**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to notify one resident ( Resident #4) of an altercation with another resident and two residents (Resident #4 and #8) after falls out of five sampled residents. The facility census was 45. 1. Review of the facility's Significant Condition Change and Notification policy, dated November 2019, showed staff are directed as follows:-The purpose is to ensure that the resident's family and/or representative are notified of resident changes such as an accident or incident, with or without injury, that has the potential for needed medical practitioner intervention;-A significant change in the resident's physical, mental or psychosocial status examples include: new bruises, allegation of abuse or neglect, or other abnormal assessment findings;-Calls will be made to the resident's representative until they are reached. A message may be left on an answering machine that does not give specific examples but leaves a request for the facility to be called;-All significant changes will be recorded in the resident record.2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/01/25, showed staff assessed the resident as follows:-Cognitively impaired;-Required partial to moderate assistance with wheelchair locomotion;-Dependent for all transfers;-Had two non-injury falls since prior assessment;-Diagnosis of dementia.Review of the resident's nurses notes, dated 06/01/25 through 09/08/25, showed staff documented;-On 06/07/25 at 7:41 A.M., Resident found on the floor near the bathroom in his/her room. The nurses note did not contain documentation staff notified the family and/or responsible party of the fall;-On 06/20/25 at 11:25 A.M., Resident spilled coffee on his/her lap. He/She was noted to have a four by four red area to his/her left groin. New treatment orders were obtained. The nurses note did not contain documentation staff notified the family and/or responsible party of the fall.-On 07/02/25 at 11:05 P.M.: LPN A documented he/she heard a wheelchair fall over in the hallway and upon further assessment the resident was on the floor lying next to a reclining wheelchair he/she knocked over. The nurses note did not contain documentation staff notified the family and/or responsible party of the fall.-07/12/25 at 12:41 A.M., Resident observed on the floor on his/her right hip/buttocks area after sliding out of bed. The nurses note did not contain documentation staff notified the family and/or responsible party of the fall.Review of facility's abuse and neglect investigation, dated 09/09/25, showed staff documented the resident in an altercation with another resident on 09/05/25. Review of the resident's nurses notes, dated 09/05/25, did not contain documentation staff notified the family and/or responsible party of the altercation.During an interview on 09/08/25 at 12:50 P.M., the legal guardian said he/she is not informed of a lot of things to include falls. He/She was not informed of the resident-to-resident incident that allegedly occurred on 09/05/25.During an interview on 09/08/25 at 2:30 P.M., LPN B said nurses are responsible to notify the physician of any changes in condition to the resident that include falls, resident to resident altercations and anything else that would be considered a change in condition. He/She said he/she should have notified the family and documented the change in condition with the resident that was reported to occur on 09/05/25 with the resident and a peer but was busy and didn't. 3. Review of Resident #8's admission MDS, dated [DATE], showed staff assessed the resident as follows:-Cognitively intact;-Had limited range of motion in one upper and one lower extremity;-Required partial to moderate assistance with transfers to a wheelchair;-Fell one to six months prior to admission;-Diagnosis of stroke and dementia.Review of the resident's Face Sheet showed it contained two emergency contacts and one power of attorney (legal document allowing a designated person to make decisions and act on the granters behalf).Review of facility's list of falls, dated 09/08/25, showed the resident had a fall on 08/18/25.Review of the resident's nurse notes, dated 06/01/25 through 09/08/25, showed staff documented:-On 08/18/25 did not contain documentation staff notified the family and/or representative of a fall; -On 08/19/25 at 12:26 P.M., resident on fall follow up charting. The nurses note did not contain documentation staff notified the family and/or representative of the fall;-On 08/26/25 at 11:00 P.M., resident on the floor next to his/her bed with legs crossed. The nurses note did not contain documentation staff notified the family and/or representative of the fall.4. During an interview on 09/08/25 at 2:30 P.M., Licensed Practical Nurse LPN B said nurses are responsible to notify the physician of any changes in condition to the resident that include falls, resident to resident altercations and anything else that would be considered a change in condition. He/She said the nurse should document the notification in the nurse notes. He/She said he/she was busy and did not get to it.During an interview on 09/08/25 at 3:00 P.M., the administrator said the nurses are responsible to notify the families any time there is a fall, incident involving the resident or changes in treatments and should be documented in the resident record. He/She was not aware the families and/or responsible parties were not informed.Complaint #2609897

Based on record review and interview, facility staff failed to prevent commingling of five residents' funds (Resident #8, #27, #26, #38, and #40) out of 23 sampled personal funds, with the facility operating funds, and failed to reconcile the resident trust monthly for two of 12 months sampled. The facility census was 47. 1. Review of the facility's policy titled Resident Funds, undated, showed resident funds will be maintained by the facility and reconciled regularly. Review of the facility's policy titled Private Collections Policy and Procedures, revised 01/20/21, showed the primary responsibility of the facility's Business Office Manager (BOM) to maintain Account's Receivable (AR) amounts, with oversight provided by the Administrator. Review of the facility's policy titled Facility Resident Trust Fund Policy, revised 05/2012, showed the resident trust fund will be managed and accounted for in accordance with state and federal guidelines. All resident trust should be maintained in one collective interest-bearing bank account separate from any other facility operating accounts and money. The resident fund bank account must be reconciled monthly immediately upon receipt of the bank statement. 2. Review of the facility's monthly resident trust reconciliation records showed it did not contain a monthly reconciliation for March 2024 or June 2024. 3. Review of the facility's-maintained AR Aging report, dated 11/19/24, showed current residents with personal funds held in the facility operating account: -Resident #8 with a credit balance of $26,037.26 with a start date of 05/01/24; -Resident #27 with a credit balance of $698.80 with a start date of 08/01/24; -Resident #26 with a credit balance of $247.89 with a start date of 08/13/24; -Resident #38 with a credit balance of $3,524.00 with a start date of 08/15/24; -Resident #40 with a credit balance of $1,474.00 with a start date of 08/15/24. 4. During an interview on 11/20/24 at 8:30 A.M., the Administrator said the BOM is responsible for the facility's Accounts Payable (AP), the Regional BOM is responsible for the facility's resident trust along with reconciliation, and accounts receivable is responsible for the AR/Aging. The Administrator said he/she is ultimately responsible to ensure funds are completed and reconciled. The Administrator said he/she is not able to find the resident trust reconciliations from March 2024 or June 2024 and does not know if they were completed or not. The Administrator said the facility does not have written authorization to hold resident funds and commingle in the facility funds. During an interview on 11/20/24 at 9:00 A.M., Accounts Receivable Employee said he/she took over the position in August 2024. He/She has worked through the Aging Report since he/she took it over trying to determine what credits need refunded, but he/she does not have it completed yet. He/She said the Aging Report should be reviewed monthly and if a credit is discovered he/she should research it to determine if a refund should be issued. He/She said refunds should be issued within 30 days of discharge and that is not happening. He/She said the facility does not have written permission to hold resident funds in the facility funds. During an interview on 11/20/24 at 1:30 P.M., Administrator said resident funds should be returned within 30 days of discharge and that is not happening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility staff failed to provide refunds of personal funds to the residents from the facility operating account within 30 days of discharge for three (Resident #58, #59, and #56) out of five sampled residents. The facility census was 47. 1. Review of the facility's policy titled Resident Funds, undated, showed resident funds will be maintained by the facility and reconciled regularly. Review of the facility's policy titled Private Collections Policy and Procedures, revised [DATE] showed the primary responsibility of the facility's Business Office Manager (BOM), is to maintain Account's Receivable (AR) amounts, with oversight provided by the Administrator. Review of the facility's policy titled Facility Resident Trust Fund Policy, revised 05/2012, showed the resident trust fund will be managed and accounted for in accordance with state and federal guidelines. Refund check requests for discharged or expired residents must be completed within five business days of the resident discharge. Per state regulations, a completed discharge/trust fund accounting form reflecting discharge date and monies disbursed must be sent to the caseworker with in five days. Facility shall refund the balance of the resident's personal funds when a resident is discharged , the amount shall be refunded by the end of the month following the month of discharge or by state/federal guidelines if more stringent. 2. Review of the facility's-maintained Account Receivable (AR) Aging report, dated [DATE], showed residents with personal funds held in the facility operating account: -Resident #58, discharged from the facility on [DATE], with a credit balance of $3,060.00; -Resident #59, discharged from the facility on [DATE], with a credit balance of $5,106.00; -Resident #56, discharged from the facility on [DATE], with a credit balance of $2687.09. 3. During an interview on [DATE] at 8:30 A.M., the Administrator said the BOM is responsible for the facility Accounts Payable (AP), the Regional BOM is responsible for the facility's resident trust along with reconciliation, and the accounts receivable is responsible for the AR/Aging. The Administrator said he/she is ultimately responsible to ensure refunds are issued timely. During an interview on [DATE] at 9:00 A.M., the Accounts Receivable Employee said he/she has worked through the Aging Report since he/she took it over to determine what credits need refunded but he/she does not have them completed yet. He/She said the Aging Report should be reviewed monthly and if a credit is discovered he/she should research it to determine if a refund should be issued. He/She said refunds should be issued within 30 days of discharge and that is not happening at this time. During an interview on [DATE] at 1:30 P.M., the Administrator said resident funds should be returned within 30 days of discharge and that is not happening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide the appropriate Center for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) for three residents (Resident #54, #55, and #248) out of three sampled residents whom the facility-initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 47. 1. Review of the facility's policy titled Advanced Beneficiary Notices, revised 07/14/22, showed a NOMNC form shall be issued to the resident/representative with Medicare covered services are ending, no matter if the resident is leaving the facility or remaining at the facility. This informs the resident/representative on how to request an appeal or expedite determination from their Quality Improvement Organization (QIO). To ensure the resident/representative has enough time to make a decision whether or not to receive the services in question and assume the financial responsibility, the notice shall be provide within 48 hours of the last anticipated covered day. The notice shall be written legibly in a language and/or format the resident/representative understands, verbal explanations detailing the reasons for determination of possible non-coverage shall be provided. The notice shall be hand-delivered to obtain beneficiary or representative signature. The original notice shall be kept by the facility and a copy provided to the resident/representative. 2. Review of Resident #54's medical record showed: -Medicare Part A skilled services started on 08/16/24; -Last covered day of Medicare Part A skilled services on 08/30/24; -Facility initiated discharge from Medicare Part A services; -discharged to home on [DATE]; -Did not contain a NOMNC. During an interview on 11/20/24 at 1:30 P.M., the Administrator said the resident used three Medicare Part A days with 77 remaining. 3. Review of Resident #55's medical record showed: -Medicare Part A skilled services started on 07/27/24; -Last covered day of Medicare Part A skilled services on 07/29/24; -Facility initiated discharge from Medicare Part A services; -discharged to home on [DATE]; -Did not contain a NOMNC. During an interview on 11/20/24 at 1:30 P.M., the Administrator said the resident used 31 Medicare Part A days with 49 remaining. 4. Review of Resident #248's medical record showed: -Medicare Part A skilled services started on 10/08/24; -Last covered day of Medicare Part A skilled services on 10/28/24; -Facility initiated discharge from Medicare Part A services; -discharged to home on [DATE]; -Did not contain a NOMNC. During an interview on 11/20/24 at 1:30 P.M., the Administrator said the resident used 21 Medicare Part A days with 59 remaining. 5. During an interview on 11/20/24 at 1:30 P.M., the Administrator said the previous Social Service Designee (SSD) left employment with the facility in June 2024 and he/she has been responsible since that time to ensure the NOMNCs were completed timely. The Administrator said he/she did not start completing the notices until this month. The Administrator said he/she knows he/she is ultimately responsible to ensure the notices are completed, but he/she did not do them due to trying to cover too many roles in the facility. The Administrator said if the facility initiates a Medicare Part A discharge the NOMNC should be issued and signed by the resident or the responsible party at least 48 hours prior to the Medicare Part A last covered date. The administrator said the NOMNC's had not been completed correctly.

Based on interview and record review, facility staff failed to check the Employee Disqualification List (EDL) a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident), criminal background check (CBC), Family Care Safety Registry (FCSR), and Nurse Aide (NA) Registry prior to hire in accordance with their facility policy for three employees (Licensed Practical Nurse (LPN) V, Housekeeper W, and Dietary Aide (DA) X) out of six sampled employees. The facility census was 47. 1. Review of the facility's policy titled Background Investigations, revised 12/12/23, showed employee background checks, licensure verification, and criminal conviction record checks are conducted on all personnel making application for employment. The facility will not employ persons having a findings entered into the state nurse aide registry, or disciplinary action on his/her professional license regarding abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of property. 2. Review of DA X's personnel file showed: -Date of hire 08/09/24; -FCSR letter dated requested 08/14/24 and received 08/29/24; -CBC requested 08/14/24 and dated 08/29/24. Review of DA X's timecard showed his/her first day of work as 08/09/24. 3. Review of Housekeeper W's personnel file showed: -Date of hire 10/28/24; -FCSR letter requested and recieved on 10/30/24; -EDL verification dated 11/19/24; -Did not contain documentation of CBC or NA Registry verification. Review of Housekeeper W's timecard showed his/her first day of work as 10/28/24. 4. Review of LPN V's personnel file showed: -Date of hire 11/04/24; -Did not contain documentation of a FCSR or CBC. Review of LPN V's timecard showed his/her first day of work as 10/07/24. 5. During an interview on 11/20/24 at 8:30 A.M., the Administrator said he/she is responsible to complete the pre-employment screenings on all new hires since June 2024. The administrator said once the facility decides to hire a new employee, he/she completes the pre-employment screenings of the FCSR, CBC, EDL, and NA registry checks. The administrator said all screenings should be completed prior to the employee's date of hire. The administrator said the reason pre-employment screenings were late or did not get done is due to him/her having too many job roles in the facility since the change of ownership and things just get missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility staff failed to thoroughly complete a quarterly Minimum Data Set (MDS), a federally mandated assessment tool, as directed by the Resident Assessment Instrument (RAI) manual for four residents (Resident #1, #2, #4, and #11) out of twelve sampled residents. The facility census was 47. 1. Review of the RAI manual, dated 10/1/2024, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. -The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status; -The assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts; -Section C, Cognitive Patterns, determines the resident's attention, orientation, and ability to register and recall information, and whether the resident has signs and symptoms of delirium; -A dash value indicates that an item was not assessed; -Residents should be the primary source of information for resident assessment items; -Most residents are able to attempt the Brief Interview for Mental Status (BIMS), a structured cognitive interview; -A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance; -Without an attempted structured cognitive interview, a resident might be mislabeled based on their appearance or assumed diagnosis; -Structured interviews will efficiently provide insight into the resident's current condition that will enhance good care; -Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted but was not done. 2. Review of Resident #1's Quarterly MDS, dated [DATE], showed the resident interview portion of the BIMS assessment and mood assessment coded as not assessed. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed the resident interview portion of the BIMS assessment and mood assessment coded as not assessed. 4. Review of Resident #4's Quarterly MDS, dated [DATE], showed the resident interview portion of the BIMS assessment coded as should not be assessed due to being rarely/ never understood and the staff interview portion of the assessment coded as not assessed. Review showed the resident mood assessment coded as should not be assessed due to being rarely/never understood and the staff interview portion coded as not assessed. 5. Review of Resident #11 Quarterly MDS, dated [DATE], showed the resident interview portion of the BIMS assessment blank and the staff interview portion of the assessment coded as not assessed. Review showed the resident interview of the mood assessment coded as not assessed and the staff interview portion coded as not assessed. 6. During an interview on 11/21/24 at 11:42 A.M., The MDS coordinator said he/she has been in this position since May, but has been working night shifts. The DON was the back up person for completing MDS assessments. During an interview on 11/21/24 at 11:46 A.M., the Director of Nursing (DON) said the Social Services Director (SSD) is supposed to complete the resident interview assessments. The DON said the SSD did not complete the assessments, so when the MDS assessment came due he/she did not have the information and coded the assessments as not assessed. The DON said he/she did not complete the assessments himself/herself,because he/she had been instructed by corporate to not do the SSD's job. During an interview on 11/21/24 at 1:02 P.M., the Administrator said the DON is the Registered Nurse (RN) responsible for checking the MDS input since the MDS Coordinator is a Licensed Practical Nurse. The Administrator said he/she did not know at the time the MDS assessments were not being done correctly. The SSD had been responsible for the BIMS portion. The Administrator said he/she became aware last month the assessments were not done correctly. The SSD did not do his/her job. The DON who is an RN signs off and would be responsible as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to review and revise the comprehensive care plan for two residents (Resident #4 and #5) for changes in Activities of Daily Living (ADL) needs, one resident (Resident #8) who developed a pressure ulcer, and for one resident (Resident #11) with weight loss out of a sample of 12 residents. The facility census was 47. 1. Review of the facility policy titled, Comprehensive Care Plans, dated 06/02/2022, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, professional standards of practice, medical provider orders, and resident's goal and preferences. The comprehensive care plan will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS - a federally mandated assessment tool) assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 2. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as dependent on staff for chair/bed to-chair transfers and used a wheelchair for transportation with staff assistance. Review of the resident's care plan in use during the survey, dated 07/20/23, showed staff documented the resident required assistance from two staff members with transfers. The care plan did not contain interventions on how to transfer the resident. Observation on 11/18/24 at 3:22 P.M., showed staff transferred the resident with a mechanical lift. During an interview on 11/21/24 at 10:08 A.M., Certified Nurse Aide (CNA) G said staff use a mechanical lift to transfer the resident. The CNA said staff know how to transfer the resident from communication with the nurses, but it should be in the resident's care plan. During an interview on 11/21/24 at 10:11 A.M., the Assistant Director of Nursing (ADON) said the resident required a mechanical lift for transfers and this should be on the care plan. The ADON said the MDS coordinator is responsible for updating the care plans and in his/her absence the Director of Nursing (DON) is responsible. During an interview on 11/21/24 at 11:50 A.M., the MDS coordinator said if a resident required a mechanical lift for transfers the care plan should show it. The MDS coordinator said if the care plan shows a resident required assistance from two staff members for transfers and staff are using a mechanical lift the care plan is inaccurate. The MDS coordinator said he/she is not sure why it had not been updated. During an interview on 11/21/24 at 12:17 P.M., the DON said the resident's care plan should be updated to showed the resident required a mechanical lift for transfers. He/She said it was an oversight that it was not updated. During an interview on 11/21/24 at 1:05 P.M., the Administrator said the resident's transfer needs should be accurate on the care plans. The MDS coordinator is responsible for updating the care plans. It is ultimately the responsibility of the DON to ensure the care plans are complete and accurate. 3. Review of Resident #5's Annual MDS, dated [DATE], showed staff assessed the resident as dependent on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility and transfers. Review of the resident's care plan, revised 11/15/24, showed staff documented the resident required assistance from one staff member with bathing, dressing, personal hygiene and oral care, and toileting. The resident required supervision from staff for bed mobility and transfers. Observation on 11/20/24 at 10:20 A.M., showed CNA C and CNA G assisted the resident with a transfer from the bed to his/her wheelchair with the use of a gait belt. During an interview on 11/21/24 at 10:04 A.M., CNA G said the resident required assistance from two staff members for transfers and was dependent on staff for cares. The CNA said this should be in the resident's care plan, but it was not. The care plan needed to be updated. During an interview on 11/21/24 at 10:15 A.M., the ADON said the resident required two staff members for transfers and sometimes used a mechanical lift. The ADON said one staff assist with ADLs was not accurate anymore. The ADON said the resident's care plan should say two staff assist with ADLs and mechanical lift as needed. During an interview on 11/21/24 at 11:50 A.M., the MDS Coordinator said the resident had a change in his/her ADL care and it should have been added to the care plan. The MDS Coordinator said he/she was aware the resident required assistance from two staff members for transfers. The MDS Coordinator said the care plan should have been updated to show the resident was a two person assist with ADLs. During an interview on 11/21/24 at 12:01 P.M., the DON said he/she would expect a decline in ADLs to be updated on the care plan. The DON said the MDS Coordinator was responsible, but while the MDS Coordinator was gone, he/she tried to keep up with the care plan updates and had a hard time unfortunately. The DON said the resident's care plan for one staff assist was not accurate for the resident at this time. During an interview on 11/21/24 at 1:03 P.M., the Administrator said ADL declines should be on the resident's care plan. The Administrator said the nurses should notify the MDS Coordinator in the morning meeting and the MDS Coordinator should update the care plans. The Administrator said the responsibility of care plans ultimately falls on the DON. 4. Review of Resident #8's admission MDS, dated [DATE], showed care area triggered for pressure ulcers and should be on the care plan. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -At risk for pressure ulcers; -No pressure ulcers; -Pressure reducing devices in chair and bed; -Used a wheelchair; -Required partial to moderate assist for toileting, shower/bathe self; and personal hygiene. Review of the resident's weekly skin assessment, dated 10/03/24, showed staff documented a new unstageable pressure ulcer (wound can not be staged because the wound is covered by necrotic tissues and eschar (dead tissue that eventually sloughs off healthy skin after an injury) on his/her right heel measured 5 centimeters (cm) x 3 cm with eschar. Review of the resident's Physician Order Sheet (POS), dated October 2024, showed orders: -On 10/4/24 for heel protectors to feet and/or float heels on pillow every day and night shift for wound care; -On 10/5/24 to apply skin prep to right heel daily. Review of the resident's care plan, dated 11/15/24, showed the care plan did not contain direction for staff in regard to the resident's risk for developing pressure ulcers or current pressure ulcers. During an interview on 11/21/24 at 10:13 A.M., CNA G said pressure ulcers should be on the care plan and should include what cares need to be done for the resident. The CNA said interventions like heel protectors, pillows, or other items to help with pressure relief should be listed on the care plan. CNA G said he/she did not know the resident's care plan did not contain interventions for pressure relief. The MDS Coordinator is responsible for updating the care plans. During an interview on 11/21/24 at 10:15 A.M., Licensed Practical Nurse (LPN) E said pressure ulcers should be on the care plan and he/she did not know the care plan did not address the resident's pressure ulcer. LPN E said anyone can update the care plans, but it is usually nurses that update it, and pressure ulcers should be on the care plan. LPN E said he/she believed the resident's pressure ulcer started around the first part of October 2024, so it should be on the care plan. During an interview on 11/21/24 at 10:18 A.M., the ADON said pressure ulcers should be on the care plan if the resident has one or if they are at risk for developing one. The ADON said the care plan should contain what treatments and pressure relief interventions are used. He/she said typically the MDS Coordinator or DON update the care plans, but any nurse can add small changes. The ADON did not know the care plan did not contain information in regard to the resident's pressure ulcer. During an interview on 11/21/24 at 10:50 A.M., the DON said the MDS Coordinator had been pulled to work the floor for two to three months, so he/she had been helping with care plans. The DON said pressure ulcers should be on the care plan, and he/she did not know the resident's new pressure ulcer had not been added. The DON said it is important to be on the care plan so that the whole team can be aware of what the treatments are, and he/she takes full responsibility for it not being on there. During an interview on 11/21/24 at 10:50 A.M., the Administrator said pressure ulcers should be on the care plan, and he/she did not know the resident's care plan had not been updated. The Administrator said it is important to be on the care plan so the whole team can be aware of what the issue is and so everyone can be involved and treatments are carried out for the resident. The Administrator said the responsibility of care plans ultimately falls on the DON. During an interview on 11/21/24 at 11:51 A.M., the MDS Coordinator said he/she has been the MDS coordinator since May 2024, but had been pulled to work night shift, so the DON had been updating care plans. The MDS Coordinator said pressure ulcer prevention and if a resident actually has a pressure ulcer should be on the care plan. He/she said it would be important so everyone is aware to turn and reposition, to make sure the resident is clean and dry, to ensure nutritional needs are addressed and if they need boots or any other devices. The MDS Coordinator said he/she did not know the resident's pressure ulcer was not on the care plan, but it should be and he/she was working nights and missed it. 5. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident had a significant weight loss and received a mechanically altered diet. Review of the Dietitian Consult note, dated 08/09/24, showed the Registered Dietician (RD) documented the resident's August weight at 180 pounds (lbs), which is significantly decreased. Will recommend a house supplement with lunch. Review of the resident's November 2024 POS showed an order, dated 08/14/24, for staff to provide the resident with a house supplement at lunch daily. Review of the resident's care plan, revised 10/29/24, showed it did not contain direction for staff in regard to a house supplement at lunch. Observation on 11/18/24 at 12:48 P.M., showed unknown staff assisted resident at lunch. The resident was in his/her wheelchair at the table for residents who required staff assistance. The resident did not receive his/her lunch supplement. Observation on 11/19/24 at 12:21 P.M., the ADON sat down beside the resident at the table for residents who required assistance from staff in the lunch room. The ADON assisted the resident with bites of food and drinks. The resident did not receive a lunch supplement. During an interview on 11/21/24 at 10:07 A.M., CNA G said he/she did not know the resident got a house supplement at lunch. The CNA said it should be care planned if a resident gets a house supplement. During an interview on 11/21/24 at 10:09 A.M., the ADON said he/she did not know the resident was supposed to have a supplement for lunch, because he/she does not check the orders everyday. The ADON said the supplement should be on the resident's care plan. The ADON said he/she is not certain if it is on the resident's care plan. During an interview on 11/21/24 at 11:54 A.M., the MDS Coordinator said interventions for weight loss should be on the resident's care plan. The MDS Coordinator said he/she did not know the resident had an order for a supplement at lunch for the past three months. During an interview on 11/21/24 at 12:06 P.M., the DON said the supplement should have been added to the resident's care plan. The DON said he/she did not know why it had not added to the care plan, it had probably been missed. During an interview on 11/21/24 at 1:02 P.M., the Administrator said the resident's supplement should be on the care plan. The Administrator said the MDS Coordinator is responsible and so is the DON, who signs off on the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure the residents' environment remained free of accident hazards when facility staff failed to provide safe mechanical lift for two (Residents #1 and #4) out of two sampled residents and failed to store razors/sharps and hazardous chemicals in a safe manner not accessible to residents. The facility census was 47. 1. Review of the facility's undated policy, How to Use a Mechanical Lift, showed staff should spread the base of the lift to its widest possible position to maximize stability when raising the resident. When transferring a resident from the bed the legs of the base should be open and locked prior to attaching the resident sling. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/31/24 showed the resident was dependent on staff for chair/bed-to-chair transfers. Review of Resident #1's care plan, dated 12/01/23, showed staff documented the resident required the use of a mechanical lift for transfers. Observation on 11/18/24 at 12:06 P.M., showed Certified Nurse Aide (CNA) R and CNA U entered the resident's room with a mechanical lift and a tilt-in-space (wheelchair that can tilt backward) wheelchair. CNA R placed the lift under the bed with the legs of the lift closed, raised the resident, and moved the lift in front of the wheelchair without the base of the lift spread. 3. Review of Resident #4's quarterly MDS, dated [DATE] showed the resident was dependent on staff for chair/bed-to-chair transfers. Review of Resident #4's care plan, dated 07/20/23, showed staff documented the resident required assistance from two staff members for transfers. Observation on 11/18/24 at 3:22 P.M., showed CNA R and CNA T entered the resident's room. The CNAs lifted the resident in the mechanical lift with the legs of the lift in the opened position, moved the lift around the chair and closed the legs of the lift. The CNAs pushed the lift under the bed and lowered the resident to the bed with the legs of the lift closed. 4. During an interview on 11/18/24 at 12:19 P.M., CNA R said the legs of the lift should be open while moving the resident and closed when the lift is under the bed. The CNA said the legs of the lift should be open when it is being moved. The CNA said they were in their zone and that's why they did not open the legs of the lift. During an interview on 11/21/24 at 8:47 A.M., the Assistant Director of Nursing (ADON) said the legs of the lift should be open at all times. The legs of the lift should be open all the way anytime the resident is suspended in the air. The ADON said if the legs of the lift are not open all the way the resident could fall or the lift could tip over. During an interview on 11/21/24 at 12:17 P.M., The Director of Nursing (DON) said the legs of the lift should be closed during transfers and only open when maneuvering around a wheelchair. The DON said the legs of the lift should remain closed when under the bed and when the lift is turned. To put a resident in a chair staff may have to open the legs of the lift to get around the wheelchair. The DON said if the legs of the lift are open the lift is at risk for tipping over. During an interview on 11/21/24 at 1:124 P.M., the Administrator said the legs of the hydraulic lift should be open for stability during transfers. He/she said if staff are not opening the legs of the lift it could cause it to tip or the resident could fall and sustain injuries. The Administrator said staff have been in-serviced on this topic many times and he/she is unsure why they are performing unsafe transfers. 5. Review of the policies provided by the facility from 11/19/24 through 11/21/24, showed the records did not contain a policy related to the storage of razors/sharps and hazardous chemicals. Review of the product labels for the bottles of quaternary ammonium based disinfectant spray and all-purpose cleaner with bleach, showed warnings which directed the products were hazardous to humans, could cause eye and skin irritation, and were harmful if swallowed. Observations on 11/19/24 at 11:55 A.M. and 1:50 P.M. and on 11/20/24 at 9:20 A.M., showed the door to the 100 hall shower room unlocked and the room unattended by staff. Observation showed an opened box of shaving razors, a 12.5 ounce (oz.) bottle and a 32 oz. bottle of quaternary ammonium based disinfectant spray and a 34 oz. spray bottle of all-purpose cleaner with bleach stored unsecured in the room. Observation showed residents near by on the hall. During an interview on 11/20/24 at 9:20 A.M., the Maintenance Director said the razors and cleaning chemicals should be stored in a locked cabinet when not in use by staff and staff are trained on this requirement. The Maintenance Director said all staff are responsible for the proper storage of razors and chemicals and, while he/she looks as he/she goes around the building, he/she did not know if anyone had been assigned to monitor the storage of sharps and chemicals routinely. The Maintenance Director said the facility did have at least one resident that is confused and wanders. During an interview on 11/21/24 at 8:00 A.M., the Administrator said sharp items, such as razors, and hazardous chemicals should be stored behind a locked door and the maintenance director is responsible to monitor the storage of sharps and chemicals at least weekly. The Administrator said he/she did not know staff left razors and chemicals unsecured in the shower room.

Based on observation, interview, and record review, facility staff failed to reconcile narcotics at the change of shift when the medication cart changed from one staff member to another for four of four medication carts. The facility census was 47. 1. Review of the facility's policy titled Controlled Substance administration and Accountability, revised 04/07/22, showed the facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure. All controlled substances obtained from the medication cart or cabinet are recorded on the designated usage form, written documentation must be legible with all information provided. Areas without automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for 24 hour recording of controlled substances. The amount on hand is checked against the amount used from the documentation records. The entire amount of controlled substance obtained or dispensed is accounted for. 2. Review of the facility's Nurse Medication Cart Liquids on-coming and off-going narcotic count sheet, dated 11/1/24 through 11/21/24, did not contain two licensed staff signatures for narcotic counts at shift change from 11/2/24 to 11/21/24. 3. Review of the facility's Nurse Medication Cart Pills on-coming and off-going narcotic count sheet, dated 11/1/24 through 11/21/24, did not contain two licensed staff signatures for narcotic counts at shift change from 11/2/24 to 11/21/24. During an interview on 11/20/24 at 11:00 A.M., Licensed Practical Nurse (LPN) E said he/she is the charge nurse and responsible for the nurse cart. LPN E said the proper way to count narcotics is with two licensed staff members, the off-going and on-coming staff person, to ensure the narcotic count is correct. LPN E said not all agency staff have access to the narcotic count computer system. 4. Review of the facility's 100/200 Hall Medication Cart Liquids, on-coming and off-going narcotic count sheet, dated 11/1/24 through 11/21/24, did not contain two licensed staff signatures for narcotic counts at shift change from 11/2/24 to 11/21/24. 5. Review of the facility's 300 Hall Medication Cart Liquids, on-coming and off-going narcotic count sheet, dated 11/1/24 through 11/21/24, did not contain two licensed staff signatures for narcotic counts at shift change from 11/2/24 to 11/21/24. 6. During an interview on 11/19/24 at 2:50 P.M., LPN F said the facility staff count narcotic cards with the computer system. He/She said the agency staff do not have access to the computer system to count or sign out a narcotic. LPN F said he/she does not count with the off-going licensed staff and just compares the computer count against the remaining amount in the cards to determine if there is a discrepancy. LPN F said the charge nurse or Certified Medication Technician (CMT) do not have access to a narcotic count log. LPN F said two licensed staff members should count narcotic medications with the change of the cart at the end of the shift. LPN F it should be the off-going and on-coming licensed staff counting narcotics to ensure when the staff accept the keys to the count is correct. During an interview on 11/19/24 at 3:10 P.M., CMT J said he/she is a day shift CMT and follows agency staff each shift. CMT J said he/she does not count narcotics with the off-going nurse due to agency staff not having access to the computer system to count. CMT J said he/he compares what the computer says to the amount in the cards. CMT J said there is no way to see a shift narcotic count. During an interview on 11/19/24 at 3:45 P.M., the Assistant Director of Nursing (ADON) said the facility changed from a paper narcotic count log to the computer system around June 2024 when the new company bought the facility. The ADON said not all agency staff have access to the narcotic count portion of the computer system and they do not use paper logs. The ADON said there is no way to pull a 24-hour narcotic count report showing the off-going and on-coming staff responsible. The ADON said the proper way to count narcotics is with two licensed staff members, the off-going and on-coming person, and both sign the narcotic count log ensuring the count is correct. During an interview on 11/20/24 at 5:30 A.M., LPN O said he/she is an agency nurse who works at the facility occasionally. LPN O said he/she did not have access to the computer narcotic counting system until a few days ago. LPN O said prior to the past few days he/she did not complete shiftly narcotic counts due to not having computer access. LPN O said the proper way to count narcotics is with two licensed staff, one being the off-going and one being the on-coming staff person. During an interview on 11/20/24 at 5:45 A.M., CMT P said not all agency staff have access to the computer narcotic count system and he/she is not always able to count with the off-going staff. During an interview on 11/20/24 at 1:30 P.M., the DON said narcotic counts should be completed with the computer narcotic count system and the card. The DON said not all agency staff have access to the narcotic count system and in order for the count to be correct they would need access. The DON said the facility does not keep paper narcotic count logs anymore and this changed when the facility changed ownership a few months ago. During an interview on 11/20/24 at 1:40 P.M., the Administrator said the facility changed ownership in June 2024 and at that time converted to a computer narcotic count system. The Administrator said he/she is aware not all agency staff have access to the narcotic computer count system and he/she is working to get them access. The Administrator said the proper way to count narcotics is with the off-going and on-coming licensed staff members.

Based on observation, interview, and record review, facility staff failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of bacteria and other infection causing contaminants during the provision of care for two residents (Residents #40 and #53) out of a sample of two residents. Staff failed to perform appropriate hand hygiene during incontinence care for two residents (Residents #1 and #4) out of a sample of 12. The facility census was 47. 1. Review of the facility's policy titled Enhanced Barrier Precautions, revised 12/12/23, showed the facility will implement EBP for the prevention of transmission of multidrug-resistant organisms (MDRO). EBP refers to the use of gown and gloves for use during high-contact resident care activities for resident known to be colonized or infected with a MDRO as those at increase risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Make gowns and gloves available immediately outside the resident's room. The Infection Preventionist (IP) will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care urinary catheters, central lines, feeding tubes, tracheostomy and wound care. 2. Observation on 11/18/24 at 1:00 P.M., showed outside of Resident #40's room an EBP stop sign with instruction for staff to wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device and wound care. Observation on 11/18/24 at 1:02 P.M., showed Registered Nurse (RN) D, RN U and Certified Nurse Aide (CNA) C entered the resident's room to perform perineal care. The resident had an indwelling catheter. RN D, RN U and CNA C entered the resident's room, washed hands and applied gloves. Observation showed the staff provided perineal care and did not wear gowns throughout the care. Observation showed the resident's room or outside the room did not contain gowns. During an interview on 11/18/24 at 1:08 P.M., CNA C said staff provided perineal care to the resident. The CNA said he/she did not know if the resident was on EBP or what EBP was. The CNA said he/she did not know if he/she was supposed to wear a gown when he/she provided care for the resident. The CNA said no one had taught him/her about EBP. During an interview on 11/18/24 at 1:13 P.M., RN D said EBP was required for the resident if staff was emptying his/her catheter bag, but not for perineal care. The RN said staff had EBP training about six months ago. The RN said he/she provided perineal care. 3. Observation on 11/19/24 at 10:00 A.M., showed outside of Resident #53's room an EBP stop sign with instruction for staff to wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device and wound care. Observation on 11/19/24 at 10:05 A.M., showed CNA S applied gloves and transferred the resident from the wheelchair to the bed and placed a catheter bag on his/her pant leg. The CNA removed the resident's pants and brief and moved the catheter bag to the bed frame. The CNA did not wear a gown. During an interview on 11/19/24 at 10:19 A.M., CNA S said EBP was required when a resident had a colostomy bag, catheter, or a wound. The CNA said staff should wear a gown with a resident who requires EBP. The CNA said they were nervous and that is why they did not wear a gown to provide care. 4. During an interview on 11/20/24 at 3:00 P.M., the IP/Assistant Director of Nursing (ADON) said staff should wear a gown and gloves when providing perineal care for residents with a catheter. The IP said he/she does not know why staff did not wear gowns. The IP said staff has been inserviced on handwashing, personal protective equipment (PPE), and EBP. The IP said staff should wear a gown and gloves when providing care for residents who require EBPs. He/She said staff should have had gowns on before before they removed resident #53's brief. During an interview on 11/21/24 at 12:15 P.M., the Director of Nursing (DON) said staff have been educated on EBP and know they should wear gowns and gloves when they provide care. The DON said staff should have worn gowns and gloves during perineal care. The DON said EBP should be used for residents who have a catheter, a wound, and MDROs. There are informational signs outside of the residents' doors and staff are directed to use a gown and gloves when providing direct patient care. He/she said EBP is for the residents' protection. Staff were educated and continue to receive education weekly about EBP. During an interview on 11/21/24 at 1:08 P.M., the Administrator said staff should wear a gown, gloves and mask for care with residents on EBP. The administrator said staff should have worn a gown when providing perineal care due to the residents' catheter. The Administrator said if the staff does not wear a gown, there is a risk of infection. The Administrator said staff have been trained multiple times and he/she doesn't know why staff did not wear gowns. 5. Review of the facility's policy titled Hand Hygiene, revised May 2022, showed the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (applying) gloves and immediately after removing gloves. 6. Observation on 11/18/24 at 12:06 P.M., showed CNA R entered Resident #1's room with perineal care supplies, performed hand hygiene and applied clean gloves. The CNA cleaned the resident's bottom and removed the lift pad. With the same gloves on the CNA placed a clean brief, cleansed the resident's perineal area, removed an incontinence pad from under the resident, put a lift pad under the resident, and put on a clean brief and pants. The CNA removed his/her gloves, did not perform hand hygiene, and covered the resident with a blanket and lowered the bed. During an interview on 11/18/24 at 12:19 P.M., CNA R said gloves should be changed and hands should be washed every time a resident is touched. The CNA said he/she should have washed his/her after providing care. The CNA said he/she did not perform hand hygiene because she/she was nervous and in the zone. 7. Observation on 11/18/24 at 3:22 P.M., showed CNA T entered Resident #4's room, performed hand hygiene and gathered supplies for perineal care. The CNA tucked the lift pad under the resident and rolled him/her while he/she removed the resident's pants and soiled brief. The CNA used wipes to clean the resident's back side, rolled the resident over, and with the same gloves on, undressed the resident, cleansed the resident's perineal area, and touched the resident's blanket. The CNA removed gloves, performed hand hygiene, applied barrier cream to the resident's bottom, removed gloves, did not perform hand hygiene and touched the resident's blanket. 8. During an interview on 11/20/24 at 3:18 P.M., the ADON/IP said staff should change their gloves and wash their hands when providing perineal care, when moving from dirty to clean tasks, when their gloves are soiled, and before and after care. During an interview on 11/21/24 at 12:12 P.M., the DON said hand hygiene should be done when moving from a dirty to clean task, and before and after perineal care. If hand hygiene is not completed, staff could be spreading bacteria to other residents or staff. During an interview on 11/21/24 at 1:08 P.M., the Administrator said staff should perform hand hygiene all the time when providing perineal care, before and after care, when moving from a dirty to clean tasks and anytime they change gloves. If staff do not perform hand hygiene appropriately, they could spread bacteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to properly document the resident's discharge summary and failed to arrange for the resident's medications to be sent to the pharmacy upon discharge from the facility for one resident. (Resident #1) The facility census was 47. 1. Review of the facility's Medications and Discharge policy, undated, showed staff are directed as follows: -A post-discharge plan of care that is developed with the participation of the resident and his/her family, which will assist the resident to adjust to his/her new living environment. A post-discharge plan of care means the discharge planning process which includes: assessing continuing care needs and developing plan designed to ensure the individual's needs will be met after discharge from the facility; -Ensure the discharging resident has immediate access to medications is considered part of the nursing facility's responsibility in planning post-discharge care. It is a requirement that a physician's order be obtained and instructions given before releasing any medications to the resident or the resident's designee. Furthermore, the facility shall maintain records of medications released to the resident, designee, or the pharmacy upon discharge. The type of pay for the medications should be considered when deciding whether or not to request a physician's order to send the current medications at the facility with the resident. Medicare Part A resident's medications are covered under Skilled Nursing Facility Prospective Payment System (SNF PPS) per the Medicare Benefits Policy Manual. Medicaid resident's medications are paid by the state Medicaid agency (MO Healthnet); -For Medicare Part A PPS residents, the facility is required to pay for all medications while the resident is in the Medicare stay. Upon discharge from the Medicare stay, the facility would not be expected to send the unused current medications with the resident. However, the facility is expected to foresee that the resident will need prescriptions filled and make arrangements with the physician to call in prescriptions to the pharmacy of the resident's/designee's choice; -Medications are just one important consideration when discharging resident's from your facility. This is why there is the post discharge plan of care requirement. Proper discharge takes careful consideration and planning ahead. Make sure your care planning team is aware of these requirements. 2. Review of Resident #1's discharge minimum data set (MDS) assessments, a federally mandated assessment tool, showed the resident discharged from the facility on 11/9/23. Review of the resident's medical record showed the resident discharged from the facility on 11/9/23. Review of the medical record showed the record did not contain a discharge summary. Review of the resident's Physician Order Sheets (POS's), dated 11/1/23-11/27/23, showed the medical record did not contain an order to release medications to the resident. Review showed the medical records did not contain documentation staff notified the physician or pharmacy. Review of the resident's progress notes, dated 11/1/23-11/27/23, showed the progress notes did not contain documentation the physician notified of the anticipated discharge, or medications had been sent to the pharmacy. Review of the resident's hospital Discharge summary, dated [DATE], showed the resident continue all current medications as previously ordered with the addition of Meclizine (medication used for dizziness) 12.5 milligrams. Review showed the hopsital staff called Meclizine 12.5 mg into the pharmacy. During an interview on 11/27/23 at 9:00 A.M., the resident said he/she was discharged from the facility on 11/9/23. He/She said there was an appointment pre-determined for a surgery at the hospital and when he/she discharged from the hospital he/she went to the facility to pick up his/her belongings and the nurse in charge refused to give him/her the medications or to call them into the pharmacy. The resident said the hospital did not call in any of his/her medications because they thought the nursing home did so he/she went without pain medications all weekend after surgery until he/she was able to get ahold of his/her primary care physician. The resident said he/she was discharged from the hospital to home after his/her surgery. During an interview on 11/27/23 at 2:00 P.M., Licensed Practical Nurse (LPN) C said anytime a resident is discharged from the facility they are always told about the discharge and the residents belongings and medications are always sent with the resident. He/She said however for the resident when he/she and his/her family asked for them when they picked up his/her belongings the DON refused to send the medications with him/her. During an interview on 11/27/23 at 2:30 P.M., the Administrator said the resident was given a notice of discharge on [DATE] for a scheduled surgery on 11/9/23. He/She said the plan the entire time was for the resident to be discharged for the surgery and he/she would not return. He/She said the medications were not given to the resident when he/she discharged because there was not an order to do so per the DON. The Administrator said he/she was unaware as to why the discharge summary was not completed for resident or why plans were not in place for his/her discharge because that was the plan the entire time, was for him/her to discharge from their facility then go for his/her outpatient surgery then return home. During an interview on 11/27/23 at 2:45 P.M., the DON said the resident and his/her family asked for medications and he/she said there were not orders to send the medications with him/her so he/she refused to do so. The DON said he/she did not try to call the physician to get an order because there was no time, the resident got upset and left. He/She said the Social Service Director (SSD) is the one responsible to do the discharge summary so he/she does not know why it was not completed as the plan was for him/her to discharge to the hospital to have surgery and would not return to the facility. The DON said he/she had spoke to the hospital therapist who said he/she was ready for discharge and wanted to know if their therapy department was done so he/she spoke to them and everyone agreed he/she was ready for discharge. He/She said it would be the expectation since the resident was at the hospital they would have provided him/her with scripts for medications. During an interview on 11/27/23 at 2:55 P.M., the Regional Director said the resident was on Medicare A services so the medications would not have been sent with the resident. He/She did not know how the resident would get his/her medications but said he/she had just been discharged from the hospital so would expect the hospital to send in the medication requests. During an interview on 12/6/23 at 1:37 P.M., the SSD said he/she is brand new to the facility and has only been the SSD for two weeks now. He/She said a discharge summary or plan should be started upon admission but did not know why one was not completed. During an interview on 11/27/23 at 3:30 P.M., the pharmacy staff said they had not received any prescriptions called in by the hospital or the facility for Resident #1. MO00227333, MO00227282

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to follow physician orders for monitoring one resident's (Resident #15) dialysis port (a place to reach the blood for dialysis which is a procedure to purify the blood of a person whose kidneys are not working normally) and failed to maintain ongoing communication with the dialysis clinic. The facility census was 49. 1. Review of the facility's Hemodialysis policy, reviewed 11/2/23, showed this facility will provide the necessary care and treatment, consistent with professional standards of practice, medical provider orders, the comprehensive person-centered care plan, and the resident's goals and preference, to meet the special medical nursing, mental, and psychosocial needs of residents receiving hemodialysis. This will include: -The ongoing assessment of the resident's condition and monitoring for complications, implementation of appropriate intervention, and using appropriate infection control practices and; -Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility will coordinate and collaborate with the dialysis facility to assure that: a. The resident's needs related to dialysis treatment are met; b. Documentation requirements are met to assure that treatments are provided as ordered buy the physician, medical provider, and dialysis team; c. There is ongoing communication and collaboration for the development, coordination, and implementation of the dialysis care plan by nursing home and dialysis staff. The care plan should identify both nursing home and dialysis staff responsibilities. -The facility shall receive a dialysis summary report from the dialysis center upon return from dialysis. If the report is not received, nursing staff will contact the dialysis center to receive report; -The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications; -The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the medical provider, dialysis facility and/or nephrologist. Review of the facility's Long Term Care Facility Outpatient Dialysis Services Coordination agreement, dated 09/18/18, showed the Long Term Care Facility shall provide for the interchange of information useful or necessary for the care of End Stage Renal Disease (ESRD), Residents, including a contact person at the Long Term Care Facility whose responsibilities include assisting with the coordination of Renal Dialysis Services for ESRD residents. Review of the Resident #15's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required specialized treatment of dialysis; -Diagnoses of renal (kidney) insufficiency, renal failure, diabetes, hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), pulmonary problems, and vision problems. Review of the resident's Physican Order Sheet (POS), dated 10/23 showed an orders for staff to: -Monitor dialysis access site. If bleeding, apply pressure to site and notify physician immediately. Do not leave resident alone until bleeding has stopped or until until Emergency Medical Services (EMS) arrives; -Monitor dialysis fistula (a surgically placed connection between and artery and vein for the purpose of dialysis) every shift for thrill (a vibration caused by blood flowing through the fistula and can be felt by placing fingers just above the incision line) and bruit (a sound heard through a stethoscope; a murmur). If no thrill or bruit noted, notify MD. Review of the resident's care plan, dated 03/31/23, showed the following: -Resident received dialysis on Monday, Wednesday, and Friday; -Review communication form or flow sheet after treatment and implement new orders or recommendations; -Monitor/document/report to MD as needed an signs or symptoms of infection to dialysis access site: Redness, Swelling, warmth or drainage. Review of the resident's Treatment Administration Record, dated October 2023 showed staff did not document they monitored the resident's dialysis access/AV fistula on 10/08/23, 10/12/23, 10/13/23, 10/17/23, 10/21/23, 10/24/23, and 10/26/23. During an interview on 10/31/23 at 10:30 A.M., the resident said when he/she returns from dialysis, staff did not assess his/her fistula or check his/her vital signs. During an interview on 11/02/23 at 9:17 A.M., the Director of Nursing (DON) said nursing monitored the port site after dialysis and documented this on the TAR. He/She said the dialysis center called if there were any concerns or problems and there was a dialysis notebook carried in the resident's backpack. During an interview on 11/03/23 at 9:20 A.M., the Licensed Practical Nurse (LPN) Q and Registered Nurse (RN) P said a resident on dialysis should be monitored for bleeding and the physician orders for monitoring should be carried out as directed by the physician. If a resident was not monitored for bleeding, complications in medical care could adversely affect the resident. LPN Q and RN P said when a resident went out to dialysis the dialysis facility should send back information regarding the resident. The nurse should document information in the medical record, and the sheet should be uploaded to the electronic medical record under documents. During an interview on 11/03/23 at 11:19 A.M., the administrator, DON and Regional Director of Operations said the communication from the dialysis center was rare, and the dialysis center only called to notify if the resident would be returning early or late. The dialysis center was expected to send communication paperwork back with the resident, and all physician orders for monitoring post-dialysis should be followed by the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical, and nursing needs when staff failed to address advanced directives, hospice, use of heel boots, use of a Broda chair (reclining wheelchair), and Activities of Daily Living (ADL)s (meal assistance, transfer techniques) specific to one resident (Resident #5), failed to address bowel and bladder, advanced directives, pressure ulcer prevention, and hospice for one resident (Resident #27), and failed to address meal assistance and risk of/actual weight loss for one resident (Resident #30). The facility census was 49. 1. Review of the facility's Care Planning-Interdisciplinary Team policy, reviewed 01/2017, showed facility staff are directed to: -Upon completion of comprehensive assessments, Care Area Assessment (CAA) Summaries will be triggered to flag areas of concern that may need to be addressed in the Plan of Care (POC) for each resident. Each triggered CAA will be reviewed by designated staff to determine if a triggered even affects the resident's function and quality of life or if the resident is at significant risk of developing the triggered condition. -While CAAs identify common areas of concern in nursing home residents, the POC is not to be limited the triggered areas. The comprehensive POC is not to be limited to the triggered areas. The comprehensive POC must address all care issues that are relevant to the individual, whether or not they are specifically covered in the Comprehensive Assessment process. The policy did not include directions for consultation the resident and the resident's representatives. 2. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required total assistance of one staff for bed mobility, dressing, hygiene, and bathing; -Required total assistance of two staff for transfers; -Had a pressure ulcer; -At risk for pressure ulcers. Review of the resident's care plan, revised on 05/22/23, showed the staff were directed to do the following: -Low bed; -Did not contain direction for code status; -Did not contain direction for hospice care; -Did not contain direction for bilateral foot boots at all times; -Did not contain direction for the use of a Broda chair -Did not contain specific directions for Activities of Daily (ADLs) such as mechanical lift transfers, meal assistance, and the amount of care assistance the resident required. Observation on 10/31/23 at 10:41 A.M., showed the resident sat in his/her room in a Broda chair with a mechanical lift pad under him/her. Observation on 10/31/23 at 11:58 A.M., showed the resident sat in the dining room at an assist dining table in a Broda chair. Observation on 11/01/23 at 9:00 A.M., showed the resident lay in a regular bed. Observation on 11/01/23 at 9:19 A.M., showed the resident wore a heel boot on his/her left foot only. Observation on 11/01/23 at 9:22 A.M., showed CNA F and CNA H performed a mechanical lift transfer on the resident from his/her Broda chair to his/her bed. Observation on 11/01/23 at 11:05 A.M., showed the resident lay in a regular bed with a heel boot on his/her left foot only. Observation on 11/01/23 at 1:50 P.M., showed the resident lay in a regular bed. Observation on 11/02/23 at 8:12 A.M., showed the resident lay in a regular bed. Observation on 11/02/23 at 9:48 A.M., showed the resident sat at the nurse's station in his/her Broda chair and wore a heel boot on his/her left foot only. Observation on 11/03/23 at 8:30 A.M., showed the resident sat in his/her Broda chair and wore no heel boots. Observation on 11/03/23 at 10:28 A.M., showed the resident sat in his/her Broda chair at the nurses station and worn no heel boots. 3. Review of Resident #27's nurses note, dated 08/15/23, showed the presence of a Stage II (the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) pressure wound to the coccyx (tailbone). Review of the resident's Braden Scale for Predicting Pressure Score showed on 08/15/23 and 08/22/23 staff assessed the resident was at mild risk for pressure ulcer development. Review of the resident's admission MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required physical assistance of one staff for bed mobility and transfers; -Did not toilet in the 7-day look back period; -Had an indwelling catheter (tube in the bladder to drain urine); -Incontinent of bowel; -Not at risk of developing a pressure wound; -Had no pressure wounds; -Did not use hospice; -Diagnosis of anemia and dementia. Review of the resident's Braden Scale for Predicting Pressure Score showed on 08/30/23 and 09/06/23 staff assessed the resident at moderate risk for developing pressure ulcers. Review of the resident's care plan dated 09/01/23 showed the following: -Daily skin assessments, report abnormalities to the nurse; -The care plan did not contain documentation of the use of an indwelling catheter, the discontinuation of an indwelling catheter, an individualized toileting plan, advanced directives, pressure ulcer prevention strategies, and addition of hospice services. Review of the resident' record showed the following: -On 09/20/23, a change to hospice services; -On 10/08/23, a nurse note showed the resident's indwelling catheter was removed and not replaced; -On 10/26/23, a physician order for Do Not Resuscitate (DNR). Observation on 11/01/23 at 8:37 A.M., showed Certified Nurse Aide (CNA) F and Certified Medication Technician (CMT) I provide bowel and bladder incontinence care on the resident. Further observation showed a pressure wound to the coccyx and heel and lack of an indwelling catheter. During an interview on 11/01/23 at 8:37 A.M., CNA F said the resident was incontinent and had wound on the coccyx and heels. He/She said the resident's catheter was removed a while ago. 4. Review of Resident #30's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, dressing, toileting, hygiene; -Required total assistance of two staff for transfers, and bathing; -Required limited assistance of one staff for eating. Review of the resident's care plan, revised 11/02/23 showed the staff were directed to do the following: -Regular diet; -Able to hold a cup and eat finger foods independently; -Did not contain direction for assistance with meal set up; -Did not contain direction for weight loss risk and weekly weights. Review of the Physician's Orders (POS), dated 11/02/23 showed the resident had an order for No Added Salt (NAS) diet with regular texture. Observation on 10/31/23 at 10:32 A.M., showed the resident had deformed fingers in both hands. Observation on 11/02/23 at 8:40 A.M., showed the Director of Nursing (DON) served the resident his/her breakfast tray on a white plate with regular silverware. Further observation showed the DON sat the resident upright in his/her bed and prepared his/her tray for him/her. The resident ate his/her breakfast after the DON assisted him/her with tray set up. Observation on 11/03/23 at 8:35 A.M., showed CNA F served the resident his/her breakfast tray but did not assist him/her to prepare his/her food. Further observation showed NA K later offered to open his/her silverware and assist the resident with his/her butter and sugar for the oatmeal. Observation showed the resident was served his/her meal on a white plate with regular silverware. During an interview on 11/03/23 at 10:44 A.M., CNA F said that the resident needs assistance with tray set up but is able to feed himself/herself. He/She said the resident needs assistance with cutting up his/her food, and putting condiments on his/her food. 5. During an interview on 11/03/23 at 09:00 A.M., the MDS nurse said updates to the care plans can be completed by any of the nurses while the CNAs only have access to view them. He/She said the care plans should be updated quarterly and with any significant change such as if they have new orders. The MDS nurse said he/she reviews the 24-hour report daily for changes in condition and updates the care plans at that time. He/She said a significant change is not required if a resident goes to the hospital and returns on hospice services such as resident #27 since the resident was out at the hospital longer than 24 hours. The MDS nurse said he/she was trained by a regional nurse and uses the RAI manual as a guide for the care planning process. The care plans should include code status, hospice, discharge planning, medical diagnosis, specialized treatments such as braces, medications, type of assistance needed specific to the resident and weights/nutrition and dialysis. He/She said she should have updated the care plan for resident #27 but just missed it. The MDS Coordinator said the care plan and physicians orders should match each other. During an interview on 11/03/23 at 11:19 A.M., the Director of Nursing (DON) said the CNAs have access to the care plan and the care plans should be individualized to include adaptive equipment, risks for weight loss and pressure, hospice, code status, and activities of daily living specific to the amount of assistance they need. He/She said all nurses can update the care plans. The DON said that the care plan should be updated quarterly, with any significant change, and as needed. He/She said the MDS Coordinator is ultimately responsible for ensuring the care plans are accurate and up to date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to maintain professional standards of documentation when staff failed to document wound measurements and appearance of wounds weekly for two residents (Resident #5 and #27), failed to follow physician orders for one resident (Resident #5) who was ordered the application of heel boots to both feet, failed to obtain and document weights as ordered daily for one resident (Resident #1) and weekly weights and dietary assistance for one resident (Resident #30). The facility census was 49. 1. Review of the facility's Skin and Wound Management policy, dated July 2017, showed: -The nurse shall describe and document/report the following: a full assessment of the pressure sore including location, stage, length, width and depth, presence of exudate (drainage), or necrotic (dead) tissue; -Pain assessment; -Resident's mobility status; -Current treatment, including support surfaces, and; -All active diagnosis. 2. Review of Resident #5's care plan, dated 05/22/23, showed the staff were directed to do the following: -At risk for pressure ulcers; -Follow facility policies/protocols for the prevention/treatment of skin breakdown; -Administer treatments as ordered and monitor for effectiveness; -Assess/record/monitor wound healing, measure length, width, depth where possible; -Assess and document status of wound perimeter, wound bed, and healing progress, report improvements/declines to the physician. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required total assistance of one staff for bed mobility, dressing, hygiene, and bathing; -Required total assistance of two staff for transfers; -Had a pressure ulcer; -At risk for pressure ulcers. Review of the resident's weekly skin assessments showed staff assessed the resident as follows: -07/07/23 no new change this week: right hip stage III (full thickness tissue loss), left hip stage I (non-blanchable reddening of the skin), bilateral buttock red, groin red and excoriated; but did not contain measurements; -07/14/23 no new change this week: right hip wound, left hip redness, left knee abrasion, groin redness, lower extremity folds redness; but did not contain measurements; -07/21/23 no new change this week: right hip stage III wound, coccyx redness, groin redness, all pressure points knees/ankle/heels; but did not contain measurements; -07/28/23 no new change this week: left hip two open areas, right hip one open area, groin redness; but did not contain measurements; -08/04/23 no new change this week: groin red, right hip wound, left buttock wound, redness to all pressure points such as heels/ankles/knees/coccyx, left knee abrasion; but did not contain measurements; -08/11/23 no new change this week and did not contain any further documentation. -08/18/23 no new change this week and did not contain any further documentation. -08/25/23 no new change this week and did not contain any further documentation; -09/01/23 no new change this week and did not contain any further documentation; -09/08/23 no new change this week and did not contain any further documentation; -09/15/23 no new change this week and did not contain any further documentation; -09/29/23 no new change this week: wounds to left heel and right hip; but did not contain any measurements; -10/06/23 no new change this week: wounds present left knee scab, left heel, right hip; but did not contain measurements; -10/13/23 no new change this week: wounds continue to left heel, left knee abrasion, right hip wound; but did not contain measurements; -10/26/23 no new changes this week: left heel wound and right hip wound; but did not contain any measurements. Review of the resident's Physician's Orders Sheet (POS), dated 11/02/23, showed the resident had orders for the following: -Boots to bilateral feet at all times for pressure reduction; -Weekly skin assessments. Observation on 11/01/23 at 9:19 A.M., showed the resident wore a heel boot on her left foot only. Observation on 11/01/23 at 9:22 A.M., showed Certified Nurse Assistant (CNA) H and CNA F provided care to the resident and the resident's left heel boot fell off. CNA H put the left heel boot back on the resident, but did not put a heel boot on his/her right foot. Observation on 11/01/23 at 11:05 A.M., showed the resident in his/her bed with a heel boot on his/her left foot only. Observation on 11/02/23 at 9:48 A.M., showed the resident sat at the nurse's station in his/her Broada chair with only a left heel boot on. Observation on 11/03/23 at 8:30 A.M., showed the resident sat in his/her Broada chair and wore no heel boots. Observation on 11/03/23 at 10:28 A.M., showed the resident sat in his/her Broada chair at the nurse's station and wore no heel boots. 3. Review of Resident #27's admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Cognitively impaired; -Required physical assistance of one staff for bed mobility and transfers; -Not a risk for developing pressure wounds; -Had no pressure wound. Review of the resident's POS, showed an order on 08/15/23 for skin assessment weekly every Tuesday on day-shift and document findings in weekly skin assessment. Review of the resident's nursing admission/readmission data collection form, dated 08/15/23, showed the assessment did not contain appearance of the stage II, the depth of the wound, or the presence of pain, exudate, or necrosis to the wound. Review of the resident's weekly skin assessments showed staff assessed the resident as follows: -08/22/23, staff assessed the resident had a small reddened area on the buttock did not contain any further documentation; -08/29/23, staff did not document assessment of the resident's buttock wound to show ongoing monitoring for improvement or decline; -09/05/23, staff did not document an assessment of the heel wound to show ongoing monitoring for improvement or decline; -09/12/23, staff did not complete an assessment; -09/20/23, staff did not complete an assessment when the resident returned from the hospital; -10/05/23, staff documented there were no new changes, the care plan was current, and an update was not needed and did not contain any further documentation; -10/12/23, no new changes this week, care plan is current, update not needed and did not contain any further documentation; -10/19/23, no new changes this week, care plan not reviewed and did not contain any further documentation; -10/26/23, no new changes this week, left heel open area continued and area on buttocks continued update not needed and did not contain any further documentation During an interview on 11/02/23 at 11:34 A.M., the Medical Director said he/she would expect staff to measure the size and depth of the wounds and document them per the facility protocol. During an interview on 11/03/23 at 9:00 A.M., Licensed Practical Nurse (LPN) Q and Registered Nurse (RN) P said the nurses were responsible to document weekly skin assessments in the electronic health record (EHR). RN P said measurements and appearance including maceration (the chemical disolving of muscle and other soft tissue) should be included in the weekly skin assessments. LPN Q said he/she believed the staff were educated on what and when to report for skin issues and documentation for skin assessments during orientation. LPN Q said the Director of Nursing (DON) did wound reports but said if it was not documented it was not done and they would not know if the wound was getting better or worse. During an interview on 11/03/23 at 11:23 A.M., the Director of Nursing (DON) said skin assessments should include the size, location, and description of wounds including scratches and bruising and be completed weekly by the RN, Assistant Director of Nursing (ADON) or DON. He/She said if measurements were not documented, it was not done and would not be able to tell if getting better or worse. During an interview on 11/03/23 at 9:00 A.M., the ADON said that the DON ultimately oversaw the wounds in the facility and completed a wound report. The ADON said that the weekly skin assessments should be completed by the treatment nurse and they were expected to document them accurately including the description of the wound, measurements, any drainage, and odor. He/She said if a wound was not documented on correctly then there is no way to know if it is getting better or worse and it could result in a negative outcome for the resident. During an interview on 11/03/23 at 11:19 A.M., the DON and Administrator both said that weekly skin assessments were currently being completed by a nurse on the floor and should be documented in the resident's chart. The DON said he/she expected the documentation to have measurements of the wound, a description, any drainage noted, etc. He/She said that if the documentation was not accurate then there is no way to tell if the resident's wound was getting better or worse. 4. Review of the facility's Weight Assessment and Intervention policy, dated January 2017, showed: -Nursing staff will weigh residents on admission, weekly for four weeks thereafter. If no weight concerns, weights will be obtained monthly; -Weights will be documented in the medical record. Review of the facility's Medical Provider Orders policy, dated 2021 showed staff should follow all medical provider orders timely unless there was an emergency that would temporarily delay the implementation of the order. 5. Review of Resident #1's admission MDS dated [DATE], showed staff assessed the resident as: -Unassessed cognitive status; -Diagnosis of diabetes, stroke and hemiplegia (paralysis of one side). Review of the POS, dated 11/02/23 showed an order on 09/19/23 for daily weights. Review of the resident's medical record showed staff documented the resident's weight on 9/19/23. Additional review showed the record did not contain further documented weights. 6. Review of the Resident #30's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, dressing, toileting, hygiene; -Required total assistance of two staff for transfers, and bathing; -Required limited assistance of one staff for eating. Review of the resident's care plan, revised 09/08/23, showed staff were directed to do the following: -Red plate and curved spoon at all meals; -Did not contain direction for weekly weights. Review of the resident's POS, dated 11/02/23, showed the resident had the following orders: -Curved spoon and red plate at all meals; -Weekly weights on Friday, start date 09/11/23. Review of the resident's weights showed staff did not document the resident's weight on 09/15/23, 09/29/23, 10/06/23, and 10/13/23. Observation on 10/31/23 at 10:32 A.M., showed the resident had impairments to his/her fingers on both hands. Observation on 11/01/23 at 8:55 A.M., showed staff served the resident his/her breakfast on a white plate with regular utensils. Observation on 11/02/23 at 8:40 A.M., showed the Director of Nursing (DON) served the resident his/her breakfast tray on a white plate with regular silverware. Observation on 11/03/23 at 8:35 A.M., showed staff served the resident his/her meal on a white plate with regular silverware. During an interview on 11/03/23 at 10:30 A.M., Dietary aide (DA) N said that the resident is served meals on a red plate as a therapy recommendation. He/She said the red plate broke about a week ago and they have no back up. He/She said he/she is not sure why the resident was not provided his/her curved spoon at meals since they do have that available to use. He/She said he/she knows there is an order for the resident to have a red plate and curved spoon at all meals. During an interview on 11/03/23 at 10:32 A.M., the therapy program manager said he/she was told two days ago that the residents red plate was broken and he/she thinks the Administrator was going to order a new one. During an interview on 11/03/23 at 10:44 A.M., CNA F and Nurse Assistant (NA) L both said they are not sure what the red plate is for or why the resident has not been getting served his/her meals on it. CNA F said he/she thinks the plate has an edge on it. CNA F said he/she isn't sure why the resident hasn't been served his/her curved spoon at meals either. During an interview on 11/03/23 at 9:00 A.M., the ADON and MDS Coordinator said neither knew why the resident had a red plate ordered or the significance of it being the color red, and why the resident was not being served his/her meals on it as ordered. The ADON said all weights were to be documented in to the resident's chart including daily, weekly, and monthly. He/She said the charge nurse made a list each day of who needed a weight. The CNAs obtained those weights and the charge nurse documented them in the chart. During an interview on 11/03/23 at 11:19 A.M., the Director of Operations said the resident's red plate was broken recently and the facility did not have a back-up plate. The Director of Operations said a new plate has been ordered and should arrive in a few days. During an interview n 11/03/23 at 11:19 A.M., the Administrator said he/she was not sure why the plate was red but the reason the resident had this special plate was it had tall sides on it and he/she could scoop up his/her food easier with it. The Administrator was not sure why the resident was not being served with his/her curved spoon as the order stated. During an interview on 11/03/23 at 11:19 A.M., the DON and Administrator both said that all physician's orders should be followed, and if something was not documented then it was not done. The DON said that all weights are documented in the resident's chart this includes daily, weekly, and monthly weights. He/She said he/she did not know why the resident did not have weekly weight documented per orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility staff failed to provide safe mechanical lift transfers for three residents (Resident #2, #5, and #27). The facility census was 49. 1. Review of the facility's policy titled, Safe Resident Handling/Transfers, revised 11/02/23, showed staff were directed to do the following: -Ensure residents are handled and transferred safely to prevent or minimize risk for injury; -Mechanical lifting equipment or other approved transferring aides will be used based on the resident's needs; -Staff will inspect the equipment prior to use to ensure functionality and alert maintenance or other designee if not functioning properly; -Two staff members must be utilized when transferring residents with a mechanical lift; -Staff will be educated on the safe handling/transfer practices to include the use of mechanical lift devices upon hire, annually, and as the need arises; -Staff members are expected to maintain compliance with safe handling/transfer practices; -Resident lifting and transferring will be performed according to the resident's individual plan of care; -Staff will perform mechanical lift transfers according to the manufactures instructions for use of the device. Review of the Invacare Hoyer Lift Owner's Installation and Operating Instructions, showed the following instructions: -When using an adjustable base lift, the legs MUST BE in the maximum OPENED/LOCKED position BEFORE lifting the patient; -The top edge of the sling fabric should be slightly above the patient's head; -The bottom edge of the sling fabric should then be a few inches above the back of the patient's knees. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/08/23, showed staff assessed the resident as follows: -Severely cognitively impaired; -Required total assistance of one staff for bed mobility, dressing, hygiene, and bathing; -Required total assistance of two staff for transfers. Observation on 11/01/23 at 11:21 A.M., showed Certified Nurse Assistant (CNA) H and CNA U used the mechanical lift and raised the resident from the bed, pivoted the lift toward the resident's wheelchair, and lowered the resident into the wheelchair with the lift legs in the closed/shut position. The staff did not keep the lift legs opened while the resident was raised off of a surface with the lift. 3. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required total assistance of one staff for bed mobility, dressing, hygiene, and bathing; -Required total assistance of two staff for transfers. Review of the resident's care plan, dated 05/26/23, showed it did not contain directions for transfer assistance and activities of daily living (ADL) care. Observation on 11/01/23 at 9:22 A.M., showed CNA H and CNA F provided transfer assistance to the resident using a mechanical lift from the Broada chair to the bed. CNA H attached the sling to the mechanical lift without repositioning the sling. CNA H raised the mechanical lift while CNA F held onto the resident with both hands. The sling was positioned above the resident's waist line and his/her buttocks hung from the sling in the air. Observation on 11/01/23 at 11:40 A.M., showed CNA H and NA L raised the resident from the bed using the mechanical lift with the legs in the closed position, pivoted the lift with the legs closed to the resident's wheelchair, and then opened the left legs to fit around the resident's chair while lowering the resident into the chair. The staff did not keep the left legs opened while the resident was raised off of a surface with the lift. 4. Review of Resident #27's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; -Required partial to moderate assistance for sit to stand transfers and chair to bed and bed to chair transfers. Review of the resident's care plan, dated 11/02/23, showed it did not contain directions for transfer assistance and ADL care. Observation on 11/01/23 at 9:22 A.M., showed Certified Medication Technician (CMT) I and CNA F provided transfer assistance to the resident using a mechanical lift from a reclining wheelchair to the bed. CNA F lifted the resident from the reclining wheelchair and moved the resident over the bed and left the resident suspended in the air without hands on the resident. During an interview on 11/01/23 at 11:15 AM CMT I said two staff should assist with all hoyer transfers. One staff to guide the lift and the other to hold and guide the resident. He/She said he/she should have held onto the resident, but was close in case something happened. 5. During an interview on 11/03/23 at 9:00 A.M., the Assistant Director of Nursing (ADON) and MDS Coordinator said that staff are trained on mechanical lifts upon hire and also as needed. The MDS Coordinator said that the mechanical legs should be open to provide a more stable base during transfer. They both said that they expect two staff members to perform mechanical lift transfers and one staff should keep their hands on the resident at all times during the transfer to guide the resident and provide safety. The ADON said that the sling should be placed above the resident's shoulders and cover below the resident's buttock to their thighs. He/She said at no time should a resident's buttock be hanging out of the sling as that is not safe. During an interview on 11/03/23 at 10:44 A.M., CNA F and Nurse Assistant (NA) L said that a mechanical lift transfer always requires two staff members. NA L said that the mechanical lift legs should be closed while under the resident's bed, but open any other time during transfer. Both CNA F and NA L said the second staff member should always keep their hands on the resident to guide the resident and maintain safety. CNA F said the sling should be placed above the resident shoulder and down to their thighs. He/She said that a resident's buttock should never be left out of the sling for safety reasons. During an interview on 11/03/23 at 11:19 A.M., the Director of Nursing (DON) said that he/she expected there to be two staff members present when a mechanical lift transfer was being performed on a resident. He/She said that the proper sling placement should be above the resident's shoulders and support their head, to below the resident's buttock under towards their knees. He/She said the sling should never be placed above a resident's waist, and that a resident's buttock should never be left to hang out of the sling for safety purposes. He/She said that one staff member should raise and lower the lift while the other staff member should keep their hands on the resident during the transfer. He/She said the mechanical lift legs should in open in order to provide more stability for the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during incontinent care for four residents, (Resident #2, #5, #23, and #27), during wound care for one resident (Resident #16) and during medication administration and insulin administration for three residents (Resident #32, #35, and #44). In addition, facility staff failed to sanitize a mechanical lift between three residents (Resident #2, #5, and #27) and perform hand hygiene. The census was 49. 1. Review of the facility's policy titled, Hand Hygiene, reviewed 11/2/23, showed staff are instructed to do the following: -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Hand hygiene when using soap and water: 1. Wet hands when using water 2. Apply to hands the amount of soap recommended by the manufacturer; 3. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers; 4. Rinse hands with water; 5. Dry thoroughly with a single-use towel; 6. Use clean towel to turn off the faucet. -Hand hygiene is indicated and will be performed under the conditions listed: 1. Between resident contacts; 2. After handling contaminated objects; 3. Before applying and after removing personal protective equipment, including gloves; 4. Before preparing or handling medications; 5. Before and after handling clean or soiled dressings, linens, etc.; 6. Before performing resident care procedures; 7. After handling items potentially contaminated with blood, body fluids, secretions, or excretions; 8. When, during resident care, moving from a contaminated body site to a clean body site; 9. After assistance with personal body functions (e.g., elimination, hair grooming, smoking). 2. Review of the facility's policy titled, Perineal Care, reviewed 11/2/23, showed staff were directed to provide perineal care to incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown: -Perform hand hygiene and put on gloves; -If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard; -Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using separate washcloth or wipes; -Wet washcloth and apply perineal cleanser. If using a prepackaged product, open package and obtain the wet cloth; -Remove gloves and discard. Perform hand hygiene. 3. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 08/28/23, showed staff assessed the resident as follows: -Severely cognitively impaired; -Required extensive, two or more persons physical assistance for bed mobility and transfers; -Required extensive, one person physical assistance for dressing and toileting; -Always incontinent of bowl and bladder. Observation on 11/01/23 at 11:21 A.M., showed Certified Nursing Assistant (CNA) U did not change his/her gloves after he/she provided perineal care or before he/she placed a clean brief on the resident. 4. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Dependent for all mobility and cares; -Always incontinent of bowl and bladder. Observation on 11/01/23 at 9:22 A.M., showed CNA H and CNA F entered the resident's room to provided incontinence care for the resident. CNA H and CNA F did not wash his/her hands before they provided resident care. Observation showed CNA H provided perineal care and wiped multiple times in a back and forth motion with the same wipe. Observation showed CNA H continued to wear the same soiled gloves and placed a clean brief on the resident. Observation showed CNA H removed his/her gloves, put the resident's pants on his/her chair, and repositioned the resident. CNA H did not wash his/her hands before he/she left the resident room. 5. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required substantial assistance for bed mobility, transfers, and toileting; -Dependent for lower body dressing; -Frequently incontinent of urine and occasionally incontinent of bowel. Observation on 11/01/23 at 11:32 A.M., showed CNA X and Nursing Assistant (NA) L assisted the resident to use the bedside commode. CNA X did not perform hand hygiene before he/she exited the resident's room. During an interview on 11/03/23 at 10:44 A.M. NA L said that the proper way to do peri-care is to wipe front to back and change or fold the wipe each time. He/She said staff should wash their hands before and after resident care and with any glove changes. 6. Review of Resident #27's admission MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Had no toileting in the 7-day lookback period; -Had an indwelling catheter (tube inserted to drain the bladder); -Diagnosis of dementia. Observation on 11/01/23 at 08:37 A.M., showed Certified Medication Technician (CMT) I and CNA F performed incontinence care on the resident. CNA F wiped the resident's buttock in a circular motion with the same portion the wet wipe to remove bowel movement and then removed his/her gloves. CNA F did not perform hand hygiene in between glove changes. CNA F applied new gloves, applied a barrier cream to the resident's buttocks, gathered the trash/linens, removed his/her gloves, left the room and did not perform hand hygiene. CNA F entered the room with clean linen and did not wash his/her hands before he/she applied new gloves. CMT I did not change his/her gloves after he/she provided incontinence care or before he/she applied barrier cream. CMT I did not perform hand hygiene after he/she removed gloves or before he/she positioned resident, touched the doorknob, privacy curtain, fall mat, bed control, light switch, nightstand and reclining wheelchair. CMT I did not perform hand hygiene before he/she left the resident's room. During an interview on 11/03/23 at 10:44 A.M., CNA F said the proper way to wash your hands is with soap and water, dry them with a paper towel, then get a clean paper towel and turn off the water. He/She said staff should wash their hands before and after resident care and with any glove changes. During an interview on 11/01/23 at 11:15 A.M., CMT I said staff are supposed to wash his/her hands when entering a room, before leaving a room, between dirty and clean areas and between glove changes. He/She should have washed his/her hands more often but was nervous. He/She said that failing to wash his/her hands could result in cross contamination (spread of germs) to other areas of the body or other residents and/or staff. During an interview on 11/01/23 at 4:15 P.M. Registered Nurse (RN) A said staff should always wash their hand before and after resident care. He/She said that staff should also wash their hands anytime they change gloves. During an interview on 11/03/23 at 9:00 A.M., the Assistant Director of Nursing (ADON) said staff should wash their hands before and after resident care, and with any glove change to prevent the spread of germs and cross contamination from resident to resident. During an interview on 11/03/23 at 9:00 A.M., the MDS Coordinator said staff should wash their hands before and after resident care, and with any glove change to prevent the spread of germs and cross contamination from resident to resident. He/She said that staff should change their gloves after they provide peri-care to a resident and wash their hand then put new gloves on to finish the rest of the care a resident may need. He/She said that peri-care should be done front to back and using a clean wipe or part of the wash cloth with each swipe. During an interview 11/03/23 at 11:19 A.M., the Administrator said that staff are expected to wash their hand before and after resident care, and with any glove change. He/She that if peri-care is provided that a staff member should change their gloves and wash their hands prior to doing any further care with a resident as their hands and gloves are soiled. During an interview 11/03/23 at 11:19 A.M., the DON said that staff are expected to wash their hand before and after resident care, and with any glove change. He/She said that if peri-care is provided that a staff member should change their gloves and wash their hands prior to doing any further care with a resident as their hands and gloves are soiled. He/She said peri-care should be provided front to back and that each wipe should be done with a clean wipe. 7. Review of the facility's Skin and Wound Care Management, revised July 2017, showed staff are instructed to the following: -Wash and dry your hands thoroughly. -Put on clean gloves. Loosen tape and remove soiled dressing. -Put glove over dressing and discard into plastic or biohazard bag. -Wash and dry your hands thoroughly. -Cleanse the wound with ordered cleanser. 8. Observation on 11/02/23 at 9:20 A.M., showed the Assistant Director of Nursing (ADON) provided wound care for Resident #16's skin tear left arm. The ADON did not change his/her gloves after he/she touched the medication cart or before he/she sprayed wound cleaner on gauze or opened the Calcium Alginate (water-insoluble, gelatinous, cream colored substance dressing used for the granulation phase of wound repair) dressing. The ADON did not change his/her gloves after he/she removed the soiled dressing or before he/she cleaned the wound. During an interview on 11/03/23 at 9:00 A.M., the ADON said during a dressing change staff should never touch the treatment cart then removed the resident's dressing with the same pair of gloves on. He/She said that the dirty dressing should be removed, then the staff member should remove their soiled gloves, wash their hands, then put on clean gloves to clean the resident's wound and replace the new dressing. During an interview on 11/03/23 at 9:00 A.M., the MDS Coordinator said during a dressing change staff should never touch the treatment cart then removed the resident's dressing with the same pair of gloves on. He/She said that the dirty dressing should be removed, then the staff member should remove their soiled gloves, wash their hands, then put on clean gloves to clean the resident's wound and replace the new dressing During an interview 11/03/23 at 11:19 A.M., the DON said staff need to wash their hands before and after, and with glove change. He/She said gloves need to be changed between the dirty and clean process and at no time should the dirty gloves touch the resident wound or clean dressing. He/She said staff should not touch the treatment cart with gloves on then remove the resident's dressing wearing the same gloves because this can cause an infection and lead to a poor outcome for the resident. The DON said the proper way staff should wash their hand is to use soap and water scrubbing for 30 seconds, rinse, dry with a paper towel, and then get a clean paper towel to turn off the faucet. 9. Review of the facility's Medication Administration Policy, reviewed 11/2/23 showed staff are instructed: -Wash hands prior to administration per facility protocol and product; -After medication administration, wash hands per facility protocol and product. 16. Observation on 11/01/23 at 4:15 P.M., showed RN A performed a blood sugar check and gave insulin to Resident #32. RN A checked the resident's blood sugar then removed his/her gloves but did not wash his/her hand before he/she put on clean gloves. He/She washed his/her hands and turned the water faucet off with his/her bare hands. 10. Observation on 11/02/23 at 7:32 A.M., showed CMT E prepared medication for Resident #44. The CMT dropped one pill on top of the medication cart, picked up the dropped pill and broke a scored tablet with bare ungloved hands. CMT E administered medication for the resident, returned to his/her medication cart, prepared medication for Resident #35, and administered the resident's medication. CMT E did not perform hand hygiene between residents. During an interview on 11/03/23 at 10:32 A.M., CMT E said staff should wash their hands or sanitize between each resident so bacteria is not spread and never touch medication with bare hands. He/She said it was not done because he/she was nervous but should have. During an interview on 11/03/23 at 9:00 A.M., RN P said staff should wash their hands after administration of medication to every 3 residents and sanitize between each one to prevent spread of infections. He/She said staff should not touch pills without gloves on. During an interview on 11/03/23 at 11:19 A.M., the DON said staff should wear gloves when handling medication. He/She said staff should wash their hands or sanitize between residents when passing medication. 11. Review of the facility's policy titled, Safe Resident Handling/Transfers, reviewed 11/02/23, showed safe handling when transferred to prevent or minimize risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. The lift(s) will be cleaned and disinfected according to manufacturers' instructions and after each resident use. Review of the Mechanical Lift Owner's Installation and Operating Instructions, undated, the direction to clean the lift is to use a soft cloth, dampened with water and a small amount of mild detergent, is all that is needed to clean the patient lift. The lift can be cleaned with non-abrasive cleaners. 12. Observation on 11/01/23 at 8:37 A.M., showed CMT I and CNA F used the mechanical lift to transfer Resident #27 to bed. An unknown staff came into the room, obtained the lift and took it directly into Resident #1's room. Observation showed the unknown staff did not clean the hoyer lift before he/she transferred Resident #1 to his/her recliner. During an interview on 11/01/23 at 11:15 A.M., showed CMT I said the lift should be cleaned after each resident and before use on the next resident to prevent germs from spreading. During an interview on 11/03/23 at 10:44 A.M., CNA F said staff should sanitize equipment before and after resident use. 13. Observation on 11/01/23 at 9:22 A.M., showed CNA H and CNA F used the mechanical lift to transfer Resident #5 from his/her Broda (wheelchair that provides supportive positioning) chair to the bed. CNA H or CNA F did not sanitize the mechanical lift before or after the transfer. 14. Observation on 11/01/23 at 11:21 A.M., showed CNA U transferred Resident #2 with the mechanical lift to his/her wheelchair. Observation showed CNA U took the mechanical lift out of the residents room to the storage room and did not clean or sanitize the lift after use. During an interview on 11/03/23 at 10:44 A.M. NA L said staff should sanitize equipment before and after resident care. During an interview 11/03/23 at 11:19 A.M., the Administrator and DON both said that any equipment should be sanitized before and after resident use.

Based on observation and interviews, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility failed to employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 49. 1. Observation on 10/31/23 from 10:03 A.M. through 12:15 P.M., showed [NAME] N directed and assisted facility kitchen and nursing staff in the completion of kitchen tasks while he/she prepared and served the lunch meal. During an interview on 10/31/23 at 10:07 A.M., [NAME] N said the facility did not have a full-time Certified Dietary Manager (CDM). He/She said the last CDM left the facility about eight weeks ago and [NAME] T was filling in. He/She also said [NAME] T is not a CDM. During an interview on 11/02/23 at 7:55 A.M., the administrator said the facility did not have a full-time CDM in place. He/She said the previous CDM left his/her position in the middle of September 2023 but still worked on an as needed basis. He/She also said the facility identified a replacement to start next week but the replacement is not a CDM. The administrator also said the facility will work with the new hire to complete ServSafe Manager training in addition to the new hire's background in skilled nursing facility dietary work.

Based on interview and record review, facility staff failed to ensure three Nurse Aides (NAs) (NA A, NA B, and NA C) completed the nurse aide training program within four months of their employment in the facility. The facility census was 49. 1. Review of NA A's personnel file showed a hire date of 07/13/22. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During a telephone interview on 9/15/23 at 9:29 A.M., the administrator said she did not know why NA A had not been certified and said, I didn't realize he/she hadn't been certified. I assumed the instructor had been doing that. I realize now she was not. During a telephone interview on 9/26/23 at 9:21 A.M., the nurse aide instructor said NA A kept missing classes. 2. Review of NA B's personnel file showed a hire date of 4/3/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 3. Review of NA C's personnel file showed a hire date of 4/10/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. 4. During an interview on 8/29/23 at 12:39 P.M., the Business Office Manager said NA A, NA B and NA C were still working as nurse aides and had not yet been certified. During a telephone interview on 9/1/23 at 1:03 P.M., the Director of Nursing (DON) said he/she thought the exception to requiring nurse aides to be certified within four months ended 5/31/23. He/She said that is why NA A, NA B, and NA C had not been certified yet. During a telephone interview on 9/15/23 at 9:29 A.M., the administrator said NA B and NA C had not gotten certified yet because there was a delay in getting training materials which kept them from having classes as frequently as they wanted. During an interview on 9/25/23 at 1:53 P.M., the administrator said she expected the instructor to to make sure the nurse aides were certified timely. During a telephone interview on 9/26/23 at 9:21 A.M., the nurse aide instructor said management had expected him/her to keep track of hire dates in relation to making sure staff were certified. He/She said in the past the DON or Assistant DON would cordinate with office staff, but there had been many changes in those areas over the last year. MO00223614

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility staff failed to maintain monthly pharmacist documentation, and ensure the Pharmacist Medication Regimen Review (MRR) was completed for two residents (Resident #9 and #38) out of five sampled residents. The facility census was 43. 1. Review of the facility's Medication Regimen Review (MRR) Policy, dated 6/1/2018, showed: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly.MRR's involve reporting of findings with recommendations for improvement. All findings and recommendations are reported to the Director of Nursing (DON), the attending physician, the medical director, and the administrator; -Recommendations are acted upon and documented by the facility staff and/or the prescriber. 2. Review of the facility's Documentation and Communication of Consultant Pharmacist Recommendation policy, dated 6/1/18, showed: -Comments and recommendations concerning medication therapy are communicated in a timely fashion.The timing of these recommendations should enable a response prior to the next MRR. In the event of a problem requiring the immediate attention of the prescriber, the responsible prescriber or physician's designee is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere in the resident's medical record; -Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the DON and/or the consultant pharmacist may contact the Medical Director. 3. Review of the facility's Psychotropic Medication Use policy, dated February 2021, showed: -Residents will ony recieve psychotropic medications when necessary to treat specific conditions for which they are indicated and effective; -Antipsychotic medications shall generally be used only for the following conditions/diagnosis as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): -Schizophrenia; -Schizoaffective disorder; -Schizophreniform disorder; -Tourette's Disorder; -Huntingtons Disease; -Diagnosis alone do not warrant the use of psychotropic medication; -Gradual dose reductions (GDR) of psychotropic medications will be done as outlined per federal regulations; -Addendum to policy, dated 10/10/18 showed approved diagnosis that are appropriate for antipsychotic medication use as Schizophrenia, Huntingtons Chorea, Tourette Syndrome, and Psychosis. 4. Review of Resident #9's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/18/22, showed staff assessed the resident as: -Rarely or never understood; -Cognitively impaired; -Diagnoses of Dementia with behaviors, anxiety, and depression; -Behavior symptoms not exhibited; -Gradual Dose Reduction (GDR) (tapering of a medication to meet therapeutic needs or discontinue if no longer needed) not been documented by a physician as clinically contraindicated. Review of the Phycian's Order Sheets (POS)'s dated, June 2022, showed orders for: -Seroquel (an antipsychotic) 25 mg daily at bedtime for behaviors. Review of the nursing notes from December 2021 through May 2022 showed the following pharmacy consult progress notes: -3/24/22 - MRR completed; See antipsychotic recommendation. Review of the medical record showed it did not contain documentation of the March 24, 2022 recommendation or follow up from the physician. During an interview on 6/16/22 at 11:45 A.M., the Director of Nursing said he/she is new to the position and is unable to locate the pharmacy consultant recommendation for resident #9 for March 2022. He/she said it is his/her responsibilty to ensure pharmacy consults are completed by the pharmacist and the physician. 5. Review of Resident #38's Quarterly MDS, dated [DATE], showed staff assessed the resident: -Cognitively intact; -Diagnosis of Bipolar (disorder associated with episodes of mood swings ranging form depressive lows to manic highs), schizophrenia (breakdown in the relation bewtween thought, emotion, and behavior, leading to faulty perception), major depressive disorder, recurrent, severe with psychotic symptoms (hallucinations and delusions); -Exhibited psychosis; -Had verbal behavior symptoms one to three days out of seven days in the look back period; -GDR has not been documented by a physician as clinically contraindicated. Review of the care plan, revised 1/14/22, showed: -Uses psychotropic medication Haldol r/t Schizophrenia, Bipolar mood disorder and major depressive disorder. Interventions included administering antipsychotic medications as ordered and monitor/document for side effects and effectiveness, Consult the pharmacy and physicain to coside dosage reduction when clincally appropriate -Has the potential for a mood problem r/t Bipolar depression, and other psychiatric diagnosis. Interventions included to consult with pharmacy, and physician to consider dosage reduction when clinically appropriate. Review of the POS, undated, showed orders for: -Zyprexa 5 mg (antipsychotic) one tablet by mouth two times a day for schizoaffective disorder; - Haloperidol Lactate Solution (antipsychotic) 5 mg/Mililitter (ml) Inject one ml intramuscularly (IM) (Given via needle directly into muscle tissue) every eight hours as needed for psychosis; - Haldol Decanoate Solution 50 mg/ml (Haloperidol Decanoate) Inject 50 mg IM every 30 day(s) for schizophrenia. Review of the nurses notes from Janruary 2022 through May 2022 showed the following pharmacy consult progress notes: -5/24/22 - Medication Regimen Review (MRR) completed see recommendations antipsychotic therapy reecommendation; -1/21/22 - MRR completed see recommendations for psychotropic managment. Review of the medical record showed it did not contain documentation or follow up from the physician for the following recommendations in regard to the pharmacy recommendations. 6. During an interview on 6/16/22 at 12:08 P.M. the Registered nurse (RN) E said the pharmacists reviews the resident's medications monthly and staff are expected to bring any recommedations to the doctors attention. He/She said he/she does not know who is responsible for making sure they are done. He/She said a gradual dose reduction (GDR) would depend upon the medication the resident is taking and if the doctor said it was clinically contraindicated. During an interview on 6/16/22 at 12:12 P.M., the MDS coordinator said it is the Director of Nursing (DON)'s responsibility to ensure GDRs are completed with the physician. He/she said GDRs should be completed every 90 days or upon what the physician recommends. He/she said the pharmacist comes monthly, makes recommendations to the DON who reviews them and gives them to the nursing staff to follow up on with the physician, a note is written on the consult by the nurse and/or the physician and then it is scanned into the computer after taking off any orders. During an interview on 6/16/22 at 12:27 P.M. the Licensed practical nurse (LPN) F said the he/she would bring a pharmacy recommendation to the physician's attention. He/She said the pharmacist does the medication reviews and the nurses are responsible for making sure they are done. He/She said a GDR should be done every 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the residents' medical and nursing needs when they failed to address personal hygiene and grooming for four residents (Resident #7, #19, #35, and #42). The facility census was 43. 1. Review of the facility's Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, 3.0 and Care Planning Policy, undated, showed: -The Comprehensive Care Plan will be individualized to each resident; -Included in the Comprehensive Care Plan will be the resident's right to refuse treatment, and any specialized services the facility will provide; -The Comprehensive Care Plan will be revised on an ongoing basis to reflect changes in the resident and/or changes in the care the resident is receiving; including interventions, measurable objectives, goals, and care instructions; -The Comprehensive Care Plan shall be adhered to in caring for the resident and outline the resident's care needs. 2. Review of Resident #7's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision and setup help for personal hygiene. Review of the care plan, dated 4/7/22, showed it did contain direction for staff in regards to the resident's facial hair preferences. Observation on 6/13/22 at 1:54 P.M., showed the resident had long hair on his/her chin. Observation on 6/14/22 at 9:45 A.M., showed the resident had long hair on his/her chin. Observation on 6/15/22 at 8:14 A.M., showed the resident had long hairs on his/her chin. Observation on 6/16/22 at 7:41 A.M., showed the resident had long hair on his/her chin. 3. Review of Resident #19's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required supervision and setup help for eating; -Required assistance from one staff member for personal hygiene. Review of the care plan, dated 5/31/22, showed it directed staff to check the resident's fingernail length and trim and clean on shower days, and as necessary. Observation on 6/14/22 at 1:16 P.M., showed the resident had long fingernails with debris under them. Observation on 6/15/22 at 8:12 A.M., showed the resident had long fingernails with debris under them. Observation on 6/16/22 at 7:50 A.M., showed the resident had long fingernails with debris under them. 4. Review of Resident #35's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision and setup help for personal hygiene. Review of the care plan, dated 5/31/22, showed it did not contain direction for staff in regards to the resident's facial hair preference. Observation on 6/13/22 at 11:01 A.M., showed the resident had hair on his/her upper lip and chin. Observation on 6/14/22 at 8:42 A.M., showed the resident had hair on his/her upper lip and chin. Observation on 6/16/22 at 7:56 A.M., showed the resident had hair on his/her upper lip and chin. During an interview on 6/13/22 at 11:01 A.M., the resident said he/she would prefer to have his/her hair plucked. He/She said it had been a while since staff had offered to shave him/her. He/She said it bothers him/her to have hair on his/her upper lip and chin. 5. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision and setup help for transfers, dressing, and personal hygiene; Review of the care plan, dated 6/17/22, showed the resident required assistance from one staff member for bathing, personal hygiene and oral care. Further review showed it did not contain direction for staff in regards to the resident's facial hair preference. Observation on 6/13/22 at 11:00 A.M., showed the resident had greasy and unkempt hair. He/She had hair on his/her chin. During an interview on 6/13/22 at 11:00 A.M., the resident said he/she could not remember the last time he/she had a shower. Observations on 6/15/22 at 8:48 A.M., showed the resident had greasy and unkempt hair and he/she had hair on his/her chin. During an interview on 6/15/22 at 8:48 A.M., the resident said he/she still had not received a shower. Observation on 6/16/22 at 7:29 A.M., showed the resident had greasy and unkempt hair and he/she had hair on his/her chin. During an interview on 6/16/22 at 7:29 A.M., the resident said he/she still had not received a shower. He/She said it bothers him/her to have facial hair. He/She said it had been a while since staff had offered to shave him/her. During an interview on 6/16/22 at 11:41 A.M., Certified Nurse Aide (CNA) A said he/she did not know who updated the care plans. He/She said the care plans should be updated monthly. He/She said he/she is an agency staff member, so he/she is unable to access resident information on the computer, because he/she has not been given access. The CNA said he/she would expect facial hair preferences listed on the care plan. He/She said the care plan is used to provide specific information to help with resident care. During an interview on 6/16/22 at 11:41 A.M., CNA B said he/she is not sure who updates the care plans, or when they are updated. He/She said the purpose of the care plan is to ensure staff have the the information available to provide care appropriate to the resident. He/She said all care should be listed on the care plan. CNA B said this should include facial hair grooming. During an interview on 6/16/22 at 11:45 A.M., the Director of Nursing (DON) and Administrator said the MDS nurse is responsible for updating care plans, but nurses add interventions regarding acute changes in care, such as falls. The DON said he/she expects care plans to be updated quarterly and if the resident has a change in condition. He/She said the care plan should include shaving and showering preferences. During an interview on 6/16/22 at 12:08 P.M. Registered Nurse (RN) E said the Social Services Director (SSD) is responsible for updating care plans and the MDS coordinator is responsible for making sure they are up to date. He/She said the nursing staff and direct care staff have access to the care plans. RN E said he/she would expect personal hygiene preferences, including facial hair, to be listed on the care plan. During an interview on 6/16/22 at 12:12 P.M., the MDS Nurse said any manager/staff member who completes sections of the MDS can access and update the care plan. He/She said he/she completes and updates the nursing related care sections. The MDS nurse said he/she does not including shaving preferences in the care plan. He/she said preferences like shaving, showers, and nail care should be in the care plan so staff know what the resident prefers. He/she said everyone has access to review care plans. During an interview on 6/16/22 at 12:27 P.M. Licensed Practical Nurse (LPN) F said the nurses and CNAs have access to care plans. He/She said the MDS coordinator is responsible for updating care plans, but he/she did not know how often they were updated. He/She said he/she did not know who was responsible for keeping care plans up to date. LPN F said he/she would expect the resident's care plan to include preferences for personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to revise the care plan for one resident (Resident #32) who utilized bed rails, and one resident (Resident #38) who utilized palm protectors, psychotropic medications, and who did not require the use of bed rails. The facility census was 43. 1. Review of the facility's Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, 3.0 and Care Planning Policy, undated, showed: -The Comprehensive Care Plan will also be individualized to each resident; -Comprehensive Care Plan will be updated when a change of condition is warranted; -Included in the Comprehensive Care Plan will be the resident's right to refuse treatment, any specialized services the facility will provide, the resident's goals for admission, desired outcomes, and discharge plans; -The Comprehensive Care Plan will be revised on an ongoing basis to reflect changes in the resident and/or changes in the care the resident is receiving including interventions, measurable objectives, goals, and care instructions; -The Comprehensive Care Plan shall be adhered to in caring for the resident and outline the resident's care needs; -All staff will have access to the comprehensive care plan and know that is it located in the resident's chart under the care plan tab. 2. Review of Resident #32's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of fracture of the left femur (bone in upper leg), morbid obesity due to excess calories, and hypertensive heart disease with heart failure; -Totally dependent upon two or more staff members for for bed mobility; -Bed rails not used. Review of the care plan, dated 5/20/22, showed it did not contain direction for staff in regard to the resident's use of bed rails, his/her goals, or interventions. Observation on 6/14/22 at 8:34 A.M. showed the resident sat in his/her wheelchair. Bed rails were up on both sides. Observation on 6/14/22 at 11:04 A.M. showed the resident in bed with bed rails up on both sides. Observation on 6/14/22 at 2:03 P.M. showed the resident in bed with bed rails up on both sides. Observation on 6/15/22 10:15 A.M. showed the resident in bed with bed rails up on both sides. Observation on 6/15/22 2:04 P.M. showed the resident in bed with bed rails up on both sides. Observation on 6/16/22 7:40 A.M. showed the resident in bed with bed rails up on both sides. 3. Review of Resident #38's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of Bipolar (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (breakdown in the relation between thought, emotion, and behavior, leading to faulty perception); -Totally dependent upon one staff member for dressing; -Has functional limitation in range of motion to both upper extremities. Review of the resident care plan, revised 1/14/22, showed -Resident used Ativan (anxiolytic) related to Schizophrenia, Bipolar mood disorder and major depressive disorder; -Utilizes bed rails; Review of the care plan showed it did not contain direction for staff in regard to the resident's palm protectors. Review of the resident's Physician Order Sheet (POS), undated, showed the resident's Ativan 0.5 milligram (mg) (medication used to treat anxiety) was discontinued on 4/6/22. Observation on 6/13/22 at 12:03 P.M. showed the resident sat in his/her wheelchair in the dining room with palm protectors on both hands. Observation on 6/13/22 at 2:15 P.M. showed the resident in bed with palm protectors to both hands. He/She did not have bed rails on his/her bed. Observation on 6/14/22 at 11:06 A.M. showed the resident in bed with palm protectors to both hands. He/She did not have bed rails on his/her bed. Observation on 6/15/22 at 9:24 A.M. showed the resident in bed with palm protectors to both hands. He/She did not have bed rails on his/her bed. During an interview on 6/16/22 at 11:41 A.M., Certified Nurses Aide (CNA) A said he/she didn't know who updated the care plans. He/She said he/she is from agency staffing, and has not been provided access to the computer. He/She said the care plan should show if a resident uses bed rails. He/She said he/she knew resident #38 wore palm protectors. He/She said he/she knew that because he/she was told by staff. During an interview on 6/16/22 at 11:41 A.M., CNA B said he/she is not sure who or when the care plans are updated. He/She said the care plan provides the type of care specific to the resident. He/She said he/she did not have access to the care plans. He/She said bed rails, contracture devices, and medications should be listed in the care plan. He/She said if the care is no longer used, or needed it should be removed from the care plan. During an interview on 6/16/22 at 11:45 A.M., the Director of Nursing (DON) and Administrator said the MDS nurse is responsible for ensuring care plans are up to date and everyone has access to them. The DON said he/she expects the care plans to include psychotropic medication use, bed rails, and positioning and/or contracture devices. During an interview on 6/16/22 at 12:08 P.M. Registered Nurse (RN) E said the Social Services Designee (SSD) is responsible for updating care plans and the MDS coordinator is responsible for making sure they are up to date. He/She said nursing staff and direct care staff have access to the care plans. RN E said he/she would expect bed rails, contracture devices, and psychotropic medications listed on the care plan. He/She said the care plan should be updated if there is any change to the resident's care or medications. During an interview on 6/16/22 at 12:12 P.M., the MDS nurse said he/she is responsible for ensuring care plans are up to date. He/She said the physician orders, as well as, medication and treatment records are all part of the care plan and he/she would expect to see contracture management in the treatment orders. He/she said Resident #38 does have palm protectors but he/she did not know if the care plan addressed them or not. He/she said the care plan should also include safety devices, such as bed rails and should be updated if/when they are discontinued. He/She said medications such as psychotropics, should be addressed in the care plan. During an interview on 6/16/22 at 12:27 P.M. Licensed Practical Nurse (LPN) F said the nurses and CNAs have access to care plans. He/She said the MDS coordinator is responsible for updating care plans, but he/she did not know how often they were updated. LPN F said he/she would expect the resident's care plan to include bed rails, contracture devices, and pyschotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, staff failed to obtain an order for one resident (Resident #42)'s dialysis (the clinical purification of blood by filtering, as a substitute for the normal function of the kidney), and failed to facilitate communication with the dialysis clinic. The facility census was 43. 1. The facility could not provide a physicians order policy. 2. Review of the facility's Dialysis Communication Policy, dated 2/21, showed: - It is the policy of the facility to communicate openly and effectively with any provider of dialysis for a resident of the facility; -DON or designee will contact dialysis unit to establish the communication, explain the facility will be sending a communication form that will facilitate the sharing of resident information surrounding dialysis; -A dialysis communication form will be used to send information to and from the facility to the dialysis center and back; -The nurse in charge of the care of the resident on the days of scheduled dialysis shall initiate the dialysis communication form and will ensure the form is sent with the resident; -Upon return of the resident from the dialysis center, the nurse in charge of the resident will review the communication form and will obtain necessary post dialysis information; -If there are any questions regarding the completion of the form or needs of the resident, the nurse will call the dialysis center for a telephone report of any significant information needed; -The nurse will complete post dialysis information on the dialysis communication form. Completed form will be scanned into the electronic health record; 3. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Has diagnoses of Renal failure, heart failure, and hypertension; -Receives dialysis. Review of the progress notes, dated 2/15/2022, showed staff documented the resident returned from a dialysis appointment. Further review, showed the dialysis clinic placed a catheter (a soft tube placed in a large vein in the neck, which allows access for blood to be circulated in and out of the body) in the resident's right upper chest. Review of a Dialysis Clinic progress note, dated 2/18/22, showed the resident was scheduled to start hemodialysis as soon as his/her catheter was placed. Review of the care plan, dated 6/17/22, showed staff documented the resident received hemo-dialysis (a machine filters wastes, salts, and fluid from the blood) related to chronic kidney disease. He/She received dialysis on Tuesday, Thursday and Saturday, unless otherwise scheduled. Review of the POSs, undated, showed they did not contain an order for dialysis or direction for staff in regard to care for the resident's dialysis access site. Review of the Dialysis Communication Record, showed it did not contain communication to, or from the dialysis center, from 3/19/22 to 5/27/22, or from 5/29/22 to 6/16/22. Observation on 6/14/22 at 8:36 A.M., showed the resident had a bandage on his/her right upper chest that covered his/her dialysis catheter. During an interview on 6/14/22 at 8:23 A.M., Driver C said he/she drives the resident to his/her dialysis on Tuesday, Thursday and Saturday. He/She said staff don't give him/her any paperwork for the resident to take to his/her appointment. During an interview on 6/16/22 at 7:29 A.M., the resident said the facility does not send paperwork with him/her when he/she goes to dialysis. During an interview on 6/16/22 at 11:41 A.M., CNA B said he/she did not know if an order was required for dialysis. He/She said he/she did not know if paperwork was sent with the resident when he/she went to dialysis. During an interview on 6/16/22 at 11:45 A.M., the Administrator and Director of Nursing (DON) said there should be a physician's order for dialysis, and the nurses are expected to send a form for facility/clinic communication every time the resident goes. He/She said the care plans should contain resident specific care needs such as dialysis, positioning and/or contracture devices, and should be updated with any changes. During an interview on 6/16/22 at 12:08 P.M., RN E said there should be a physician's order for dialysis, and a communication sheet should be sent with the resident to every appointment. He/She said the charge nurse should fill out the form and send it with the resident or transportation designee. During an interview on 6/16/22 at 12:12 P.M., the MDS nurse said he/she had never seen or heard of an order for dialysis, but he/she said he/she would think residents should have one. He/She said he/she did not know if the nurses were completing the dialysis communication form and sending it with the resident, but they should be. During an interview on 6/16/22 at 12:27 P.M., LPN F said he/she would expect to see a physician's order for dialysis. He/She said staff do have a communication form, but it has not been used. He/She said the nurses are responsible for sending it with the resident and staff have not sent the binder containing the form because they dropped the ball. During an interview on 6/16/22 at 12:52 P.M., the DON said he/she could not locate documentation of dialysis communication from 3/19/22 through 5/27/22 and 5/29/22 through 6/16/22. During an interview on 6/17/22 at 3:44 P.M. the DON said physician orders are checked monthly. He/She said should be updated with any change or new order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to assist residents with Activities of Daily Living (ADLs) (everyday tasks), for four residents (Resident #19, #28, #35 and #42). The facility census was 43. 1. Review of Resident #19's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/7/22, showed staff assessed the resident as: -Severe cognitive impairment; -Required supervision and setup help from one staff member for eating; -Required assistance from one staff member for toileting and personal hygiene; -Did not reject care. Review of the care plan, dated 5/31/22, showed it directed staff to check the resident's fingernail length, and trim and clean the nails on shower days, and as necessary (PRN). Observation on 6/14/22 at 1:16 P.M., showed the resident had long fingernails with debris under them. Observations on 6/15/22 at 8:12 A.M., showed the resident had long fingernails with debris under them. Observation on 6/16/22 at 7:50 A.M., showed the resident had long fingernails with debris under them. 2. Review of Resident #28's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision and setup help for eating, and toileting; -Required assistance from one staff member for personal hygiene; -Did not reject care. Observation on 6/15/22 at 8:21 A.M., showed the resident had long fingernails. Observation on 6/16/22 at 12:04 P.M., showed the resident had long fingernails with debris under them. During an interview on 6/16/22 at 12:04 P.M., the resident said he/she did not like his/her nails long, and he/she did not like dirt under them. He/She said it had been weeks since his/her fingernails had been trimmed. 3. Review of Resident #35's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision and setup help for personal hygiene; -Did not reject care. Review of the care plan, dated 5/31/22, showed it did not contain direction for staff in regards to the resident's facial hair preference. Observation on 6/13/22 at 11:01 A.M., showed the resident had hair on his/her upper lip and chin. During an interview on 6/13/22 at 11:01 A.M., the resident said he/she preferred to have his/her facial hair plucked. He/She said it had been a while since staff offered to shave him/her. He/She said it bothers him/her to have facial hair. Observation on 6/14/22 at 8:42 A.M., showed the resident had hair on his/her upper lip and chin. Observation on 6/16/22 at 7:56 A.M., showed the resident had hair on his/her upper lip and chin. 4. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision and setup help from one staff member for personal hygiene; -Did not reject care. Observation on 6/13/22 at 11:00 A.M., showed the resident had greasy unkempt hair and hair on his/her chin. During an interview on 6/13/22 at 11:00 A.M., the resident said he/she did not know the last time he/she had a shower. Observation on 6/15/22 at 8:48 A.M., showed the resident had greasy unkempt hair and hair on his/her chin. During an interview on 6/15/22 at 8:48 A.M., the resident said he/she had not received a shower. Observation on 6/16/22 at 7:29 A.M., showed the resident had unkempt hair and hair on his/her chin. During an interview on 6/16/22 at 7:29 A.M., the resident said he/she had not received a shower. He/She said it bothers him/her to have facial hair. Review of the resident's shower sheets, dated 6/16/22, showed staff staff documented the resident refused a shower, but staff were to attempt a shower after he/she returned from his/her dialysis (the clinical purification of blood, as a substitute for normal kidney function) appointment. Review of the care plan, updated 6/17/22, showed the resident preferred two showers a week and required assistance from one staff member with bathing, and personal hygiene. Further review showed it did contain direction for staff in regards to the resident's facial hair preference. During an interview on 6/16/22 at 11:41 A.M., Certified Nurse Aide (CNA) A said he/she did not know how often residents were given or offered showers. He/She said residents are shaved and their nails are trimmed on shower days, or PRN. He/She said he/she knew some of the residents had facial hair and long nails. He/She said he/she did not know the facility's policy for shaving and nail care, or who was responsible for completing it. During an interview on 6/16/22 at 12:12 P.M., CNA B said the nurses aides are responsible for providing shaves, nail care and showers. He/She said residents should be showered twice a week, and they are shaved and nails care is provided during the shower. He/She said he/she was aware some of the residents had facial hair. He/She said he/she did not know why nails were not being trimmed. During an interview on 6/16/22 at 12:12 P.M., the MDS Nurse said he/she thinks showers are completed by the CNA's weekly. He/she said the charge nurses are responsible for ensuring showers, nail care, and shaving is complete. During an interview on 6/16/22 at 11:45 A.M., the Director of Nursing (DON) said showers are not an issue because the management nurses step in and help. He/she said CNAs are responsible for completing showers, shaves and nail care.