychotropic medication. Administer psychotropic medications as ordered by physician; -Resident has chronic pain. Anticipate the resident's need for pain relief; -Resident has chronic renal failure related to kidney disease stage 3. Administer medications as ordered by physician. Observation on 07/29/24, at 9:18 A.M., showed CMT M the following: -The CMT used hand sanitizer before preparing the resident's medications; -The CMT punched medications from bubble packed cards into a medication cup: -The CMT dispensed medications from bottles by pouring pill into the lid and then into the medication cup: -The CMT entered the resident's room and placed the medication cup on top of a tapestry runner covering a dresser. The cup tipped over, spilling out multiple pills. The CMT used a plastic spoon to scoop the pills up and put them back into the cup and said, At least they didn't hit the floor. The CMT gave the cup of pills to the resident with a drink. During an interview on 07/30/24, at 1:33 P.M., with the Administrator, DON, Clinical Nurse Consultant, and Corporate Director of Operations, the DON said staff should follow all infection control guidelines. They should discard dropped pills and re-dispense them. 3. Review of the undated manufacturer's manual titled Glucocard, the glucometer used, showed the following disinfecting procedures: -Wear appropriate protective gear such as disposable gloves; -Open the cap of the disinfectant container and pull out one towelette and close the cap; -Wipe the entire surface of the glucometer three times horizontally and three times vertically using a new towelette to remove blood borne pathogens; -Dispose of the used towelettes in the trash; -Allow exteriors to remain wet for the corresponding contact time for each disinfectant; -After disinfection, the users gloves should be removed to be thrown away and hands washed before proceeding to the next patient. 4. Review of Resident #74's face sheet showed the following information: -admission date of 04/15/24; -Diagnoses include type two diabetes. Review of the resident's current care plan showed the resident to receive diabetic medications and fasting blood glucose levels as ordered by the doctor. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact and resident received insulin injections seven days a week. Observation on 07/29/24, at 11:56 A.M., showed LPN T completed another resident's accucheck and placed the glucometer into a sani-wipe (without wiping or thoroughly wetting the glucometer) and placed the glucometer onto medication cart next to a second wrapped glucometer. LPN T sanitized his/her hands, donned gloves, obtained a test strip and placed it into the 2nd glucometer that he/she obtained from the top of the medication cart that had been wrapped in a sani-wipe. LPN T obtained an alcohol wipe and prepped the resident's finger. LPN T obtained a lancet, obtained blood from the resident's finger, and placed it onto the test strip. LPN T obtained a sani-wipe from its container and wrapped the glucometer (without wiping or thoroughly wetting the glucometer) and placed it on the medication cart. 5. Review of Resident #22's face sheet showed the following: -admission date of 10/04/20; -Diagnoses included diabetes mellitus. Review of the resident's significant change MDS, dated [DATE], showed resident's cognition intact and received insulin on seven of the previous seven days. Review of the resident care plan, last updated 07/23/24, showed the following information: -At risk for pain related to disease process; -Resident had diabetes mellitus. Staff to obtain fasting blood sugar as ordered by doctor. Observation on 07/26/24, at 11:40 A.M., showed LPN V used hand sanitizer and prepared supplies to perform an accucheck for the resident. LPN V unwrapped glucometer #2 (the same machine used to complete the previous accucheck for the previous). The LPN did not wipe the machine with a sani-cloth and did not allow time for the machine to air dry, and completed the Accucheck. 6. Review of Resident #14's face sheet showed the following: -admission date of 02/19/13; -Diagnoses included diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed resident had severely impaired cognition and received insulin on seven of the previous seven days. Review of the resident's care plan, last updated 05/25/24, showed resident had diabetes mellitus and staff to obtain fasting serum blood sugar as ordered by doctor. Observation on 07/26/24, at 12:12 P.M., showed LPN G used hand sanitizer and donned gloves to perform an accucheck for the resident. LPN G wrapped the glucometer in a sani-wipe without first wiping it clean and placed the machine on top of the treatment cart. 7. During an interview on 07/29/24, at 1:40 P.M., LPN T said upon finishing an accucheck, he/she wrapped the glucometer in a sani-wipe and let it sit for five minutes, after that, the glucometer is sanitized and he/she goes on using it. 8, During an interview on 07/30/24, at 12:08 P.M., the Admissions Coordinator said glucometers should be sanitized with sanitizing wipes. The glucometers must actually be wiped down and then let dry before they are considered sanitized. 9. During an interview on 07/30/24, at 1:33 P.M., with the Administrator, DON, Clinical Nurse Consultant, and Corporate Director of Operations, the DON said staff should follow all infection control guidelines.

Based on observation, interview, and record review, the facility failed to follow standards of practice and keep food safe from potential contamination or bacterial growth when staff failed to ensure cups and glasses were air dried before being stored. The facility census was 101. Review showed the facility did not provide a policy regarding drying of dishes. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 1. Observations on 07/23/24, at 8:46 A.M., showed 53 small water and juice cups/glasses stored/stacked upside down on a the tray in a manner that trapped water and did not allow for airflow for drying. Observations on 07/26/24, at 11:55 P.M., showed 49 small water and juice cups/glasses stored/stacked upside down on a the tray in a manner that trapped water and did not allow for airflow for drying. During an interview on 07/29/24, at 2:40 P.M., Dietary Aide (DA) W said the following: -He/she was not aware that the dishes had to be dried before they could be stacked/placed upside down trapping water; -he/she was told glasses must be completely dry before putting them away. During an interview on 07/29/24, at 2:50 P.M., DA X said the following: -He/she was told dishes could not be stored away while still wet; -He/she said they were told that it can cause bacteria to grow. During an interview on 07/29/24, at 3:00 P.M., the Dietary Manager (DM) said he/she was not aware that drinking glasses were being placed upside down in a manner that trapped water and prevented air drying. During an interview on 07/29/24, at 2:40 P.M., the Administrator said the following: -Staff have looked for a policy regarding air drying dishes before storing, but are unable to locate anything related; ought liners that they thought would work to line the trays; -He/she did not realize there was not enough of an air gap to allow for airflow and drying.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure effective pain management was provided to all residents, consistent with professional standards of practice, when staff failed to administer one resident's (Resident #8) as needed pain medication when the resident requested the mediation due to pain and showed physical signs of pain. The census was 99. Review of the facility policy, Administering Oral Medications, revised 10/2010, showed the following: -For tablets or capsules from a bottle. pour the desired number into the bottle cap and transfer to the medication cup. Do not touch the medication with hands. Return extra capsules/tablets to the bottle. All medications to be given at the same time can be placed in the same cup except those that require assessment (e.g., vital signs) prior to administration; -For unit dose tablets and capsules, place packaged medications directly into the medication cup; -Confirm the identity of the resident; -Explain the procedure to the resident; -Place medications on the bedside table or tray; -Offer water to assist the resident in swallowing medications; -Allow the resident to swallow oral tablets or capsules at his or her comfortable pace; -If a medication falls to the floor, discard and document per facility protocol. Repeat the preparation; -Remain with the resident until all medications have been taken. 1. Review of Resident #8's face sheet showed the following: -admission date of 01/24/24; -Diagnoses included severe sepsis with septic shock (condition that happens when one's blood pressure drops to a dangerously low level after an infection), type 2 diabetes mellitus (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) with diabetic chronic kidney disease, and bacteremia (viable bacteria in the blood). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required supervision assistance for mobility and transfers; -Resident had pain occasionally and received as needed pain medication in the last five days; -Pain effects sleep occasionally. Review of the resident's care plan, dated 01/27/24, showed the following: -The resident had pain; -The resident will not have an interruption in normal activities due to pain through the review date; -The resident has an order for hydrocodone-acetaminophen (Norco - used to treat moderate to severe pain ) oral tablet 5-235 milligram (mg); -Administer Norco oral tablet 5-235 mg every six hours as needed per orders; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Evaluate the effectiveness of pain interventions; -The resident's pain is alleviated/relieved by rest and pain medications. Review of the resident's current POS showed the following: -An order, dated 01/24/24, for Norco oral tablet 5-325 mg, give one tablet by mouth every six hours as needed for pain, not to exceed four tablets in one day. Review of the resident's February 20234 MAR/TAR showed staff did not document administration of Norco oral tablet to the resident. Review of the resident's narcotic record showed the following: -On 01/31/24, at 2:04 P.M., staff noted one dose of Norco 5-325 mg administered with a balance forward of 78 pills; -On unknown date, staff noted one does of Norco 5-325 mg administered with a balance forward of 77 pills; -On 02/01/24, at 11:20 P.M., staff placed a slash mark thru dose given a balance forward of 76 pills; -Attached to the narcotic record was a Medication Disposition Form, dated 02/01/24 that showed one tablet identified and removed from the count. The form was signed by the Director of Nursing (DON) and Registered Nurse (RN) I. During an interview on 02/08/24, at 9:32 A.M., the resident said the following: -He/she did not receive his/her Norco on the night of 02/01/24. He/she was in a lot of pain in his/her wound site and felt like it was 10 on a scale of one to 10. He/she asked for his/her pain medication multiple times from the certified nurse aide (CNA). The staff never brought the medication; -He/she was also in pain the following morning, but he/she did receive pain medication. During an interview on 02/08/24, at 1:12 P.M., the CNA B said the following: -The resident said he/she did not receive his/her pain medication on the night of 02/01/24. The resident requested it three times between around 8:00 P.M. and 9:00 P.M.; -The resident was wincing and moving around like he/she could not get comfortable; -He/she reported to the nurse three times that the resident had requested pain medication. During interviews on 02/08/24, at 12:48 P.M., and 02/09/24, at 11:40 P.M., the Assistant Director of Nursing (ADON) said the following: -He/she arrived at the facility between 9:00 and 9:30 P.M. on 02/01/24 to cover for a nurse who had to leave. He/she took report from Licensed Practical Nurse (LPN) C; -The nurse the ADON replaced had already left the building when he/she arrived; -He/she pulled up the MAR/TAR and started doing rounds on the residents; -Medications should be administered as ordered by the physician and then documented on the MAR/TAR and Narcotics records if it is a controlled medication; -The MAR/TAR and the narcotics records should match, however, the narcotics log is not used as an administration record; -He/she was not aware of any residents being in pain on the night of 02/01/2024 as the result of not getting their pain medication. During an interview on 02/08/24, at 12:13 P.M., the Director of Nursing said generally, medications should be administered as ordered by the physician. MO0000231298

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** MO00231261 Based on record review and interview, the facility failed to keep all residents free from misappropriation when the staff could not account of 17 doses of medication, affecting twelve residents (Resident #2, #4, #8, #9, #10, #1, #3, #5, #6, #11, #12 and #7), that were the possession of the facility. The facility census was 99. Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation Prevention Program, revised 04/2021, showed the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 2022, showed the following information: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported lo local, state and federal guidance (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported; -All allegations are thoroughly investigated. The Administrator initiates investigations; -Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations; -Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement; -The Administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. 1. Review of the Follow-Up Investigation Report, undated, showed the following: -Licensed Practical Nurse (LPN) A was the alleged perpetrator; -Multiple pills were found in LPN A's pockets when taken out of the facility to a police car. Police brought the pills back into facility and all were identified and signed out of narcotic book. All medications were identified and accounted for. There were no missing medications. Upon notification of arrest, facility Assistant Director of Nursing (ADON) called into facility to cover shift and collect keys; - LPN A was interviewed on 02/05/24, at approximately 12:00 P.M. LPN A was asked why he/she pulled narcotics out of narcotic box without signing them out and if this was policy. LPN A said, No, I just usually sign out all medications at the end of shift. LPN A also said he/she had pulled the pills at the beginning of his/her shift, placed them in individual pill distribution cups, and placed them in his/her pocket for administration. -The ADON arrived to the facility at approximately 9:30 P.M. and LPN D was seated at the 400 hall nurses' station and gave him/her a brief overview of what he/she had witnessed and then reported back to his/her assigned hall; -He/she went to the 100/200 hall nurses' station to retrieve the 400 hall unit keys from LPN C. LPN C and the ADON then returned back to 400 hall nurses station to give report and count the medication log. LPN C said he/she and LPN D had already counted after LPN A had given the keys to LPN C. LPN C had flagged the medications with slips of paper in the medication book that were incorrect. He/she confirmed the inaccurate counts of medication. The medications were not yet signed out in the med log or on the electronic MAR/TAR. 2. During an interview on 02/14/24, at 9:30 A.M., the Narcotics Detective said the following: -Police officers were dispatched to the facility on [DATE] at 8:20 P.M. ; -The officers arrested LPN A and took him/her out of the facility. The officers found six white pills loose in two of LPN A's pockets; -The facility staff identified the pills as three oxycodone pills (a controlled substance used to treat moderate to several pain), one Lortab (a controlled substance used to treat moderate to several pain) pill, one Xanax (a controlled substance used to treat anxiety) and one Norco (a controlled substance used to treat moderate to several pain) pill; -The six pills were confiscated when the nurse was taken out of the facility by the police officers. 3. During an interview on 02/08/24 the Director of Nursing (DON) said the following: -The handwritten list of residents and medications is the list of medications that were missing from the count; -There were 17 pills total that were missing from the count; -He/she made the list based off of sticky notes that were left in the Narcotic book by LPN C and LPN D. -All of the pills were found in LPN A's pocket by the police officers and identified by LPN A and LPN B; -He/she thought all the pills were accounted for and not actually missing; -He/she was not aware that there were only six pills found in LPN A's pocket. 4. Review of Resident #2's face sheet showed the following: -admission date of 01/19/24; -Diagnoses included cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of the left leg, multiple sclerosis (a long-lasting (chronic) disease of the central nervous system), muscle wasting and atrophy (wasting away), and weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/22/24, showed the following: -The resident was cognitively intact; -The resident required partial/moderate assistance for mobility and transfers; -The resident has pain occasionally and received as needed pain medication in the last five days; -Pain effects sleep. Review of the resident's care plan, dated 01/30/24, showed the following: -The resident was on pain medication therapy as needed; -Administer analgesic medications as ordered by physician. Monitor/ document side effects and effectiveness every shift; -The resident had an order for oxycodone 5 milligram (mg); -Evaluate the effectiveness of pain interventions. Review of the facility provided handwritten list, undated, showed one tablet of the resident's oxycodone could not be accounted for. Review of the resident's current Physicians Order Sheet (POS) showed an order, dated 01/19/24, for oxycodone HCL oral tablet 5 mg, give one tablet by mouth every four hours as needed for moderate to severe pain. Review of the resident's current Medication Administration Record (MAR)/Treatment Administration Record (TAR), dated 02/01/24, showed staff did not document administering oxycodone HCL in the evening or night. Review of the resident's Narcotic Record showed the following: -On 02/01/24, at 11:30 A.M., oxycodone 5 mg, one dose was given with balance forward of 51; -On 02/01/24, at 11:20 P.M., oxycodone 5 mg, one dose documented as given with a slash mark, balance forward showed 50 with another slash mark. The Narcotic Record was signed by LPN C and the ADON; -Attached to the narcotic record was a Medication Disposition Form, dated 02/01/24 at 11:30 P.M., that said medication identified and removed from the count, signed by the Director of Nursing (DON) and Registered Nurse (RN) I. 5. Review of Resident #4's face sheet showed the following: -admission date of 01/10/24; -Diagnoses included rhabdomyolysis (a rare muscle injury where muscles break down), muscle wasting and atrophy, chronic pain syndrome, and low back pain. Review of the resident's care plan, updated 02/01/24, showed the following: -The resident had chronic pain due to lower back, ankles, and right leg chronic pain syndrome; -The resident has an order for Norco oral tablet 7.5-325 mg; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Evaluate the effectiveness of pain interventions Review of the resident's discharge MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident required substantial/maximal assistance for mobility and transfers; -The resident had pain frequently and received as needed pain medication in the last five days; -Pain effects sleep frequently. Review of the facility provided handwritten list, undated, showed one tablet of the resident's Norco could not be accounted for. Review of the resident's current POS showed an order, dated 01/09/24, for Norco oral tablet 7.5-325 mg, give one tablet by mouth every 12 hours as needed for pain. Review of the resident's MAR/TAR, dated 02/01/24, showed staff did not document administering an evening does of the resident's event does of Norco oral tablet 7.5-325 mg. Review of the resident's nurses' notes, dated 02/01/24, showed staff did not document regarding the resident's Norco. Review of the resident's narcotic record showed the following: -On 02/01/24, at 5:00 A.M., staff documented administration of Norco 7.5 mg, one tablet, with balance forward of 49, -On 02/01/24, at 11:20 P.M., dose given had a slash mark balance forward and showed 48 amount. In received was another slash mark. The form was signed by LPN C and the ADON; -Attached to the narcotic record was a Medication Disposition Form, dated 01/01/24, with one tablet identified and removed from the count. The form was signed by the DON and RN I. 6. Review of Resident #8's face sheet showed an admission date of 01/24/24. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident required supervision assistance for mobility and transfers; -The resident has pain occasionally and received as needed pain medication in the last five days; -Pain effects sleep occasionally. Review of the resident's care plan, dated 01/27/24, showed the following: -The resident has pain; -The resident will not have an interruption in normal activities due to pain through the review date; -The resident has an order for hydrocodone-acetaminophen (Norco) oral tablet 5-235 mg; -Administer Norco oral tablet 5-235 mg every six hours as needed per orders -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; -Evaluate the effectiveness of pain interventions; -The residents pain is alleviated/relieved by rest and pain medications. Review of the facility provided handwritten list, undated, showed one tablet of the resident's Norco could not be accounted for. Review of the resident's current POS showed the following: -An order, dated 01/24/24, for Norco (hydrocodone-acetaminophen) oral tablet 5-325 mg, give one tablet by mouth every six hours as needed for pain, not to exceed four tablets in one day. Review of the resident's MAR/TAR, dated 02/01/24, showed staff did not document administration of an evening dose off Norco. Review of the resident's narcotic record showed the following: -On 01/31/24, at 2:04 P.M., staff noted one dose of Norco 5-325 removed with balance forward of 78; -On, no date given, staff noted Norco 5-325 no dose was given, however balance forward showed 77, -On 02/01/24, at 11:20 P.M., staff noted a slash mark with balance forward of 76 of Norco 5-325. Staff noted amount received with another slash mark. The line was signed by LPN C and the ADON; -Attached to the narcotic record was a Medication Disposition Form, dated 02/01/24, with one tablet identified and removed from the count. The form was signed by the DON and RN I. 7. Review of Resident #9's face sheet showed the following: -admission date of 02/25/23; -Diagnoses included osteomyelitis (infection of the bone) of the vertebra, thoracic region, pain in right hip, and chronic pain syndrome. Review of the resident's care plan, dated 03/07/23, showed the following: -The resident is on pain medication therapy as needed; -The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Required partial/moderate assistance for mobility and transfers; -The resident has pain occasionally and received as needed pain medication in the last five days; -Pain effects sleep occasionally. Review of the facility provided handwritten list, undated, showed one tablet of the resident's pregabalin (Lyrica - used to treat nerve pain) 50 mg, could not be accounted for. Review of the resident's current POS showed an order, dated 02/25/23, for Lyrica oral capsule, 8 mcg, give one capsule by mouth three times a day related to chronic pain syndrome. Review of the resident's narcotic record showed the following: -On 02/01/24, at 1:00 P.M., staff administered pregablin (Lyrica) 50 mg with balance forward of 73; -On 02/01/24, at 11:20 P.M., pregablin 50 mg had a slash mark with balance forward showed that showed 72. The amount received marked another slash mark. The line was signed by LPN C and the ADON; -Attached to the narcotic record was a Medication Disposition Form, dated 02/01/24, that showed one tablet identified and removed from the count. The form was signed by the DON and RN I. 8. Review of Resident #10's face sheet showed the following: -admission date of 01/10/24; -Diagnoses included muscle wasting and atrophy. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident required partial/moderate assistance for mobility and transfers; -The resident has pain occasionally and received as needed pain medication in the last five days; -Pain effects sleep occasionally. Review of the resident's care plan, dated 01/27/24 showed the following: -The resident has chronic pain due to general body pain; -Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the facility provided handwritten list, undated, showed two of the resident's Lomotil (a controlled substance used to treat diarrhea) could not be accounted for. Review of the resident's current POS showed an order, dated 01/30/24, for Lomotil oral tablet 2 5-0.025 mg, give two tablets by mouth four times a day to treat malignant (cancer) neoplasm of overlapping sites of rectum, anus and anal canal. Review of the resident's February 2024 MAR/TAR showed staff did not document administration of Lomotil at the scheduled time of 9:00 P.M. on 02/01/24. Review of the resident's nurses' notes showed did not document regarding the missed dose of Lotomil on 02/01/24. Review of the resident's narcotic record showed the following: -On 02/01/24, at 5:00 P.M., staff documented administration of Lomotil, two pills given, with balance forward forward of 74; -On 02/01/24, at 11:20 P.M., staff marked a slash mark and listed balance forward of 72. The amount received was marked with another slash mark. The line was signed by LPN C and the ADON; -Attached to the narcotic record was a Medication Disposition Form, dated 02/01/24, that identified two tablets removed from the count and signed by the DON and RN I. 9. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 06/02/23; -Diagnoses included fracture of left lower leg. Review of resident's care plan, revised on 02/01/24, showed the following: -The resident is on sedative/hypnotic therapy related to insomnia; -Order for zolpidem tartrate (a controls substance, sedative/hypnotic) oral tablet 5 mg; -The staff should administer sedative/hypnotic medications as ordered by physician. -The resident has acute/chronic pain related to left ankle fracture; -The staff should administer analgesia (oxycodone 5 mg, two tabs every 8 hours as needed) as per orders, give half hour before treatments or care; -The staff should anticipate the resident's need for pain relief and respond immediately to any complain of pain. Review of the facility provided handwritten list, undated, showed the two of the resident's oxycodone, five mg, and one of the resident's zolpidem, five mg, could not be accounted for. Review of resident's February 2024 POS showed the following: -An order, dated 01/08/24, for zolpidem tartrate oral tablet, 5 mg, 1 tablet by mouth at bedtime related to insomnia; -An order, dated 01/23/24, for oxycodone HCI oral tablet 5 mg, give 2 tablets by mouth every 8 hours as needed for pain related to acute pain due to trauma. Review of the resident's February 2024 MAR/TAR showed the following: -On 02/01/24, at 9:00 P.M., staff did not document they administered zolpidem, 5 mg, to the resident; -On 02/01/24, staff did not document they administered the evening dose of oxycodone 5 mg, to the resident. Review of the resident's nurse progress notes, dated 02/01/24, showed staff did not document regarding the zolpidem and oxycodone not being administered. Review of the resident's narcotic log for oxycodone showed the following: -On 02/01/24, at 3:00 A.M., staff administered two tabs to the resident, with remaining count of 54 tabs. -On 02/01/24. at 11:20 P.M., staff documented a line (-) as dose given with remaining count of 52 tabs; -On 02/01/24 staff identified two tabs as removed from count on the medication disposition page signed by the DON and RN I. 10. Review of Resident #3's face sheet showed the following: -admission date of 01/18/24; -Diagnoses included intertrochanteric fracture of right femur (hip fracture) and muscle wasting and atrophy. Review of resident's care plan, initiated on 01/18/24, showed the following: -The resident has acute pain related to right humerus fracture and right femur fracture; -The resident has an order for oxycodone HCL oral tablet 5 mg; -The staff will administer medications as ordered and monitor/document for side effects and effectiveness; -The resident is cognitively intact. Review of the facility provided handwritten list, undated, showed the two of the resident's oxycodone's could not be accounted for. Review of resident's February 2024 POS showed an order, dated 01/27/24, for oxycodone HCI capsule 5 mg, give one capsule by mouth every six hours a needed for moderate to severe pain. Review of the resident's February 2024 MAR/TAR showed on 02/01/24, at 9:00 P.M., staff did not document they administered oxycodone to the resident. Review of the resident's progress notes, dated 02/01/24, showed staff did not document regarding the resident's oxycodone. Review of the resident's narcotic log for oxycodone 5 mg tabs showed the following: -On 02/01/24, at 9:40 A.M., staff administered one tab to the resident with remaining count of 39 tabs; -On 02/01/24, at 11:20 P.M., staff documented a line (-) as dose given with remaining count of 37 tabs; -On 02/01/24, staff identified two tabs as removed from count on the medication disposition page signed by the DON and RN I. 11. Review of Resident #5's face sheet showed the following: -admission date of 01/12/24; -Diagnoses included fracture of unspecified part of neck of right femur (hip fracture) and muscle wasting and atrophy. Review of resident's care plan, initiated on 01/12/24, showed the following: -The resident has acute pain related to right hip fracture; -The resident has an order for oxycodone HCL oral tablet 5 mg; -The staff should administer analgesics as ordered by the physician; -The staff should anticipate the resident's need for pain relief and respond immediately to a complaint of pain. Review of the facility provided handwritten list, undated, showed the one of he resident's oxycodone's could not be accounted for. Review of resident's February 2024 POS showed an order, dated 01/12/24, for oxycodone HCL oral tablet 5 mg, give one tablet by mouth every four hours as needed for pain related to fracture or unspecified part of neck of right femur, initial encounter for closed fracture. Review of the resident's February 2024 MAR/TAR showed on 02/01/24, staff did not document they administered the evening dose of oxycodone to the resident. Review of the resident's progress notes, dated 02/01/24, showed staff did not document regarding the oxycodone. residents Oxycodone. Review of the resident's narcotic log for oxycodone 5 mg tabs, showed the following: -On 02/01/24. at 1:00 A.M., staff administered one tab to the resident with remaining count of 48 tabs. -On 02/01/24, at 11:20 P.M., staff documented a line (-) as dose given with remaining count of 47 tab; -On 02/01/24, staff identified one tab as removed from count on the medication disposition page signed by the DON and RN I. 12. Review of Resident #6's face sheet showed the following: -admission date of 01/24/24; -Diagnoses included fracture of fourth lumbar vertebra (compression fracture of the spine) and respiratory failure. Review of resident's care plan, initiated on 01/31/24, showed the following: -The resident is on pain medication therapy related to injury L4 fracture; -The resident has an order for hydrocodone-acetaminophen oral tablet 10-325 mg; -The staff should administer analgesic medications as ordered by physician. Staff should monitor/document side effects and effectiveness every shift; -The resident uses anti-anxiety medications related to anxiety disorder; -The resident has an order for Xanax (a controlled substance, antianxiety medication) oral tablet 0.25 mg; -The staff should administer anti-anxiety medications as ordered by physician. Staff should monitor/document effects and effectiveness every shift. Review of the facility provided handwritten list, undated, showed the one of the resident's Xanax and one of the resident's hydrocodone-acetaminophen's could not be accounted for. Review of resident's February 2024 physician order summary report showed the following: -An order, dated 01/24/24, for hydrocodone-acetaminophen oral tablet 10-325 mg, give one table by mouth every six hours as needed for pain; -An order, dated 01/25/24, for Xanax oral tablet 0.25 mg, give one tablet by mouth every 24 hours as needed for anxiety for 14 days. Review of the resident's February 2024 MAR/TAR showed the following: -On 02/01/24, staff did not document they administered the evening dose of hydrocodone-acetaminophen 10-325 mg, to the resident; -On 02/01/24, staff did not document they administered the daily dose of Xanax 0.25 mg to the resident. Review of the resident's progress notes, dated 02/01/24, showed staff did not document regarding the hydrocodone-acetaminophen or Xanax. Review of the resident's narcotic log for hydrocodone-acetaminophen 10/325 mg tabs, showed the following: -On 02/01/24, staff documented receiving 90 tabs from the pharmacy; -On 02/01/24. at 11:20 P.M., staff documented a line (-) as dose given with remaining count of 89 tabs; -On 02/01/24 staff identified one tab as removed from count on the medication disposition page signed by the DON and RN I. Review of resident's narcotic log for Xanax. 25 mg tabs, showed the following: -On 02/01/24. at 11:20 P.M., staff documented one dose administered with remaining count of seven; -On 02/01/24, staff identified one tab as removed from count on the medication disposition page signed by the DON and RN I. 13. Review of Resident #11's face sheet showed the following: -admission date of 01/31/24; -Diagnoses included pathological fracture (a broken bone caused by disease, often by the spread of cancer to the bone), Review of resident's care plan .initiated on 01/31/24, showed the following: -The resident has an order for Percocet (oxycodone) oral tablet 10-325 mg; -The staff should administer analgesics (percocet oral tablet 10-325 mg) as ordered by the physician. The staff should monitor for side effects and effectiveness. Review of the facility provided handwritten list, undated, showed one of the resident's Percocets could not be accounted for. Review of resident's February 2024 POS showed an order, dated 01/31/24, for Percocet oral tablet 10-325 mg, give one tablet by mouth three times a day for pain. Review of the resident's February 2024 MAR/TAR showed the following: -On 02/01/24, at 8:00 P.M., staff did not document they administered Percocet mg to the resident. Review of the resident's nurses' progress notes, dated 02/01/24, showed staff did not document regarding the Percocet. Review of the resident's narcotic log for Percocet 10/325, showed the following: -On 02/01/24, at 1:00 P.M. , staff documented balance forward of five tablets ; -On 02/01/24. at 11:20 P.M., staff documented a line one dose given with remaining count of 4 tablets; -On 02/01/24, staff identified one tab as removed from count on the medication disposition page signed by the DON and RN I. 13. Review of Resident #12's face sheet showed the following: -admission date of 01/29/24; -Diagnoses included muscle wasting and atrophy and fracture of right femur (broken thighbone). Review of resident's care plan, revised on 02/01/24, showed the following: -The resident had acute pain related to right hip fracture; -The resident had an order for oxycodone oral tablet 5 mg. Review of resident's February 2024 POS showed an order, dated 01/29/24, for oxycodone oral tablet 5 mg, give one tablet by mouth every four hours as needed for moderate to severe pain related to fracture of right hip. Review of the resident's February 2024 MAR/TAR showed on 02/01/24, staff did not document they administered the evening dose of oxycodone 5 mg to the resident. Review of the resident's nurses' progress notes, dated 02/1/24, showed staff did not related to the oxycodone. Review of the resident's narcotic log for oxycodone 5 mg tabs, showed the following: -On 02/01/24, staff documented receiving 174 tabs from the pharmacy; -On 02/01/24, at 11:20 P.M., staff documented a line (-) as dose given with remaining count of 173 tabs; -On 02/01/24, staff identified one tab as removed from count on the medication disposition page signed by the DON and RN I. 14. Review of Resident #7's face sheet showed the following: -admission date of 01/25/24; -Diagnoses included unspecified fracture of fifth lumbar vertebra (fracture to the lower spine), and muscle wasting and atrophy. Review of resident's care plan, initiated on 01/26/24, showed the following: -The resident is on pain medication therapy PRN; -Order for oxycodone-acetaminophen tablet 5-325 mg; -The staff should administer analgesic medications as ordered by physician; -The staff should monitor/document side effects and effectiveness every shift. Review of resident's February 2024 POS showed an order, dated 01/25/24, for oxycodone-acetaminophen tablet 5-325 mg, give one tablet by mouth every four hours as needed for pain, not to exceed six tabs in 24 hours. Review of the resident's February 2024 MAR/TAR showed on 02/01/24, staff did not document they administered the evening dose of oxycodone-acetaminophen 5-325 mg, to the resident. Review of the resident's nurse progress notes, dated 02/01/24, showed staff did not document regarding the resident's oxycodone. Review of the resident's narcotic log for Percocet 5/325 mg tabs showed the following: -On 02/01/24, at 4:30 P.M., staff administered one tab to the resident with remaining count of 22 tabs; -On 02/01/24, at 11:20 P.M., staff documented a line (-) as dose given with remaining count of 21 tabs; -On 02/01/2024 staff identified one tab as removed from count on the medication disposition page signed by the DON and RN I. 15. During an interview on 02/08/24, at 12:48 P.M., the ADON said the following: -He/she got a call from LPN C that police officers were in the building and taking LPN A; -He/she arrived at the facility between 9:00 A.M. and 9:30 P.M. He/she took report from LPN C; -The police had already left the building with LPN A. He/she counted the medications from the lock box; -The medications that were missing from the count had been identified by LPN C and LPN D and been confiscated and taken out of the building by the police; -He/she pulled up the MAR/TAR and started doing rounds on the residents; -He/she put slash marks (-) on the narcotics record to show the medications were not administered and show that the medications were not accounted for and could be taken out of the count. During an interview on 02/08/24, at 1:12 P.M., Certified Nurse Aide (CNA) B said it is not appropriate to take a resident's medication. The staff are educated about misappropriation and taking a resident's medication. During an interview on 02/08/24, at 2:00 P.M., LPN C said the following: -On 02/01/24, at around 8:45 P.M., a CNA came to get him/her due to there being police in the facility; -He/she went to the hall where the officers were and saw they had put LPN A in handcuffs; -He/she called the ADON who was the manager on call; -The police officer said LPN A was under arrest and took her outside. They then returned with a clear Ziploc bag with six to eight pills in it that they said had been found in LPN As pockets; -It is not appropriate to put resident medications in staff's pockets; -He/she worked with LPN D to identify the medications. He/she believes there was two pills of Norco, one Percocet, one Xanax, and one oxycodone. He/she believes there were more duplicates, but could not remember; -He/she did a complete narcotics count with LPN D and there were 17 total pills missing from the count; -The amount of pills that were in LPN A's pocket did not account for all of the missing medication. The count had been correct prior to the LPN A's shift; -He/she and the ADON signed the narcotic sheets of the missing medication; -He/she let the ADON and DON know that there were missing medications. During an interview on 02/08/24, at 3:33 P.M., LPN D said the following: -On 02/01/24, at around 9:00 P.M., CNA E came and told him/her that their were police officers in the building; -The police officers arrested LPN A and took him/her outside; -They brought back in clear plastic bag without about seven pills in it and said they had found it in LPN A's pockets. They asked for LPN C and LPN D to identify the medication and they did; -He/she does not know why LPN A had medication in his/her pockets. It is not appropriate to put resident medication loose in their pockets or to pop multiple residents' medication at the same time; -He/she does not remember what the pills were; -The police officers then took the pills with them; -He/she helped LPN C complete the narcotic count and found there to be more missing medication than what was in LPN A's pocket; -He/she marked all of the missing medication with a sticky note on the pages were the count was off. During an interview on 02/08/24, at 4:04 P.M., CMT F said the following: -He/She had been on break with CNA E and came back in the building at 8:30 P.M., -CMT F said that there were three police officers at the vending machines and the officers asked to be taken to LPN A; -CMT F took the officers to the 400 hall where LPN A was working; -CMT F said the police officers went into room [ROOM NUMBER] and arrested LPN A; -CMT F said that LPN A gave the keys to the med cart to LPN C; -CMT F said that two police offers came back in the building and had a clear Ziploc bag with 6 to 7 pills in it; -CMT F said that LPN C and LPN D identified the pills for the police; -LPN C and LPN D went through the narcotic book and identified medications that were missing; -CMT F said that it is not appropriate for staff to have medications belonging to residents in their pockets; -CMT F said that it is not appropriate to take[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** MO0000231298 Based on interview and record review, the facility failed to ensure all residents' medical records were complete and accurate when faciltiy staff failed to document if treatments were completed for four residents (Resident #2, #4, #9, and #10) and failed to follow-up with the residents regarding potentally missed treatments. The census was 99. 1. Review of Resident #2's face sheet showed the following: -admission date of 01/19/24; -Diagnoses included cellulitis (a bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of the left leg, multiple sclerosis (a long-lasting (chronic) disease of the central nervous system), muscle wasting and atrophy (waste away), hypotension (low blood pressure), weakness, severe sepsis with septic shock (when a person's body responds improperly to an infection and causes your organs to malfunction). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/22/24, showed the following: -The resident was cognitively intact; -The resident required partial/moderate assistance for mobility and transfers. Review of the resident's care plan, dated 01/30/24, showed the following: -Potential for pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) development due to limited mobility and weakness; -The resident will have intact skin, free of redness, blisters or discoloration by/through the review date; -Administer treatments as ordered and monitor for effectiveness; -Actual impairment with excoriation to peri, groin, and buttock due to moisture associated skin damage (MASD); -The resident skin injury will be healed by review; -Keep skin clean and dry. Review of the resident's current Physicians' Order Sheet (POS) showed the following: -An order, dated 01/24/24, for mineral cream to left lower leg two times daily to promote skin integrity every day and evening shift; -A current order for Nystatin External Powder 100000 Unit/GM (gram) (Nyastatin Topical - treats fungal or yeast infections of the skin), apply to bilateral breast, pannus, and groin topically every shift for MASD/yeast; -Micatin Cream 2% (miconazole nitrate), apply to buttock topically every shift for MASD/yeast. Review of the resident's Medication Administration Record (MAR)/Treatement Administration Record (TAR), dated February 2024, showed the following: -On 02/01/24, staff document the evening does of mineral cream was not adminitered. The Assistant Director of Nursing (ADON) entered code nine, indicating to see nurses' notes; -On 02/01/24, staff docmented the evening does of Nystatin External Powder, was not administered. The ADON entered code nine, indicating to see nurses' notes; -On 02/01/24, staff dcumented the evening does of Micatin Cream 2% was not administered. The ADON entered code nine, which indicated to see nurses' notes. Review of the resident's nurses' notes showed the following: -On 02/02/24 at 12:49 A.M., the ADON documented adminitration of Nystatin External Powder was not documented on the previous shift; -On 02/02/24, at 12:49 A.M., the ADON documented administration of mineral cream was not documented on the previous shift; - On 02/01/24, at 12:49 A.M., the ADON documented administation of Micatin Cream was not documented on the previous shift. 2. Review of Resident #4's face sheet showed the following: -admission date of 01/10/24; -Diagnoses included rhabdomyolysis (s a rare muscle injury where muscles break down), cognitive communication deficit, muscle wasting and atrophy, chronic pain syndrome, and low back pain. Review of the resident's care plan, updated 02/01/24, showed the following: -Had potential for pressure ulcer development due to limited mobility; -The resident will have intact skin, free of redness, blisters or discoloration by/through the review date; -Administer treatments as ordered and monitor for effectiveness; -Potential/actual impairment to skin integrity due to MASD to pannus, groin, and under the breasts; -The resident will maintain or develop clean and intact skin by the review date; -Keep skin clean and dry. Review of the resident's discharge MDS, dated [DATE], showed the following: -Cognitively intact; -Required substantial/maximal assistance for mobility and transfers; -Had pain frequently and received as needed pain medication in the last five days; -Pain effected sleep frequently. Review of the resident's current POS showed the following: -An order, dated 01/09/24, for Nystatin External Powder, apply to bilateral breast, pannus, and groin topically every day and evening shift for MASD/yeast; -An order, dated 01/09/24, to complete accu-check (used to check blood sugar levels) before meals and at bedtime; -An order, dated 11/11/24, due to MASD to bilateral buttock. Staff to cleanse with soap and water or incontinent wipe, apply clamoseptine (uesd to treat and prevent minor skin irritations) every shift until resolved. Review of the resident's February 2024 MAR/TAR showed the following: -On 02/01/24, staff documented the administrastion of Nystatin External Powder was not administered. The ADON entered a code nine, indicating see nures's notes; -On 02/01/24, staff did not document accu-checks for the evening were not completed. Staff did not document a reason; -On 02/01/24, staff documented the administration of clamoseptine was not completed on the evening shift. Staff entered a code nine, indictating to see nurses' notes. Review of the resident's nurses' notes, dated 02/02/4, showed the following: -On 02/02/24, at 12:50 A.M., the ADON documented Nystatin External Powder was not documented as administered from the previous shift; -On 02/02/24 , at 12:50 A.M., the ADON documented clamoseptine was not documented as administered from the previous shift. (Staff did not document regarding the potentially missed accu-checks.) 3. Review of Resident #9's face sheet showed the following: -admission date of 02/25/23; -Diagnoses included type two diabetes mellitus with diabetic chronic kidney disease, osteomyelitis (infection of the bone) of the vertebra, pain in right hip, dementia, and chronic pain syndrome. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident required partial/moderate assistance for mobility and transfers. Review of the resident's current POS showed the following: -An order, dated 11/27/23, for Premarin vaginal cream .625 mg/gram (gm), insert one gram vaginally every other evening related to urinary tract infections. Review of the resident's February 2024 MAR/TAR showed the following: -On 02/01/24, staff documented the Premarin vaginal cream .625 mg/gm, was not administered. The ADON entered a code nine, indicating see nurses' notes. 4. Review of Resident #10's face sheet showed the following: -admission date of 01/10/24; -Diagnoses included COVID-19, pneumonia, muscle wasting and atrophy, and cognitive communication deficit. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -The resident required partial/moderate assistance for mobility and transfers. Review of the resident's current POS showed the following: -An order, dated 01/10/24, to apply tubigrip (light compression stocking) to left arm due to edema (swelling) in the morning and remove at night every day and evening shift. Review of the resident's February 2024 MAR/TAR showed the following: -On 02/01/24, staff documented tubigrip order to left arm due was not addressed that evening. Staff entered a code nine, indicating see nurses' notes. Review of the resident's nurses notes showed the following: -On 02/02/24, at 12:47 A.M., the ADON documented tubigrip order showed evening shift did not documented if the action occurred. 5. During interviews on 02/08/24, at 12:48 P.M., and on 02/09/24, at 11:40 P.M., the ADON said the following: -He/she got a call that a nurse had to leave the facility unexpectedly. The nurse had already left the building when the ADON arrived; -The ADON arrived at the facility between 9:00 P.M. and 9:30 P.M. He/she took report from another nurse on duty Licensed Practical Nurse (LPN) C; -He/she pulled up the MAR/TAR and started doing rounds on the residents; -If he/she documented a nine on the MAR/TAR, there should be a note in the nurses' notes as to why the treatment was not completed; -He/she documented Not documented from previous shift because she assumed the treatments had been completed by the nurse that left, before he/she got to the facility. The ADON did not ask the residents if they had recieved their treatments; -Treatments should be administered as ordered by the physician and then documented on the MAR/TAR. During an interview on 02/08/24, at 12:13 P.M., the Director of Nursing (DON) said the following: -He/she said to ask the ADON when asked about treatments not administered the night of 02/01/24; -Generally, treatments should be administered as ordered by the physican.

**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 four residents (Residents #1, #2, #3, and #4). The facility had a census of 93. Record review showed the facility did not provide a policy regarding bathing/showering of residents. 1. Record review of Resident #1's face sheet showed the following: - admission date of 11/2/21; -Diagnoses included cerebral infarction (stroke), dysphagia (difficulty in swallowing), and generalized anxiety. Record review of the resident's quarterly Minimum Data Set (MDS - a federally required assessment completed by facility staff), dated 7/29/22, showed the following: -Cognitively intact; -Requires one person physical assistance with bathing. Record review of the resident's care plan, revised 11/7/22, showed the following: -The resident has a self-care performance deficit related to cerebral infarction and weakness with bathing/showering, needing extensive assist of one staff for assistance. (Staff did not address the frequency of showers on the resident's care plan.) Record review of the resident's activities of daily living bathing record, dated 11/29/22 to 1/4/23, showed the following: -Bathing was marked not applicable on 11/3/22; -The resident received a shower on 11/7/22; -The resident received a whirlpool bath on 11/18/22 (11 days after the prior bath/shower); -Bathing was marked not applicable on and 11/19/22; -The resident received a whirlpool bath on 11/29/22 (11 days after the prior bath/shower); -The resident received a whirlpool bath on 12/9/2022 (10 days after the prior bath/shower); -The resident received a whirlpool bath on 12/12/2022; -The resident received a whirlpool bath on 12/15/2022; -The resident received a shower on 12/22/22 (7 days after the prior bath/shower); -The resident received a shower on 1/4/23 (13 days after the prior bath/shower). During an interview on 1/4/23, at 9:50 A.M., the resident said his/her bath days are Mondays and Thursdays. He/she has not had a shower in two weeks. He/she finally got a shower yesterday before going to the doctor. The showers are spotty. Shower Aide A is sometimes pulled from showers to work the floor. The resident said he/she feels itchy and cannot sleep without a shower. 2. Record review of Resident #2's face sheet showed the following: -admission date of 9/12/22; -Diagnoses of pneumonia (an inflammatory condition of the lungs) and type two diabetes (a health condition characterized by high blood sugar, insulin resistance, and relative lack of insulin). Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident is cognitively intact; -The resident requires one person physical assistance with bathing. Record review of the resident's care plan, revised 9/21/22, showed the following: -The resident has an activities of daily living self-care performance deficit related to weakness with bathing/showering; -The resident prefers showers on Monday and Thursday day shift. Record review of the resident's activities of daily living bathing record, dated 11/3/2022 to 1/2/2023, showed the following: -The resident received a shower on 11/3/22; -The resident received a shower on 11/7/22; -The resident received a shower on 11/10/22; -Bathing was marked not applicable on 11/19/22; -The resident received a shower on 11/23/22 (13 days after the prior bath/shower); -The resident received a shower on 11/28/22; -The resident received a shower on 12/8/22 (10 days after the prior bath/shower); -The resident received a shower on 12/15/22 (7 days after the prior bath/shower); -The resident refused a shower 12/19/22; -The resident received a bed bath on 12/22/22; -The resident received a shower on 12/30/22 (8 days after the prior bath/shower); -The resident received a shower on 1/2/23. During an interview on 1/4/23, at 10:15 A.M., the resident said he/she does not get a shower when he/she wants one. He/she wants a shower every other day. He/she finally got a shower Monday. He/she said he/she refused one because of having pneumonia. On 12/25/22, staff told the resident he/she had a shower, but the resident and his/her daughter know the resident did not get a shower that day. The resident's hair was nasty that day. For a long time, he/she was lucky to get one shower a week. They keep pulling the shower aide to work the floor due to short-staffing. Not getting a shower makes the resident feel like he/she is not worthy. He/she feels unclean and he/she worries about how he/she smells. The resident feels like everybody notices when he/she hasn't had a shower. 3. Record review of Resident #3's face sheet showed the following: -admission date of 8/26/21; -Diagnoses of atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart), major depression, anxiety disorder, and bilateral (both sides) above the knee amputations. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Requires physical help limited to transfer only/setup help only in the part of bathing. Record review of the resident's care plan, revised 8/26/22, showed the following: -The resident has an activities of daily living self-care performance deficit related to activity intolerance and impaired balance, and transfers with minimal assistance of one staff in shower for safety. -The care plan does not address frequency of showers. (Staff did not address the frequency of showers on the resident's care plan.) Record review of the resident's activities of daily living bathing record, dated 11/4/22 to 1/4/23, showed the following: -Bathing was marked not applicable on 11/4/22; -The resident received a shower on 11/7/22; -The resident received a shower on 11/10/22; -The resident refused bathing on 11/11/22; -The resident received a shower on 11/18/22 (7 days after the last offered shower/bath); -The resident received a shower on 11/21/22; -The resident received a shower on 11/28/22 (7 days after the prior bath/shower); -The resident received a shower on 12/8/22 (11 days after the prior bath/shower); -The resident received a shower on 12/12/22; -The resident received a shower on 12/15/22; -The resident received a shower on 12/19/22, -Bathing was marked not applicable on 12/23/22; -Bathing was marked not applicable on and 12/30/22; -The resident refused bathing on 1/1/23 (13 days after last documented bath/shower); -The resident received a shower on and 1/4/23. During an interview on 1/4/23, at 10:30 A.M., the resident said he/she does not get a shower when he/she wants one. Recently the resident has only been getting a shower once a week, but he/she wants one twice a week. They have been having to pull the shower aide to work the floor, so then the residents do not get showers. Not getting a shower makes the resident feel bad. 4. Record review of Resident #4's face sheet showed the following: -admission date of 5/20/22; -Diagnoses of morbid obesity due to excess calories (extremely overweight), major depression, and chronic heart failure. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Requires one person physical assistance with bathing. Record review of the resident's care plan, revised 11/14/22, showed the following: -The resident has an activities of daily living self-care performance deficit related to bilateral above the knee amputations, and requires extensive assist of one staff for bathing/showering. (Staff did not address the frequency of showers on the resident's care plan.) Record review of the resident's activities of daily living bathing record, dated 11/3/22 to 1/2/23, showed the following: -The resident received a shower on 11/3/22; -The resident received a shower on 11/7/22; -The resident received a shower on 11/10/22; -The resident received a shower on 11/24/22 (14 days after the prior shower/bath); -The resident received a shower on 11/28/22; -The resident received a shower on 12/08/22 (10 days after the prior bath/shower); -The resident received a shower on 12/12/22; -The resident received a shower on 12/19/22 (7 days after the prior bath/shower); -The resident received a shower on 12/22/22; -The resident received a shower on 12/26/22; -The resident received a shower on 01/02/23 (7 days after the prior bath/shower). During an interview on 1/4/23, at 12:42 P.M., the resident said he/she does not get a shower when he/she wants one. He/she is supposed to get a shower twice a week. The resident got a shower on Monday, but before that he/she waited two weeks for a shower. Staff said they pulled the shower aide to work the floor three times in a row because they were short-staffed. Not getting a shower makes the resident feel filthy. It makes the resident not want to come to lunch because he/she is dirty. He/she has bad skin so it is important that he/she gets a shower. He/she would like a shower every day if possible, but a shower twice a week would be acceptable. The resident said the facility mentioned a shower twice a week during the admission process. 5. During an interview on 1/4/23, at 1:08 P.M., Shower Aide A said residents do not always get a shower when they want one. Residents are supposed to get a shower twice a week, but recently they're lucky to get one once a week. The facility has been short-staffed, so the shower aides get pulled to work the floor. There's just too much floor work then, so the showers do not get done at that point. 6. During an interview on 1/4/23, at 1:26 P.M., Shower Aide B said residents have scheduled shower days, either Monday and Thursday or Tuesday and Fridays. Lately, he/she has been pulled to the floor to work as an aide, so then he/she doesn't have time to give all the showers. He/she has received a lot of complaints from residents about them not getting their showers. Management tells him/her to still do showers when he/she works the floor, but Shower Aide B said there is just too much work and not enough time to do all the showers then. If residents complain of not getting showers, he/she offers that resident a shower right then. He/she documents them on a shower sheet and also in the electronic health record. He/she forgot to document three showers when he/she got pulled to work on the floor as an aide on 300 hall. Shower Aide B turns his/her sheets into the nurse unit manager's box. He/she is unsure what happens to the shower sheets then. Showers show up in all aides' electronic screens to be done before the shower aides have a chance to document them as done. For some reason, showers show up for all aides to do them even though the showers are not assigned to them. 7. During an interview on 1/4/23, at 1:48 P.M., Certified Nurse Aide (CNA) C said residents get a shower when they want one, but they have a right to refuse. He/she reports refusals to the nurse. Residents have complained of not getting a shower. When this happens, he/she tells the charge nurse. He/she will give a shower if the shower aide is not available. It's not possible to work the floor and be the shower aide. That's too much work and it is unsafe for residents. 8. During an interview on 1/4/23, at 2:43 P.M., the Licensed Practical Nurse (LPN) Unit Manager D said residents get a shower when they want one. If a resident complains of not getting a shower staff will offer one to them. Shower aides document showers in the electronic health record. The shower aide turns in a roster highlighting who he/she has showered that day. He/she makes sure the showers have all been documented in the electronic health record. He/she said not applicable in the electronic health record is not supposed to be checked for shower charting. He/she interprets those showers has not being done. There is a bath aide Monday, Tuesday, Thursday, and Friday for ten hour shifts. There are no shower aides scheduled to work on Wednesday, Saturday, or Sunday. 9. During an interview on 1/4/23, at 2:57 P.M., Registered Nurse (RN) E said there is a Monday/Thursday or Tuesday/Friday schedule for baths. If a resident refuses a shower on their shower day and then wants a shower on Wednesday, there is no shower aide on that day to give one. Sometimes residents complain of not getting showers on their shower days, especially if the shower aide is pulled from showers to work the floor, or if the shower aide calls in sick. He/she is not involved in documenting or tracking showers. The nurse unit manager does that. There is no way a shower aide can do showers still if they are pulled to work the floor. That's just too much work just being the floor aide. 10. During an interview on 1/4/23, at 12:16 P.M., the Director of Nursing (DON) said the facility recently had an in-service that even if the shower aides are pulled to the floor the facility and the aides are still responsible to do showers. There have been days where there's no documentation charted for showers. Sometimes night shift staff document not applicable if showers pop up on their shift as needed since the showers are not due then. 11. During an interview on 1/4/23, at 3:10 P.M., the Administrator and DON said the facility does not have a policy on frequency of showers. They said the facility's care plans do not address frequency of showers wanted by residents. Certain room numbers receive a shower on certain days, unless otherwise requested by the resident. They said if they know a resident wants a shower the resident gets a shower. The facility has a shower schedule Monday and Thursday or Tuesday and Friday. There is a shower aide assigned to each hall. Due to holidays and illnesses the last two weeks, the facility has had to pull the shower aides to work the floor more. There is no policy on frequency of showers or preferences regarding showers. When residents ask about shower frequency during admission, the facility verbally tells them they will get a shower twice a week. MO00212026

Based on observation, interview, and record review, the facility failed to ensure all food was protected from possible contamination when the ice machine reflector shield in the kitchen was not clean and when the facility staff failed to store opened food items in a manner to protect the food items from possible contamination. The facility census was 94. 1. Record review of the facility policy titled Ice Machines and Ice Storage Chests, revised January 2012, showed the following: -The facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. The Infection Preventionist (or designee) maintains a copy of these procedures. Record review of the facility policy titled Sanitation, revised October 2008, showed the following: -Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Record review of the facility's weekly cleaning schedule showed the schedule did not include cleaning the inside of the ice machine. Observations on 9/19/2022, beginning at 9:43 A.M., showed the facility ice machine in the beverage area of the kitchen had several black spots and a large spot of white substance. Observation on 9/20/2022, at 9:36 A.M., showed the facility ice machine in the beverage area of the kitchen reflector shield had several black spots and a large spot of a white substance. During an interview on 9/21/2022, at 2:54 P.M., Dietary Aide (DA) K said the following: -All kitchen staff is responsible for cleaning the ice machine; -He/she did not know if there is a schedule to clean it; -The reflector shield inside the ice machine should not have black spots or a white substance on it. During an interview on 9/21/2022, at 3:00 P.M., DA L said the following: -All staff are responsible for cleaning the ice machine; -There is no schedule to clean the ice machine; -The reflector shield inside the ice machine should not have black spots or a white white substance on it. During an interview on 9/21/2022, at 3:04 P.M., the Dietary Manager (DM) said the following: -All staff is responsible for cleaning the ice machine; -The reflector shield inside the ice machine should not have black spots or a white substance on it. During an interview on 9/22/2022, at 2:15 P.M., the Administrator said the following: -Staff should clean the ice machine on a regular basis and the DM should complete weekly round checks for cleanliness; -The reflector shield inside the ice machine should not have black spots or a white substance on it. 2. Record review of the facility policy titled Food Receiving and Storage, revised October 2017, showed the following: -All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use bydate). Record review of the 2013 Missouri Food Code showed the following information: -Food shall be protected from contamination by storing the food in a clean, dry location. and where it is not exposed to splash, dust, or other contamination. Observations on 9/20/2022, beginning at 9:43 A.M., in the kitchen showed the following: -Box of instant mashed potatoes opened and unsealed (open to possible contamination) with no label; -Bag of hot dogs opened in an unsealed zip lock bag (open to possible contamination) with no label; -Margarine block opened to air (open to possible contamination); -Bag of frozen squash opened to air (open to possible contamination); -Bag of corn flakes and cheerios opened and unsealed (open to possible contamination); -Bag of tortilla chips opened to air (open to possible contamination). Observations from 9/20/2022, at 9:36 A.M., in the kitchen showed the following: -Box of instant mashed potatoes opened and unsealed (open to possible contamination). During an interview on 9/21/2022, at 2:54 P.M., DA K said the following: -Opened food products should be placed in a zip lock bag and sealed with a label identifying the product and date opened; -Food should never be left open to air; -All kitchen staff is responsible food storage. During an interview on 9/21/2022, at 3:00 P.M., DA L said the following: -All opened food should be sealed in a zip lock bag, labeled with a date and name of product. -Food products should never be opened to air and unlabeled. During an interview on 9/21/2022, at 3:04 P.M., the DM said the following: -All food items should be bagged and sealed in a zip lock bag once opened and a label should be written, including the product, date opened and use by date; -Food products should never be opened to air and unlabeled. During an interview on 9/22/2022, at 2:15 P.M., the Administrator said the following: -Kitchen staff is expected to use the CLAD (closed, labeled and dated) method for food storage; -All opened food products should be labeled with the product name and date opened and no food items should be left open to the air.

Based on observation, interview, and record review, the facility staff failed to provide reasonable accommodations of individual needs and preferences by failing to ensure acceptable lighting to encourage independent activities for one resident (Resident #29). The facility census was 106. Record review of the facility's policy titled Quality of Life-Accommodation of Needs, dated August 2009, showed the following: -The resident's individual needs and preferences shall be accommodated to the extent possible, except when health and safety of the individual or other residents would be endangered; -The resident's individual needs and preferences, including need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. 1. Record review of Resident #29's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 3/3/17; -Diagnoses included primary lateral sclerosis (a disease characterized by progressive muscle weakness in the voluntary muscles), paraplegia (paralysis of the legs), macular degeneration (a disease that causes vision loss), vitreous degeneration (a disease of the eye resulting in small moving dots or gray spots and lines in the field of vision), presbyopia (loss of ability to see things clearly up close), and cataracts (clouding of the lens of the eye). Record review of the resident's care plan, reviewed date 6/10/19, showed direction for the following: -The resident prefers self-directed activities such as writing letters, coloring, and reading in his/her room where he/she is most comfortable; -Ensure resident has needed resources and supplies of writing material, magazines, and colored pencils; -Ancillary services by social services to address visual needs; -Provide resident education regarding visual loss; -Routinely assess resident for changes in visual functioning and follow up with referrals as needed. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/12/19, showed the following: -Cognitively intact; -Impaired vision; -Wears corrective lenses; -Required extensive assistance of two staff for bed mobility and transfers. Observation and interview on 9/30/19, at 9:03 A.M., showed the resident sitting in bed, with head of bed elevated looking at a computer tablet. A florescent wall light with an opaque (not able to see through) cover on. There was no additional lighting in the room. The resident said he/she did not have adequate lighting in his/her room to see details plainly. The resident said he/she had an overhead lamp that helped him/her see up close detail that was broken by staff when he/she was moved from across the hall several months ago. He/she said the administrator had promised to replace the lamp. Observation on 10/3/19, at 10:15 A.M., showed the resident sitting in an electric wheelchair, facing the window, coloring. During an interview on 10/7/19, at 11:30 A.M., the resident said he/she questioned staff about the broken lamp. He/she said the administrator told him/her that the base of the lamp broke away from the pole and the lamp was thrown away. The resident said he/she would have liked to have seen the lamp to see if it could have been repaired. The administrator told him/her she was working on replacing the lamp and had a couple picked out. He/she said working on crafts is difficult due to his/her vision without an overhead lamp. He/she said she enjoys adult coloring books, making stationery, writing letters, cutting magazines, and used to crochet. During an interview on 10/07/19, at 1:03 P.M., the administrator said the resident changed rooms from one side of the hall to the opposite side on 5/24/19. During an interview on 10/8/19. at 8:53 A.M., the resident said his/her family member brought the lamp in after admission as she was having difficulty seeing in the room. He/she used the light until the move to current room. He/she said the wall light over the bed will brighten if turned on at the switch by the door, but if on, it turns on the bright for the roommate's side of the room as well. He/she said if the head of the bed is elevated it shadows the wall light. The resident said he/she had cataract surgery, but was told he/she had scarring on the left eye so the surgery did not help on the left. He/she said he/she tries to get as much sunlight as possible from the roommate's side of the room, but cloudy days are really difficult for him/her. During an interview on 10/8/19, at 9:07 A.M., Certified Nurse Assistant (CNA) B said the following: -The resident loves to do crafts in his/her room; -Staff open the blinds per the resident request for more light; -The resident did have a floor lamp in her room that he/she used before he/she moved to the current room, but no longer has one. During an interview on 10/8/19, at 9:50 A.M., the social worker said if an item is broken by staff the administrator will replace the item or reimburse. She said she was not aware of the resident having a lamp. The resident does a lot of close up craft work and enjoys viewing the computer tablet. She said she feels the resident's vision is adequate with glasses. During an interview on 10/8/19, at 10:00 A.M., with the administrator and the Director of Nursing (DON), the administrator said the resident did have a floor lamp. She said the lamp was broken prior to the move. The lamp was thrown away due to safety concerns. She said the lamp had not been replaced, as she was trying to find one the resident liked. She said she had offered lamps, but the resident declined the ones offered. The DON said he was not aware of any visual concerns for the resident. During an interview on 10/8/19, at 1:42 P.M., the administrator said she was unable to find any documentation regarding the broken lamp or offers to replace. -

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%, affecting two residents (Resident #54 and #60). The facility census was 106. According to Medscape website (medical reference website for healthcare professionals) showed the following: -Rapid-acting insulin can cause hypoglycemia (low blood glucose). This may occur when enough calories are not consumed after taking the insulin within the time frame; -Older adults may be more sensitive to the side effects of low blood glucose from rapid acting insulin's. Record review of the Novolog (rapid-acting insulin) undated manufacturer's insert showed the following: -Novolog starts acting fast; -A meal should be eaten within five to ten minutes of taking a dose of Novolog; -Dosage adjustments may be needed in regards to timing of food intake. Record review of the Humalog (rapid-acting insulin) undated manufacturer's insert showed the following: -Humalog starts acting fast; -A meal should be eaten within 15 minutes of taking a dose of Humalog; -Dosage adjustments may be needed in regards to timing of food intake. Record review of the facility's policy titled Insulin Administration, dated September 2014, showed the following: -Nursing staff will have specific manufacturer instructions on all forms of insulin prior to their use; -Rapid acting insulin has an onset (how quickly the insulin reaches the blood stream and begins to lower the blood sugar) of 10 to 15 minutes. 1. Record review of Resident #54's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 5/21/19; -Diagnosis of insulin-dependent diabetes mellitus (IDDM-a form of diabetes in which there is little or no ability to produce insulin and is dependent on insulin injections). Record review of the resident's physician order, dated 5/21/19, showed staff to administer Insulin Aspart solution (brand name Novolog) seven units subcutaneously (under the skin) with meals. Observation on 10/3/19 showed the following: -At 11:22 A.M., Licensed Practical Nurse (LPN) A administered seven units of Novolog insulin to the resident; -At 11:24 A.M., the resident began propelling self out of room towards the day room; -At 12:30 P.M., staff served the resident lunch in the day room. The resident began eating 68 minutes after the LPN administered the Novolog insulin. 2. Record review of Resident #60's face sheet showed the following: -admission date of 8/26/19; -Diagnosis of IDDM. Record review of the resident's physician order, dated 9/30/19, showed staff to administer Humalog insulin according to a sliding scale (progressive increase in the pre-meal insulin does, based on pre-defined blood glucose ranges) before meals and at bedtime; -If blood glucose level is 0-149 milligrams/deciliter (mg/dL), administer two units of insulin; -If blood glucose level is 150-199 mg/dL, administer four units of insulin; -If blood glucose level is 200-249 mg/dL, administer six units of insulin; -If blood glucose level is 250-399 mg/dL, administer eight units of insulin; -If blood glucose level is 400 -999 mg/dL, administer no insulin and notify the physician. Observation on 10/3/19 showed the following: -At 11:25 A.M., LPN A administered six units of Humalog insulin to the resident according to the sliding scale (based on a blood glucose level of 210 mg/dL); -At 12:15 P.M., staff brought the resident to the dining room; -Staff served the resident lunch at 12:28 P.M., The resident began eating 63 minutes after the LPN administered the resident's Humalog insulin. 3. During an interview on 10/8/19, at 10:15 A.M., LPN E said the following: -Residents should eat within ten minutes after administration of a rapid acting insulin; -If a meal is not available within ten minutes, a snack should be provided; -Snacks are available on the medication cart. 4. During an interview on 10/8/19, at 10:30 A.M., the Director of Nursing (DON) said staff should follow the manufacturer's instructions for rapid acting insulin administration and the guidelines set for providing food after insulin administration. Nurses should monitor to ensure the resident receives food within the guidelines after insulin is administered. If the meal is not served within the time frame, the nurse should provide the resident a snack to prevent a drop in their blood glucose level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the potential spread of bacteria, or other infections causing contaminants, when performing blood glucose testing on two residents (Resident #54 and Resident #60) out of a sample of 22 residents. The facility census was 106. Record review of the facility's policy titled Blood Sampling-Capillary Finger Sticks, dated September 2014, showed the following: -Wash hands and don gloves; -Place blood glucose monitoring devise on a clean field; -Remove gloves, and discard after obtaining the blood sample. 1. Record review of Resident #54's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admit date [DATE]; -Diagnosis of insulin-dependent diabetes mellitus (IDDM-a form of diabetes in which there is little or no ability to produce insulin and is dependent on insulin injections). Record review of the resident's physician order, dated 5/22/19, showed staff to administer accuchecks (blood glucose testing) before each meal and at bedtime. 2. Record review of Resident #60's face sheet showed the following: -admission dated 8/26/19; -Diagnosis of IDDM. Record review of the resident's physician order, dated 9/30/19, showed staff to administer Humalog insulin (rapid acting insulin) according to a sliding scale (progressive increase in the pre-meal insulin does, based on pre-defined blood glucose ranges) before meals and at bedtime; -If blood glucose level is 0-149 milligrams/deciliter (mg/dL), administer two units of insulin; -If blood glucose level is 150-199 mg/dL, administer four units of insulin; -If blood glucose level is 200-249 mg/dL, administer six units of insulin; -If blood glucose level is 250-399 mg/dL, administer eight units of insulin; -If blood glucose level is 400 -999 mg/dL, administer no insulin and notify the physician. 3. Observation on 10/3/19, at 11:20 A.M., showed Licensed Practical Nurse (LPN) A wash his/her hands and don gloves. The nurse did not prepare the glucose monitoring device. The nurse wiped Resident#36's finger with an alcohol prep (swab pre-moistened with alcohol) and stuck the resident's finger with a lancet (a small sharp devise) and obtained blood from the finger. The nurse wiped the blood with a cotton ball using his/her right hand. The nurse stepped back to the medication cart and disposed of the used cotton ball and alcohol prep. Without changing gloves, the nurse opened the medication cart top drawer and removed the glucose monitoring device and opened the container of glucose monitoring strips located on top of the cart. The nurse reached into the container of strips using his/her first finger of his/her right hand and removed a strip and placed the strip in the glucose monitoring devise and completed the blood glucose test for the resident. The nurse removed the gloves and used hand sanitizing gel. The container of glucose strips was left opened on the top of the medication cart. The nurse pushed the medication cart to Resident #60's room, used hand sanitizer gel and donned gloves. The nurse removed a strip from the open container of glucose test strips and inserted a strip into a glucose testing devise. The nurse entered the resident's room and laid the glucose testing device in a chair in the resident's room, and then laid it directly on the linens in the residents bed without using a clean field barrier. The nurse completed the glucose test, and removed gloves, and used hand sanitizer. The nurse closed the container of glucose testing strips and returned them to the top drawer of the medication cart. During an interview on 10/8/19, at 10:15 A.M., LPN E said after a completing a blood glucose, test gloves should be removed and disposed of. Contaminated gloves should be removed before touching other items. Using contaminated gloves to obtain a glucose test strip would contaminate the entire container of strips and they should be discarded. During an interview on 10/8/19, at 10:30 A.M., the Director of Nursing (DON) said the following: - Gloves are considered contaminated after coming in contact with blood or other body fluids; - He expects staff to remove soiled gloves before touching other items; - If glucose test strips are contaminated, staff should not use the strips and the strips should be discarded; -Using contaminated blood glucose strips puts the residents at risk for infections.

Based on observation, interview, and record review, the facility failed to store medications according to professional standards and manufacturer's guidelines when staff failed to note when a vial of insulin was opened; failed to ensure the disposal of outdated tuberculin testing solutions and stock medication; and failed to ensure medications were stored behind at least one lock when not directly supervised by facility staff to ensure medications were inaccessible to unauthorized staff and residents. The facility census was 106. 1. Record review of the facility's policy titled Storage of Medications and Security of the Medication Cart, dated April 2017, showed the following: -Staff must secure the medication cart during the medication pass to prevent unauthorized entry; -The medication cart should be parked in the resident's doorway, if not possible the cart should be parked in the hallway against the wall with doors and drawers facing the wall; -The medication cart must be locked if the staff enters the resident's room; -Medication carts must be securely locked at all times when out of the staff view. Observation on 10/3/19, at 8:30 A.M., showed an unlocked medication cart parked in the 300 hallway. No staff was in the area. Multiple residents were in the day room adjacent to the medication cart. At 8:36 A.M., Certified Medication Technician (CMT) F opened a resident's door, walked to the medication cart, and opened it without using a key. Observation on 10/4/19, at 10:00 A.M., showed CMT F left a medication cart unlocked in the 300 hall. The CMT entered a resident room and closed the door. Staff was not in the area. Two residents were sitting in the day room adjacent to the medication cart. During an interview on 10/8/19, at 10:15 A.M., Licensed Practical Nurse (LPN) E said medication carts should be locked at al times if not in direct sight of staff. During interviews on 10/8/19, at 10:30 A.M. and 11:45 A.M., the Director of Nursing (DON) said medication carts should always be locked if not is use or if out of sight of staff. 2. Record review of the facility's policy titled Storage of Medications and Security of the Medication Cart, dated April 2017, showed the following: -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs must be returned to the dispensing pharmacy or destroyed in accordance with established guidelines. 3. During observation and interview on 10/3/19, at 8:55 A.M., of the 100/200 hall medication room showed one open vial of tuberculosis (TB) solution (a solution injected just under the skin to test for TB) in the medication refrigerator, dated 8/10/19. The manufacturer's instructions on the box showed once the vial is opened it should be discarded after 30 days. LPN D said the TB solution is outdated and should have been destroyed. He/she said the TB solution is used for residents and staff. During an interview on 10/4/19, at 9:50 A.M., LPN A said injectable medication, to include tuberculin solution, should be destroyed 28 days after the vial is opened for use. Staff should date the vial when opened. During interviews on 10/8/19, at 10:30 A.M. and 11:45 A.M., the DON said opened TB solution should be discarded 30 days after opened. 4. Record review of Resident #36's face sheet showed the following: -admit date of 7/31/18; -Diagnosis of chronic kidney disease (long standing disease of the kidneys leading to kidney failure). Record review of the resident's physician order, dated 8/30/18, directed staff to administer Sodium Bicarbonate 650 mg two times daily for high potassium. Observation and interview on 10/3/19, at 3:55 P.M., of the 300 hall medication cart showed a stock bottle Sodium Bicarbonate (a medication to relieve stomach acid and to aid with electrolyte balance), dated as opened on 8/21/18. The manufacture's expiration date on the label showed expired 5/2019. The bottle was two/thirds empty. CMT C said staff administer the Sodium Bicarbonate to Resident #36 daily. He/she said the bottle had been in the cart for a prolonged time and was the only bottle of Sodium Bicarbonate available in the medication cart. He/she said the medication was expired and should not be used. During an interview on 10/8/19, at 10:15 A.M., LPN E said the following: -Stock medications are dated when opened and should not be used after the expiration date; -Staff should look at expiration dates prior to administering medication; -Expired medication should be destroyed; -The pharmacist monitors periodically for expiration dates. During an interviews on 10/8/19, at 10:30 A.M. and 11:45 A.M., the DON said stock medication should not be given past the manufacturer's expiration date. Staff should monitor the expiration date prior to administering each dose. 5. Record review of the facility's policy titled Administering Medications, dated April 2010, showed the following: -Expiration date on the medication label must be checked prior to administration; -When opening a multi-use container the date should be recorded on the container. Record review of the facility's policy titled Storage of Medications and Security of the Medication Cart, dated April 2017, showed the following: -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs must be returned to the dispensing pharmacy or destroyed in accordance with established guidelines. According to the United States Pharmacopeia Dispensing Information (USPDI) as well as the United States Food and Drug Administration (FDA), once opened, insulin must not be used after 28 days due to loss of potency and the risk of contamination. Record review of Resident #72's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admit date of 5/10/19; -Diagnosis of diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose)). Record review of the resident's physician order, dated 8/27/19, showed staff to administer Novolog insulin (rapid acting insulin) according to a sliding scale (progressive increase in the pre-meal insulin dose, based on pre-defined blood glucose ranges). -If blood glucose level is 201-250 milligrams/deciliter (mg/dL), administer one unit of insulin; -If blood glucose level is 251-299 mg/dL, administer two units of insulin; -If blood glucose level is 300-999 mg/dL, notify the physician. During observation and interview on 10/3/19, at 9:05 A.M., of the 200 hall nurses' medication cart showed one vial of Novolog insulin labeled for Resident #72. LPN D said he/she gave Resident#72 his/her insulin earlier that morning and did not realize the insulin was undated. Insulin vials are dated when opened and discarded after day 28. He/she said the insulin needed to be discarded. Staff should check the open date prior to administering the insulin. During an interview on 10/4/19, at 9:50 A.M., LPN A said injectable medication, to include insulin, should be destroyed 28 days after the vial is opened for use. Staff should date the vial when opened. During an interview on 10/8/19, at 10:15 A.M., LPN E said insulin is dated when opened and destroyed after 28 days. During interviews on 10/8/19, at 10:30 A.M. and 11:45 A.M., the Director of Nursing (DON) said all insulin should be dated when opened and should be discarded after 28 days. He said if insulin is undated, staff should discard the insulin. 6. During interviews on 10/8/19, at 10:30 A.M. and 11:45 A.M., the DON said nurses should monitor the open date on injectable medication. The medication should not be used if past the time frame.

Based on observation, interviews, and record review, the facility failed keep food safe from potential contamination when the stove and the tilt fryer had a build-up of grease and lint that could potentially contaminate food prepared for residents. The facility census was 106. 1. Record review of the facility's policy titled Cleaning Schedules, undated, showed the following: -The Dietary Manager (DM) will develop and enforce the cleaning schedules, and monitor the completions of assigned cleaning tasks in order to promote a sanitary environment; -A weekly cleaning schedule should be posted in the dietary department, listing all cleaning tasks, frequency of those tasks, and the employee position responsible for completion of the tasks. The cleaning schedules should be filed for three months, or in accordance with state regulations. Observations on 9/30/19, beginning at 9:38 A.M., showed the following: -The stove front had a grease and lint mixture accumulated around the knobs and down the length of the front of the stove. When staff would walk by or work around the stove, the lint would be move; -The inside of the oven had a build-up of grease and lint lining the side walls and lower corner edges. Observations of the tilt fryer showed the front of the machine, where the mechanical wheel is located, had a green tint with a build-up of a grease. The sides of the tilt machine had a large, crusty build-up of grease that was dried and beginning to chip into smaller pieces. Record review of the facility's cleaning schedule, dated 10/1/19 - 10/14/19 showed the following: -All jobs to be done at least three times a week and staff to initial after the cleaning is completed; -Staff did not intial cleaning the range hood and vents; -The tilt fryer machine was not listed on the cleaning schedule. During an interview on 1/10/18, at 10:05 A.M., Dietary Aide (DA) G said the following: -Everyone in the kitchen has cleaning duty; -Each person is assigned certain tasks; -His/her personal task is to clean the range hood/stove front, dessert cart, and the walk-in freezer; -He/she said he/she had missed doing it; -He/she was not sure who was to clean the tilt fryer. During an interview on 1/10/18, at 10:11 A.M., Dietary [NAME] H said often the cooks will clean the stove and tilt fryer. During an interview on 1/10/18, at 10:16 A.M., the DM said the following: -Staff are good at following the cleaning schedule; -If he/she notices any areas that need attention, he/she will point them out to staff; -He/she would expect the front of the stove to be clean and not have a build-up of grease and grime. During an interview on 1/10/18, at 10:26 A.M., DA I said the following: -Everyone pitches in to help with cleaning; -This is done whenever there is free time; -The cooks would be the ones to clean the stove and around the stove. During an interview on 1/10/18, at 10:32 A.M., DA J said the following: -He/she will usually clean whenever there is a break; -He/she will use the cleaning list that is posted; -Anyone who has free time could clean the stove.