Based on interview and record review, the facility failed to follow their abuse and neglect policy regarding screening staff members when the facility failed to complete an Employee Disqualification List (EDL - a list that lists staff who are unable to work in long-term care in the state) check and a Nurse Aide (NA) Registry (registry which shows if someone has a Federal Indicator (indicates individuals the person cannot work in long-term care)) check for one employee (Registered Nurse (RN) A). The facility had a census of 99. Review of the facility's policy titled Abuse, Neglect, and Exploitation Policy and Procedure, updated 07/2022, showed the following: -The names of all potential employees will be checked against the list maintained by the state of persons who may not be eligible for employment within a long-term care facility; -CNA registry will be checked on all new hires. Staff will print a copy for employee file prior to employment and according to state law; -Facility's are prohibited from employing individuals who have been found guilt of abuse, neglect, mistreatment or exploitation of residents or misappropriation of a resident's property by a court of law; -Any person investigated and found to be on the EDL, or who is found guilty of any A or B felony violation, in accordance to chapter 565,566 or 569 RSMO will be allowed to maintain employment; -The EDL is checked on a quarterly basis for all employees; -Any person whose name appears on the EDL will be terminated upon notification 1. Review of RN A's personnel file showed the following: -Hire date on 11/27/22; -Staff documented an EDL check on 08/15/24 (over 20 months after hire/start date); -Staff documented a NA Registry check on 08/15/24 (almost 20 months after hire/start date). During an interview on 08/15/24, at 2:15 P.M., Licensed Practical Nurse (LPN) B said the following: -He/she assisted with hiring and orientation/training of new employees; -He/she is responsible to ensure criminal background checks and EDL checks have been completed; -He/she also will look at the NA check for licensure and a letter from the Family Care Registry; -He/she ensures all of this is done with all new staff; -RN A was already hired with the company and transferred from another state. That state did not require an EDL or NA registry check as far as he/she was aware; -He/she is unsure why an EDL/ NA registry was not completed once RN A transferred to the facility; -He/she added the EDL check and NA registry check today; -He/she said an EDL and NA registry check should be done for all new employees; -Checking the EDL and NA registry is required before the employee can have contact with residents. During an interview on 08/15/24, at 2:50 P.M., the Director of Nursing (DON) said the following: -LPN B did the background checks and the EDL and NA registry would be included; -He/she will assist at times, but LPN B was primarily the one who does this; -He/she is unsure why this was overlooked, but said it would have been an oversight; -Completing the EDL and NA registry check should be done prior to the hiring of new staff. During an interview on 08/16/24, at 3:15 P.M., the Administrator said the following: -During covid, he/she brought RN A over from a sister-facility in another state; -RN A stayed on as a as needed employee and also worked in another town full-time; -LPN B is the one who will ensure staff are cleared through all background checks prior to being hired; -The other state does not require an EDL or NA registry check, so this is where the process was not followed-through on he/she suspects; -The EDL and NA registry should have been checked, according to Missouri code.

Based on observation, interview, and record review, the facility failed to provide all necessary activities of daily living (including assistance with meals) to all residents ensure good nutrition when facility staff failed to assist one resident (Resident #17) with eating in a timely fashion. The facility census was 99. 1. Review of Resident #17's face sheet (brief resident profile sheet) showed the following information: -admission date of 11/07/22; -Diagnoses included unspecified protein-calorie malnutrition (a wasting condition resulting from a diet inadequate in either protein or calories or both). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument filled out by facility staff), dated 05/10/24, showed the following: -Moderate cognitive impairment; -Dependent with eating; -At risk for malnutrition. Review of the resident's Nutrition Diagnosis Criteria, dated 05/13/24, showed the resident at risk for malnutrition. Review of the resident's care plan, last revised on 08/14/24, showed the following information: -On 11/22/22, staff care planned to serve regular diet as ordered; -On 11/22/22, staff care planned to offer substitutions if resident was not eating and/or did not like something; -On 11/22/22, staff care planned notify physician if resident gained/lost five percent in a month; -On 05/22/23, staff care planned to offer a fork and spoon with each meal; -On 05/22/23, staff care planned to cut food into bite size pieces. (Staff did not care plan regarding assistance needed from staff to eat.) Observation on 08/12/24 of the noon meal showed the following: -At 11:55 A.M., the resident sat at the dining room table with his/her eyes closed and head down. The staff placed the resident's plate, with plate guard attached and consisting of a regular diet of pork fritter, scalloped potatoes, and green beans in front of the resident. The staff did not attempt to wake the resident. -At 12:21 P.M., the staff started serving room trays and the resident sat at the table with eyes closed and head down not eating. -At 12:23 P.M. (28 minutes after the resident's meal was served), a staff member woke the resident up and began cueing the resident to eat. After the resident began to put green beans on his/her fork and attempted to start eating, the staff member left the table. -At 12:34 P.M., the resident had green beans on his/her fork, but was unable to bring them to his/her mouth. The resident sat at the table holding the fork with the green beans. -At 1:15 P.M. (over an hour after the resident's meal was served), a staff member sat down and began assisting the resident to eat. Observation on 08/13/24, of the noon meal, showed the following: -At 12:13 P.M., staff placed a plate, with a plate guard attached, consisting of a regular diet of fried chicken (on the bone), mashed potatoes, corn, roll and pears in front of the resident. Staff opened the resident's silverware, but did not assist with removing the chicken from the bone. The resident picked up the chicken leg and began chewing on the end of the leg. The resident continued to eat the backside of the chicken leg and could not get the leg turned around to get to the meat. -At 12:25 P.M., the resident continued to attempt to find the meat on the chicken leg and was not attempting to feed him/herself any of the side items on the plate. -At 12:41 P.M. (28 minutes after them meal was served to the resident), Certified Nursing Assistant (CNA) CC knelt on the floor beside the resident and began to assist the resident to eat. -At 1:12 P.M., the CNA asked if the resident was finished with his/her meal, then rolled the resident to the television room. The resident ate 25% of the meal. During an interview on 08/15/24, at 9:11 A.M., CNA T said the resident used a plate guard and special utensils. He/She has good days and bad days, so some days the resident required more help than others. The resident did better in the middle of the day, but the staff watch him/her throughout the meal to see if the resident needed assistance. He/she would not wait longer than five to ten minutes before encouraging or assisting the resident to eat. During an interview on 08/15/24, at 10:05 A.M., CNA U said the resident did well with finger foods, but would need assistance with food that required a fork or spoon. The resident used a plate guard. Once the plate was put in front of the resident, if there was enough staff, he/she would expect staff to start assisting the resident to eat immediately. But, if there was not enough staff, staff should finish serving trays and then sit and start assisting the residents to eat. The residents should not have to wait longer than five minutes. A resident waiting 15 to 20 minutes would not be acceptable. During an interview on 08/16/24, at 9:03 A.M., MDS Coordinator X said independent residents are served their trays first so that staff can immediately sit down and help provide meal assistance to those who need help. The resident eats well some days and other days he/she is sleepy and needs help, but staff can tell quickly, within a couple minutes, if the resident is awake and talkative or sleepy and groggy. The resident always needed setup help and would require meat to be torn off the bone of chicken and silverware to be setup. He/she would not consider the resident to be at risk for weight loss. During an interview on 08/16/24, at 9:51 A.M., the Clinical Dietary Nurse said the resident was at risk for weight loss and is monitored. The resident eats by him/herself and does not need assistance beyond the setup of silverware. Even if staff encouraged a resident to eat by themselves, staff should still sit with the resident. If the resident did not eat, staff should offer other foods or a shake. The resident had orders for mighty shakes with medication pass and for a bedtime snack. During an interview on 08/16/24, at 12:35 P.M., the Director of Nursing (DON) said she would not consider the resident at risk for weight loss. The resident had his/her days and could take bites on his/her own, but needed encouragement. Staff should not make the resident wait longer than five to ten minutes before assisting him/her with eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident # 67's face sheet showed the following: -admission date of 06/02/24; -Diagnoses included anorexia (anorexia is a significant loss of appetite which may be induced by a variety of causes including advanced dementia, changes in taste and smell, tooth loss or edentulism, and delayed gastric (stomach) emptying), dementia, abnormal weight loss, and hypothyroidism (a condition in which the body's tissues are exposed to a subnormal concentration of thyroid hormone). Review of the resident's Nutrition Risk Evaluation, dated 06/05/24, showed the following: -Resident's most current weight was 85 pounds; -Resident added to the high risk roster; -Resident had low body mass index (BMI - a calculation that used a person's weight and height to categorize them as underweight, normal weight, overweight, or obese); -Admit with hospice services; -Offer mighty shake; -Mechanical soft diet (a texture-modified diet that makes foods easier to chew and swallow by pureeing, blending, finely chopping, or grinding food). Review of the resident's physician order sheet (POS), dated 08/16/24, showed an order, dated 06/07/24, for mighty shakes after meals. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Partial to moderate assistance with eating; -Has had weight loss of five percent or more in the last month, or more than ten percent in the past six months; -Complaints of difficulty or pain with swallowing. -Resident is on hospice services. (Staff did not care plan the intervention of mighty shakes.) Review of the resident's care plan, last revised on 07/03/24, showed the following information: -admitted to hospice on 06/14/24; -Offer substitutions if resident is not eating and/or does not like something; -Offer supplements as directed; -Let the physician know if resident gained/lost five percent in a month; -Serve diet as ordered, now a regular diet (risk versus benefit form signed by family). Review of the resident's July 2024 MAR showed staff did not have a place to document administration of the mighty shake. Observation on 08/12/24, beginning at 11:57 A.M., of the noon meal showed staff did not provide or offer a mighty shake to the resident. Observation on 08/13/24, beginning at 12:17 P.M., of the noon meal showed staff did provide or offer a mighty shake to the resident. Observation on 08/14/24, beginning at 11:57 A.M., of the noon meal showed staff did not provide or offer a mighty shake to the resident. Review of the resident's care plan showed the following information: -On 08/14/24, staff added the intervention to offer mighty shakes after meals; -On 08/14/24, staff added intervention to assist with meals. Resident may forget to eat or not use silverware. During an interview on 08/15/24, at 9:11 A.M., CNA T said he/she did not know for sure if the resident got a mighty shake. The kitchen usually handled that. During an interview on 08/15/24, at 11:13 A.M., Dietary Aide DD said the resident got mighty shakes at the table after meals. Review of the resident's diet on the back of the unit's kitchen door on 08/15/24 showed the following: -Cut food into bite size pieces; -No crispy food; -Mighty shakes after meals only. During an interview on 08/15/24, at 11:19 A.M., CMT V said the mighty shakes show up on the MAR. Sometimes the MAR will ask for a percentage and sometimes the MAR will ask if the resident received the shake. If CMT V knows the aides are busy he/she will give the shakes him/herself. He/she had not seen an order for the resident to have a mighty shake, but if the resident does not eat, the CMT recommends that he/she gets one. The mighty shakes do not show up on the MAR at times. During an interview on 08/15/24, at 2:31 P.M., LPN W said he/she considered the resident someone at risk for weight loss. The resident's mighty shakes should show up on the MAR for the CMT. The resident had no other specific recommendations. The Clinical Dietary Nurse and the Dietary Manager make the recommendations for the residents. The Clinical Dietary nurse is responsible for updating the care plans regarding weight loss and weight loss interventions. During an interview on 08/16/24, at 9:03 A.M., MDS Coordinator X said he/she could not find the resident's mighty shake on the MAR as it did not have a specific time to be charted. Sometimes, the homemakers give the mighty shakes, sometimes CNA or CMT will give it. During an interview on 08/16/24, at 9:51 A.M., the Clinical Dietary Nurse said he considered the resident at risk for weight loss. His/her Mighty Shake should be documented on the MAR. He had found some that have not flowed to the MAR. He thought when the order was put in, the order did not get linked to the MAR. The resident had an order for Mighty Shakes, dated 06/07/24. Since it did not get linked to the MAR, there is no way to tell if the resident received his/her Mighty Shake since 06/07/24. He did not know if the care plan would be updated for Mighty Shakes. Review of the resident's MAR, dated 08/01/24 through 08/15/24, showed staff did not have a place to document administration of the Mighty Shake. During an interview on 08/16/24, at 12:35 A.M., the DON said the resident was at risk for weight loss. The resident was on weekly SNAR and weekly weight. The resident has an order for mighty shakes. If the resident ate good, staff might wait to give him/her the mighty shake. If not, it may be given while the resident is still at the table. Based on observation, interview, and record review, the facility failed to ensure diets were provided as ordered when staff failed to to care plan and provide physician ordered dietary supplements to one resident (Resident #54) who experienced weight loss and one resident (Resident #67) at risk for weight loss. The facility census was 99. Review of the facility's policy titled SNAR (Skin, Nutrition, And At Risk) Policy and Procedure, dated 12/23, showed the following information: -The facility will ensure that the resident maintains, to the extent possible, acceptable parameters of nutritional status to refuse risk of weight loss; -If weight loss/gain of five percent in thirty days is noted on monthly weights, the resident will be added to the weekly SNAR meeting for review; -The dietary manager will bring the list of residents on fluid restrictions, supplements ordered/furnished, and any recommendations that the registered dietician may have made; -The physician will be notified of recommendations made by the registered dietician or observations from the inter-disciplinary team (IDT) and then the interdisciplinary team will note any new orders received from the physician; -The resident's care plan will be revised at this time of any changes and interventions. 1. Review of Resident #54's face sheet (brief look at resident information) showed the following: -admission date of 11/18/21; -Diagnoses include Parkinson's disease (a disorder of the central nervous system that affects movement), dysthymic disorder (a mental health disorder that involves long-term, mild to moderate depression), chronic kidney disease, and high blood pressure. Review of the resident's electronic medical record (EMR) showed the following: -On 02/12/24, the resident weighed 154.4 pounds; -On 05/13/24, the resident weighed 144.6 pounds (loss of 9.8 pounds or 6.3 percent in three months). Review of the resident's current care plan showed staff did not address the weight loss, or add new intervention to address the weight loss. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool filled out by facility staff), dated 05/27/24, showed the following: -Moderate cognitive impairment; -Required supervision or touching assistance for eating; -No swallowing difficulty; -Had not had weight loss of five percent or more in the last month, or more than ten percent in the past six months. Review of the resident's EMR showed on 07/12/24, the resident weighed 139.6 pounds (a loss of 5 pounds or 3.4 percent in two months). Review of the resident's current care plan showed staff did not address the weight loss, or add new intervention to address the weight loss. Observation on 08/12/24, at 12:05 P.M., of the meal showed the resident in the dining room with food, water, and juice in front of him/her. Staff did not provide the resident with a mighty shake or ice-cream. Observation on 08/14/24, at 11:48 A.M., showed the resident in the dining room with food, water, and juice in front of him/her. Staff did not provide a mighty shake or ice-cream. Review of the resident's Medication Administration Records (MAR) and Treatment Administration Record, dated 05/01/24 to 08/14/2024, showed staff did not document providing a nutritional supplement to the resident. Review of the document titled, Resident's Diets-[NAME], dated 08/15/24, placed on the back side of the [NAME] kitchen door, showed the following information for the resident: -Regular Diet; -Cut up meats, likes peanut butter, mashed potatoes, eggs, milk, vanilla ice cream, and coffee with lots of cream/sugar. (The document did not list the resident was to receive mighty shakes.) Observation on 08/15/24, at 12:08 P.M., of the meal showed the resident in the dinning room with food, water, and juice in front of him/her. Staff did not provide a mighty shake or ice-cream. During an interview on 08/15/24, at 2:44 P.M., Registered Nurse (RN) M said checking for daily weight loss is the charge nurse's responsibility. Weekly weights are the responsibility of the Dietary Consultant Nurse. If there was an issue with the weekly weights, the Dietary Consultant Nurse would place the resident on the SNAR list and the resident would most likely be provided supplements. These supplements should populate on the MAR. That is how the staff would know what the resident should be receiving. RN M looked in the resident's EMR and said he/she saw the order for a supplement, but also saw the order was put in incorrectly and it did not populate over to the MAR. The order was put into the system in May of 2024. During an interview on 08/15/24, at 2:53 P.M., the Dietary Consultant Nurse said he checked weights of at-risk resident's every week. He then tracks the weights for four weeks. If there is a loss or gain, he contacts the resident's physician and facility dietician. The dietician will usually prescribe supplements and the physician will prescribe any medication needed. He is responsible for entering these orders into the EMR. He believed the resident has had a weight loss of three percent this month and that he was on a supplement three times a day. The Dietary Consultant Nurse reviewed the resident's EMR and the order was entered into the EMR in May 2024, but it appears the order was revised this day. He believed that dining services was who passed out the supplements, but the CMT's are supposed to chart it within the MAR. He expected any weight loss issues and or supplements to be seen in the care plan. During an interview on 08/16/24, at 10:47 A.M., the Dietary Manager said the Dietary Consultant Nurse let him and his department know what needed to be done for the residents regarding weight loss or gain. Him and the Dietary Consultant Nurse fill out the Resident's Diets-[NAME] document and ensure correct documentation is within it. Dietary Staff/Homemakers are supposed to give the residents the mighty shakes. The nurses and CMTs document it in the resident's MAR. He had not been made aware of any weight loss and or supplements needed for the resident, so his staff would not know to be giving the resident the supplement. Review of the resident's care plan, dated 08/16/24, showed the following information: -At risk for weight loss; -On regular diet. Meal intake had been good since admission and resident was able to eat unassisted, but required assistance opening packages and cutting up foods; -Staff to notify physician if there is a weight loss/gain of five percent or more in a month; -Staff to provide mighty shakes as ordered; -Monitor intake, weight, and healing. Staff to provide supplements per orders, and refer to registered dietician as indicated. During an interview on 08/15/24, at 12:28 P.M., Certified Medication Technician (CMT) L said he/she was not sure if the resident was supposed to be getting mighty shakes and ice cream. This would populate on his/her MAR if the resident had an order for it. CMT L double checked the MAR and said he/she did not see mighty shakes and ice cream populating for the resident. During an interview on 08/14/24, at 12:50 P.M., Licensed Practical Nurse (LPN) J said he/she thought the CMTs were responsible for ensuring supplements were given. There is a Dietary Consultant Nurse that monitors dietary needs and weights as well as manages all feedings and supplements. During an interview on 08/16/24, at 12:35 P.M., the Director of Nursing (DON) said residents with nutritional risk for weight loss should be on the SNAR list and the dietician would look at them and make recommendations. The Dietary Consultant Nurse would put those orders into the EMR and he should also update the Residents Diets-[NAME] document. Some of the supplements were not populating on the MAR, such as for this resident. During an interview on 08/16/24, at 1:46 P.M., the Administrator said for residents at risk for weight loss, he expected staff to be following through with supplement/medication orders and updating the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the hot water temperatures at sinks at a temperature to prevent that reduced the possibility of burns when hot water in multiple resident access areas measured in access of 120 degrees Fahrenheit (F). The facility had a census of 99. Review of the the US Consumer Product Safety Commission (CPSC) document Avoiding Tap Water Scalds, dated 03/2012, showed the following: -The majority of injuries involving tap water scalds are to the elderly and children under the age of five; -The CPSC urges all users to lower their water heaters to 120 degrees F; -Most adults will suffer third-degree burns if exposed to 150 degreed F water for two seconds; -Burns will also occur with a six-second exposure to 140 degreed F water or with a thirty second exposure to 130 degree F water; If the temperature is 120 degrees F, a five minute exposure could result in third-degree burns Review of a facility policy entitled Safe Water Temperatures, dated 01/01/24, showed the following: -It is the policy of the facility to maintain appropriate water temperatures in resident care areas; -Water temperatures will be set to a temperature of no more than 120 degrees F, or the state's allowable maximum water temperature; -Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed; -Documentation of testing will be maintained for three years and kept in the maintenance office. 1. Review of the facility's hot temperature logs showed staff documented checking the hot water reading in two residents rooms per hall per week, the hall's water tank, and the dishwasher. 2. Observations on 08/15/24, at 3:39 P.M., showed the following:: -The hot water in the hall/public bathroom [ROOM NUMBER], located across from the kitchen door, (unlocked and accessible to residents) measured 130.1 degrees F; -The hot water in the hall/public bathroom [ROOM NUMBER], located across form the kitchen door, (unlocked and accessible to residents) measured 132.8 degrees F. Observations on 08/16/24 showed the following: -At 11:22 A.M., the hot water in the hall/public bathroom [ROOM NUMBER] measured 134.1 degrees F; -At 11:24 A.M., the hot water in the hall/public bathroom, near the [NAME] neighborhood living room (accessible to residents), measured 122.0 degrees F; -At 11:27 A.M., the hot water in hall/public bathroom [ROOM NUMBER] measured 130.2 degrees F. 3. Review of Resident #37's face sheet (gives basic profile information) showed the following: -admission date of 07/18/24; -Diagnoses included metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood), type 2 diabetes with peripheral angiopathy (nerve pain in the extremities), peripheral vascular disease (poor blood circulation), and osteoarthritis. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 07/25/24, showed the following: -Severely impaired cognition; -Functional limitation in range of motion to one lower extremity; -Utilized a walker or wheelchair for mobility. Review of the resident's care plan, last updated 08/01/24, showed the following: -May have difficulty remembering due to decreased cognitive status; -Memory and decision-making process may not be as reliable as it used to be. Resident might forget safety factors, so caregivers need to help stay as safe as possible Observation on 08/16/24, at 1:25 A.M., showed the hot water temperature in the resident's bathroom measured 132.3 degrees F. 4. Review of Resident #255's face sheet showed the following: -admission date of 08/05/24; -Diagnoses included hip fracture and late onset Alzheimer's disease. Review of the resident's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Functional limitation in range of motion to one lower extremity; -Utilized a wheelchair for mobility. Review of the resident's care plan, last updated 08/14/24, showed the resident had difficulty remembering and becomes easily confused related to Alzheimer's. Observation on 08/16/24, at 11:32 A.M., showed the hot water temperature in the resident's bathroom measured 134.6 degrees F. 5. During an interview on 08/16/24, at 11:32 A.M., Maintenance Staff P said they check the water temperatures of two resident rooms per hall daily. The Maintenance Director is usually the person who does the checks and records them in a logbook. 6. During an interview on 08/16/24, at 11:50 A.M., the Maintenance Director said they randomly select two resident rooms per hall per week and check the water temperatures daily, along with the hall's water tank and dishwasher. They did not currently include the hall/public bathrooms in the temperature checks. 7. During an interview on 08/16/24, at 1:22 P.M., the Administrator said the maintenance department should routinely check the water temperatures in resident rooms and the hall/public access bathrooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and effective medication administration system for all residents when staff failed to maintain an accurate reconciliation and accounting for controlled medications (substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) for one resident (Resident #356) and when staff failed to destroy expired or unused medications for [NAME] and Chestnut Neighborhoods. The facility census was 99. 1. Review of a facility policy entitled Medication Storage, dated 01/01/24, showed the following: -Any discrepancies which cannot be resolved must be reported immediately. Staff to notify the Director of Nursing (DON), charge nurse, or designee and the pharmacy and complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; -The DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy, and possibly the State Licensure Board for Nursing Home Administrators; -Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. Review of Resident #356's face sheet (brief look at resident information) showed the following information: -admission date of 08/06/24; -Diagnoses included drug induced polyneuropathy (when multiple peripheral nerves become damaged), anorexia (an eating disorder that causes people to obsess about their weight and food), anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and diabetes. Review of the resident's care plan, initiated on 08/10/24, showed the following information: -Staff to administer diuretics, opioids, and diabetic medication as prescribed and monitor for any adverse side effects; -Staff to give anti-diarrheal medications as prescribed. Review of the resident's Physician Order Sheet (POS), dated 08/01/24 through 08/31/24, showed the following orders: -A current order for diphenoxylate-atropine (an antidiarrheal medication, controlled substance), 2.5-0.025 mg (milligram), give one tablet by mouth every four hours as needed, for diarrhea. Observation on 08/14/24, at 3:12 P.M., showed [NAME] neighborhood controlled medication lock box contained the following: -One bottle of diphenoxylate atropine containing two tablets; -The count sheet showed three tablets remaining. Review of the resident's Medication Administration Record (MAR), dated 08/01/24 through 08/31/24, showed diphenoxylate-atropine 2.5-0.025 mg had not been administered since 08/08/24 at 12:07 P.M. During an interview on 08/14/24, at 3:12 P.M. Certified Medication Technician (CMT) L said he/she believed the night shift nurse gave the medication, so CMT L wrote the date and time down and added a sticky note on the page to remind the night shift nurse to sign out the medication. When asked if CMT L typically takes the keys to the controlled substance box if the count is off, he/she said yes, all he/she does is leave a sticky note for the staff member to sign. He/she believed the night nurse must have gotten busy with morning report and simply forgot, because the two of them discussed it prior to CMT L taking the keys. During an interview on 08/14/24, at 4:34 P.M., [NAME] Neighborhood Charge Nurse/ Licensed Practical Nurse (LPN) J said he/she was not aware that there was a discrepancy in the controlled count. The CMT for that hall was CMT L and that was who took the count today and did not notify LPN J of any discrepancy. If LPN J had known about the discrepancy, he/she would have reported it to the nurse on call, or the Director of Nursing (DON). The nurse on call or DON would have come in and resolved the discrepancy prior to the count being signed over to CMT L. LPN J said if he/she ever noticed a discrepancy, he/she reported it to the nurse on call, or DON and does not accept the count until it's been resolved. During an interview on 08/14/24, at 4:42 P.M., [NAME] Neighborhood Supervisor/Registered Nurse (RN) M said he/she, the nurse on call, or the DON should have been notified of the discrepancy. Once they are notified of such, they immediately begin investigating and no oncoming staff is to accept the count and no off going staff is to leave the facility until the discrepancy has been resolved. He/she was not aware there was a current discrepancy. It is never acceptable to place a sticky note for someone else to eventually sign, it needs to be taken care of immediately. During an interview on 08/14/24, at 4:48 P.M., the DON said RN M had just let her know about the discrepancy. The DON, Assistant Director of Nursing (ADON) and RN M were currently investigating the discrepancy. The DON said if the oncoming staff is aware of whom did not sign a medication out, they could flag the medication to be signed, however they should still let the DON and RN M know what is going on. The DON said she was currently calling the night shift nurse who was responsible for signing out the medication to get it corrected immediately. The DON said she believed she knew what happened, She believe the night shift nurse accidentally signed off the wrong medication. She does expect staff to ensure they know where the error is coming from prior to any shift leaving the building. During an interview on 08/15/24, at 4:34 P.M., CMT N said if the shift count of the narcotics and controlled medications is off, staff shouldn't accept the keys or sign off on the log. If the previous shift cannot resolve a discrepancy, staff should tell the charge nurse or the DON. During an interview on 08/15/24, at 12:26 P.M., CMT O said he/she would not accept the keys from the previous shift staff if the narcotic shift count was off. Staff should get it resolved first. During an interview on 08/15/24, at 4:48 P.M., the DON said if the shift count of controlled medications is off (count doesn't match the logbook documentation), staff should let the Mentor/Unit Manager or the DON or Assistant Director of Nursing (ADON) know immediately. There would have to be an investigation to resolve the discrepancy. The medication administration record showed the nurse documented administration on the wrong medication, causing a discrepancy on the logbook. The nurse should have resolved the issue and corrected documentation before the next shift staff accepted the keys to the medication cart and locked cabinet and box 2. Review of a facility policy entitled Medication Storage, dated 01/01/24, showed the following: -The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. Observation on 08/14/24, at 3:02 P.M., of the [NAME] Neighborhood overstock and wound supplies cart showed the following: -A strip pack that contained fourteen tablets of dexamethasone (a corticosteroid that helps relieve inflammation) with an expiration date of 07/30/24 that belonged to a deceased /discharged resident. Observation on 08/14/24, at 3:12 P.M., of the [NAME] Neighborhood controlled medication lock box showed the following: -Fifty-six tablets of OxyContin (opioid analgesic, schedule II-controlled substance with abuse potential, used to treat pain) 20 mg with a note on the count sheet that said do not use for Resident #356; -One bottle that contained seventeen tablets of OxyContin 20 mg with a note on the count sheet that said do not use for Resident #356; -One bottle that contained fifty-nine and a half tablets of Percocet (opioid analgesic, schedule II-controlled substance with abuse potential, used to treat pain) 5/325 with a note on the count sheet that said do not use for Resident #356; -Fifty-three tablets of Oxycodone (opioid analgesic, schedule II-controlled substance with abuse potential, used to treat pain) 5 mg for a deceased /discharged resident; -One bottle containing 21 ml (milliliters) of morphine solution (opioid analgesic, schedule II-controlled substance with abuse potential, used to treat pain) for a deceased /discharged resident; -One full/unopened bottle containing 30 ml of Morphine Solution for a deceased /discharged resident. Observation on 08/15/24, at 12:35 P.M., of the Chestnut Neighborhood medication cart showed the following: -One bottle of Systane (relieves dry eyes) eye drops belonging to Resident #34 expired on 07/22; -One bottle of acetaminophen (nonsteroidal anti-inflammatory - NSAID drug used to relieve pain) 500 mg belonging to Resident #58, expired on 06/30/24; -One card of Hyoscyamine (central muscarinic antagonist used to treat muscle cramps in the bowels and bladder) 0.125 mg belonging to Resident #71, expired on 08/06/24; -One bottle of ibuprofen (NSAID used to relieve pain) 200 mg belonging to Resident, #61 expired on 01/23; -One bottle of Colace (stool softner) 100 mg belonging to Resident #62, expired on 03/24; -One bottle of milk of magnesia (laxative) belonging to Resident #62, expired on 07/23; -One bottle of stock geri-lanta (antacid), expired on 04/24; -One box of Daytime Cold and Flu belonging to Resident #71, expired on 10/21; -One box of Metamucil (fiber supplement) packets belonging to Resident #50, expired on 02/24. During an interview on 08/14/24, at 4:42 P.M., RN M said expired medications and medications from deceased or discharged residents destroyed and not used. During an interview on 08/16/24, at 9:38 A.M., LPN J the protocol for expired medications is to pull it from the cart, don't use it, and destroy it. LPN's can destroy anything that is not a narcotic. If the medication is a narcotic, there must be two RNs to destroy. If he/she found medications from deceased or discharged residents, he/she would notify a manager and take it out of the cart. During an interview on 08/16/24, at 11:28 A.M., the DON said expired and medications from deceased or discharged residents should be destroyed and not used. During an interview on 08/16/24, at 1:46 P.M., the Administrator said medications from deceased or discharged residents and/or expired medications should not be used. The staff should let RN M or DON know so they can destroy the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 08/12/24, at 9:19 A.M., showed the [NAME] hall medication cart contained several medication cards, over the counter medications, and supplies. The cart was unlocked and faced the nurses' station. Several residents were in the living room adjacent from the medication cart. At 9:21 A.M., a staff member came by and locked the cart. Observation on 08/14/24, at 9:47 A.M., showed the [NAME] hall medication cart contained several medication cards, over the counter medications, and supplies. The cart was unlocked and faced the nurses' station and adjacent from the living room. The medication cart was out of sight of CMT L who was in the dining room. Several residents in the living room area, next to the medication cart. At 9:51 A.M., CMT L walked up to the cart and locked it. During an interview on 08/16/24, at 9:38 A.M., Licensed Practical Nurse (LPN) J said medication carts should be locked at all times. During an interview on 08/16/24, at 11:28 A.M., Registered Nurse (RN) M said medication carts should be locked at all times unless it is in use by a certified medication technician or nurse. During an interview on 08/16/24, at 12:35 P.M., the DON and ADON said having medication carts unlocked is not acceptable. During an interview on 08/16/24, at 1:46 P.M., the Administrator said medication carts should be locked at all times. 3. Review of Resident #70's face sheet, showed the following information: -admission date of 07/07/24 -Diagnoses include emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe), hypercapnia (an increase in partial pressure of carbon dioxide), and high blood pressure. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/31/24, showed the following information: -Cognitively intact; -Did not receive any high-risk drug class medications. Review of the resident's care plan, revised on 06/12/24, showed staff did not care plan self-administration of medications. Review of the resident's Physician Order Sheet (POS), dated 08/01/24 through 08/31/24, showed staff did not note an order for keeping medications at bedside or self-administration. Review of the resident's Medication Administration Record (MAR), dated 08/01/24 through 08/31/24, showed staff did not note an order for the resident to keep medications at bedside or self-administration. Observation on 08/12/24, at 9:10 A.M., showed the resident in his/her room, laying on the bed. Two inhalers, labeled fluticasone propionate (treats allergy symptoms by decreasing inflammation in the nose) and one bottle labeled echinacea (a dietary supplement for the common cold and other infections) were on top of the resident's bedside table. During an interview on 08/13/24, at 9:04 A.M., The resident said he/she no longer used those medications that are on top of his/her bedside table. The medications were only used by him/her when he/she was sick a while back. Observation on 08/13/24, at 2:09 P.M., showed the resident in his/her room, laying on the bed. Two inhalers, labeled fluticasone propionate and one bottle labeled echinacea were on top of the resident's bedside table. Observation on 08/14/24, at 8:49 A.M., showed the resident in his/her room, laying on the bed. Two inhalers labeled fluticasone propionate and one bottle labeled echinacea were on top of the resident's bedside table. Observation on 08/15/24, at 9:26 A.M., showed the resident in his/her room, laying on the bed. Two inhalers labeled fluticasone propionate and one bottle labeled echinacea were on top of the resident's bedside table. During an interview on 08/16/24, at 9:38 A.M., LPN J said medications should never be left on a resident's bedside table. The only reason that would happen is if they have a physician's order to do so. During an interview on 08/16/24, at 11:28 A.M., RN M said he/she is not aware wether or not the resident had a physician's order for his/her medications to be at bedside. If the resident did have an order, that would also be in the care plan. If the resident does not have an order, leaving any medications at bedside would not be acceptable. During an interview on 08/16/24, at 12:35 P.M., the DON and ADON said leaving medications at bedside without a physician's order was not acceptable. The DON said that there must be a physician's order for leaving medications at bedside, and that information should also be found in the care plan. During an interview on 08/16/24, at 1:46 P.M., the Administrator said it was not acceptable to leave medications at bedside without a physician's order. 4. Observation on 08/14/24, at 3:02 P.M., inside of the treatment and overflow cart inside the nursing station on the [NAME] neighborhood showed the following medication with prescription labels removed: -One Santyl (a Federal and Drug Administration (FDA) approved medication that removes dead tissue from wounds); -One Diclofenac 3% cream (a nonsteroidal anti-inflammatory drug used to treat mild to moderate pain); -One Mometasone Furoate 0.1% cream (a corticosteroid ointment used to treat skin conditions such as eczema, and psoriasis); -One Ketoconazole 2% (an antifungal medicine that is used to treat skin infections caused by yeast); -One Diclofenac 1% cream. During an interview on 08/14/24, at 3:02 P.M., LPN J said creams are sometimes unlabeled because other staff use those medications for other residents as the needs arise, especially Santyl as it is expensive. During an interview on 08/16/24, at 11:28 A.M., RN M said it would not be acceptable to tear off prescription labels with the purpose of using the medications for other residents. During an interview on 08/16/24, at 12:35 P.M., the DON said it would not be acceptable to tear off prescription labels with the purpose of using the medications for other residents. During an interview of 08/16/24, at 1:46 P.M., the Administrator said it would not be acceptable to tear off prescription labels with the purpose of using the medications for other residents. Based on observation, interview, and record review, the facility failed to ensure all medications were stored and labeled in accordance with standards of practice when staff failed to store controlled substances under two locks, when medication carts were left unlocked when unattended, when staff left medications on the nightstand of one resident (Resident #70), and when staff removed prescription labels from medications. The facility census was 99. Review of a facility policy entitled Medication Storage, dated 01/01/24, showed the following: -It is the policy of the facility to ensure all medications housed on the premises are stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security; -All drugs and biologicals will be stored in locked compartments (such as medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls; -Only authorized personnel will have access to the keys to locked compartments; -During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart; -Narcotics and Controlled Substances: Schedule II drugs and back-up stock of Schedule III, IV, and V medications are stored under double-lock and key; -Schedule II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator. 1. Observation and interview on 08/15/24, at 12:26 P.M., on the Dogwood hall with Certified Medication Technician (CMT) O showed the following: -The door to nurses' office was open with no staff was present in the room; -CMT O entered the office and indicated a cabinet door was where the narcotics and controlled substances were kept. The CMT grasped the cabinet handle and opened the door without using a key. -The CMT then used a key to unlock the narcotic/controlled substance box located within the cabinet. Multiple pharmacy packaged medications were present. -CMT O said other medications were also stored in the cabinet, such as medications brought in by residents from home and not currently in use. -CMT O verified that the cabinet door was not locked when he/she opened it and said staff was expected to lock both the narcotics box and the cabinet door after its use. During an interview on 08/15/24, at 4:34 P.M., CMT N said staff should always lock the cabinet where the narcotics locked box is kept and should ensure the locked box is also secured. During an interview on 08/16/24, at 12:35 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said having medication cabinets unlocked is not acceptable. During an interview on 08/16/24, at 1:46 P.M., the Administrator said medication cabinets should be locked at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an effective program of infection control when staff failed to communicate an infection control plan to all staff and implement a consistent infection control plan for one resident (Resident #17) who had a current diagnosis of Clostridium difficile (C. Diff - a highly contagious germ that causes diarrhea and inflammation of the colon). Facility staff also failed to perform hand hygiene per standards of practice when providing cares to two residents (Resident #17 and Resident #67) and when administering medication per a feeding tube for one resident (Resident #2). Facility staff also failed to use infection control practices per standards of practice when completing accuchecks (a meter that measures glucose in whole blood) and failed to properly disinfect glucometers (measures how much sugar is in the blood sample) for one resident (Resident #22). The facility census was 99. Review of the facility's policy titled Hand Hygiene, revised January 2024, showed the following: -Staff will perform hand hygiene when indicated. Using proper technique consistent with accepted standards of practice; -Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations; -Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 1. Review of the facility's policy titled Management of C. Difficile Infection, revised January 2024, showed the following information: -All staff are to wear gloves and gown upon entry into the resident's room and while providing care of the resident with C. difficile infection; -Hand hygiene shall be performed by hand washing with soap and water in accordance with facility policy for hand hygiene; -Maintain on contact precautions for the duration of illness, but no less than 48 hours after diarrhea has resolved. Review of the facility's policy titled Enhanced Barrier Precautions (EBP), revised April 2024, showed the following information: -The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an Multi-Drug Resistant Organism (MDRO) that is not currently targeted by Centers for Disease Control (CDC), but may be considered epidemiologically important; -Make gowns and gloves available in designated area of the resident's room; -Position a trash can inside the resident room and near the exit for discarding PPE (personal protective equipment - protective clothing such as gowns, gloves, goggles or other garments designed to protect workers from infection or injury) after removal, prior to exit of the room or before providing care for another resident in the same room; -High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device use, and/or wound care. Review of the CDC Implementation of PPE Use in Nursing Homes to Prevent Spread of MDROs, dated 04/02/24, showed the following: -EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO; -When implementing contact precautions or enhanced barrier precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use; -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE; -For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves; -Make PPE, including gowns and gloves, available immediately outside of the resident room; -Contact precautions are recommended for all residents who have another infection (such as C-diff) or condition. Review of Resident #17's face sheet (brief resident profile sheet) showed the following information: -admission date of 11/07/22; -Diagnoses included metabolic enterocolitis (enterocolitis- inflammation of the small intestine) due to clostridium difficile. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/10/24, showed the following information: -Moderately cognitively impaired; -Dependent on staff for toileting, bathing, dressing, and mobility; -Frequently incontinent of bowel and bladder. Observation on 08/12/24, at 3:42 P.M., showed the resident sat in a wheelchair in the room. There were no isolation sign on the door or PPE supplies observed in or near the room. Observation on 08/13/24, at 9:25 A.M., showed the resident in the bed sleeping and an EBP sign on the door. Review of the resident's care plan, revised 08/14/24, showed the following information: -Contact precautions; -Provide PPE equipment per protocol; -Provide peri care with each incontinent episode; -Evidence based precautions; -Please wear a gown and gloves (and mask if indicated) when providing direct care. Observation on 08/14/24, at 2:30 P.M., showed the following: -Certified Nursing Assistant (CNA) R and CNA S entered the resident's room; -CNA R and CNA S washed their hands and applied gowns and gloves; -CNA S observed the mechanical lift (sit to stand lift - helps transfer a resident with limited mobility from a seated position to a standing position) did not have a battery. He/she removed the PPE and left the room; -When CNA S returned with the battery, he/she did not perform hand hygiene. The CNA reapplied gown and gloves with no hand hygiene and attached the battery to the sit to stand lift; -CNA R and CNA S transferred the resident to the toilet with the mechanical lift. The resident's brief was saturated with urine; -CNA R gave the resident toilet paper to wipe him/herself. CNA R then assisted resident's with cleaning his/her peri area. CNA R then took the dirty toilet paper from the resident and placed the toilet paper in the trash. The CNA did not remove his/her gloves; -The staff stood the resident back up with the mechanical lift; -While the resident stood, CNA S wiped the resident twice with clean wash cloths. The CNA removed his/her gloves and did not perform hand hygiene; -CNA R and CNA S pulled up the resident's brief and clothes, rolled the resident back to the wheelchair, and sat him/her down in the wheelchair; -CNA R and CNA S hooked the resident back up to the sit to stand. CNA S did not have gloves on and CNA R continued to wear the same contaminated gloves while operating the lift; -The CNAs transferred the resident into the bed with the sit to stand lift. CNA S, without washing hands and with no gloves, and CNA R while continuing to wear the same contaminated gloves, placed a pillow under his/her legs to float the resident's heels, and pulled up the covers over the resident; -CNA R handed the resident his/her call light and then removed the contaminated gloves, CNA S gathered the trash. CNA S and CNA R washed their hands. CNA R lowered the bed and wheeled out the sit to stand into the hall and to the shower room; -CNA R placed the sit to stand in the shower room and did not clean it. Observation on 08/15/24, at 9:09 A.M., showed CNA T and CNA U in the resident room unhooking the resident's sling from the mechanical lift. The resident sat in the wheelchair. Staff did not have gowns or gloves on. During an interview on 08/15/24, at 10:00 A.M., CNA T said he/she and CNA U had changed the resident in the bed, sat him/her up, and transferred the resident to the wheelchair with the sit to stand mechanical lift. Both CNAs had gown and gloves on during the provision of peri care and had removed the gown and gloves after placing the sling behind the resident and attaching it to the sit to stand lift. During an interview on 08/15/24, at 10:05 A.M., CNA U said he/she and CNA T went into the room and applied gown and gloves and provided peri care for the resident. The CNAs applied the sling, connected the sling to the sit to stand lift, removed their gowns and gloves, rolled the resident to his/her wheelchair, and sat the resident in his/her wheelchair. CNA U and CNA T washed their hands and then washed the resident's face. Observation on 08/15/24, at 11:53 A.M., showed the following: -CNA T entered the resident's room, washed his/her hands, and applied gown and gloves; -The resident sat in his/her wheelchair; -CNA U entered the resident's room and did not perform hand hygiene. The CNA applied gown and gloves; -CNA T placed the sit to stand sling behind the resident and connected it to the sit to stand lift. He/she then raised the resident into a standing position; -CNA T and CNA U rolled the resident in the lift to the bathroom and lowered him/her onto the toilet; -CNA U removed the resident's brief. The brief contained semi formed, yellow stool with mucus and a strong odor; -CNA U unhooked the resident from the sit to stand so brief could be placed. CNA U hooked the resident back to the sit to stand lift. The resident had a bowel movement while sitting on the toilet. CNA U cleansed the resident and pulled up his/her brief; -CNA U removed gown and gloves and helped roll the resident back to his/her wheelchair, then washed his/her hands; -CNA T removed the gown and gloves. The CNA put on new gloves, did not perform hand hygiene, and wiped down the lift with bleach wipes; -CNA U put on new gloves, did not put on a gown, and cleaned loose fecal material off the toilet with bleach wipes; -CNA U gathered the trash and left the room with the bag containing contaminated trash and took it down the hall to the main trash can. During an interview on 08/15/24, at 9:11 A.M., CNA T said the resident was on EBP because he/she had C. diff but they took the resident off because he/she was not having many loose bowel movements. During an interview on 08/15/24, at 10:05 A.M., CNA U said the following: -EBP signs are different from contact isolation signs. Contact isolation signs have a stop sign and say to check with the nurse; -Contact isolation would also have a three-tier drawer system outside of the room; -The resident is on EBP. This would require gown and gloves before providing direct care such as transfers or peri care; -Transfers to wheelchair would count as direct care. During an interview on 08/15/24, at 11:19 A.M., Certified Medical Technician (CMT) V said the following: -The resident was on contact isolation; -There should be a sign on the door for this; -There should be PPE in the hallway and staff should be putting this on before entering the room; -There should be two different trash cans in the resident's room, one for regular trash and one for the biohazard trash. During an interview on 08/15/24, at 2:31 P.M., Licensed Practical Nurse (LPN) W said the following: -The resident generally still has one or two loose bowel movements a day and still currently has C. diff; -Staff should be wearing gown and gloves throughout care with residents on isolation; -The resident is on contact isolation, but can come out of the room, once he/she has a brief on because the bowel movement is contained; -The contact isolation sign is different from the EBP sign and staff should ask the nurse who is on isolation based on the sign on the door directing them too; -When questioned about the difference in the EBP sign versus the contact isolation sign, the LPN realized the resident only had an EBP sign on his/her door. The LPN asked the MDS coordinator what type of isolation the resident was on. The MDS coordinator was unsure also.; -The LPN placed a contact isolation sign on the resident's door; -The isolation supplies are on the back of the resident's door; -The contaminated trash goes straight to the hamper room and should be placed in a biohazard bag. During an interview on 08/15/24, at 2:56 P.M., the Director of Nursing (DON) said the following: -The medical director is aware of the resident having loose bowel movements and C. diff positive status; -The medical director did not feel the resident needed to be on contact isolation as he/she may always have loose bowel movements; -The DON made the decision to place the resident on EBP as a precaution not a requirement. During an interview on 08/16/24, at 11:29 A.M., the facility's Medical Director said several weeks ago, he discussed the situation with the facility staff and determined they could just do universal precautions for the resident's care. Staff should wear gloves and wash their hands. He was not sure if staff should wear gowns or not when providing care for the resident. If handling body fluids, staff should wear gloves. During an interview on 08/16/24, at 12:35 P.M., the DON said gown and gloves would be expected to be put on before care for anyone on EBP and to be worn all throughout care. Hand hygiene should be performed when finished. During an interview on 08/16/24, at 1:30 P.M., MDS Coordinator X said the resident's care plan should reflect that the resident is on EBP not contact isolation. During an interview on 08/16/24, at 1:46 P.M., the Administrator said he would expect staff to update care plans as needed. 2. Review of Resident # 67's face sheet (brief resident profile sheet) showed the following information: -admission date of 06/02/24; -Diagnoses included dementia. Review of the resident's admission MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Dependent on staff for toileting, bathing, dressing, and mobility; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised 07/03/24, showed the following information: -Apply barrier cream after each incontinence; -Assist resident to toilet upon rising, before and after meals, at HS (bedtime), and throughout the night as needed; -Check on resident frequently to ensure he/she is clean and dry; -Provide peri care with each incontinent episode; -One to two staff assistance with toileting. Observation on 08/12/24, at 1:22 P.M., showed the following: -LPN Y and CNA Z enter the resident's room to change the resident; -The LPN and CNA washed their hands and applied gloves. The staff then removed the resident's pants; -The CNA took one wet wipe and wiped down one side of the resident's peri-area, took another wipe and wiped down the other side, and took a third wiped and wiped down the middle of the peri-area; -The staff rolled the resident onto his/her side and the CNA began wiping the resident's bottom with multiple wipes. Bowel movement was visible on the wipes; - The CNA rolled up the soiled brief and removed it and then placed a clean brief under the resident; -The CNA took a wipe and cleaned the resident's perineal area from the front to the back, while continuing to wear the same contaminated gloves (potentially introducing bacteria into the urethal tract); -The CNA removed his/her gloves and took off the resident's glasses, covered the resident up, placed a pillow between his/her legs, lowered the bed, moved resident's wheelchair against the wall and placed the fall mat back down on the floor; -The LPN performed hand hygiene; -The CNA gathered trash and then washed his/her hands. During an interview on 08/15/24, at 9:11 A.M., CNA T said hands should be washed before and after incontinence care, or anytime during care if they become dirty. Staff should wash their hands after removing gloves, after providing care, and before handling personal items. During an interview on 08/15/24, at 10:05 A.M., CNA U said hands should be washed before and after incontinent care or if gloves get contaminated. After providing care, staff should wash their hands before touching personal items. During a interview on 08/15/24, at 2:31 P.M., LPN W said hands should be washed before and after peri care. They should also be washed immediately after peri care and before touching personal items. During an interview on 08/16/24, at 12:35 P.M., the DON said the following: -Hands should be washed before and after peri care; -Gloves are a layer of protection and hands should not have to be immediately washed once gloves are taken off before touching personal items; -If a staff member's hands are not visibly soiled and they did not leave the room after removing the gloves, then they should not have to wash their hands until all care is finished. During an interview on 08/16/24, at 1:46 P.M., the Administrator said when gloves are removed hands should be washed. 3. Review of the facility policy titled Flushing/verifying Placement with a Feeding Tube, undated, showed the following: -Wash hands prior to the procedure according to the facility policy; -Put on clean gloves; -Flush utilizing the 60 milliliter (ml) catheter tip syringe with the prescribed amount of water as ordered, before and after feedings and medications or as directed by the physician; -Wash hands after the procedure. Review of Resident #2's face sheet (brief resident profile sheet), showed the following information: -admission date of 02/23/24; -Diagnoses included other diseases of the pharynx (diseases that affect the throat), protein-calorie malnutrition (a wasting condition resulting from a diet inadequate in either protein or calories or both), and gastrostomy status (tube that is inserted through the stomach wall and into the stomach). Review of the resident's care plan, revised 02/12/24, showed the following information: -Currently receiving Isosource (nutritional supplement) 1.5 percutaneous endoscopic gastrotomy (PEG) tube feedings throughout the day via boluses (method of feeding liquid nutrition through a feeding tube at mealtimes); -Administer feedings and free water flushes as ordered; -Crush medications and administer them via PEG tube. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Independent with ADLs (activities of Daily Living- bathing, dressing, grooming); -Always continent; -Resident has a feeding tube. Review of the resident's Physician's Order Sheet (POS), dated 08/14/24, showed the following: -Nothing by mouth diet (NPO); -Flush PEG tube with water before and after each bolus; -Administer 120 ml before and after each bolus; -Give 240 ml Isosource 1.5 four times a day; -Flush PEG tube with 30 ml of water before and after meds. Observation on 08/13/24, at 9:38 A.M., showed the following: -LPN W sat at the nurses' station and said it was time to administer the resident's tube feeding bolus and medications. He/she walked to the resident's room; -The LPN then entered the resident's bathroom and open the locked bathroom cabinet to remove his/her medications; -The LPN placed each medication into separate cups and took them back to the resident's dresser and crushed each one separately in the plastic bag; -The nurse placed 425 ml of tap water into the graduate container and carried it to the bedside; -The LPN applied gown and gloves, The LPN did not perform hand hygiene; -The LPN diluted all the medications with 30 ml of water; -The LPN connected a 60 ml syringe to the resident's PEG tube and flushed it with approximately 125 ml of tap water; -The nurse administered each medication separately followed with a 30 ml flush that was poured directly into the syringe; -Once the LPN gave the last medication, the LPN administered the 240 ml feeding bolus. -When the LPN completed the bolus he/she flushed the tube with the remaining water, which was approximately 60 ml; -The LPN removed his/her PPE and performed hand hygiene. During an interview on 08/15/24, at 2:31 P.M., LPN W said staff should wash their hands before and after medications and tube feeding boluses. During an interview on 08/16/24, at 12:35 P.M., the DON said staff should be washing their hands before doing anything with a feeding tube. 4. Review of the facility's policy titled Glucometer Sampling Policy and Procedure, dated 01/01/24, showed the following information: -Wash hands, explain procedure, apply gloves, and clean glucometer with sani-wipe. Allow glucometer to air dry. Remove and discard gloves and sani-wipe. Provide a clean surface for glucometer and supplies; -Apply gloves, wipe area to be lanced with an alcohol wipe, and allow to dry; -Obtain blood sample, apply blood sample to glucometer according to direction specific to glucometer used, and discard lancet in the sharps container; -Read glucometer, clean glucometer with sani-wipe and allow to dry, remove gloves, and place gloves and sani-wipe in an appropriate receptacle; -Wash hands and record glucometer reading. Review of Resident #22's face sheet showed the following information: -admission date of 07/17/24; -Diagnoses included type II diabetes. Review of the resident's admission MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Received insulin injections seven days a week. Review of the resident's care plan, revised on 08/16/24, showed the following information: -Educate regarding medications and importance of compliance; -Administer diabetic medication as ordered by doctor, monitor, and document side effects and effectiveness. Review of the resident's POS, dated 08/01/24 through 08/31/24, showed the following: -A current order for insulin lispro (rapid acting insulin) subcutaneous (under the skin) solution 100 unit/ml (milliliter), inject as per the following sliding scale subcutaneously before meals and at bedtime: -If blood sugar is 131 milligrams/deciliter (mg/dL) to 180 mg/dL, administer 4 units of insulin; -If blood sugar is 181 mg/dL to 240 mg/dL, administer 8 units of insulin; -If blood sugar is 241 mg/dL to 300 mg/dL, administer 10 units of insulin; -If blood sugar is 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -If blood sugar is 351 mg/dL to 400 mg/dL, administer 16 units of insulin; -If blood sugar is 401 mg/dL to 500 mg/dL, administer 30 units of insulin; -If blood sugar is 501 mg/dL or greater, contact physician. Observation on 08/13/24, at 8:52 A.M., showed the following: -LPN K previously obtained another resident's blood sugar. He/she sanitized his/her hands and donned gloves. While donning gloves, he/she dropped one glove onto the ground in the hallway. -LPN K picked up the glove and placed it onto the clean box of gloves. LPN K doffed gloves, sanitized hands, donned new gloves, and obtained the resident's blood sugar with a result of 291 mg/dL. LPN K said the resident would be receiving 10 units of insulin. -Upon exiting the resident's room, LPN K disposed of lancet and glucose strip and placed the used glucometer on top of the glove box that was on the medication cart. -LPN K doffed gloves, sanitized hands, donned new gloves, and retrieved the used glucometer from on top of the glove box, wrapped it inside of a Sani-wipe (without wiping it down), and sat it onto the medication cart. -LPN K obtained the resident's insulin pen, attached needle, primed needle with 2 units of insulin, and dialed the dose to 10 units. -LPN K administered insulin to the resident in the left lower quadrant. LPN K exited the resident's room, doffed gloves, and disposed of needle and trash. During an interview on 08/16/24, at 9:38 A.M., LPN J said glucometers should be disinfected before and after every use. Staff must wipe the down the glucometer with a Sani-cloth, dispose of the Sani-wipe, and then let the glucometer dry on a clean barrier prior to the next use. He/she said it would not be acceptable to lay the glucometer down on the cart after obtaining a blood sample. That would be considered cross contamination or an infection control issue. Staff should immediately disinfect the glucometer. He/she said it would not be appropriate to drop something on the floor and place it somewhere for continued use. The dropped item should be thrown away and should not touch other clean items. During an interview on 08/16/24, at 11:28 A.M., RN M said he/she expects glucometers to be disinfected by wiping it down with a Sani-wipe, wrap the glucometer in the wipe for two minutes, then dispose of the wipe. It should be allowed to air dry before use. He/she said it would not be acceptable to lay the glucometer down onto the medication cart, after use and prior to disinfection. It was not acceptable to drop something onto the floor and then place it somewhere for continued use. The dropped item should be thrown away and should not touch other clean items. During an interview on 08/16/24, at 12:35 P.M., the DON and Assistant Director of Nursing (ADON) said glucometers must be disinfected between each use. The DON said staff are expected to take Sani-wipe, wipe the glucometer, then take another Sani-wipe and wrap it around the glucometer for two minutes before each use. The DON was not sure if the glucometer needed to dry to be considered disinfected. The ADON said there was a dry time and the glucometer should be allowed to air dry prior to use. Both ADON and DON said it was not acceptable to pick up an item off the floor and place it somewhere for continued use. The dropped item should be thrown away and should not touch other clean items. During an interview on 08/16/24, at 1:46 P.M., the Administrator said he expected staff to follow policy regarding glucometer disinfection. It is not acceptable to pick up dirty item off the floor and put back with the clean items. The dirty item should be thrown away.

Based on observation, interview, and record review, the facility failed to keep all food safe from potential contamination at all times when staff failed to where hairnets properly while in working in the facilities kitchens. The facility census was 99. Review of the facility's policy titled Dietary Employee Personal Hygiene, dated 01/01/24, showed the following information: -The purpose was to prevent contamination of food by food service employees; -All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food; -Head coverings must be clean. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following: -Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. -A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and lines; and unwrapped single-service and singled-use articles. 1. Observation on 08/14/24, at 1:38 P.M., showed Homemaker Q walked through the kitchen. He/she was not wearing a hairnet and his/her hair hung below his/her shoulders. Observation and interview on 08/14/24, at 1:44 P.M., with [NAME] D showed the following: -Baker D was in the kitchen with out a hair or beard net. He/she then walked over next to the kitchen door, put on the beard net over his/her facial hair, but did not put on a hair net covering his/her hair on his/her head; -He/she said hairnets should be put on when entering the kitchen, but he/she had forgotten to do so today. Observation on 08/16/24, at 12:24 P.M., in the Redbud neighborhood, Homemaker D wore a hairnet, but failed to ensure all his/her hair was secured. The hairnet was not covering his/her long hair pieces on the front, sides, or back. During an interview on 08/16/24, at 12:24 P.M., Homemaker D said the following: -Everyone who does anything with food should be wearing a hairnet; -He/she knows that his/her hair won't stay in very well; -He/she only the roots of the hair must be covered and it is okay for the loose hairs to be outside of the hairnet. Observation on 08/16/24, at 12:30 P.M., in the Dogwood neighborhood, showed Homemaker F wore a hairnet that did not secure his/her hair. His/her hair came out from under the hair net. During an interview on 08/16/24, at 12:24 P.M., Homemaker F said the following: -He/she said everyone should be wearing hair nets; -He/she does wear hairnets as staff are supposed to be doing, but they do not stay on well. During an interview on 08/16/24, at 1:05 P.M., Homemaker G said hairnets and any face covering should be covering all hair and worn anytime working in the kitchen or around food. During an interview on 08/14/24, at 1:40 P.M., Chef C said everyone working in the kitchen is required to wear a net, covering all hair. During an interview on 08/14/24, at 1:45 P.M., the Dietary Manager, said he/she expects anyone working behind the kitchen doors to have a hair net covering all hair. During an interview on 08/16/24, at 2:50 P.M., the Administrator said any staff working in the kitchen is expected to be wearing a hairnet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a sanitary environment for all residents and staff when staff failed to ensure ceiling vents, light covers, walls, and non-contact food surfaces were clean. The facility census was 99. Review of the facility's policy titled Standard Operating Procedure, Cleanliness and Sanitation of the Dining Room, dated 01/01/24, showed staff to routinely clean all areas of the dining room, including equipment such as service refrigerators, etc. Review of the facility's policy titled Equipment Cleaning and Sanitizing, dated 01/01/24, showed the following: -Equipment is washed, rinsed and sanitized after each use to ensure the safety of food served to residents; -Employees who use equipment will be responsible for washing and sanitizing after each use; -The food service manager will conduct a visual inspection of all equipment to be certain that it is being cleaned properly. 1. Observation on 08/12/24, at 8:52 A.M., ice machine in the main kitchen showed the following: -Dark smear marks across the front of the ice machine; -Lime build-up, about ½ inch in length, on the rubber lining where the door closes. Observation on 08/12/24, at approximately 9:00 A.M., of the kitchen in the Chestnut neighborhood showed the following: -The ceiling vent, over ice machine station, was dirty with a fuzzy lint that visibly moved when the air was on; -The light fixture above the ice machine had a multiple dead bugs inside; -The front of freezer was dirty with splatter stains and smear marks. Observation on 08/16/24, at approximately 12:35 P.M., of the kitchen in the Chestnut neighborhood showed the following: -The light fixture over sink had several dead bugs inside; -The ceiling vent remained dirty; The front of the freezer remained dirty. Observation on 08/12/24, at approximately 9:10 A.M., of the kitchen in [NAME] neighborhood showed the following: -The ceiling vent, over ice machine station, was dirty with a fuzzy lint that visibly moved when the air was on; -The front of the refrigerator was dirty; -The front of the freezer was dirty with dark smear marks and food splatters. Observation on 08/16/24, at approximately 12:45 P.M., of the kitchen in [NAME] neighborhood showed the following: -The front of the refrigerator remained dirty; -The ceiling vent remained dirty; -The front of the freezer remained dirty. Observation on 08/12/24, at approximately 9:20 A.M., of the kitchen in [NAME] neighborhood showed the following: -The ceiling vent, over ice machine station, was dirty with a fuzzy lint that visibly moved when the air was on; -The ice machine had brown smear marks on the right side; -The wall behind ice machine and near the ceiling was dirty and had cobwebs present; -The light over sink had dead bugs laying in the light fixture; -The front of the freezer was dirty with food platters. Observation on 08/16/24, at approximately 12:55 P.M., of the kitchen in [NAME] neighborhood showed the following: -The ceiling vent, over ice machine station, remained dirty; -The ice machine remained dirty; -Cobwebs remained on the wall behind ice machine; -The light over the sink had dead bugs present in the light fixture; -The front of freezer remained dirty. Observation on 08/12/24, at approximately 9:40 A.M., of the kitchen in the Redbud neighborhood showed the following: -The ceiling vent, over ice machine station, was dirty with a fuzzy lint that visibly moved when the air was on; -The front of freezer had splatter stains and smear marks. Observation on 8/16/24, at approximately 12:15 P.M., of the kitchen in the Redbud neighborhood showed the following: -The ceiling vent remained dirty with lint; -The dishwasher remained dirty with splatter stains and smears. Observation on 08/12/24, at 9:50 P.M., of the kitchen in the Dogwood neighborhood showed the following: -Cobwebs present on the back wall, near the ceiling; -The front of freezer was dirty with splatter stains and smear marks. Observation on 08/16/24, at approximately 12:25 P.M., of the kitchen in the Dogwood neighborhood showed the following: -Cobwebs remained on the back wall; -The front of freezer remained dirty with splatter stains and smear marks. During an interview on 08/16/24, at approximately 12:20 P.M., Homemaker D said he/she used to use a checklist to clean everything, but now he/she just knows what to do and does it on his/her own. During an interview on 08/16/24, at approximately 12:30 P.M., Homemaker E said the following: -He/she used to use a list for all cleaning chores, but now just knows what to do; -He/she is not sure who is responsible for cleaning the ceiling vents and/or walls behind the ice machine; -He/she is the one who does the wiping down of all the appliances and counters. During an interview on 08/16/24, at approximately 12:40 P.M., Homemaker F said it was the homemaker's job to do the cleaning in the kitchen/dining room areas. He/she did the cleaning of these areas and tried to get them looking good, but there are quite a few stains. During an interview on 08/16/24, at approximately 12:50 P.M., Homemaker G said the following: -He/she knew from when they went through training and did their orientation how to clean the kitchen area; -He/she made sure to clean the kitchen/dining area following each meal; -Maintenance or housekeeping will do the cleaning of the walls behind the sink and the ceiling vents. During an interview on 08/16/24, at approximately 1:00 P.M., Homemaker H said the following: -He/she did all the cleaning of the kitchen and dining room area; -He/she thought maintenance or housekeeping did the ceiling vents, but he/she was not sure; -He/she was taught what to do when he/she was trained as a new employee. During an interview on 08/16/24, at approximately 2:00 P.M., the Dietary Manager said the following: -The homemakers are expected to keep all of their kitchens and serve-out areas clean and well sanitized; -Each homemaker had been trained through orientation and follow-up in-services regarding how to keep the kitchens in clean, working order; -There would be no reason for ice machines or the surfaces of any appliances, such as freezers or refrigerators, to be dirty; -The homemakers would be responsible for all surface areas in the kitchen where they are able to reach; -Maintenance would be responsible for the ceiling vents and light fixtures. During an interview on 08/16/24, at approximately 2:50 P.M., the Administrator said the following: -It is the housekeeping department that is responsible for cleaning the walls behind the ice machine and the ceiling vents; -The homemakers should be cleaning most of the kitchen and serve-out areas. FACILITY

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of possible physical abuse made my one resident (Resident #1) out of seven sampled residents. The facility census was 97. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 01/01/23, showed the following: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes; -Reporting timeframes: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 06/02/23; -Diagnoses included dementia, delusional disorder, depression, and anxiety. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/23/23, showed the following: -The resident had severe cognitive impairment; -The resident had no behaviors or delusions; -The resident required maximum assistance from staff for oral hygiene, toilet hygiene, showering and upper body dressing and was dependent on staff for lower body dressing, putting on and taking off footwear and personal hygiene; -The resident required maximum assistance from staff for bed mobility, transfers and locomotion and used a wheelchair for locomotion. Review of the resident's current care plan showed the following: -He/she was resistive to care related to adjustment to a nursing home, anxiety and dementia. If he/she resisted activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting), please reassure him/her that he/she was okay, leave and return five to ten minutes later and try again. -Provide consistencies with his/her cares to promote comfort with ADLs. Please maintain consistency in timing of ADLs, caregivers and routine as much as possible. Review of the resident's nurse's progress note dated 03/07/24, at 9:59 A.M., showed, in part, the following: -The resident was having behaviors this morning with care staff. The resident was oriented to task at hand, agreeable at first, then changed his/her mind and began yelling and screaming at staff. He/she did get physically combative, but a family friend was able to re-direct him/her after all staff were out of the immediate reach of the resident; -The resident has had increasing frequency of behaviors, increase in delusions, and made accusations against staff for trespassing, stealing his/her clothes and purse, taking his/her car keys and pinching him/her on purpose; -Investigation performed with these reports and the resident was accounted for by multiple staff members and often times by this RN as the resident stays in the living room outside of this RN's office door and is in direct line of sight or sound; -Verified locations of alleged stolen items, which are all accounted for by the family member. Review of the facility's investigation, dated 03/07/24, showed the following: -On 03/07/24, at approximately 9:59 A.M., the resident was in the living room, in line of sight by Registered Nurse (RN) A, and stated that staff were trespassing on her property, stealing her clothes, taking her car keys, and pinching him/her on purpose. The RN immediately reported the resident's statements to Administrator; -The resident is noted per physician and staff documentation to have issues with anxiety, hallucinations, and intermittent confusion. The skin assessment completed on 03/07/24 and 03/09/24 showed no signs of pinching while the family member disproved the stolen items; -Within two hours of RN A notifying the Administrator, the Interdisciplinary Team (IDT) concluded that there was no abuse, neglect, or exploitation. Through interviewing staff, residents, family, and physician, it was determined that the root cause of the incident was hallucinations. During an interview on 05/14/24, at 1:18 P.M., RN A said the following: -On 03/07/24, the resident reported staff putting water down his/her throat during a shower, misappropriation, and staff pinching him/her on purpose. The resident alleged trespassing, stealing, and physical abuse; -All allegations of abuse should be reported; -The resident's allegation of abuse should have been reported to DHSS within two hours. During an interview on 05/14/24, at 10:59 A.M., Licensed Practical Nurse (LPN) C said the following: -If a resident reported abuse to a certified nursing assistant (CNA) or certified medication technician (CMT), they ensured the resident was safe and then reported to the charge nurse immediately. The charge nurse notified the Administrator immediately and the Administrator reported to DHSS immediately. During an interview on 05/14/24, at 11:16 A.M., CNA E said the following: -If a resident reported abuse to him/her, he/she reported this to the charge nurse immediately; -Administration reported to DHSS immediately. During an interview on 05/14/24, at 12:10 P.M., RN B said the following: -If a resident reported abuse, he/she got the resident to safety and then immediately reported to the Director of Nursing (DON) or Administrator; -The DON or Administrator reported to DHSS within two hours. During an interview on 05/14/24, at 12:15 P.M., CMT D said the following: -If a resident reported abuse to him/her, he/she made sure the resident was safe and then immediately reported to the charge nurse; -The Administration reported to DHSS within two hours. During an interview of 05/14/24, at 1:09 P.M., CNA F said the following: -If a resident reported abuse to him/her, he/she made sure the resident was safe and reported to the charge nurse immediately; -The DON reported to DHSS within two hours. During an interview on 05/14/24, at 1:55 P.M., the DON said the following: -The resident's allegation of staff intentionally pinching the resident was reported to the Administrator; -Types of abuse included physical, emotional, exploitation and verbal; -If a resident reported abuse to a CNA, they reported to the charge nurse. The charge nurse reported to her and the Administrator; -The Administrator and DON completed an investigation and if they did not find the allegation of abuse happened, they did not report to DHSS; -Only suspected allegations of abuse, neglect, or exploitation needed reported to DHSS within two hours and this depended on if the resident was confused or delusional. During an interview on 05/14/24, at 2:19 P.M., the Administrator said the following: -RN A reported the resident's allegations to him; -The RN completed an investigation and skin assessment and notified the physician and resident's responsible party. The RN also got the psychologist involved in the resident's care and the physician adjusted the resident's medications due to the resident's hallucinations; -He did not report the allegation to DHSS because the RN investigated and found the allegation unsubstantiated so there was no suspected abuse, neglect, or exploitation of the resident; -If a resident reported abuse to staff, staff reported this to him. He had two hours to come to a conclusion on reporting the allegation; -If he could disprove the allegation within the two hours, he did not have to report to DHSS. MO00235926

Based on record review and interview, the facility failed to keep all residents free from misappropriation when one staff member (Certified Nurse Aide (CNA) A) asked for and then took money from one resident (Resident #1). The facility census 99. On 03/20/24, at approximately 9:45 A.M., the Administrator was notified of the Past Non-Compliance that occurred on 01/24/24. The Administrator immediately started an investigation, notified DHSS by self-report on 03/20/24, at 12:29 P.M., and notified the police on 03/20/24, at 11:47 A.M. All facility staff were notified of required training and completed the computer misappropriation training 03/20/24. CNA A was terminated on 03/20/24 due to not following the facility's policy. The facility implemented continued abuse and neglect training at orientation and quarterly. The staff development nurse will randomly review abuse and neglect competencies with staff on varying shifts. The Administrator or designee will review monthly for the next 90 days and the results will be reviewed in the monthly QAPI (quality assurance performance improvement) meeting. The noncompliance was corrected on 03/20/24. Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation Prevention Program, revised 04/2021, showed the following: -The facility has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation or misappropriation of property by any perpetrator including, but not exclusive to any staff member or volunteer of the facility or any contracted agency staff, vendors, family member or visitors of a resident or other residents, or any other resident; -Each resident has the right to be free from all types of abuse; -Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion; -Mistreatment means inappropriate treatment or exploitation of a resident; -Reasonable person concept is the psychosocial combined influences or psychological factors of social environment, physical, emotional and or mental wellness effects on a reasonable person if in the resident's position. Review of the facility's Senior Living Handbook, dated October 2020, showed the following: -Steer clear of conflicts of interest. -Playing favorites or having conflicts of interest (in practice or in appearance) are activities which run counter to the fair treatment to which we are all entitled. Employees and affiliates must avoid any relationship, influence, or situation that might impair, or appear to impair, abilities to make objective and fair decisions when meeting their responsibilities. Employees must fully disclose the facts of any questionable situation to their supervisor of the Chief Compliance Officer; -Some examples of potential conflict of interest might include, acceptance of payment or service from customers or vendors; -Avoid illegal or questionable gifts or favors; -As long as the interaction does not violate a policy of the recipient's organization, it is an acceptable practice to provide meals, refreshment, entertainment and continuing professional education seminars and materials of reasonable value in conjunction with business and professional discussions with non-governmental personnel. The acceptance of gifts greater that $25.00 or less from customers, potential customers or vendors is prohibited unless specifically coordinated by the [NAME] President of Human Resources. Federal, state, and local government departments and agencies are governed by laws and regulations concerning acceptance by their employees or entertainment, meals, gifts, gratuities, and other things of value from firms and persons with whom these departments and agencies have business relations or over whom they have regulatory authority. 1. Review of Resident #1's face sheet (a snapshot of resident information) showed the following: -admission date of 04/18/07; -Diagnoses included congestive heart failure (CHF - complex clinical syndrome characterized by inefficient myocardial performance, resulting in compromised blood supply to the body), pneumonia, quadriplegia C5-C7 (paralysis of all four limbs), and chronic pain; -Responsible for self. Review of the resident's care plan, dated 11/07/22, showed the following: -The resident had behaviors and fixations on his/her medical issues and tended to elaborate on incidences, mislead occurrences, decline to follow physicians orders and recommendations, and attempt to manipulate staff to get what he/she wants; -The resident will have his/her needs anticipated and met over the review period; -Be patient with the resident. It is difficult not to be able to walk and do everyday things him/herself, health is what he/she can control; -Educate caregivers on successful coping and interaction strategies; -Explain all procedures to him/her before starting and allow him/her time to adjust to change; -Explain/reinforce why behavior is inappropriate and /or unacceptable. -The resident wants to live at the facility with pride, dignity, and independence to their fullest potential; -The resident wants to be treated with the same dignity that they would be treated in their own home; -The resident has some cognitive decline and may need extra help at times. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/11/24, showed the following: -Resident is cognitively intact; -Resident had exhibited no behaviors in the assessment period; -Resident requires maximal/substantial assistance for sit to stand transfers. Review of the facility's investigation, dated 03/20/24, showed the following: -On 03/20/24, at approximately 9:45 A.M., the resident met with the Administrator in regard to a gift that he/she had given to CNA A on 01/24/24. Per policy, the Administrator notified the Regional Operations Director and Regional Nurse Consultant. An investigation regarding the incident was started immediately and a message was left with the Department of Health and Senior Services (DHSS) at approximately 11:00 A.M. to determine if this was a reportable incident. The accused employee was suspended pending the results of the investigation; -The resident provided a signed check from him/her to CNA A, dated 01/24/24 for $2,000; -The resident said CNA A accidentally merged the resident into a phone call. During the phone the resident heard CNA A say the resident was obsessed with him/her; -The resident came forward at this time so CNA A could not direct this into a scenario where the resident was trying to buy his/her love; -The resident said the money was to help with the CNA's child's surgery. CNA A would bring his/her child in when he/she worked during the weekend to see the resident; -CNA A said the resident gave him/her the check to cash and give to one of his/her friends. CNA A could not produce any witnesses or receipts. The resident tried to kiss him/her and this is what caused him/her to come forward; -CNA A violated the facility's Code of business Conduct and Ethics section 9. The acceptance of gifts greater that $25.00 or less from customers. During an interview on 04/11/24, at 10:20 A.M., the resident said the following: -On about the third week of January 2024, CNA A told the resident that his/her child needed a surgery. CNA brought his/her child into the facility and showed him/her the child to show that he/she needed the surgery; -CNA A asked him/her for $500 dollars to pay for the surgery and he/she said okay. CNA A then asked for $2,000 to pay for his/her daughter's surgery; -CNA A wrote out the check and he/she signed it; -In late March 2024, CNA A called him/her on his/her cell phone. He/she then got another call and thought he/she hung up on the resident. CNA A had actually made it a three way call. CNA A said the resident was infatuated with him/her and that the resident would not leave her alone. He/she called him back and became defensive and emotional when the resident confronted him/her about it and told him/her he/she would not give him/her anymore money. He/she felt like the way he/she talked about him/her was inappropriate and unprofessional; -He/she reported to Registered Nurse (RN) B about the incident. He/she felt like he/she should tell the Administrator about giving CNA A the money. Observations on 04/11/24, at 1:51 P.M., showed the resident pulled up the deposited check to CNA A, dated 01/24/24 for $2,000 dollars, on his/her computer. During an interview on 04/11/24, at 10:45 A.M., CNA C said it is not appropriate to ask a resident for money and it is not appropriate to take money from a resident. During an interview on 04/18/24, at 11:24 A.M., CNA E said the following: -He/she was aware that CNA A and the resident would call each other on their cell phones. He/she did not feel this was really appropriate; -It is not ever appropriate to ask a resident for money. They are dependent on staff for care and that seems really wrong and could be manipulative. A staff member should not take money from a resident. During an interview on 04/11/24, at 10:48 A.M., Licensed Practical Nurse (LPN) D said he/she had been educated about misappropriation many times by the facility with the last education being in March. It is not appropriate to take money from a resident and is considered misappropriation. During an interview on 04/11/24, at 2:59 P.M., RN C said the following: -On 03/19/24, at around 8:30 P.M., the resident told him/her that he/she had given money to someone that he/she was trying to help out. The resident did not say how much money; -He/she knows it is not appropriate for staff to accept money from residents or to ask for money from residents; -He/she told him he/she had to report it to the Director of Nursing (DON) and Administrator and he/she did so; -The resident also told him/her about a merged phone call where the resident heard CNA A say the resident was obsessed with him/her and the resident and CNA A had gotten into an argument; -He/she did not feel like it was appropriate for a CNA to have the resident's personal cell phone number. During an interview on 04/18/24, at 11:09 P.M., the Social Services Director (SSD) said it is not appropriate to take money from a resident. It could be misappropriation due to it being a conflict of interest. Staff should not ask a resident for money. During an interview on 04/11/24, at 2:07 P.M., the DON said the following: -It is not appropriate to take money from a resident or to ask a resident for money. He/she was not aware of the CNA taking any money from the resident until he/she reported it in March; -The staff should be professional and residents should not be aware of what is going on in their personal lives; -CNA A initially said he/she was giving the money to someone else for the resident, but then admitted to cashing the $2,000.00 check from the resident which was against policy. During an interview on 04/18/24, at 2:25 P.M., the Administrator and DON said the following: -It is not appropriate for a staff member to ever ask a resident for money; -It is against policy for a staff member to accept a gift of money more than $25. MO00233487

Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff pulled the incorrect medication from the stat safe (electronic emergency/stat-dose cabinet. The stat safe is electronically locked and medication is removed from drawers) for one resident (Resident #1) resulting in the resident receiving the incorrect medication for five days. The facility census was 77. The Administrator was notified on 11/09/2022 of the Past Non-Compliance which occurred on 11/4/2022 through 11/8/2022. Facility staff started an investigation, n-serviced licensed staff who were involved in medication pulls from the stat safe and medication administration. Staff completed an audit of all resident medication cabinets potentially affected during this period of time and were finished on 11/11/2022. The noncompliance was corrected on 11/11/2022. Record review of a facility's document titled Medication Administration, copyright 2022, showed the following: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review Medication Administration Record (MAR) to identify medication to be administered; -Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time; -Administer medication as ordered in accordance with manufacturer specifications. Provide appropriate amount of fluid; -Observe resident consumption of medication; -Sign MAR after administration. -Report and document any adverse side effects or refusals; -Correct any discrepancies and report to nurse manager. Record review of a facility's document titled Medication Errors, copyright 2022, showed the following: -It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring resident receive care and services safely in an environment free of significant medication errors; -The facility shall ensure medication will be administered according to physician orders; per manufacturer's specifications regarding the preparation and administration of the drug or biologic; and in accordance with accepted standards and principles which apply to professionals providing services; -Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines; -Resident's condition: if the resident's condition requires rigid control, such as monitoring of lab values; -Drug category: if the medication is from a category that usually requires the resident to be titrated to a specific blood level with a narrow therapeutic index (NTI); -Frequency of Error: If an error is occurring repeatedly such as an omission of a resident's medication several times; -The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: -Incorrect dose, route of administration, dosage form, time of administration; -Medication omission; -Incorrect medication; -Medication administration observation will be conducted periodically to evaluate facility medication administration practices; -To prevent medication errors and ensure safe medication administration, nurses should verify the following information: -Right medication, dose, route, and time of administration; -Right resident and right documentation; -If a medication error occurs, the following procedure will be initiated: -The nurse assesses and examines the resident's condition and notified the physician as soon as possible; -Monitor and document the resident's condition, including response to medical treatment or nursing interventions; -Document actions taken in the medical record; -Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. Record review of the Ropinirole (medication used to treat restless legs syndrome (RLS - unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them) Package insert/prescribing information, updated 09/01/2022, showed the following information: -Ropinirole tablets are indicated for the treatment of Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement); -Ropinirole tablets are indicated for the treatment of moderate-to-severe primary RLS; -The recommended starting dose of Ropinirole for Parkinson's disease is 0.25 mg (milligram) three times daily; -The recommended starting dose for RLS is 0.25 mg daily one to three hours before bedtime. - Ropinirole is contraindicated in patients known to have a allergic reaction (including urticaria (hives), angioedema (facial swelling), rash, pruritus (itching)) to Ropinirole; - Advise patients that they may experience syncope (fainting), and may develop hypotension (low blood pressure) with or without symptoms such as dizziness, nausea, syncope, and sometimes sweating while taking Ropinirole tablets, especially if they are elderly; -Inform patients that they may experience hallucinations (unreal visions, sounds, or sensations), and that other psychotic-like behavior can occur while taking Ropinirole tablets. Record review of Risperidone (an atypical antipsychotic used to treat schizophrenia (serious mental disorder in which people interpret reality abnormally) and bipolar disorder (mental condition marked by alternating periods of elation and depression) package insert/prescribing information, updated 01/01/2022, showed the following: - Risperidone tablets are indicated for the treatment of schizophrenia; - Risperidone tablets are indicated for the treatment of acute manic or mixed episodes associated with bipolar disorder; -Off-label used to treat behavioral and psychological symptoms of dementia; -Risperidone is not addictive, but stopping it suddenly can cause problems such as difficulty sleeping, feeling or being sick, sweating, and uncontrollable muscle movements. 1. Record review of Resident #1's face sheet (brief resident information sheet) showed the following information: -admission date of 7/20/2022; -Diagnosis included intracranial injury (brain injury usually caused by an outside force, such as a violent blow to the head) with loss of consciousness, altered mental status (changes in cognition, mood, behavior), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood), dysphagia (sensation of difficulty or abnormality of swallowing ) oropharyngeal phase (difficulty initiating a swallow), and Parkinson's disease. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 10/22/2022, showed the following: -Severe cognitive impairment; -Diagnosis included dementia, bipolar disorder, Parkinson's disease, heart failure, Traumatic brain injury, and seizure (sudden, uncontrolled electrical disturbance in the brain) disorder; -Required extensive assistance of one staff for transfers, mobility, personal hygiene, toileting, eating, and bed mobility. Record review of the resident's current physician's orders showed the following information: -An order, dated 10/26/2022, for Risperidone tablet 0.5 milligram (mg), give 3 tablets by mouth at bedtime related to dementia with behavioral disturbance. Record review of the resident's November 2022 MAR showed the following: -An order, dated 10/26/2022, for Risperidone tablet 0.5 mg, give 3 tablets by mouth at bedtime related to dementia with behavioral disturbance to equal 1.5 mg; -Staff documented the resident received the medication every night at bedtime. Record review of the resident's medical record showed staff did not document information related to a medication administration error. Record review of the facility's undated Medication Error Notice, sent to the physician, showed the following information: -Resident order for Risperdal 1.5 mg (3 tablets of 0.5 mg = 1.5 mg) at bedtime had been ordered since 10/26/2022; -Certified Medication Technician (CMT) A was working on 11/4/2022 and went to the stat safe and pulled Ropinirole 1.0 mg and Ropinirole 0.5 mg at this time; -CMT worked on the resident's hall from 11/4/2022 through 11/8/2022, in which he/she administered Ropinirole 1.5 mg at bedtime each night; -On 11/9/2022, CMT B found the medication in the resident's cabinet and pulled this medication out of the cabinet and reported to the charge nurse; -Correct medication of Risperdal 1.5 mg was pulled from stat safe and administered correctly; -On 11/9/2022, staff notified the physician; -The Director of Nursing (DON) notified the resident's responsible party of the medication error; -After reviewing information, it appears medication was pulled due to sound alike medications. Record review of the facility's Medication Error Report, dated 11/9/2022, showed the following: -Date of error 11/4/2022; -Date physician notified 11/9/2022; -Medication ordered Risperidone 0.5 mg, take 3 tablets by mouth at bedtime; -Description of error: Nurse and CMT pulled Ropinerole 1 mg tablet and Ropinerole 0.5 mg tablet; -Ropinirole administered 11/4/2022 through 11/8/2022; -Another CMT noticed the wrong medication cards; -Outcome to the resident: Resident had increased combativeness, agitation, and more difficult to re-direct. During an interview on 11/22/2022, at 12:35 P.M., Registered Nurse (RN) E (who was involved in the medication error) said that staff should review physician orders and verify the drug and dose prior to administering medications to residents. He/she said that the stat safe required two staff to access and pull medication cards. He she said that if a medication error occurred the staff should notify the charge nurse, DON, Assitant Director of Nursing (ADON), physician, resident family, and nurses should monitor the resident closely for side effects. He/she said there had been a recent medication error that was related to a labeling error. During an interview on 11/22/2022, at 10:45 A.M., the resident's family member said the facility notified him/her that the resident had become more agitated and combative with staff and the facility advised they would look for another facility that would take the resident. The facility then called later that day and said that the resident had received incorrect medications for five nights and that he/she would be able to stay at the facility. During an interview on 11/22/2022, at 11:00 A.M., CMT C said that staff are trained to check the medication and the physician orders three times for right resident, right medication, right time, and right dose prior to administering medications. Any medication errors should be reported to the charge nurse. During an interview on 11/22/2022, at 11:10 A.M., Licensed Practical Nurse (LPN) D said that staff should check the medication card and drug name against the physician orders and ensure they are providing the medication correctly to the right resident. If a medication error was made or discovered, the staff should notify the DON or nurse in charge. There was a recent error discovered that a staff member had pulled Ropinirole instead of Risperidone. The medication cards pulled from the stat safe have a label that includes the medication name and dosage, but it does not include the resident name or physician orders for that resident. He/she said that staff should always double check the information with the physician orders. During an interview on 11/22/2022, at 12:50 P.M., CMT F said that he/she was trained to check medication orders in the computer and the medication card three times before administering any medication to a resident. The stat safe requires two staff members to log in with finger prints to check out medications that were not available from the pharmacy yet. Staff should notify the charge nurse if they had any question or concerns related to resident medications. During an interview on 11/22/2022, at 1:20 P.M., with the DON, Assitant Director of Nursing (ADON), and Administration, the DON said that staff are to check the MAR for the six rights of medication administration: right resident, right drug, right dose, right time, right route, and right documentation. He/she said that a staff member pulled the wrong medication from the state safe, a sound-alike, spelled-alike medication was pulled. The resident did have some increased behaviors after receiving the incorrect medication. The physician and family were notified of the error and the resident was monitored by nursing staff. MO00209893

Based on observation, interview, and record review, the facility failed to ensure all residents were free from abuse and neglect when one staff member (LPN K ) reviewed to assist one resident (Resident #71) with his/her bowel regimen and when one staff member (LPN K) spoke to one resident (Resident #32) in a harsh manner that included profane language. The facility's total census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -This facility has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation or misappropriation of property by any perpetrator; -All staff will demonstrate familiarity with the signs of abuse, neglect; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or service that are necessary to attain or maintain physical, mental and psychosocial well being. This presumes that instances of abuse of all residents even those in a coma, cause physical harm, or pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse facilitated or enabled through the use the technology. Willful, as used in this definition of abuse, means that the individual must have acted deliberately, not that the individual must have intended to inflict injury of harm; -Neglect means the failure of this facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress; -Mental abuse includes, but is not limited to, treating as a child, humiliation, harassment, and threats of punishment or deprivation. Mental abuse also includes but not limited to facility staff taking or using photographs or recordings in any manner that wound demean or humiliate a resident or residents; -All residents receive protective oversight 24 hours per day. The staff is charged with the responsibility to protect residents from abusive staff members and from other residents who might be acting in an aggressive manner. 1. Record review of Resident #71's face sheet (a general information sheet) showed the following: -admission date of 4/18/07; -Diagnoses included chronic pain, constipation, neurogenic bowel (the inability to control defecation due to a deterioration of or injury to the nervous system, resulting in fecal incontinence or constipation), and quadriplegia (affected by or related to paralysis of all four limbs). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 09/07/22, showed the following information: -Cognitively intact; -Resident required extensive physical assistance of two plus staff for transfers, bed mobility, dressing, personal hygiene, toileting and bathing. Record review of the resident's care plan, last updated 09/15/22, showed the following: -The resident needed extensive assist from one to two caregivers with using the bathroom. The resident used the bathroom in his/her room for bowel movements and needs digital stimulation from a nurse due to spinal cord injury. Resident to do this every evening prior to going to bed in resident's nightly routine. Record review of the resident's current physician's order sheet showed the following: -An order, dated 7/4/2018, for staff to provide a digital stimulation nightly per resident's request, second to paraplegia, at bedtime for regularity. During an interview on 09/27/22, at 1:00 P.M., the resident said the following: -He/she is on a bowel monitoring program that includes getting his/her bowels stimulated so he/she can have a bowel movement or he/she could get impacted; -LPN K refused to assist in his/her bowel program. During an interview on 9/27/22, at 2:49 P.M., Certified Nurse Aide (CNA) I said the following: -The resident is on a bowel monitoring program and has to be set-up and two staff and a nurse will assist. The nurse will digitally stimulate the resident so the resident can have a bowel movement daily; -One day CNA I and another CNA had set-up the shower chair and bedside commode and went to get LPN K. LPN K told CNA I he/she would not provide this care and refused to assist the resident; -CNA I heard LPN K tell the resident he/she would not help him/her. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -CNA I reported to LPN L that LPN K refused to help with the resident's bowel monitoring program; -The resident had an accident during the day and needed help from the staff to do the bowel monitoring program earlier than the usual time in the evening; -LPN L reported this incident to LPN H after he/she got the resident cleaned up and placed back in his/her wheelchair; -All staff should be prepared that if the resident tells you he/she needs help then staff should assist the resident, nurses should be educated. During an interview on 10/03/22, at 2:44 P.M., the Assistant Director of Nursing (ADON) said the following: -The resident was alert and oriented, extensive assistance of staff; -The resident has a bowel program scheduled for the evening shift, evening nurse goes in and does a digital stimulation until the resident feels he/she's had enough of a bowel movement. Usually only once per day at night, the resident goes to bed after the bowel program is completed; -She knew of about three times that he has required digital stimulation during the day if he felt he was constipate; -The aides prepare the resident and nurse provides the digital stimulation. He could potentially get impacted if everyone always refuses to do the care; -The resident knows what is normal for him/her, he/she has been like this for a while; -Staff should address if the resident felt he/she needed further assistance during a day shift. If the resident requested at a different time, that should be done. 2. Record review of Resident #32's facesheet showed the following: -admission date of 1/18/22 ; -Diagnoses included epilepsy (seizure disorder), dysphasia (difficulty in swallowing), stroke, and prostate cancer. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -The resident came to the nursing station door during report and LPN K told the resident to shut the fuck up. LPN K said he/she wanted to give report and go home. LPN K then became nice and asked resident Am I going to have to turn you over my knee and bust your ass, Oh never mind you are a dirty old person and you would like that.; -The resident started crying, tears in his/her eyes. The resident had came to the nurses' station because he/she was having a post traumatic stress disorder (PTSD) melt down; -LPN L took the the resident to his/her room and sat with him/her for about 20 minutes, calming him/her down. During an interview on 09/29/22, at 1:55 P.M., LPN K said the following: -He/she has said she would put the resident over his/her knee and spank him; -He/she said they were joking about something. It has been said more than once. He/she doesn't usually say spank you, she says You don't want me to put you over my knee now do you?; -It is always just innocent banter, always joking. During an interview on 9/28/22, at 2:05 P.M., the resident did not recall the above incident. 3. During an interview on 10/03/22, at 2:44 P.M., the ADON said the following: -Would consider abuse physical (if followed through on the spanking), mental, emotional, verbal cursing. All would fall into emotional abuse; -Refusing to provide care would be considered neglect type situation. Not meeting any resident needs would be considered a neglect. 4. During an interview on 10/03/22, at 3:35 P.M., the Administrator and the Director of Nursing (DON) said the following: -Staff should not curse at residents or tell the resident to get away from them; -Staff should not call resident names; -Staff should never refuse to provide cares to a resident. MO00207614

Based on observation, record review, and interview, the facility failed ensure all residents received supervision and assistance devices to prevent possible elopements when staff failed to check the daily functioning status of one resident's (Resident #42) wanderguard bracelet. The facility had a census of 81. Record review of the facility policy, titled Preventative Action Plan for Wandering/Elopement of Residents, dated April 2020, showed the following: -All residents who enter the facility will have an Elopement Risk Assessment completed at the time of admission; -If the assessment determines the resident to be at risk for exit seeking behavior or attempting an elopement, the facility will begin immediate action to prevent the elopement, such actions included: -Receipt of physician order for a wander guard bracelet if determined by the inter-disciplinary team (IDT - staff members working together, with a common purpose, to set goals, make decisions and share resources and responsibilities); -Resident's care plan updated to reflect the risk for elopement and the approaches to be taken to prevent such; -The facility will maintain a daily log check for proper functioning of the wandering system. This is to include all doors in the facility, which has the wandering system; -The individual designated by the administration of the facility will check this system; -The administrator of the facility is responsible for viewing the log on a weekly basis to ensure this practice is being carried out in the facility; -It is the responsibility of all staff to report the attempts of any resident trying to leave the facility unassisted or without knowledge of the staff. 1. Record review of Resident #42's face sheet showed the following information: -admission date of 1/30/2021; -Diagnoses included myasthenia gravis (condition caused by a breakdown in communication between nerves and muscles resulting in weakness in the arm and leg muscles, double vision, and difficulties with speech and chewing), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), generalized anxiety disorder, and rheumatoid arthritis (chronic inflammatory disorder affecting many joints). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/16/22, showed the following information: -Severe cognitive deficit; -Resident required extensive physical assistance of one staff for personal hygiene and toileting; -Resident required limited physical assistance of one staff for transfers, bed mobility, walking in room, mobility, and dressing. Record review of the resident's quarterly Elopement Risk Assessment, dated 8/24/2022, showed staff documented the resident was at risk for elopement. Record review of the resident's care plan, dated 8/24/2022, showed the following: -Resident may try to leave the facility without supervision and was unsafe to do so; -Staff should provide the resident with structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; -The resident had a wander guard bracelet to the right ankle. Record review of the resident's current physician's order sheet showed the following: -An order, dated 10/26/2021, for staff to ensure the wander guard to the right ankle was on and working properly. Observation of the resident on 9/27/2022, at 10:30 A.M., showed the resident resting in bed with a wander guard located on the resident's left ankle under a sock. Observation of the resident on 9/28/2022, at 11:00 A.M., showed the resident seated in the wheelchair in the main common area with wander guard on the left ankle. Record review of the daily wanderguard monitoring book located at the front desk showed the following: -The resident's name was not located on the current resident list dated 9/27/2022; -The resident's name not written on the daily monitoring check list from 05/14/2022 to 10/02/2022. During an interview on 9/29/2022, at 11:00 A.M., Certified Nurse Aide (CNA) C said the nursing staff check residents that have a wander guard for location and status every hour, this included the resident. During an interview on 9/29/22, at 11:30 A.M., Licensed Practical Nurse (LPN) D said the nursing staff check that residents' wander guards are intact on each shift. This task shows on the resident's treatment administration record (TAR). The concierge staff check the functional status of the wanderguard possibly once per week. Residents with wander guards are also monitored every hour for location and status by nursing staff. During an interview on 10/03/22, at 10:10 A.M., the Concierge Supervisor said that the concierge staff test the main doors, the interior doors with the wanderguard system, and each resident with wander guards every day for proper functioning. He/she said the list currently included five residents. He/she said that the nursing staff had to check out a wanderguard with the concierge staff and at that time the resident's name is placed on the concierge list for daily testing of the system and when the wander guard was removed the nursing staff returned the wanderguard to the front desk to be re-used after sanitization. He/she reviewed the book and said that the resident was last on the daily monitoring list on 5/13/2022. Observation and interview on 10/03/22, at 10:20 A.M., Concierge Staff F said that he/she completed the main resident list that showed which residents currently had wander guard bracelets. He/she said that the nurses come to the front desk to check out the wanderguard and the concierge staff add the resident to the list at that time. He/she said every morning he/she checked that the system was working by obtaining the small box and a wander guard, took the items to the front door and the interior doors that had wander alarms and then went to check each resident on the list. After request, Concierge F entered the resident's room and the resident was resting in bed. The concierge used a box to check the functioning of the wanderguard located on the resident's left ankle. He/she said that he/she was not aware the resident had a wanderguard at this time, as the resident's name was not on the list. He/she knows that in the past the resident had a wander guard. He/she had not checked the resident's wanderguard for several months because the resident's name was not on the list in the binder. He/she was not sure why the resident was not on the list. During an interview on 10/03/22, at 10:32 A.M., LPN D said he/she had a list of residents to check on every hour, this list included the resident, for risk of elopement and the resident had a wanderguard on his/her ankle. He/she said that concierge staff check the functioning of wander guards. He/she did not know if the resident's wander guard had been checked for functioning. During an interview on 10/03/22, at 10:40 A.M., the Director of Nursing (DON) said that staff complete elopement screenings on residents and if found to need a wander guard the nurses go to the front desk to check out a wander guard from the front desk. In order for a wander guard to be removed the nurses have to complete an elopement risk screening and then the staff review at an IDT meeting. If a wander guard can be removed the nursing staff turn the wander guard back in to the front desk. She was unsure where the confusion was and why the resident was not on the list to check that it was functioning. During an interview on 10/03/22, at 1:20 P.M., the Administrator said that the concierge staff check the functioning of the wander guards daily and the nursing staff check that the wander guard is intact each shift. He was made aware that the resident was not on this list to check the functioning status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to management and to the State Survey Agency (Department of Health and Senior Services -DHSS) within two hours of the allegations being made when staff were aware of reports of possible abuse involving four residents (Resident #1, Resident #32, Resident #55, and Resident #71). The facility census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -All staff will demonstrate familiarity with the signs of abuse, neglect. Any such signs of abuse and neglect will be reported to the Administrator and/or Director of Nursing (DON)/designee immediately. The Administrator, DON or designee will notify the State agency and local law enforcement immediately, but no later than 2 hours after allegation; -The facility Administrator or designee is responsible for reporting cases of possible abuse, neglect including involuntary seclusion, and exploitation to external agencies in accordance with state laws and regulatory agencies; -All facility employees and volunteers are educated that all alleged or suspected violations involving mistreatment, neglect, abuse or exploitation including injuries of unknown origin and involuntary seclusion and misappropriation of elder property are reported immediately to the Administrator, DON, or designee. Any report of neglect or abuse made by a resident, family member, visitor or employee will be reported to the State and Local law enforcement immediately, but no later than two hours after allegations is made. 1. Record review of Resident #71's face sheet (a general information sheet) showed the following: -admission date of 4/18/07; -Diagnoses included chronic pain, constipation, neurogenic bowel (the inability to control defecation due to a deterioration of or injury to the nervous system, resulting in fecal incontinence or constipation) and quadriplegia (affected by or related to paralysis of all four limbs). Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Resident required extensive physical assistance of two plus staff for transfers, bed mobility, dressing, personal hygiene, toileting and bathing. Record review of the current physician's order sheet showed the following: -An order, dated 7/4/18, for staff to provide a digital stimulation nightly per residents request second to paraplegia at bedtime for regularity. Record review of the resident's care plan, last updated 09/15/22, showed the following: -The resident needs extensive assist from one to two caregivers with using the bathroom. The resident uses the bathroom in his/her room for bowel movements and needs digital stimulation from a nurse due to my spinal cord injury. During an interview on 09/27/22, at 1:00 P.M., the resident said the following: -He/she is on a bowel monitoring program that includes getting his/her bowels stimulated so he/she can have a bowel movement or he/she could get impacted; -Licensed Practical Nurse (LPN) K refused to assist in his/her bowel program; -The resident has reported this to Certified Nurse Aide (CNA) I and LPN L. During an interview on 9/27/22, at 2:49 P.M., CNA I said the following: -The resident is on a bowel monitoring program and has to be set-up and two staff and a nurse will assist. The nurse will digitally stimulate the resident so the resident can have a bowel movement daily; -One day CNA I and another CNA had set-up the shower chair and bedside commode and went to get LPN K. LPN K told CNA I he/she would not provide this care and refused to assist the resident; -CNA I heard LPN K tell the resident he/she would not help him/her; -CNA I reported this to LPN L. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -CNA I reported to LPN L that LPN K refused to help with the resident's bowel monitoring program; -The resident had an accident during the day and needed help from the staff to do the bowel monitoring program earlier than the usual time in the evening; -LPN L reported this incident to LPN H after he/she got the resident cleaned up and placed back in his/her wheelchair. During an interview on 10/03/22, at 2:44 P.M., the Assistant Director of Nursing (ADON) said the following: -The resident was alert and oriented, extensive assistance of staff; -The resident has a bowel program scheduled for the evening shift, evening nurse goes in and does a digital stimulation until the resident feels he/she's had enough of a bowel movement. Usually only once per day at night, the resident goes to bed after the bowel program is completed; -She knew of about three times that he has required digital stimulation during the day if he felt he was constipate; -The aides prepare the resident and nurse provides the digital stimulation. He could potentially get impacted if everyone always refuses to do the care; -The resident knows what is normal for him/her, he/she has been like this for a while; -Staff should address if the resident felt he/she needed further assistance during a day shift. If the resident requested at a different time, that should be done. Record review of facility records showed the facility did not provide documentation staff reporting the allegation of possible abuse/neglect of the resident to DHSS with in two hours after staff became aware of the allegation. Record review of DHSS records showed no self-report regarding the allegation of possible abuse/neglect was received from facility staff within two hours after staff became aware of the allegation. 2. Record review of Resident #32's face sheet, showed the following: -admission date of 1/18/22 ; -Diagnoses included epilepsy (seizure disorder), dysphagia (difficulty in swallowing), stroke, and prostate cancer. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -The resident came to the nursing station door during report and LPN K told the resident to shut the fuck up. LPN K said he/she wanted to give report and go home. LPN K then became nice and asked resident Am I going to have to turn you over my knee and bust your ass, Oh never mind you are a dirty old person and you would like that. The resident started crying, tears in his/her eyes. The resident had came to the nurses' station because he/she was having a post traumatic stress disorder (PTSD) melt down; -LPN L said he/she reported this allegation and there were witnesses statements written. He/she reported to LPN H and Registered Nurse (RN) M. Record review of facility records showed the facility did not provide documentation staff reporting the allegation of possible abuse of the resident to DHSS. Record review of DHSS records showed no self-report regarding the allegation of possible abuse was received from facility staff. 3. Record review of Resident #1's face sheet, showed the following: -admission date of 7/12/22 and discharged on 8/26/22 ; -Diagnoses included heart failure, kidney failure, high blood pressure, chronic pain mild cognitive impairment and hearing loss. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -The resident wheeled into the doorway of the nurses' station. The resident had a habit of saying nurse, nurse, nurse repetitively. LPN K looked at the resident and said shut your fucking mouth. LPN K got up from his/her chair went around LPN L and pushed on the resident's wheelchair to get him/her out of the doorway and slammed the door in the resident's face; -LPN L called and reported the incident to RN M. -The next morning he/she reported the incident to LPN H and he/she said he/she would report the incident to the Assistant Director of Nursing (DON) and it would be taken care of. Record review of facility records showed the facility did not provide documentation staff reporting the allegation of possible abuse of the resident to DHSS. Record review of DHSS records showed no self-report regarding the allegation of possible abuse was received from facility staff. 4. Record review of Resident #55's face sheet, showed the following: -admission date of 11/02/21 ; -Diagnoses included respiratory failure, kidney failure, congestive heart failure, depression, chronic pain, legal blindness, weakness, overactive bladder, and the need for assistance with personal care. During an interview on 9/27/22, at 2:49 P.M., CNA I said the following: -LPN K cursed and called the resident a fucking baby and a bitch and yelled at the resident and told her to grow up. CNA I reported this to the charge nurses, LPN L and LPN H. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -A staff reported that LPN K called the resident a bitch and a fucking baby; -The allegation was reported to the ADON. Record review of facility records showed the facility did not provide documentation staff reporting the allegation of possible abuse/neglect of the resident to DHSS. Record review of DHSS records showed no self-report regarding the allegation of possible abuse/neglect was received from facility staff. 5. During an interview on 9/27/22, at 2:49 P.M., CNA I said the following: -He/she reports all abuse to his/her charge nurse; -All allegations of abuse must be reported to the state within two hours; -He/she reported all allegation of abuse LPN H and LPN L. 6. During an interview on 9/29/22, at 9:41 A.M., LPN H said the following: -All allegations of abuse should be reported to the DON and administrator; -All allegations of abuse have to be reported to DHSS within two hours; -No one reported any allegations of abuse to him/her. 7. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -If the abuse involves and employee to resident, separate and get resident to safety and report to the DON and/or the administrator; -He/she has reported different situations to the on call nurse supervisor and to the the ADON. 8. During an on 10/03/22, at 12:25 P.M., Registered Nurse (RN) M said the following: -If he/she witnessed abuse protect the resident and immediately call the ADON or DON and if he/she could not reach them call the administrator; -All reports of abuse have to be reported to DHSS within two hours; -If he/she gets a report of abuse from staff or a resident he/she ensures the safety of the resident and make sure the abuser has no further contact with residents; -Report all allegations of abuse to the ADON, DON and the administrator. -He/she has had no allegations of abuse reported to him/her in the last couple months that he/she can recall; -He/she has not had anyone write-up any statements related to abuse of a resident; -There has been no reports of abuse reported to him/her regarding LPN K. 9. During an interview on 10/03/22, at 2:44 P.M., the ADON said the following: -If she would witness abuse she would report to the DON and the administrator; -No one has reported any abuse or neglect; -She was not aware of any of the above allegations of abuse; -All allegations of abuse should be reported. 10. During an interview on 10/03/22, at 3:35 P.M., the Administrator and the DON said the following: -The administrator and DON were not aware of any of the allegations; -All allegations of abuse to include neglect and verbal abuse should be reported; -All staff are expected report any allegation of abuse to the DON and the administrator; -All allegations of abuse should be reported to DHSS within two hours. MO00207614

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete full and documented investigation in a timely manner when staff were made aware of allegations of possible abuse/neglect involving four residents (Resident #1, Resident #32, Resident #55, and Resident #71). The facility census was 81. Record review of the facility policy Preventing Abuse/Reporting/Incidents/Investigation and Protection, updated on 4/2020 and last reviewed on 01/2022 , showed the following: -This facility has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation or misappropriation of property by any perpetrator; -Investigation process will proceed after the state notification as indicated and required. The full investigation report of the alleged or suspected violations must be completed and submitted to the state within 5 days after the appropriate abuse reporting time frame guidelines have been followed; -Persons who might have knowledge of the incident are interviewed privately and with the assurance of complete confidentiality and prohibition of retaliation against any employee making a report. The facility will not and cannot retaliate against any employee making a report; -A written record is made if the interviews and this written record becomes a part of the investigation file -In addition to interviews, the investigation may include analysis of the medical records, assessment of the resident and statements from various individuals, as well as residents; -Sufficient time will be allocated for the investigation to assure that all available information is processed -Any change in behavior may necessitate an investigation, depending upon relevant information available concerning the resident and the possible cause of the behavior change; -The results of all investigations are given to the administrator and/or his or her designated representative and to the other officials in accordance with State law, including to the State survey agency within 5 working days of the incident, and if the alleged violation is verified, appropriate action will be taken. -Results of the investigation will be made available to administration and to the resident involved 1. Record review of Resident #71's face sheet (a general information sheet) showed the following: -admission date of 4/18/07; -Diagnoses included chronic pain, constipation, neurogenic bowel (the inability to control defecation due to a deterioration of or injury to the nervous system, resulting in fecal incontinence or constipation) and quadriplegia (affected by or related to paralysis of all four limbs). Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Resident required extensive physical assistance of two plus staff for transfers, bed mobility, dressing, personal hygiene, toileting and bathing. Record review of the current physician's order sheet showed the following: -An order, dated 7/4/18, for staff to provide a digital stimulation nightly per residents request second to paraplegia at bedtime for regularity. Record review of the resident's care plan, last updated 09/15/22, showed the following: -The resident needs extensive assist from one to two caregivers with using the bathroom. The resident uses the bathroom in his/her room for bowel movements and needs digital stimulation from a nurse due to my spinal cord injury. During an interview on 09/27/22, at 1:00 P.M., the resident said the following: -He/she is on a bowel monitoring program that includes getting his/her bowels stimulated so he/she can have a bowel movement or he/she could get impacted; -Licensed Practical Nurse (LPN) K refused to assist in his/her bowel program; -The resident has reported this to Certified Nurse Aide (CNA) I and LPN L. During an interview on 9/27/22, at 2:49 P.M., CNA I said the following: -The resident is on a bowel monitoring program and has to be set-up and two staff and a nurse will assist. The nurse will digitally stimulate the resident so the resident can have a bowel movement daily; -One day CNA I and another CNA had set-up the shower chair and bedside commode and went to get LPN K. LPN K told CNA I he/she would not provide this care and refused to assist the resident; -CNA I heard LPN K tell the resident he/she would not help him/her; -CNA I reported this to LPN L. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -CNA I reported to LPN L that LPN K refused to help with the resident's bowel monitoring program; -The resident had an accident during the day and needed help from the staff to do the bowel monitoring program earlier than the usual time in the evening; -LPN L reported this incident to LPN H after he/she got the resident cleaned up and placed back in his/her wheelchair. Record review of facility records showed the facility did not provide a full investigation of the allegation of abuse/neglect within five working days of staff becoming aware of the allegation. Record review of Department of Health and Senior Services (DHSS) records showed facility staff did not provide a full investigation of the allegation of abuse/neglect within five working days of staff becoming aware of the allegation. 2. Record review of Resident #32's face sheet, showed the following: -admission date of 1/18/22 ; -Diagnoses included epilepsy (seizure disorder), dysphagia (difficulty in swallowing), stroke, and prostate cancer. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -The resident came to the nursing station door during report and LPN K told the resident to shut the fuck up. LPN K said he/she wanted to give report and go home. LPN K then became nice and asked resident Am I going to have to turn you over my knee and bust your ass, Oh never mind you are a dirty old person and you would like that. The resident started crying, tears in his/her eyes. The resident had came to the nurses' station because he/she was having a post traumatic stress disorder (PTSD) melt down; -LPN L said he/she reported this allegation and there were witnesses statements written. He/she reported to LPN H and Registered Nurse (RN) M. Record review of facility records showed the facility did not provide documentation of a full investigation of the allegation of abuse. Record review of DHSS records showed the facility did not provide documentation of a full investigation of the allegation of abuse. 3. Record review of Resident #1's face sheet, showed the following: -admission date of 7/12/22 and discharged on 8/26/22 ; -Diagnoses included heart failure, kidney failure, high blood pressure, chronic pain mild cognitive impairment and hearing loss. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -The resident wheeled into the doorway of the nurses' station. The resident had a habit of saying nurse, nurse, nurse repetitively. LPN K looked at the resident and said shut your fucking mouth. LPN K got up from his/her chair went around LPN L and pushed on the resident's wheelchair to get him/her out of the doorway and slammed the door in the resident's face; -LPN L called and reported the incident to RN M. -The next morning he/she reported the incident to LPN H and he/she said he/she would report the incident to the Assistant Director of Nursing (ADON) and it would be taken care of. Record review of facility records showed the facility did not provide documentation of a full investigation of the allegation of abuse. Record review of DHSS records showed the facility did not provide documentation of a full investigation of the allegation of abuse. 4. Record review of Resident #55's face sheet, showed the following: -admission date of 11/02/21 ; -Diagnoses included respiratory failure, kidney failure, congestive heart failure, depression, chronic pain, legal blindness, weakness, overactive bladder, and the need for assistance with personal care. During an interview on 9/27/22, at 2:49 P.M., CNA I said the following: -LPN K cursed and called the resident a fucking baby and a bitch and yelled at the resident and told her to grow up. CNA I reported this to the charge nurses, LPN L and LPN H. During an interview on 09/29/22, at 3:43 P.M., LPN L said the following: -A staff reported that LPN K called the resident a bitch and a fucking baby; -The allegation was reported to the ADON. Record review of facility records showed the facility did not provide documentation of a full investigation of the allegation of abuse. Record review of DHSS records showed the facility did not provide documentation of a full investigation of the allegation of abuse. 5. During an interview on 9/29/22 at 9:41 A.M., LPN H said the following: -No one reported any allegations of abuse to him/her; -All allegations of abuse should be reported and investigated. 6. During an interview on 10/03/22, at 12:25 P.M., RN M said the following: -All reports of abuse have to be reported and investigated; -If he/she gets a report of abuse from staff or a resident he/she ensures the safety of the resident and make sure the abuser has no further contact with residents; -He/she has had no allegations of abuse reported to him/her in the last couple months that he/she can recall; -As far as he/she knows there have been no investigations of abuse related to the residents named or LPN K. 7. During an interview on 10/03/22, at 2:44 P.M., the DON said the following: -All reported allegations of abuse should be investigated; -She was not aware of any of the above and nothing had been reported to her; -All allegations of abuse to include any neglect or verbal abuse should be investigated. 8. During an interview on 10/03/22, at 3:35 P.M., the Administrator and the Director of Nursing (DON) said the following: -All allegations of abuse should be investigated immediately; -A report of the investigation should be submitted to DHSS within five days; -They were not aware of any of the reports or any of the allegations; -All allegations of abuse should be investigated to include verbal and neglect. MO00207614

4. Record review of Resident #46's face sheet showed the following information: -admission date of 8/19/2022. Record review of the resident's medical records showed the following: -On 8/29/2022, at 9:40 A.M., staff documented the resident complained of shortness of breath with chest pressure, that his/her legs were numb, and pain at 7 out 10 scale. Staff contacted the physician and received an order to send the resident to the hospital; -On 8/30/2022, at 8:54 A.M., staff documented that social services attempted to contact the resident's family in regards to the bed hold policy. Record review of the resident's medical record showed staff did not document notification to the resident or resident's responsible party in writing of the resident's transfer to the hospital on 8/29/2022. 5. During an interview on 9/29/2022, at 11:27 A.M., Licensed Practical Nurse (LPN) D said that when a resident was sent to the hospital the nurse verbally notifies the resident's responsible party of the transfer. He/she was not aware of anything provided in writing. 6. During an interview on 9/30/2022, at 12:45 P.M., Registered Nurse (RN) E said that when the staff have to send a resident to the hospital they send the face sheet, the physician orders, and hospital transfer form with the Emergency Medical Service staff. The nurse verbally notifies the family or resident's responsible party by phone. He/she was not aware of anything in writing sent to the family. 7. During an interview on 9/30/2022, at 2:20 P.M., Social Services A said that he/she notifies resident families by phone of bed hold policy and explain that it will be private pay as the facility cannot charge insurance for the bed hold. He/she said that usually the nurses notify the family of hospital transfer. There was no written notice of transfer sent from social services. 8. During an interview on 10/3/2022, at 9:55 A.M., Social Services B said that he/she notifies the resident's family of bed hold policy. He/she does not send a written letter to the family. 9. During an interview on 9/30/2022, at 2:30 P.M., the Director of Nursing (DON) said that the charge nurse will notify the resident's family or responsible party of a resident change in condition before transfer usually to discuss the need and get approval for transfer unless the transfer is urgent. He/she said that the Social Service staff will call the resident's family regarding the bed hold policy. The staff might follow up by phone call regarding the transfer but she was not aware of anything provided in writing from the nursing staff. 10. During interviews on 10/3/2022, at 9:50 A.M. and 10:02 A.M., the Administrator said social services sends a written letter of transfer to the resident's family. He was not aware that the staff was not sending a written letter of transfer to the resident's family. Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital, including the reason for the transfer, for four residents (Residents #46, #53, #59, and #65). The facility census was 81. Record review of the facility's policy entitled Notice Requirements Before Transfer/Discharge, undated, showed the following information: -It is the policy of the facility to notify the resident and/or their legal guardian before transfer and/or discharge according to state and federal regulations; -Before the facility transfers or discharges a resident, the facility will obtain a physician's order for the transfer and/or discharge; notify the resident and, if known, a family member or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; and record the reasons for the transfer or discharge in the resident's medical record; -The notice included the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged ; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long-term care Ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act; -The notice will be in writing and will contain all information required by state and federal law, rules, or regulations applicable to Medicaid or Medicare cases. The agency shall develop a standard document to be used by all facilities licensed under this part for purposes of notifying residents of a discharge or transfer. Such document must include a means for a resident to request the local long-term care ombudsman council to review the notice and request information about or assistance with initiating a fair hearing with the department's Office of Appeals Hearings; -In addition to any other pertinent information included, the form shall specify the reason allowed under federal or state law that the resident is being discharge or transferred, with an explanation to support this action. Further, the form shall state the effective date of the discharge or transfer and the location to which the resident is being discharged or transferred. The form shall clearly describe the resident's appeal rights and the procedures for filing an appeal, including the right to request the local ombudsman council to review the notice of discharge or transfer. A copy of the notice must be placed in the resident's clinical record, and a copy must be transmitted to the resident's legal guardian or representative and to the local ombudsman; -If resident is unable to understand written notice/policy, resident representative will be notified and the notice will be mailed. 1. Record review of Resident #53's face sheet (gives brief information about the resident) showed the following information: -admission date of 2/2/2022. Record review of the resident's nurses' notes showed the following information: -On 8/4/2022, resident was noted to be slumped down in her chair. Staff assessed vital signs as blood pressure of 91/54 millimeters of mercury (mm/Hg) (low) and respiration rate 20 breaths per minute (high). The resident opened his/her eyes and looked at the ceiling, moving eyes slightly, but was not verbally responsive to staff. Staff received physician orders to send the resident to the hospital for evaluation. The resident was admitted to the hospital with diagnoses of acute encephalopathy (disease in which the functioning of the brain is affected by an agent or condition), pneumonia, and dehydration; -On 8/17/2022, staff received physician orders to send the resident to the hospital for evaluation related to altered mental status. Record review of the resident's medical record showed staff did not document notification to the resident or resident's responsible party in writing of the resident's transfer to the hospital on 8/4/2022 or 8/17/2022. 2. Record review of Resident #59's face sheet showed the following information: -admission date of 8/20/2022. Record review of the resident's nurses' notes showed the following information: -On 8/23/2022, the resident was sent to the hospital for evaluation due to an episode of diarrhea containing blood and the resident was lethargic (abnormally groggy). Record review of the resident's medical record showed staff did not document notification to the resident or resident's responsible party in writing of the resident's transfer to the hospital on 8/23/2022. 3. Record review of Resident #65's face sheet showed the following information: -admission date of 12/24/2015. Record review of the resident's nurses' notes showed the following information: -On 8/25/2022, staff found the resident sitting on the toilet in his/her bathroom with a large hematoma (swollen bruise) to the right forehead area. The resident complained of pain to the right forehead, was confused, and could not remember if he/she had fallen. Per physician orders, staff transferred the resident to the hospital for evaluation. Record review of the resident's medical record showed staff did not document notification to the resident or resident's responsible party in writing of the resident's transfer to the hospital on 8/25/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise care plans for two residents (Resident #49, and Resident #283) to include exit seeking behaviors and use of a seatbelt. The sample size was 20. The facility census was 72. Record review of the facility's policy titled Goals and Objectives, Care Plans, dated April 2009, showed: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. -Care plan goals and objectives are defined as the desired outcome for a specific resident problem. -When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. -Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented; are behaviorally stated; are measureable; and contain timetables to meet the resident's needs in accordance with the comprehensive assessment. -Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. -Goals and objectives are reviewed and/or revised: when there has been a significant change in the resident's condition; when the desired outcome has not been achieved; when the resident has been readmitted to the facility from a hospital/rehabilitation stay; and at least quarterly. -The resident has the right to refuse to participate in establishing care plan goals and objectives. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies. 1. Record review of Resident #49's face sheet (general resident information) showed the following information: -admission date of 9/6/19; -Diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion, memory failure), anxiety, and depression. Record review of the resident's elopement evaluation, dated 9/6/19, showed the following: -A history of, or attempted leaving the facility without informing the staff; -The resident verbally expressed the desire to go home, packed belongings, or stayed near an exit door; -The resident wandered aimlessly or non-goal-directed; -The resident's wandering behaviors were likely to affect the privacy of others. Record review of resident's Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 9/29/19, showed the following information: -Moderately Impaired; -Required extensive assistance of one staff with bed mobility, transfers, walking in his/her room, locomotion (movement) on and off the unit, dressing, toilet use, and personal hygiene; -Required limited assistance of one staff for walking in the hall; -Used a wheelchair for mobility; -Wandering behavior occurred 1 to 3 days out of seven days. Record review of the resident's physician orders showed an order, dated 10/3/19, to check the placement of the resident's wanderguard (alarm worn on wrist or ankle that activates when close to a contact switch, typically a door) every shift Record review of resident's wandering risk assessment, dated 10/3/19, showed the following: -The resident showed signs of wandering (move without rational purpose, seemingly oblivious to needs or safety); -The resident's behavior put the resident at significant risk for physical illness or injury. Record review of resident's care plan showed staff did not care plan the resident was an elopement risk, had attempted to elope, or had a wanderguard in place. During interview and observation on 10/7/19, at 12:05 P.M., showed the resident had a wanderguard on his/her left ankle. The resident said therapy placed it on his/her ankle so he/she would not leave. During an interview on 10/15/19, at 12:05 P.M., Licensed Practical Nurse (LPN) T said: -Resident was exit seeking at the side door near his/her room and at the main door. The resident said he/she wanted to go home. Staff placed a wanderguard on a resident if he/she attempted to exit the facility without staff assistance; -Care Plans are located in the electronic record and all staff would review them; -Care plan should include if a resident has a wanderguard in place. During an interview on 10/15/19, at 12:21 P.M., the MDS coordinator said he/she did not not think the care plan should include wanderguard or exit seeking behaviors, only an order for the wanderguard. Staff shoudl care plan if a resident has a wanderguard in place. During an interview on 10/15/19, at 2:58 P.M., the Director of Nursing (DON) said: -Resident would come to front door. He/she did not think resident was exit seeking, resident never tried to get out front doors; -Was not aware that resident tried to elope; -Was not aware that the resident had a wanderguard; -Care plan should include if a resident has a wanderguard in place 2. Record Review of Resident #283 face sheet showed the following: -admission date of 9/26/19; -Diagnoses include difficulty walking and unsteadiness on feet. Record review of resident's MDS, dated [DATE], showed the following information: -Cognitively intact; -Extensive assistance of two with bed mobility, transfer, dressing, and personal hygiene; -Limited assist of one for locomotion on unit; -Extensive assist of one for locomotion off unit and toilet use; -Physical help of two with bathing; -Wheelchair for mobility. Observation on 10/08/19, at 11:26 A.M., showed the resident in wheelchair with seatbelt on. Record review of resident's physicians' orders showed no order for seatbelt on wheelchair Record review of resident's care plan showed staff did not care plan the resident's seat belt. During an interview on 10/15/19, at 12:05 P.M., LPN T said: -He/she did not know resident had a seatbelt in his/her wheelchair; -Resident's seatbelt should be on the care plan. During an interview on 10/15/19, at 12:21 P.M., the MDS coordinator said: -Therapy evaluated seatbelt; -Seatbelt is on the resident's own personal wheelchair; -He/she is new to the position of MDS and would have to ask if it should be on care plan. During an interview on 10/15/19, at 2:58 P.M., the DON said the resident's seatbelt would need to be on the care plan 3. During an interview on 10/15/19, at 12:05 P.M., LPN T said care Plans are located in the electronic record and all staff whould review them. 4. During an interview on 10/15/19, at 12:21 P.M., the MDS coordinator said the following: -Staff should include, on the care plan, new physician's order and any changes with the resident; -The baseline care plan (care plan done within 48 hours of admission) is completed by admitting nurse; -The MDS coordinator reviews it the next day to see what nurse has written and to gather data about resident and uses this to develop the admission comprehenisve care plan; -Once this care plan is developed, the MDS coordinator will update it based on new orders or resident changes. 5. During an interview on 10/15/19, at 5:16 PM, the administrator said: -Care plans should contain all interventions to include seatbelt and wanderguard

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician order for oxygen for two residents (Resident #27 and Resident #78) in a selected sample of 20 residents. The facility's census was 72. Record review of the facility's Oxygen Administration policy, undated, showed the following: -It is the policy of this community to appropriately provide and monitor oxygen for residents as ordered by the physician. Initiation of oxygen therapy will be performed by a licensed nurse. Direct care staff may reapply the nasal cannula and replace sterile water in the humidifier; -When oxygen is required, an order will be obtained from the physician. 1. Record review of Resident #78's face sheet showed the following: -admitted to the facility on [DATE], re-admitted to the facility on [DATE]; -Diagnoses included pneumonia and high blood pressure. Record review of the resident's care plan, dated 9/12/19 showed the following: -Diagnoses of Chronic Obstructive Pulmonary Disease (COPD); -Administer oxygen therapy as ordered by the physician. Record review of the resident's admission minimum data set (MDS), a federally mandated comprehensive assessment tool completed by facility staff, dated 9/25/19, showed the following: -Severely impaired cognitive; -Required extensive assistance for bed mobility, transfers, dressing and toilet use; -Special treatment: Oxygen therapy. Record review of a nurse's note dated 10/8/19, at 12:11 A.M., showed a nurse documented the resident's pulse oximeter (pulse ox) (an electronic device that measures the saturation of oxygen carried in your red blood cells. Normal pulse oximeter readings usually range from 95 to 100 percent) was 89%. Staff administered 2 liters of oxygen to the resident. Observations showed the following: -On 10/08/19, at 2:46 P.M., the resident sat in his/her chair in his/her room. The resident received 2 Liters of oxygen via nasal cannula. -On 10/9/19, at 3:36 P.M., the resident sat in his/her chair in his/her room. A staff person placed the nasal cannula into the resident's nose. Record review of the resident's nurse note, dated 10/9/19 at 6:06 P.M., showed a nurse documented the resident received 2 liters of oxygen via nasal cannula. An observation on 10/10/19, at 10:14 A.M., showed the resident sat in his/her chair in his/her room. The resident received 2 Liters of oxygen via nasal cannula per oxygen concentrator During an interview on 10/10/19, at 3:12 P.M., Certified Nurse Aide (CNA) Q said the resident had an upper respiratory infection and went to the hospital. The resident just started using PRN (as needed) oxygen this past month and needed oxygen more in the last few weeks. During an interview on 10/10/19, at 3:20 P.M., Licensed Practical Nurse (LPN) P said the following: -The facility had standing physician orders for nurses to administer one liter of oxygen, if a resident's oxygen saturation was below 90%; -Staff administered oxygen, to the resident, via nasal cannula, for the last week. When LPN P reviewed the resident's physician orders, he/she did not find an order for the oxygen; -LPN P said there should be an order for the resident to have oxygen. Record review of the resident's physician order sheets (POS) showed the following: -An order, dated 10/10/19, oxygen 2 liters NC per nasal cannula to keep oxygen saturations greater than 90%; -An order, dated 10/10/19, for oxygen per nasal cannula to keep saturations greater than 90%, as needed, for shortness of breath. During an interview on 10/15/19, at 2:58 P.M. the Director of Nursing (DON) said the following: -Nursing staff entered physician orders into the computer; -If a resident did not have an order for oxygen, there were standing orders; -The resident discharged to the hospital. When he/she re-admitted to the facility, the oxygen order dropped off the POS. 2. Record review of the Resident #27's face sheet showed staff admitted the resident to the facility on 8/9/19. His/her diagnoses included severe obesity due to excess calories, muscle weakness, bi-polar disorder and major depressive disorder. Record review of the resident's admission assessment dated [DATE], at 2:15 P.M., showed a nurse documented the resident's most recent oxygen saturation was 96% with oxygen via nasal cannula. Record review of the resident's initial care plan, showed staff did not include oxygen usage or oxygen maintenance care. Record review of the resident's -------------MDS, dated [DATE], showed the following: -No cognitive impairment; -Received respiratory treatments and oxygen therapy. Record review of the resident's physician progress note, dated 9/3/19, showed the resident received Oxygen (O2) at 2 liters per minute (LPM). Observations showed the following: -On 10/8/19, at 9:20 A.M. and 12:15 P.M., the resident laid in bed with O2 via nasal cannula at 2 -On 10/9/19, at 9:20 A.M. 2:31 P.M. and 3:45 P.M., the resident laid in bed with O2 via nasal cannula at 2 LPM. -On 10/10/19, at 4:25 P.M., the resident laid in bed with O2 via nasal cannula at 2 LPM. Record review of the resident's physician order, dated 10/10/16, showed an order for 2-3 Liters of O2 per nasal cannula, as needed, to keep oxygen saturation greater than 90%. Record review of the resident's Nursing Progress, dated 9/15/19-10/11/19, show the nurses documented the resident was received O2 via nasal cannula. An observation on 10/11/19 at 9:50 A.M., showed the resident laid in bed with O2 via nasal cannula at 2 LPM. During an interview on 10/10/19, at 9:50 A.M., Resident #27's family member said the resident admitted to the facility with O2. During an interview on 10/10/19, at 9:50 A.M., Resident #27 said he/she admitted to the facility with O2. He/she received 2 LPM of O2 at home. During an interview on 10/11/19, at 10:49 A.M., CNA J said the resident used O2 since he/she admitted to the facility. Staff changed the O2 tubing if water was visible in the tube or if the tubing was stepped on. CNA J thought staff changed the tubing once a week. That information should be in his/her chart or the care plan. During an interview on 10/11/19, at 10:05 A.M., CNA K said the resident had O2 since he/she admitted to the facility. Staff switched the resident's oxygen from a concentrator to a tank when he/she transferred to the wheelchair. Staff changed the O2 tubing if it laid on the ground or had moisture in it. Staff could review the resident's care plan or ask a nurse for information on the resident. During an interview on 10/11/19, at 11:16 A.M., LPN L said he/she did not know if the resident admitted to the facility with O2, but staff added it to the resident's physician order sheet on 10/10/19, with a start date of 10/10/19. The resident received O2 without a physician's order. During an interview on 10/11/19, at 10:49 A.M., the Assistant Director of Nursing (ADON) said the resident admitted to the facility with O2. Staff did not add the order to the physician's order sheet until 10/10/19. The resident received O2 for almost two months without an order. A nurse documented the resident used O2 on the baseline care plan. During an interview on 10/15/19, at 10:03 A.M., the DON said the resident admitted to the facility with no orders for O2. During an interview on 10/15/19, at 15:16 P.M., the Administrator said if a resident used O2, there should be an order for it. The facility should conduct 24-hour audits of resident charts to ensure staff included all orders on the physician order sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ongoing communication with the dialysis (the cleaning of the blood with a machine due to the kidneys not working) center for one resident (Resident #34) who received dialysis. A sample of 20 residents was selected for review in a facility with a census of 72. Record review of the facility's End-Stage Renal Disease, Care of a Resident With Policy, revised September 2010, showed residents with end-stage renal disease (ERSD) will be cared for according to currently recognized standards of care. Staff will utilize dialysis communication form to and from dialysis. 1. Record review of Resident #34's face sheet (a general information sheet) showed the following: -The resident admitted to the facility on [DATE], and re-admitted on [DATE]; -Diagnoses included acute kidney failure (when kidneys suddenly become unable to filter waste products from your blood), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), stage 4 chronic kidney disease (loss of kidney function), congestive heart failure (heart muscle doesn't pump blood as well as it should), high blood pressure, and diabetes without complications. Record review of the resident's physician order sheet (POS), dated 7/1/19, showed the following information: -Diagnosis of acute kidney failure and chronic kidney disease, stage 4 (severe); -Dialysis three times per week on Tuesday, Thursday, and Saturday; -Ensure communication form is returned from dialysis center and filed in resident chart; -Ensure communication form filled out and sent with patient to dialysis center. Record review of the resident's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by facility staff, dated 9/6/19, showed the resident was cognitively intact. Record review of the resident's care plan, dated 9/9/19, showed the following information: -Resident required dialysis related to renal failure; -Implement immediate interventions at signs or symptoms of complications from dialysis; -Resident will have no signs or symptoms of complications from dialysis. Observations showed the resident had dialysis on 10/8/19. During an interview on 10/09/19, at 2:54 P.M., the resident said sometimes the facility gives him/her a paper to take with him/her to dialysis, but not all the time. Observations showed the resident had dialysis 10/10/19. During an interview on 10/11/19, at 11:16 A.M., Licensed Practical Nurse (LPN) L said there is a communication sheet that goes on every trip with the Resident. He/she will bring it back and the staff will put it in the resident's chart. In the chart was a form for 7/20/19, 8/22/19, 9/21/19, and an undated form. The forms have not been kept up properly. He/she should have three sheets a week. He/she started dialysis on 5/15/19 and goes three times a week. It should be in his/her orders and care plan. The physician orders says he/she should take the communication form to and from dialysis. During an interview on 10/13/19, at 2:30 P.M., the resident said he/she gets a paper to take with him/her to dialysis and he/she will bring it back to the facility. He/she said he/she gets the sheet maybe 3 out of 10 times he/she goes to dialysis. Observations showed the resident had dialysis on 10/15/19. Record review of the resident's medical record showed no dialysis communication form between the facility and the dialysis center for October 2019. During an interview on 10/15/19, at 2:58 P.M., the Director of Nursing (DON) said the protocol is to send the communication form with the resident. Sometimes they send it back and sometimes they don't. If there are new orders they will send them back. Staff complete an assessment when the resident returns. Paperwork goes with the driver, but it is not getting done regularly. During an interview on 10/15/19, at 10:13 A.M., Assistant Director of Nursing (ADON), said we have a universal communication form for dialysis and it goes out each time and sometimes we have to call to get it back. Dialysis will fax orders of changes. The ADON thinks they send it every time and coming back is the issue. The facility has new nurses and they don't know if dialysis nurses are not sending it back, communication is an issue. He/she was admitted [DATE] and his/her dialysis was revised on 9/12/19. Review of communication logs are hit or miss. They are not getting completed on a regular basis or not being completely filled out or dated. During an interview on 10/15/19, at 5:16 PM, the administrator said staff collaboration between dialysis [NAME] and facility should be done in a communication form. Mentors should check to see if they receive the form back and if not, they should contact the dialysis center for follow up.

**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 spread of bacteria or other infectious contaminants when the facility failed to attach a cap on the end of a PICC (peripherally inserted central catheter) for one resident (Resident #229) in a selected sample of 20 residents. The facility census was 72. According to Clinical Nursing Skills and Techniques 8th edition, [NAME], [NAME], & [NAME], 2014, the rationale that securing connections and the use of protective covers reduces the risk of air emboli (abnormal presence of air in the cardiovascular system), infections and entrance of microorganisms. 1. Record Review of Resident #229 face showed the following -admission date of 10/04/19; -Diagnoses include sepsis (infection that can lead to tissue damage, organ failure, and death), cognitive communication deficit, and dementia (confusion, disorientation). Record review of the resident's admission assessment Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 10/09/19, showed the following information: -Cognitively intact; -Extensive assistance of two with bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, toilet use, and personal hygiene; -Physical help of two with bathing; -Wheelchair and walker for mobility. Record review of resident's physicians' orders showed the following: -An order dated 10/07/19, to monitor PICC (peripherally inserted central catheter - inserted into vein in upper arm and guided into a large vein above the right side of the her, used to give intravenous fluids and medications) line for signs and symptoms of infection daily and report any new findings; -An order dated 10/07/19, for PICC line dressing change every seven days; -An order dated 10/08/19, for cefazolin (antibiotic) 2000 milligrams (mg) intravenously three times a day; -An order dated 10/07/19. for saline flush solution, use 10 cc (cubic centimeters, 1 cc is equivalent to 1 milliliter) intravenously three times a day for prophylactic; -An order dated 10/07/19, for heparin lock flush solution (used to prevent blood clotting and keep PICC line patent) use 5 milliliters (ml) two times a day for anticoagulant flush with heparin after normal saline flush; -An order dated 10/07/19, to use 5 ml normal saline, administer antibiotic, use 5 ml saline, use 5 ml heparin. Record review of resident's current care plan showed staff did not care plan the resident's sepsis, antibiotic treatment, or PICC line. Observation and interview on 10/09/19, at 8:20 P.M., showed the following: -There was no cap on the end of the PICC line; -Registered Nurse (RN) N said the cap fell off the table and he/she would get a new one; -RN administered IV antibiotics to resident. Observation and interview on 10/09/19, at 9:03 P.M., showed the following: -IV antibiotics completed, RN disconnected medication from end of PICC line; -RN N did not replace the cap to the end of the PICC line; -The RN said that there should be a cap on at all times. Observation and interview on 10/10/19, at 10:04 A.M., showed the following; -Resident was in wheelchair next to bed, PICC line visible with no cap on it; -Licensed Practical Nurse (LPN) M said there is usually a green cap on the end; -LPN M said the purpose of the caps is to prevent any infection or bacteria from getting in the line; -LPN M said he/she did not receive anything in morning report from RN N about the PICC line or about why there was no cap on it. During an interview on 10/10/19, at 2:21 P.M., the Director of Nursing (DON) said the following: -If a cap fell on the floor he/she would expect staff to replace it as soon as possible; -The purpose of the cap is to prevent infection. During an interview on 10/15/19, at 5:16 P.M., the Administrator said PICC lines should have a cap on the end to prevent infection.

Based on interviews and record reviews, the facility failed to document and track residents' grievances and failed to make prompt efforts to resolve the residents' grievances for four residents (Resident #31, #40, #54 and #76) out of a selected sample of 20 residents. The facility census was 72. 1. Record review of the facility's policy Right to Voice Grievances undated, showed the following: -An elder, his/her responsible party and family have the right to express a grievance or complaint about care and services provided by the facility without fear of discrimination or reprisal, including grievances with respect to treatment, care or services provided as well as those which have not been provided; -Elders and their families may also report a complaint or grievance in writing to any team member in the facility. The written complaint will be forwarded to the individual responsible for the area of service related to the complaint and/or the facility administrator; -If a grievance or complaint was provided in a written form, a written response will be provided to the individual that wrote the grievance or written complaint. A copy of all written grievances and responses will be maintained by the facility administrator. If the grievance or complaint was provided in oral form, the concern will be documented on a concern form, for appropriate investigation and follow-up; -When an elder or family member submits a complaint that the facility determines to be significant, including issues related to care, treatment, management of funds, lost clothing, and/or violation of resident rights, the administrator or designee acknowledges receipt of the grievance or complaint and notifies the elder or family member of follow-up to the grievance or complaint. 2. Record review of Resident #40's concern/grievance report, dated 9/5/19, showed the following: -Staff documented the night aide did not assist the resident to the bathroom. The resident got up on his/her own after (waiting) an hour; -Staff did not document resolution of the concern/grievance. 3. Record review of Resident #54's concern/grievance reported dated 9/18/19, showed the following: -Staff documented the resident reported staff dropped him/her off at an appointment, he/she went without a bath for several days and staff left him/her in a soiled incontinent brief; -Staff did not document resolution of the concern/grievance. 4. Record review of Resident #76's concern/grievance report dated, 9/26/19 showed the following: -The resident informed therapy he/she was unhappy with his/her care, length of time he/she wait for assistance, food, bed and wandering residents; -Staff did not document resolution of the concern/grievance. During an interview on 10/15/19 at 9:50 A.M. the resident said he/she did not receive a letter or follow up from the staff regarding the complaint he/she filed on 9/26/19. 5. Record review of Resident #31's concern/grievance report dated 10/7/19, showed the following: -Staff documented the resident's family member reported staff were not providing the resident with perineal care; -Staff did not document resolution of the concern/grievance. 6. During an interview on 10/10/19 at 11:52 A.M., 2:43 P.M. and 4:51 P.M., the social worker said the following: -Residents could file a grievance with any staff member, including social service staff; -Staff filed the grievance forms in the grievance book; -Social Services, the Director of Nursing (DON) or the administrator followed up with the residents. Staff documented their grievance follow-up in residents' electronic medical record; -Social services had not followed up, sent any letters or documented the results or conclusions of the residents grievances. 7. During an interview on 10/10/19 at 3:08 P.M. Certified Nurse Aide (CNA) O said the following: -If a resident had a grievance, he/she asked staff for a grievance form located in a manila folder in the spa; -The resident completed the grievance form and turns it into staff; -He/she did not know who the grievance officer was; -Administration ensured the resident's grievance was taken care of and the resident was satisfied. 8. During an interview on 10/10/19 at 3:20 P.M., Licensed Practical Nurse (LPN) P said the following: -A resident could ask any staff member for a grievance sheet located in the spa; -Grievance forms are turned into social services. 9. During an interview on 10/10/19 at 3:39 P.M., the DON said the following: -Grievance forms are located in the spa room; -Residents and family could fill out a grievance form and give it to the grievance officer (social services); -Staff discussed grievances in the daily clinical meetings, discussed the concerns with the resident, and educated staff; -Social services had the documentation related to grievances. 10. During an interview on 10/10/19 at approximately 4:00 P.M., and 10/15/19 at 5:16 P.M., the administrator said the following: -Staff should communicate the resolution of a grievance to the resident either in writing or verbally; -Staff should document the grievance resolution; -The grievance officer had the documention; -There was not a formal follow-up with the resident in writing. -Staff should send a letter to the resident of what the complaint was, what the facility did to resolve the complaint and the timeline of the resolution. The staff have not provided this information to the residents; -He expected the staff to follow up with the resident regarding a filed grievance.

Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate less than five percent when the staff made six errors out of 34 opportunities, resulting in an error rate of 17.6%. This affected six residents (Resident #26, Resident #37, Resident #48, Resident #229, Resident #280 and Resident #284). The facility census was 72. 1. Record review of facility's policy titled Insulin Pen Devices for Insulin Administration, undated, showed the following: -The facility will ensure that each elder receives proper and appropriate treatment and care for insulin administration per pen devices or insulin vials as ordered by a licensed physician; -Prior to administration, authorized clinical staff will verify that the medication is being administered at the proper time, in the prescribed dose, by the correct route; -Attached disposable needle to pen; -Prime pen prior to each injection to release a small amount of insulin into pen to remove any air bubbles in pen which may affect flow of insulin and cause inaccurate dosage; -Dial two (2) units of insulin on the dose selector; -Point needle up; -Firmly press plunger until a drop of insulin appears at needle tip; -Repeat step if droplet does not appear; -Dial correct dose; -Inject the insulin by pushing the button on the insulin pen completely and keep button pressed and count to five prior to removing needle from skin. 2. Record review of Resident #37 face sheet (general resident information) showed the following information: -admission date of 09/11/19; -Diagnoses include diabetes. Record review of the resident's physicians' orders showed an order to administer Novolog (fast acting insulin) subcutaneously before meals for diabetes per the following sliding scale: -If blood glucose level is 120 to 160 milligrams/deciliter (mg/dL), administer 2 units of insulin; -If blood glucose level is 161 to 200 mg/dL, administer 4 units of insulin; -If blood glucose level is 201 to 240 mg/dL, administer 6 units of insulin; -If blood glucose level is 241 to 280 mg/dL, administer 8 units of insulin; -If blood glucose level is 281 to 320 mg/dL, administer 11 units of insulin; -If blood glucose level is 321 or greater, administer 15 units of insulin. Observation and interview on 10/08/19, at 11:47 A.M., showed the following: -Resident's blood glucose was 218 mg/dL; -Licensed Practical Nurse (LPN) F drew up 6 units with Novolog pen and administered in the resident's abdomen; -LPN F did not prime the insulin pen prior to administration (potentially affecting the actual dose of insulin received by the resident). 3. Record review of Resident #280 face sheet showed the following information: -admission date of 10/01/19; -Diagnoses include diabetes. Record review of the resident's physician orders showed an order, dated 10/01/19, to administer Humalog (rapid acting insulin) subcutaneously before meals for diabetes per the following sliding scale: -If blood glucose level is 0 to 140 mg/dL, do not administer insulin; -If blood glucose level is 141 to 180 mg/dL, administer 3 units of insulin; -If blood glucose level is 181 to 220 mg/dL, administer 7 units of insulin; -If blood glucose level is 221 to 280 mg/dL, administer 10 units of insulin; -If blood glucose level is 281 to 340 mg/dL, administer 15 units of insulin; -If blood glucose level is 341 to 380 mg/dL, administer 20 units of insulin. Observation and interview on 10/09/19, at 12:03 P.M., showed the following: -Resident's blood glucose was 218 mg/dL. -LPN F was not able to connect to internet to see the resident's order. He/she did not check the resident's chart for the order; -LPN F drew up 8 units with Humalog pen and administered in the resident's right upper arm (the order showed to administer 7 units of insulin); -LPN F did not prime the insulin pen prior to administration (potentially affecting the actual dose of insulin received by the resident). 4. Record review of Resident #284 face sheet showed the following information: -admission date of 10/07/19; -Diagnoses included diabetes. Record review of the resident's physician orders showed the following: -An order, dated 10/07/19, for glargine (long-acting insulin), inject 22 units subcutaneously every morning and at bedtime for diabetes. Observation and interview on 10/08/19, at 12:03 P.M., showed the following: -LPN F dialed up 22 units glargine insulin via insulin pen and administered to resident (the order was for morning and bedtime administration); -LPN F did not prime the insulin pen prior to administration (potentially affecting the actual dose of insulin received by the resident). 5. Record review of Resident #26 face sheet (general resident information) showed the following information: -admission date of 04/18/07; -Diagnoses include quadriplegia (paralysis of the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord). Record review of resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 09/04/19, showed the resident cognitively intact. Record review of the resident's physicians' orders showed the following: -An order, dated 06/10/18, for acidophilus (supplement to aide in the growth of good gut bacteria), give two capsules by mouth three times daily. Observation and interview on 10/08/19, at 11:57 A.M., showed the following: -The LPN administered one capsule of acidophilus (probiotic) in a medicine cup (the order was for two capsules); -The LPN left the medicine cup next to resident's computer and said resident has an order to leave medications at bedside. 6. Record review of Resident #48 face sheet showed the following information: -admission date of 08/08/19; -Diagnoses included hemiplegia (paralysis on one side of body) of left side. Record review of the resident's physicians' orders showed the following: -An order, dated 9/22/19, for saline flush use 10 cubic centimeter (cc, 1 cc is equivalent to 1 ml (milliliter)) intravenously two times daily for prophylactic. Flush with saline 10 ml, followed by heparin (anticoagulant) 5 ml. Observation and interview on 10/08/19, at 4:56 P.M., LPN F flushed with 5 cc of heparin followed by 10 cc of normal saline. During an interview on 10/11/19, at 11:06 A.M., LPN F said: -When flushing a PICC line staff should flush with 5 ml of heparin and follow flush with 10 ml of normal saline; -He/she was not aware the physician's orders were to flush with normal saline first and then heparin. 7. Record Review of Resident #229's face showed the following -admission date of 10/04/19; -Diagnoses included severe sepsis (infection that can lead to tissue damage, organ failure, and death), cognitive communication deficit, and dementia (confusion, disorientation). Record review of the resident's physicians' orders showed the following: -An order, dated 10/08/19, for cefazolin (antibiotic) 2000 mg intravenously three times a day; -An order, dated 10/07/19, for saline flush solution, use 10 cc intravenously three times a day for prophylactic; -An order, dated 10/07/19, for heparin lock flush solution (used to prevent blood clotting and keep PICC line patent), use 5 ml two times a day for anticoagulant flush with heparin after normal saline flush; -An order, dated 10/07/19, for 5 ml normal saline, administer antibiotic, use 5 ml saline, use 5 ml heparin. Observation and interview on 10/10/19, at 10:04 A.M., showed LPN M administered cefazolin (medication was ordered for 8:00 A.M.). Observation and interview on 10/10/19, at 10:46 A.M., showed the following: -LPN M flushed the PICC line with 8 ml of normal saline followed by 5 ml of heparin, and then with an unknown amount of normal saline after. He/she said he/she likes to flush with a little bit of normal saline after the heparin to make sure it gets all the way through the line; -He/she said antibiotics have a set time to be administered and if medication is administered outside of that set window should call the physician; -He/she said there is an hour before and an hour after scheduled time for administration to still be considered on time; 8. During an interview on 10/10/19, at 2:21 P.M., the Director of Nursing (DON) said the following: -Antibiotics should be administered within one hour before or after scheduled time. If staff need to change administration time, staff should call the physician to make sure it is okay to change the time. Nurses should not make time changes without notifying physician; -PICC line should be flushed with 10 ml of normal saline followed by 5 ml of heparin per protocol unless physician order states differently; -Insulin pens should have the needle primed with 2 units. Those 2 units should be expelled, then dial in the ordered dose to be administered; -Insulin that is ordered for every morning should be administered in the morning unless resident was asleep or did not eat, then physician should be called for further instructions

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to prime insulin pens prior to administering insulin to three residents (Resident #37, #280, and #284) and failed administer insulin per physicians' orders for two residents (Resident #280 and #284). The facility census was 72. Record review of facility's policy titled Insulin Pen Devices for Insulin Administration, undated, showed the following: -The facility will ensure that each elder receives proper and appropriate treatment and care for insulin administration per pen devices or insulin vials as ordered by a licensed physician; -Prior to administration, authorized clinical staff will verify that the medication is being administered at the proper time, in the prescribed dose, by the correct route; -Attached disposable needle to pen; -Prime pen prior to each injection to release a small amount of insulin into pen to remove any air bubbles in pen which may affect flow of insulin and cause inaccurate dosage; -Dial two (2) units of insulin on the dose selector; -Point needle up; -Firmly press plunger until a drop of insulin appears at needle tip; -Repeat step if droplet does not appear; -Dial correct dose; -Inject the insulin by pushing the button on the insulin pen completely and keep button pressed and count to five prior to removing needle from skin. 1. Record review of Resident #37 face sheet (general resident information) showed the following information: -admission date of 09/11/19; -Diagnoses include diabetes. Record Review of resident's physicians' orders showed staff to administer administer Novolog (rapid acting insulin)subcutaneously (below skin) before meals for diabetes per the following sliding scale; -If blood glucose level is 120 to 160 milligrams/deciliter (mg/dL), administer 2 units of insulin; -If blood glucose level is 161 to 200 mg/dL, administer 4 units of insulin; -If blood glucose level is 201 to 240 mg/dL, administer 6 units of insulin; -If blood glucose level is 241 to 280 mg/dL, administer 8 units of insulin; -If blood glucose level is 281 to 320 mg/dL, administer 11 units of insulin; -If blood glucose level is 321 mg/dL or greater, administer 15 units of insulin. Observation and interview on 10/08/19, at 11:47 A.M., showed the following: -The resident's blood glucose was 218 mg/dL; -Licensed Practical Nurse (LPN) F drew up 6 units of insulin with Novolog pen and administered in resident's abdomen; -LPN F did not prime the insulin pen prior to administration (potentially affecting the actual dose of insulin received by the resident). 2. Record review of Resident #280 face sheet showed the following information: -admission date of 10/01/19; -Diagnoses included diabetes. Record review of resident's physicians' orders showed an order, dated 10/01/19, to administer Humalog ( the following: -An order dated 10/01/2019 showed Humalog (rapid acting insulin) subcutaneously before meals for diabetes per the following sliding scale: -If blood glucose level is 0 to 140 mg/dL, administer no insulin; -If blood glucose level is 141 to 180 mg/dL, administer 3 units of insulin; -If blood glucose level is 181 to 220 mg/dL, administer 7 units of insulin; -If blood glucose level is 221 to 280 mg/dL, administer 10 units of insulin; -If blood glucose level is 281 to 340 mg/dL, administer 15 units of insulin; -If blood glucose level is 341 to 380 mg/dL, administer 20 units of insulin. Observation and interview on 10/09/19, at 12:03 P.M. showed the following: -Resident's blood glucose was 218 mg/dL; -LPN F was not able to connect to internet to see resident's order. He/she did not check the resident's chart for the order; -LPN F drew up 8 units with Humalog pen and administered it in the resident's right upper arm (the resident's order showed staff to administer 7 unit of insulin); -LPN F did not prime the insulin pen prior to administration (potentially affecting the actual dose of insulin received by the resident). 3. Record review of Resident #284 face sheet showed the following information: -admission date of 10/07/19; -Diagnoses include diabetes. Record review of the resident's physician's orders showed the following: -An order dated 10/07/19, for glargine (long-acting insulin), inject 22 units subcutaneously every morning and at bedtime for diabetes. Observation and interview on 10/08/19, at 12:03 P.M., showed the following: -LPN F dialed up 22 units glargine via insulin pen and administered to resident (the order was for morning and bedtime); -LPN F did not prime the insulin pen prior to administration (potentially affecting the actual dose of insulin received by the resident). 4. During an interview on 10/10/19, at 2:21 P.M., the Director of Nursing (DON) said the following: -Insulin pens should have the needle primed with 2 units of insulin. Those 2 units should be expelled, then dial in the ordered dose to be administered; -Insulin that is ordered for every morning should be administered in the morning unless resident was asleep or did not eat, then physician should be called for further instructions.