Based on interview and record review, the facility failed to protect a resident's right to be treated with dignity and respect when staff entered the resident's room without the resident's or resident's representative's consent and removed personal belongings (Resident #9). The sample size was 20. The census was 90. Review of the facility's Resident Rights and Dignity Protocol, reviewed January 2024, showed:-Protocol: The facility recognizes the resident right to a quality of life that supports privacy, confidentiality, dignity, independent expression, choice and decision making consistent with State law and Federal regulation. Review of the facility's New Resident Information, required for signature within 24 hours of admission, showed:-Room Search Protocol. Revised November 2023; -Purpose: To assure the safety of resident, staff and visitors without violating Resident Rights, the Room Search Policy and Procedure has been established; -Policy: A resident's room may be searched if, after investigation, evidence suggests that the resident has violated facility policy regarding the possession of contraband, prohibited items or stolen property. If recreational marijuana is legalized, you still may not have it in the facility or smoke it; -Procedure: The facility staff should not conduct searches of a resident or their personal belongings unless the resident or resident representative agrees to a voluntary search and understands the reason for the search, if they refuse then legal authorities should be notified to assist as allowed by law. Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/18/25, showed:-discharged to the hospital on 4/18/25;-Exhibited no behaviors;-Diagnoses included diabetes, anxiety and bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's progress note, showed:-4/21/25 at 3:58 P.M., showed a note by the Administrator. Informed by the Director of Nursing (DON) that resident was observed with a vaporizer in room last week. The DON accompanied this writer to resident's room. Search of resident's room resulted in finding two vape pens, two boxes of wooden matches, one lighter, one vape/electric cigarette battery and six bags of edibles. All items removed from room and locked in administrator's office. Storing any smoking supplies in residents' rooms is a violation of facility policy. Having marijuana on facility property is in violation of facility policy;-4/21/25 at 4:19 P.M., showed a note by the administrator. Will discuss smoking supplies found in room with resident and family/responsible party upon return from the hospital. Review of the resident's census report, showed he/she returned from the hospital on 5/6/25. During an interview on 9/10/25 at 1:04 P.M., the resident said he/she was in the hospital for an extended amount of time. Three days after he/she was admitted to the hospital, the Administrator searched his/her room closet without his/her consent and took six bags of marijuana infused edibles and two vape pens. The resident knew he/she could not smoke marijuana at the facility but did not realize he/she could not eat it. He/She did not have an issue with the facility saying he/she could not have the items. The resident was concerned because they searched his/her room without his/her knowledge or consent. The resident found out his/her room was searched by the Administrator and DON from staff at the facility. During an interview on 9/10/25 at 1:20 P.M., the Administrator said she was informed by staff the resident had marijuana in his/her room. She and the DON searched the resident's room and found six bags of marijuana infused edibles and two vaporizer pens. She confiscated the items and called the resident's family member to pick them up. The resident was in the hospital when the room was searched. The Administrator could not recall if she obtained permission from the resident's representative prior to searching the room but did document the occurrence. During an interview on 9/12/25 at approximately 9:30 A.M., the Administrator said she did not obtain permission from the resident or representative prior to searching his/her room. The items were returned to the family, and it was explained that the items were not permitted in the facility. She expected the policies to be followed and resident consent prior to searching a resident's room. 14541571454156

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents requiring assistance with ADLs (activities of daily living) received the necessary services to maintain adequate personal hygiene in accordance with their needs and preferences (Residents #37, #48, and #71). The sample was 20. The census was 90.Review of the facility's Personal Care Needs policy, reviewed 1/2024, showed:-Protocol: The facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents. The facility also provides the needed support when the resident performs their ADLs. The interdisciplinary plan of care (IPOC) will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident plan of care. Personal care and support include but is not limited to the following: -Assistance with meals; -Bath/shower; -Grooming/dressing; -Nail care; -Peri-care; -Shave;-Procedure includes: -Develop and implement individualized interventions; -Document on individual resident care plan; -Document in the progress notes if an exception to the established plan of care occurs, i.e., refusals. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 6/12/25, showed:-Moderate cognitive impairment;-Always incontinent of bowel and bladder;-Dependent on staff for toilet hygiene, personal hygiene, bathing and putting on and taking off footwear;-Non-Alzheimer's dementia, diabetes, hemiplegia (paralysis to one side of the body), stroke and seizures. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident experiences bowel and bladder incontinence related to dementia, cognitive impairment, impaired mobility, impaired sensation related to stroke;-Interventions: The resident uses adult incontinent briefs; Monitor for soiling on routine rounds and as needed; Assist to cleanse perineum (genitals and rectal area) and change brief as needed;-Focus: The resident has an ADL and mobility deficit related to cognitive impairment and dementia, shortness of breath, compromised respiratory status, lasting effects of stroke, weakness and limited endurance;-Interventions: Bathing and showering, check nail length and trim and clean on the resident's bathing day; The resident is dependent on staff to complete personal hygiene tasks; The resident is dependent on staff for toileting needs. Observation on 9/8/25 at 7:44 A.M., showed the resident lay in bed. On both hands, the resident's fingernails were approximately one half an inch long with dark matter underneath. The resident's feet were extremely dry with large flakes of skin on the resident's navy-blue mattress. Observation and interview on 9/9/25 at 3:12 P.M., showed Certified Nurse Aide (CNA) E entered the resident's room and explained to the resident that he/she was going to turn and clean the resident. The resident lay in bed, and CNA E checked the resident's brief and said the resident was wet. CNA E positioned the resident on his/her right side and removed the resident's brief. The resident's brief and bed pad were saturated with urine, and the resident also had a large bowel movement. CNA E finished cleaning the resident and said the resident was not on his/her assignment but was helping out another CNA. The resident had extremely dry feet with large flakes of skin on the resident's navy-blue mattress. On both hands, the resident had fingernails that were approximately one-half inch long with dark matter underneath. During an interview on 9/9/25 at 3:35 P.M., CNA F said the assignment switched about 10:30 A.M., and he/she did not know the resident was on his/her assignment. The last time the resident was checked was 10:30 A.M. CNA F said any nursing staff can change residents, but is one of the CNA's primary responsibilities to check incontinent residents every two hours. Observation on 9/10/25 at 10:24 A.M., showed the resident lay in bed. On both hands the resident had long fingernails approximately one half an inch long with dark matter underneath. The resident's feet were extremely dry with large flakes of skin on the resident's navy-blue mattress. 2. Review of Resident #48's admission MDS, dated [DATE], showed:-Moderate cognitive impairment;-Rejection of care behavior not exhibited;-Lower extremity impairment on both sides;-Substantial/maximal assistance required for showering/bathing self and lower body dressing;-Partial/moderate assistance required for personal hygiene;-Diagnoses included dementia and generalized muscle weakness. Review of the resident's care plan, in use at the time of survey, showed:-Focus: ADL/mobility deficits - Interventions listed are reflective of resident's usual performance and may fluctuate. The resident has an ADL and/or mobility deficit related to activity intolerance, chronic health conditions, cognitive impairment/dementia, weakness/limited endurance; -Interventions included: Check nail length and trim and clean on bath day and as necessary. The resident requires help from staff with bathing/showering. Resident prefers to have facial hair such as a beard. The resident needs assistance from staff with personal hygiene tasks;-The care plan did not identify the resident as having a history of refusing care. Review of the resident's medical record, showed no documentation in August or September 2025 regarding the resident refusing assistance with hygiene care. Observation and interview on 9/8/25 at 7:02 A.M., showed the resident in bed with his/her feet pressed against the footboard. The resident's toenails were long, thick, and jagged with the big toenail on the right foot protruding approximately 0.5 inches from the top of the resident's toe. The middle toenail on the left foot was purple. During an interview, the resident said he/she gets assistance from staff with showers. He/She was unable to answer other specific questions regarding his/her hygiene and grooming needs and preferences. Observations on 9/9/25 at 12:41 P.M and 4:19 P.M., showed the resident's toenails remained long, thick, and jagged and the middle toenail on the left foot was purple. The resident's beard was scruffy. During an interview on 9/11/25 at 11:15 A.M., the resident said he/she wants his/her beard trimmed but needs staff to help him/her. His/Her toenails have not been trimmed. He/She cannot trim them. During an interview on 9/11/25 at 2:30 P.M., CNA C said the resident requires assistance of one staff with hygiene. He/She can make his/her needs known. Observation and interview on 9/12/25 at 9:06 A.M., showed the Nurse Manager removed the socks from the resident's feet and chunks of flakes fell onto the resident's bed. The bottoms of the resident's feet were dry and flaky. During an interview, the Nurse Manager said the resident's middle toenail was purple. Staff would have seen this when putting on the resident's socks. She would have expected staff to notify the nurse of the discolored toenail. She would have expected staff to put lotion on the resident's feet as part of daily care when getting the resident dressed, and on his/her shower days. CNAs can trim toenails, but Resident #48 will be referred to podiatry. 3. Review of Resident #71's quarterly MDS, dated [DATE], showed:-Short and long-term memory problem;-Severely impaired cognition/rarely made decisions regarding tasks of daily life;-Rejection of care behaviors not exhibited;-Upper and lower extremity impairment on one side;-Dependent for showering/bathing self and personal hygiene;-Substantial/maximal assistance required for upper body dressing;-Setup or clean-up assistance required for eating;-Diagnoses included aphasia (language disorder affecting communication), dementia, and hemiplegia or hemiparesis (weakness on one side of the body). Review of the resident's care plan, in use at the time of survey, showed:-Focus: Restorative - The resident is at risk for decline in eating/self-feeding and requires/benefits from restorative nursing intervention; -Interventions included resident prefers to eat with his/her hands;-Focus: ADL/mobility deficits - ADL self-care performance deficit related to impaired balance, limited mobility and weakness related to comorbidities. He/She will refuse showers at times. Will become aggressive with staff. Refuses nail trimming and shaving or trimming beard; -Interventions included: Be aware due to medical conditions/resident's status, ADL self-care performance and mobility are likely to fluctuate. The resident requires set-up help when eating. Supervise/assistance as needed. Check nail length and trim and clean on bath day and as necessary to nurse. The resident is usually/always dependent on staff for bathing/showering and to complete personal hygiene tasks. Encourage compliance with hygiene related tasks;-The care plan did not identify interventions for staff to follow if the resident refused care. Observations on 9/10/25 at 8:00 A.M., showed CNA A seated next to the resident in the dining room. The resident used his/her hand to pick up food while eating. His/Her fingernails were long with brown matter underneath, and the front of his/her shirt was soiled with brown streaks of liquid. CNA A poured hand sanitizer on a paper towel and used the towel to wipe the resident's hands. CNA A did not wipe underneath the resident's fingernails. The resident cooperated with the CNA and did not object or refuse assistance. CNA A brought the resident out of the dining room and to the resident's room. At 8:40 A.M., the resident was seated in his/her Broda chair (reclining chair) in his/her room. The front of the resident's shirt remained soiled and the brown matter remained underneath his/her fingernails. During an interview on 9/10/25 at 8:40 A.M., the resident looked at his/her fingernails and said they were not clean. He/She wants clean hands and fingernails. He/She does not like wearing dirty clothes. Observation and interview on 9/10/25 at 12:14 P.M., showed the resident wearing the soiled shirt, and the brown matter remained underneath his/her fingernails. During an interview, the resident said staff have not cleaned him/her up. Observation on 9/11/25 at 7:45 A.M., 8:46 A.M., and 11:13 A.M., showed the resident with long fingernails with brown matter underneath his/her fingernails. During an interview on 9/11/25 at 2:30 P.M., CNA C said the resident requires maximum assistance from staff with his/her ADLs. He/She is not oriented, but can make his/her needs known and can respond appropriately to the questions asked of him/her. He/She can be combative at times, but it's all about how staff approach him/her. Staff need to explain everything they are doing with him/her, step by step, working with him/her on his/her own time and in his/her own way. During an interview on 9/12/25 at 8:58 A.M., the Nurse Manager said the resident often refuses care. He/She may smile and seem agreeable, but then may attempt to hit staff. Staff should gauge the resident's mood when attempting to provide care. The resident has fingernails and he/she does not like people getting underneath them. When the resident is agreeable, staff should seize the opportunity to provide care as tolerated. During an interview on 9/12/25 at 8:44 A.M., the Assistant Director of Nurses (ADON) said the resident requires total assistance from staff with his/her ADLs. The resident has some behaviors of refusing care. Staff should take a calm approach when working with the resident. He/She does better with male caregivers. If the resident refuses care, staff should try again later and with a different approach. 4. During an interview on 9/11/25 at 9:45 A.M. CNA B said all incontinent residents should be checked at minimum every two hours and as needed. The resident's nails can be trimmed on their bathing day, and the resident's feet can be moisturized anytime. 5. During an interview on 9/11/25 at 2:30 P.M., CNA C said nail care should be provided by CNAs during daily care. CNAs can do toenail trimming if a resident is not diabetic or on blood thinners. Staff should check resident's feet when providing daily care. If they observe something new, like a discolored toenail, they should report it to the nurse and encourage the resident to keep their feet elevated. If a resident refuses care, staff should try again later and maybe try to find another staff to offer the assistance. When resident's clothing becomes soiled, staff should clean up the resident and change their clothes. If a resident's hands are dirty after a meal, staff should help the resident wash their hands and get underneath their fingernails. Staff should offer to help shave or trim a resident's beard as part of daily care. 6. During an interview on 9/12/25 at 8:44 A.M., the ADON said nail trims and shaving are done on a resident's shower days. CNAs can provide nail care and toenail care, unless the resident is diabetic or on a blood thinner, in which case nail care must be done by the nurse. The ADON expected staff to check resident's feet and fingernails when providing daily care. If they observe a resident's toenail is purple or dark in color, they should notify the nurse and the nurse would notify the physician. If a resident uses their hands while eating, staff should help the resident wipe their hands when they are finished eating, and get underneath the resident's fingernails. If a resident's clothing becomes soiled, staff should clean up the resident and change their clothing. During an interview on 9/12/25 at 9:15 A.M., the ADON and the Nurse Manager said they expected staff to check incontinent residents at least every two hours and as needed. Nail care and trimming can be provided by nursing staff during the resident's bath. The resident's feet can also be moisturized at any time but usually with bathing. They would expect staff to know which residents were on their assignments. 7. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she expects staff to check on incontinent residents every two hours to ensure their needs are met. Nursing staff are expected to provide fingernail care and foot care when needed. Staff should apply lotion to a resident's feet if they are noted to be dry and flaking. If staff observe a resident's toenail is discolored, they should report it to the nurse. CNAs can trim a resident's toenails unless they are diabetic. Nurses trim toenails for diabetic residents. If a resident's toenails are too thick and cannot be trimmed by the nurse, the resident should be referred to podiatry. If a resident eats with their hands, staff are expected to wash the resident's hands and get underneath their fingernails, if tolerated. If a resident's clothing becomes soiled, staff are expected to provide care to the resident and change their clothes. Resident #71 has a behavior of refusing care and can become combative with staff. When this occurs, she expected staff to redirect and reapproach later. CNAs can shave and trim a resident's beard. Offering to shave or trim a resident's beard is part of a resident's daily care. 2567916

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, comfortable, homelike environment by failing to clean one resident's bathroom after a plumbing issue (Resident #77), failing to clean one resident's wheelchair (Resident #16), failing to clean one resident's room (Resident #37) and failing to keep temperature logs on five residents with personal refrigerators (Resident #11, Resident #48, Resident #17, Resident #4 and Resident #6) The sample was 20. The census is 90. Review of the facility's 100 hall housekeeping checklist, undated, showed;-Sweep/mop soiled closets wipe walls and reduce odors;-Empty trash cans;-Dust top of rooms, light fixtures, nightstands, counter tops, dresser, dispensers, and window sills;-Clean and disinfect sinks, beds. And high touch areas and items;-Sweep rooms;-Mop floor;-Clean and disinfect inside and outside of toilets, top to bottom;-Clean and disinfect shower areas and tubs; -Dust vents;-Sweep floor;-Mop floor including inside of showers. 1.Review of Resident #77's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 6/12/25, showed:-Cognitively intact;-Independent with bed to chair and chair to bed transfers and toilet transfers;-Uses a manual wheelchair;-The resident has an indwelling urinary catheter (a tube inserted into the bladder that drains urine);-Diagnoses included neurogenic bladder (inability to urinate), depression, muscle weakness, and spinal stenosis (narrowing of the spinal canal causing pain). Observation and interview on 9/10/25 at 2:37 P.M., showed the resident was self-propelling in his/her wheelchair to the shower room on 100 hall. The resident said his/her bathroom toilet was backed up bad and there was a large amount of bowel moment on the bathroom floor, and he/she was instructed by nursing staff to empty his/her urinary catheter bag in the shower room. The resident's bathroom had brown water overflowing out of the toilet and large pieces of bowel movement on the floor. Bowel movement oozed on the side of the toilet. Towels and a thin blanket lay on the floor of the bathroom, and was saturated with brown water. At 2:40 P.M., the Assistant Director of Nursing (ADON) entered the resident's bathroom and said he would call housekeeping and maintenance to get the bathroom clean, and get the toilet fixed. Observation and interview on 9/11/25 at 9:45 A.M., showed the resident's bathroom door was open and the toilet had brown water to the top, dried bowel movement on the side of the toilet, large chunks of dried bowel movement on the floor. A pink wash basin was sitting on top of the trash can in the resident's bathroom. A plunger was located next to the toilet. A soiled towel and thin blanket were on the bathroom floor. The resident said no one came to fix his/her toilet or clean his/her bathroom. The resident said the nursing staff instructed the resident to empty his/her urine from his/her catheter bag into the wash basin, dump it in the toilet but do not flush. The resident said he/she was not going to roll his/ her wheelchair over bowel movement to empty his/her catheter. The resident said he/she used the 100-hall shower room to empty his/her catheter during the night. During an interview on 9/11/25 at 9:45 A.M., Certified Nursing Assistant (CNA) B said he/she was not aware the resident's bathroom was soiled. CNA B said he/she thought someone from maintenance locked the bathroom door so the resident and staff did not use it. The bathroom should not have been left soiled overnight. CNA B thought the bathroom was disgusting. The nursing staff can clean most of it, but the housekeeper would have to come in and disinfect the toilet and floors. CNA B would not expect the resident to use the bathroom, and it was not homelike. During an interview on 9/11/25 at 1:20 P.M., the Housekeeping Supervisor said housekeeping staff are expected to clean and disinfect bathrooms daily and as needed. During an interview on 9/12/25 at 8:20 A.M., the Maintenance Director said he was aware the building was having some plumbing issues but was not aware the resident's toilet had backed up. He expected staff to inform him verbally or fill out a work order to have it fixed. It was not homelike for the resident to have a backed-up toilet and soiled bathroom. During an interview on 9/12/25 at 9:15 A.M., the ADON and the Nurse Manager expected staff to clean the bathroom and have the housekeepers disinfect it. The bathroom should have been cleaned as soon as it happened and not have the resident have a soiled bathroom all night. 2. Review of Resident #16's quarterly MDS, dated [DATE], showed;-Cognitively intact;-Uses manual wheelchair;-Diagnoses included non-Alzheimer's dementia and anxiety. Observation and interview on 9/8/25 at 7:30 A.M., showed the resident sat in his/her wheelchair. The wheels on the wheelchair had food crumbs and dust on them. The area where the wheel connects to the wheelchair had large clumps of gray hair and dust on both sides. The resident said his/her wheelchair was disgusting and he/she would like it cleaned. The resident has never seen the facility staff clean wheelchairs. Observation on 9/9/25 at 11:19 A.M., 9/10/25 at 12:47 P.M., and 9/11/25 at 9:45 A.M., showed the resident sat in his/her wheelchair. The wheel on the resident's wheelchair had food crumbs and dust on them. The area where the wheel connects to the wheelchair had large clumps of gray hair and dust on both sides. During an interview on 9/11/25 at 9:45 A.M., CNA B said it is night shift aides who are responsible for cleaning the resident's wheelchair. There is no wheelchair cleaning schedule. CNA B said the resident's wheelchair needed to be cleaned. During an interview on 9/12/25 at 9:15 A.M., the ADON and Nurse Manager said there was no wheelchair cleaning schedule, and a schedule was just recently put in place. It is the responsibility of the CNAs to clean the residents' wheelchairs. They expected staff to clean wheelchairs if they are visibly soiled. 3. Review of Resident #37's quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Diagnoses included non-Alzheimer's dementia, diabetes, hemiplegia (paralysis to one side of the body), stroke and seizures Observation on 9/8/25 at 7:44 A.M., 9/9/25 at 11:34 A.M. and 3:04 P.M., 9/11/25 at 1:20 P.M., showed the resident lay in bed. In the corner of the resident's room behind the resident's bed, lay a crumpled cup and face mask and a large black crumblike substance around the baseboards. The resident's nightstand had a large smear of brown matter. During an interview on 9/12/25 8:20 A.M., Housekeeper D said resident daily room cleaning includes cleaning sinks, floors, furniture, moving furniture out and sweeping behind the furniture. The bathrooms are also cleaned every day. During an interview on 9/11/25 at 1:20 P.M., the Housekeeping Supervisor said resident rooms are cleaned daily and the staff are expected to follow the housekeeping checklist. She expected the housekeeping staff to clean around the baseboards and pick up any trash, move the furniture and mop and sweep behind the furniture. 4. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she expected staff to keep the bathrooms clean, report issues to the appropriate persons when a toilet backs up and she expected the bathroom to be cleaned as soon as it happens. She expected the residents' rooms to be cleaned every day, and floors swept. She expected staff to provide the residents a homelike environment. 5. Review of Resident #11's significant change MDS, dated [DATE], showed:-Cognitively intact;-Upper and lower extremity impairment on one side;-Diagnoses included chronic kidney disease and depression. Observation on 9/9/25 at 11:09 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator, and no temperature gauge inside the refrigerator. The refrigerator contained yogurt and various beverages. During an interview, the resident said he/she wasn't sure if staff checked the temperature inside the refrigerator. Observation on 9/11/25 at 8:52 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator. 6. Review of Resident #48's admission MDS, dated [DATE], showed:-Moderate cognitive impairment;-Lower extremity impairment on both sides;-Diagnoses included dementia and generalized muscle weakness. Observation on 9/9/25 at 11:04 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator. Observation on 9/10/25 at 7:53 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator. The refrigerator contained V8 juices and other beverages. During an interview on 9/10/25 at 9:38 A.M., the resident did not understand questions regarding the temperature of his/her personal refrigerator. 7. Review of Resident #17's MDS, dated [DATE], showed:-Cognitive impairment;-No behaviors;-Utilizes a manual wheelchair;-Diagnoses included diabetes, dementia, anxiety and traumatic brain injury. Observation and interview on 9/8/25 at 9:07 A.M., showed the resident sat in his/her wheelchair in his/her room. A mini refrigerator sat on a stand in the resident's room. No temperature log was on or near the refrigerator. The resident said he/she used the refrigerator regularly and keeps milk in there. Observations on 9/9/25 at 10:59 A.M., 9/10/25 at 7:45 A.M. and 9/11/25 at 8:56 A.M., showed a mini refrigerator in the resident's room. No temperature log was observed on or near the refrigerator. 8. Review of Resident #4's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included high cholesterol, dementia, and psychotic disorder. Observation on 9/9/25 at 4:20 P.M., showed the resident had a personal mini refrigerator in the room. No temperature log sheet observed. Observation and interview on 9/11/25 at 8:53 A.M., showed the resident's refrigerator did not have a temperature log sheet. The resident said he/she had never seen any staff check the refrigerator. The refrigerator contained some milk and juices. The resident's roommate said staff were supposed to check the refrigerator's temperature daily, but nobody was doing it since the time he/she was moved to the room, which was approximately a year ago. 9. Review of Resident #6's annual MDS, dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included diabetes, high cholesterol, high blood pressure, anxiety, depression and schizophrenia (a serious mental health condition that affects how people think, feel and behave). Observation and interview on 9/11/25 at 8:58 A.M., showed the resident had a personal mini refrigerator in the room, by the sink. A blank temperature log sheet was taped on the side of the refrigerator. The resident said he/she did not see any staff checking the refrigerator's temperature. He/She did not know what the piece of paper was for that was attached to the refrigerator. The refrigerator contained milk, chocolate milk and bags of salads. During an interview on 9/11/25 at 8:59 A.M., Housekeeping Aide H said they were not responsible for checking and logging temperature of the residents' personal refrigerators. He/She said the CNAs were responsible for that task. During an interview on 9/11/25 at 9:04 A.M., CNA P said the Certified Medication Technicians (CMT) used to check the temperature of the residents' personal refrigerators. He/She did not remember the last time they were being checked. He/She had not seen anyone check them lately. During an interview on 9/11/25 at 2:23 P.M., Housekeeping Aide D said housekeeping staff does not touch or monitor the temperatures of personal refrigerators in resident rooms. During an interview on 9/11/25 at 2:50 P.M., CNA B said dietary is the only department that checks the refrigerators in their kitchen. 10. During an interview on 9/12/25 at 10:49 A.M., the Administrator said housekeeping is responsible for monitoring temperatures inside resident personal refrigerators. She is unsure how often the refrigerator temperatures are checked. They should be checked routinely, and housekeeping should have some system that should be in place.1454154

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 31 opportunities observed, five errors occurred, resulting in a 16.13 % error rate. (Resident #84 and Resident #86). The census was 90. Review of the facility's Medication Administration policy, dated November 2021, showed:-To administer the following: Right medication; Right dose; Right dosage form; Right route; Right resident; and Right time;-Read the Medication Administration Record (MAR), for the ordered medication dose, dosage form, route, and time;-Verify the pharmacy prescription label on the drug and the manufacturer's identification matches the MAR;-If there is a discrepancy, check the original physician's orders and notify the pharmacy; Do no give the medication until clarified;-Verify that any further medication identifiers match the label and the medication; Identifiers may include drug size, shape and color;-Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to the MAR before administering;-Administer oral medications with a full glass of water. Review of the Novolog (an immediate release insulin) FlexPen manufacturer's insert instructions, undated, showed: Key steps in using the FlexPen include priming the pen, dialing the dose, injecting by pressing the button for at least six seconds, removing the needle, and storing the pen without a needle. 1.Review of Resident #84's medical record showed diagnosis that included atrial fibrillation (irregular heartbeat), major depressive disorder, long term use of aspirin, long term use of anticoagulant (blood thinner), heart failure, and neuropathy (pain and numbness to the lower extremities). Review of the resident's physician order sheets (POS), dated, September 2025, showed:-An order dated, 2/5/25, escitalopram oxalate 20 milligrams (mg), give one time a day for depression;-An order dated, 9/3/24, celecoxib (pain medication) capsule 200 mg, give one capsule one time a day for inflammation;-An order dated, 6/25/22, aspirin 81 mg give one tablet, one time a day for atrial fibrillation;-An order dated, 6/25/22, Eliquis (blood thinner) 5 mg, give one tablet, every 12 hours for atrial fibrillation. Observation on 9/10/25 at 8:04 A.M. showed, Certified Medication Technician (CMT) I prepared the resident's medications at the medication cart on the 100 hall. CMT I entered the resident's room and administered the resident's medications. CMT I did not administer the resident's escitalopram oxalate 20 mg, celecoxib 200 mg, aspirin 81 mg, and Eliquis 5 mg.Review of the resident's MAR, dated 9/1 to 9/30/25, showed:-An order dated, 2/5/25, escitalopram oxalate 20 mgs, give one time a day for depression; A.M. med; documented as administered;-An order dated, 9/3/24, celecoxib capsule 200mgs, give one capsule one time a day for inflammation; A.M. med: documented as administered;-An order dated, 6/25/22, aspirin 81 mg give one tablet, one time a day for atrial fibrillation; A.M. med; documented as administered;-An order dated, 6/25/22, Eliquis 5 mgs, give one tablet, every 12 hours for atrial fibrillation; A.M. med; documented as administered. During an interview on 9/10/25 at 10:49 A.M., CMT I said he/she thought he/she gave the resident all of his/her medications. CMT I thought he/she gave the medications to the resident when the surveyor was not observing but wasn't sure. CMT I said he/she double checks the medication orders on the MAR prior to administering medications. During an interview on 9/11/25 at 10:40 Licensed Practical Nurse (LPN) K said when staff are administering medications, physician orders should be followed and medications should be given at the time the MAR shows in its entirety. If a medication was not given for any reason, it should be charted as not given. Medications should be checked twice against the MAR prior to giving the medicine to ensure accuracy. During an interview on 9/12/25 at 9:15 A.M., the Assistant Director of Nursing (ADON) and the Nurse Manager said all medications are expected to be given per the physician orders in its entirety. Staff are expected to utilize the five rights when administering medications to ensure accuracy. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she expects staff to follow physician orders and accurately give residents their medications in their entirety. 2. Review of Resident #86's medical record showed diagnoses that included cognitive communication deficit and diabetes.Review of the resident's physician order sheets (POS), dated, September 2025, showed:-An order dated, 5/22/25, Novolog FlexPen subcutaneous (fatty layer of the skin) solution pen injector 100 units per milliliter (ml), inject 14 units subcutaneously with meals;-An order dated, 5/22/25, Novolog FlexPen subcutaneous solution pen injector 100 units per ml, inject per sliding scale (a measurement of blood sugar), if blood sugar is: 151-200 inject 2 units; 201-250 inject 4 units; 251-300 inject 6 units; 301-350 inject 8 units; 351-400 inject 10 units.Observation on 9/9/25 at 11:34 A.M., showed Licensed Practical Nurse (LPN) J took the resident's blood sugar and the resident's blood sugar showed 173. LPN dialed the resident's Novolog FlexPen to 16 units, entered the resident's room and administered the Novolog insulin to the back of the resident's left arm. LPN J did not prime the Novolog FlexPen prior to administering the insulin. During an interview on 9/11/25 at 8:56 A.M., Registered Nurse (RN) A said the insulin pens are to be primed with two units of insulin before administering the insulin to the resident every time. Priming the pen removes any air bubbles and ensures the insulin dose more accurate. During an interview on 9/11/25 at 10:40 A.M., LPN K said insulin FlexPens should only be primed when the pen is being used for the first time. LPN K was not aware if the insulin FlexPens should be primed with each use. During an interview on 9/12/25 at 9:15 A.M., the Assistant Director of Nursing (ADON) and the Nurse Manager said the insulin FlexPens are expected to be primed by the nursing staff administering the medication with 2 units of insulin each time the FlexPen is being used. It ensures a more accurate dose by removing any air bubbles. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she would expect staff to prime insulin FlexPens prior to each use. 1454154

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents, one with cognitive impairment, did not engage in sexual activity (Resident #1 and Resident #2). The sample was four. The census was 88. The Director of Nursing (DON) was notified on 3/19/25 at 12:40 P.M., of the past non-compliance, which occurred on 3/6/25. The facility provided in-servicing for all staff regarding the facility's abuse and neglect policy with emphasis on sexual abuse. The facility also updated Resident #1's care plan. The deficiency was corrected on 3/11/25. Review of the facility's Abuse, Neglect, Misappropriation of Resident Property Policy, dated 8/24, showed the following: -The Administrator has primary responsibility in the facility for implementation of the abuse and neglect program; -The facility will follow all state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse, sexual abuse, or involuntary seclusion; -Sexual Abuse: -Non-consensual sexual contact of any type with a resident. Includes, but is not limited to: -Unwanted intimate touching of any kind especially of breasts or perineal area; -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -Forced observation of masturbation and/or pornography; and; -Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Review of the facility Sexual Expression Policy, undated, showed the following: -Policy: The facility recognizes and respects the importance of emotional and physical intimacy without regard to sexual orientation or gender. For the purpose of this policy, sexual expression is defined as words, gestures, movements or activities; including touching, flirting, and/or physical contact which appear motivated by the desire for affection, relationship, intimacy, and/or sexual gratification; -In this regard, residents have the right to seek and engage in consensual sexual expression with other residents. Residents also have the right to access and/or obtain for private use, materials with sexually explicit content; books, magazines, film, video, pictures, or drawings. To the extent possible, residents also have the right to access a private space in support of sexual expression; It is the function and responsibility of the staff to uphold and facilitate resident sexual expression. It is also the responsibility of the facility to provide comprehensive and culturally sensitive staff training to ensure resident rights to privacy and to protect residents from abuse. The facility will also develop a care plan and updates on a quarterly basis or when there is a significant change in circumstances. -Purpose: -To ensure that residents' right to safe and healthy sexual expression is recognized, respected, supported, and maintained. -To ensure staff uphold and support resident sexual expression as defined and described in policy. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/31/24, showed the following: -Severe cognitive impairment; -No behaviors; -Diagnoses of congestive heart failure and high blood pressure. Review of the residents's care plan, showed no documentation regarding sexual behavior or expression. Review of the resident's nurse's note, dated 3/6/25 at 6:02 P.M., showed at 5:30 P.M., this nurse found an opposite sex resident in his/her room at his/her bedside, receiving oral sex. The opposite sex resident was escorted out of room, and moved to another division. There was no injury noted to resident and his/her mood is pleasant. The reporter was unable to reach his/her family member to report situation. During an interview on 3/19/25 at 9:09 A.M., the resident said the person he/she was being intimate with was his/her partner. The resident said they had been dating and were sexually active. The resident he/she cares for his/her partner and wanted to be sexually active. The resident said they had been dating for a while and he/she was very comfortable. Review of Resident #2's admission MDS, dated [DATE], showed the following: -No cognitive impairment; -No behaviors; -Diagnoses of anemia (a condition where your blood doesn't have enough healthy red blood cells or hemoglobin, leading to reduced oxygen delivery to tissues and organs, causing symptoms like fatigue, weakness, and shortness of breath), high blood pressure, and end stage renal disease (ESRD, also known as kidney failure, is a condition where the kidneys have permanently lost most of their ability to function). Review of the resident's care plan, showed no documentation regarding sexual behavior or expression. Review of the resident's nurse's note, dated 3/6/25 at 5:40 P.M., showed the resident was observed in another resident's room, receiving oral sex. The resident was asked to leave this resident's room. The resident did leave the room while chanting boo hoo. The Director of Nursing (DON) and Administrator made aware. The resident was placed on 15 minute checks monitoring. Review of the resident's medical record, showed the resident was discharged home on 3/7/25. During an interview on 3/14/25 at 10:46 A.M., Licensed Practical Nurse (LPN) A said he/she was working the day when LPN B came to him/her and said Resident #2 was in Resident #1's room. LPN A said he/she went to Resident #1's room, knocked on the door, entered the room and Resident #2 was receiving oral sex from Resident #1. LPN A said he/she could see Resident #1 laying on the bed covered up with a blanket. LPN A said he/she asked Resident #2 to leave the room and was escorted to his/her room. LPN A said Resident #1 is cognitively impaired and could not consent to sexual activity. LPN A said he/she had recently been in-serviced on the facility's Abuse and Neglect Policy. During an interview on 3/14/25 at 12:47 P.M., LPN B said on 3/6/25 at approximately 5:30 P.M., he/she was coming into work and was walking the halls glancing in resident rooms, as he/she usually does when coming on shift. He/She looked in Resident #1's room and saw Resident #2 standing over Resident #1 with his/her pants down. LPN B went to get LPN A and they went into Resident #1's room. When they entered, Resident #2's mouth was near Resident #1's genitals. LPN B had Resident #1 leave the room immediately. LPN B was recently inserviced on the facility's Abuse and Neglect Policy. During an interview on 3/19/25 at 11:35 A.M., the Social Service Director (SSD) said the two residents were friendly with each other. The SSD said the two would often sit together and talk and never thought the two would become sexually involved. The SSD said due to the low cognitive score of Resident #1, he/she would not recommend the two residents be sexually involved. He/She was recently inserviced on the facility's Abuse and Neglect Policy. During an interview on 3/19/25 at 12:40 P.M., the DON said due to Resident #1's low cognitive score, he/she would not be able to consent to sexual behavior. The DON said he/she did not know the two would be sexually involved. MO00250654

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected one of two sampled residents who expired and had money in their accounts (Resident #142). The census was 86. Review of the facility's Resident Fund Management Service (RFMS) policy, revised [DATE], showed: -Protocol: The facility will safeguard and manage resident funds in accordance with state regulation; -Procedure included: -Upon the death of a resident, the operator shall contact the Department of Social Services (DSS), MO HealthNet Division, TPL Unit, to determine if the deceased resident is a MO HealthNet participant or has been a recipient of aid, assistance, care, services, or if the resident has had moneys expended on his/her behalf of DSS. The facility shall document the contact(s) with and response(s) from DSS; -The policy failed to identify the federal requirement for notice and conveyance of funds to be completed within 30 days upon the death of a resident with funds remaining in the their account. Review of Resident #142's resident fund account, showed: -Expired [DATE]; -Ending account balance: $4,846.23; -On [DATE], the day the Department of Health and Senior Services (DHSS) onsite visit began, a TPL form completed. During an interview on [DATE] at 7:47 A.M., the Business Office Manager (BOM) said when a resident expires and has money left in the resident trust account, she is required to send a TPL to MO HealthNet regarding the remaining account balance. She thought the TPL had to be submitted within 60 days of the resident's expiration. She was not aware of the federal requirement for notice to be submitted within 30 days. During an interview on [DATE] at 8:08 A.M., the Administrator said when a resident expires leaving money in the resident trust account, she expects the BOM to submit a TPL within the federally required timeframe.

Based on observation, interview and record review, the facility failed to protect the resident's right to privacy during personal care for one of two residents observed to be provided care, when the staff exposed the resident to his/her roommate during care (Resident #19). The census was 86. Review of the facility's resident's rights, provided to the resident during the signing of the admission packet showed: Resident [NAME] of Rights - Missouri: -Each resident shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. All persons, other than the attending physician, the facility personnel necessary for a treatment or personal care, or the Division of Aging or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment or care unless consent has been given by the resident. Review of the Resident #19 significant change Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/17/24, showed: -Severe cognitive impairment; -Primary medical condition category: stroke; -Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity for toileting hygiene, shower/bath self, upper and lower body dressing, and personal hygiene; -Always incontinent of bowel and bladder. Observation on 2/7/24 at 6:20 A.M., showed Certified Nursing Assistance (CNA) G provided morning perineal care (cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) for the resident while he/she lay in bed. He/She exposed the resident with the curtains in the room opened. The roommate was in view of the resident as CNA G provided care and looked in the direction of the resident while he/she was undressed. During the interview on 2/7/24 at 1:18 P.M., the Director of Nursing (DON) said residents should be provided privacy while care is performed by the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a clean, comfortable and homelike environment for all residents when staff failed to ensure resident rooms were without odor and floors without sticky substances (Residents #6 and #73). The sample was 18. The census was 86. Review of Housekeeping Checklist for Split Hall, the hall in which Resident #6 and Resident #73 reside, showed the following tasks are to be completed by the housekeeper assigned daily: -For Offices, Activity Room, Break Room and rooms 119-126, 200 bathroom, rooms 219-226, and Extra Rooms; -Empty trash cans, wipe trash cans out; -Dust top of rooms, light fixtures, nightstands, counter tops, dressers, dispensers, window sills; -Clean and disinfect sinks, beds, and high touch areas and items (ex. Door/knobs, remotes, etc.); -Check and restock dispensers; -Sweep rooms and be sure to get under beds; -Mop floor (always put out wet floor sign); -Clean and disinfect inside and outside of toilets (top to bottom); -Clean floor around base of toilet; -Clean and disinfect shower areas and tubs; -Dust vent; -Sweep floor; -Stock toilet paper; -Mop floors include inside showers. Review of Resident #6 annual assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/8/24, showed: -Cognitively intact; -Diagnosis included debility (the state of being weak or feeble) and cardiorespiratory conditions. Review of Resident #73 quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis included debility and cardiorespiratory conditions. Observations of Resident #6's and Resident #73's room, showed: -The residents resided in the same room; -On 2/5/24 at 5:16 P.M. and 2/6/24 at 6:49 A.M., the room smelled of urine, the floor sticky, and there were black scuff marks and stains that appeared to be spilt liquids that had dried to the floor next to Resident #73's bed; -On 2/6/24 at 8:46 A.M., Housekeeper F on the hall with his/her housekeeping cart and cleaned rooms in the assigned area. He/She approached Resident #6's and Resident #73's room, the door was slightly ajar, he/she looked in and did not enter or clean the room and left the unit; -On 2/6/24 at 11:41 A.M. and 1:40 P.M., and 2/7/24 at 5:13 A.M. and 12:31 P.M., the room smelled of urine, floor was sticky, and there was black scuff marks and stains that appeared to be spilt liquids that had dried to the floor next to Resident #73's bed. During an interview on 2/7/24 at 9:57 A.M., Housekeeper F said he/she cleans each assigned area and room daily using the housekeeping checklist, starting in the bathroom and then cleans the bedroom. He/She does have supplies on hand to complete the task. He/She did not clean the room on 2/6/24 because Residents #6 and #73 were getting ready to eat lunch. During an interview on 2/7/24 at 1:18 P.M., the Director of Nursing (DON) said the resident rooms should be cleaned routinely and be without odors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to implement interventions to address a pressure ulcer and a history of falls for one resident (Resident #61). In addition, the facility failed to ensure one resident with a skin rash received an antibiotic medication, as ordered by the resident's physician (Resident #31). The sample was 18. The census was 86. 1. Review of Resident #61's medical record, showed diagnoses included stroke, anxiety disorder, dementia, traumatic brain injury, and epilepsy (seizure disorder). Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 1/2/24, for fall mats while in bed, check every shift for placement in the morning for safety. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/12/24, showed: -Severe cognitive impairment; -Rejection of care behavior not exhibited; -Dependent for putting on/taking off footwear; -Two or more falls without injury since last assessment; -One fall with injury (except major) since last assessment; -One fall with major injury since last assessment; -At risk of developing pressure ulcers; -One Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer present. Review of the resident's care plan, in use at the time of survey, showed: -Focus: 1/10/24, acquired right heel ulcer; -Interventions included soft heel boots; -Focus: Resident is at risk for falls related to gait/balance problems. History of falls with fracture; -The care plan failed to identify the resident's physician order for the use of fall mats. Observation on 2/5/24 at 10:37 A.M. and 6:10 P.M., showed the resident sat upright in a broda chair (reclining chair) with footrest raised. No boots were on the resident's feet and his/her heels were directly on footrest. Observation on 2/6/24 at 6:51 A.M., showed the resident on his/her back in bed with his/her heels directly on the bed and no boots on the resident's feet. On the right side of the resident's bed, approximately three feet from the wall, was a fall mat on the floor in between the right side of the bed and the wall. There was open space to the left side of the resident's bed and no fall mat was on the floor. Observations on 2/6/24 at 7:13 A.M. and 9:57 A.M., showed the resident sat upright in a broda chair with the footrest raised. No boots were on the resident's feet. A pillow was underneath the resident's calves. The resident's feet were crossed at the ankle with his/her right heel pressed into the footrest of the chair. Observation on 2/6/24 at 12:01 P.M., showed the resident sat upright in a broda chair with the footrest raised. No boots were on the resident's feet. A pillow was underneath the resident's calves. Both heels of the resident's feet were directly on the footrest of the chair. Observations on 2/7/24 at 5:03 A.M., 7:03 A.M., 8:30 A.M., 11:53 A.M. and 12:40 P.M., showed the resident on his/her back in bed. A fall mat was on the floor to the right side of the resident's bed. No fall mat was on the floor to the left side of the resident's bed. During an interview on 2/7/24 at 5:08 A.M., Certified Nurse Aide (CNA) N said the resident required total assistance from staff with his/her activities of daily living (ADLs). He/She did not refuse care. CNA did not think the resident was a fall risk. He/She did not think the resident was supposed to wear boots. CNAs know which residents require fall mats from receiving report. If a resident has fall mats, the mats should be on the floor on both sides of the bed, unless one side of the bed is flush to the wall. During an interview on 2/7/24 at 7:41 A.M., CNA O said the resident required total assistance from staff with his/her ADLs. He/She cannot reposition him/herself. To the CNA's knowledge, the resident does not wear soft boots. He/She is not a fall risk. CNAs know a resident is a fall risk by getting to know the resident and if there are fall mats in the resident's room. While in a resident's room, CNAs should make sure fall mats are next to the resident's bed. During an interview on 2/7/24 at 8:13 A.M., CNA P said if a resident wears soft boots, CNAs can put them on the resident. He/She does not know if the resident wears boots. The resident requires total assistance with care from staff. He/She is not alert and does not refuse care. He/She is a fall risk and requires fall mats on the sides of his/her bed. During an interview on 2/7/24 at 12:16 P.M., Registered Nurse (RN) D said the resident requires total assistance from staff with his/her care. He/She is very confused and tries to transfer on his/her own. He/She is a high fall risk and should have fall mats down on the floor on both sides of his/her bed. Nurses are responsible for implementing fall interventions, such as fall mats. Fall interventions are communicated to other staff during report. The resident has a wound on his/her heel and should be wearing soft boots. He/She does not refuse to wear the boots. CNAs can put on the resident's boots. If a resident does not want to wear their boots, CNAs should make sure the resident's heels are floated. During an interview on 2/8/24 at 10:09 A.M., the Wound Nurse said the resident has a chronic area to his/her right heel that once healed and came back a couple months ago. He/She should be wearing heel protecting boots. If he/she is not tolerating his/her boots, it is expected that nursing staff make sure the resident's feet are floated by placing a pillow underneath his/her legs. During an interview on 2/7/24 at 1:17 P.M., the Director of Nurses (DON) said the resident requires total assistance from staff with his/her ADLs. He/She has had multiple falls, including a fall resulting in a fracture. The DON thought one side of the resident's bed was flush to the wall. If there is space on either side of the resident's bed, a fall mat should be on the floor next to the side of the bed. Nursing staff providing care should ensure the fall mats are in place. The resident has a wound on his/her heel. Nursing staff is responsible for making sure the resident wears pressure relieving boots. The DON expected staff to ensure the resident's heels are floated if he/she is not tolerating the boots. During an interview on 2/8/24 at 10:17 A.M., the Administrator said she expected nursing staff to ensure fall interventions are implemented. Direct care staff and nurses are responsible for ensuring fall mats are properly placed on the sides of a resident's bed. She expected staff to implement pressure reducing measures for residents at risk of or identified as having wounds. For residents with wounds on their feet, she expected staff to offload pressure with the use of pillows for positioning or the use pressure relieving boots. Resident-specific interventions should be documented on the resident's care plan. 2. Review of Resident #31's admission MDS, dated [DATE], showed: -Usually able to make self understood; -Rejection of care behavior not exhibited; -Diagnoses included stroke, aphasia (language disorder affecting the ability to communicate), and hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body). Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident admitted with multiple pressure ulcer and skin tear wounds; -Interventions included: Administer treatments as ordered and monitor for effectiveness. Monitor/document/report as needed (PRN) any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size. Review of the resident's progress notes, dated 2/2/24, showed: -At 10:57 A.M., Licensed Practical Nurse (LPN) M documented while providing colostomy care, the nurse observed patient has a red rash on stomach. When asked if the rash is causing pain, patient shook head up and down. Physician notified; -At 11:42 A.M., LPN M documented new order for Keflex (antibiotic) 500 milligrams (mg.), three times daily, for seven days related to painful red, raised skin, warm to touch. Review of the resident's ePOS, reviewed 2/5/24 and 2/6/24, showed no orders for Keflex. During an interview on 2/7/24 at 7:53 A.M., LPN M said when a new physician order is obtained, the nurse is responsible for entering the order in the electronic medical record (EMR) as soon as possible. On 2/2/24, he/she noted a rash on the resident's stomach that was painful and warm to the touch. He/She notified the physician on that day and received an order for Keflex. During the interview, LPN M reviewed the resident's EMR and verified the order for Keflex was not on the ePOS. It looks like the order just did not get entered on the ePOS. During an interview on 2/7/24 at 12:52 P.M., the Assistant Director of Nurses (ADON) said when a new skin issues is identified, the nurse should notify the wound nurse and physician. When new orders are obtained for a skin issue, the order should be entered onto the ePOS timely, right away. The resident's order for Keflex should have been entered on the ePOS on the day the order was obtained. During an interview on 2/7/24 at 1:27 P.M., the DON said when a new skin issue is identified, she expected the nurse to assess the area and notify the physician. If the physician issues a new order, she expected the nurse to add the order to the ePOS upon receipt, or within the shift. The resident's order for Keflex, obtained on 2/2/24, should have been added to his/her ePOS right away, and the medication should have been started on 2/3/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who required assistance with activities of daily living (ADLs) received personal care and bathing assistance in accordance with their needs and preferences (Residents #31 and #16). The sample was 18. The census was 86. Review of the facility's Personal Care Needs policy, undated, showed: -Protocol: The facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of residents. The facility also provides the needed support when the resident performs their ADLs. The interdisciplinary plan of care will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident plan of care. Personal care and support include but is not limited to the following: -Bath/shower; -Grooming/dressing; -Nail care; -Shampoo; -Shave. 1. Review of Resident #31's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/25/23, showed: -Usually able to make self understood; -Rejection of care behavior not exhibited; -Upper extremity impairment on one side and lower extremity impairment on both sides; -Dependent for showers/bathing and dressing; -Substantial/maximal assistance required for personal hygiene; -Diagnoses included stroke, aphasia (language disorder affecting the ability to communicate), and hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body). Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident has an ADL self-care performance deficit related to impaired mobility; -Goal: Resident will maintain current level of function through the review date; -Interventions included: -Bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse; -Bathing/showering: Provide sponge bath when a full bath or shower cannot be tolerated. Review of the resident's medical record, showed no documentation of refusals for bathing assistance or nail care. Review of the facility's shower log, located at the nurse's station, showed: -The shower log must be completed every shift. Certified Nurse Aide (CNA) will initial next to the assigned room number when the shower is completed and report any observed skin issues to the Charge Nurse. The Charge Nurse will initial next to the CNA's initials to verify shower has been completed. Missed showers will be scheduled and completed on Sunday. All staff signing the shower log must complete the initial/signature section; -Resident scheduled for showers Tuesdays and Fridays, day shift; -On 1/26/24, Refused documented in CNA column next to the resident's room number; not signed by a Nurse; -On 1/30/24 and 2/2/24, initialed by a CNA next to the resident's room number; not signed by a Nurse. Observation and interview on 2/5/24 at 3:39 P.M., showed the resident sat upright in bed with chin-length, stringy, and greasy hair slicked behind the resident's head with thick, flaky patches along the resident's scalp. The resident had patchy hair, approximately 0.25 inches (in.) on his/her cheeks and chin. The resident had broken and jagged fingernails on his/her left hand that protruded past the tips of the resident's fingers, with a dark yellow substance underneath each fingernail. During an interview, the resident was unable to speak and nodded/shook his/her head in response to questions. The resident communicated he/she is unable to shave/trim his/her fingernails him/herself. Staff have not shaved his/her face or trimmed his/her fingernails, but he/she would like them to. He/She has not received a shower or had his/her hair washed recently, but would like to. Observations on 2/6/24 at 6:55 A.M., 8:22 A.M., 11:19 A.M., and 1:44 P.M., showed the resident with stringy and greasy hair slicked behind his/her head, with thick, flaky patches along his/her scalp. The resident had patchy hair, approximately 0.25 in., along his/her cheeks and chin. The resident had broken and jagged fingernails on his/her left hand that protruded past the tips of the resident's fingers, with a dark yellow substance underneath each fingernail. During an interview on 2/6/24 at 1:44 P.M., the resident communicated staff have not offered to bathe or shave him/her, or to trim his/her fingernails. Review of the facility's shower log, showed on 2/6/24, initialed by CNA next to the resident's room number but not signed by a Nurse. Observation and interview on 2/7/24 at 7:48 A.M., showed the resident's feet with dry, flaking skin. His/Her toenails were thick, long, and yellow. During an interview, the Wound Nurse said the resident was scheduled for an appointment with the podiatrist. Review of the resident's medical record, showed no documentation of the resident scheduled to see a podiatrist. Observation and interview on 2/7/24 at 12:40 P.M., showed the resident with stringy and greasy hair slicked behind his/her head, with thick, flaky patches along his/her scalp. The resident had patchy hair, approximately 0.25 inches, along his/her cheeks and chin. The resident had broken, jagged fingernails on his/her left hand that protruded past the tips of the resident's fingers, with a dark yellow substance underneath each fingernail. During an interview, the resident communicated staff did not provide him/her with a shower or bed bath yesterday. He/She would like to receive a shower or bed bath. He/She wants to have his/her face shaved and fingernails trimmed. During an interview on 2/7/24 at 5:08 A.M., CNA N said the resident depends on staff for total assistance with personal care. He/She does not refuse personal care. During an interview on 2/7/24 at 7:53 A.M., Licensed Practical Nurse (LPN) M said the resident typically received bed baths. He/She did not refuse bed baths. While LPN M assisted the resident on 2/2/24, he/she observed the resident had dandruff in his/her hair. To his/her knowledge, the resident does not have a medicated shampoo. Medicated shampoos address dandruff. During an interview on 2/7/24 at 12:16 P.M., Registered Nurse (RN) D said the resident requires total assistance from staff with personal hygiene. He/She does not refuse assistance with his/her personal care needs. He/She can make his wants and needs known. During an interview on 2/7/24 at 1:17 P.M., the Director of Nurses (DON) said the resident requires total assistance from staff with personal care. He/She is nonverbal, but can make his/her needs known through nodding and shaking his/her head. During an interview on 2/8/24 at approximately 11:20 A.M., Clinical Supervisor C provided documentation to show the resident was referred to the podiatrist today. He/She was not sure if the resident was referred to the podiatrist before today. Normally, the Social Services Director (SSD) is responsible for making podiatry referrals. 2. Review of Resident #16's annual MDS, dated [DATE], showed: -Cognitively intact; -Rejection of care not exhibited; -Occasionally incontinent of bladder and bowel; -Daily preferences: How important is it to you to choose between bath, shower, bed bath or sponge bath: very important; -Substantial/maximal assistance for bathing; -Diagnoses included high blood pressure, neuropathy (abnormality of the nervous system), peripheral vascular disease (PVD, poor circulation), herpes zoster eye disease (HZO, a viral infection of the nerve that supplies sensation (touch and pain) to the eye surface, eyelids, skin of the forehead and nose (trigeminal nerve). Review of the resident's care plan, revision date 8/25/23, showed: -Focus: ADL self-care performance deficit related to impairment of bilateral lower extremities, chronic pain and decreased safety awareness; -Goal: Will maintain current level of function or improve in ADLs through the review date; -Interventions included: -Bathing/showering: Resident requires limited to moderate assistance by one staff with bathing/showering two times weekly and as necessary; -Resident may refuse showers at times; -Notify nurse if resident continues to refuse; -Personal hygiene/oral care: Resident requires limited to moderate assistance. During an interview on 2/5/24 at 10:55 A.M. the resident said he/she does not get showers as scheduled on Wednesdays and Saturdays. The resident said there is not enough help on the weekends, and he/she often does not get the scheduled shower done on Saturdays. The resident said when he/she misses showers, the staff do not offer to make up the showers when they are missed. The resident said he/she has gone up to two weeks without a shower and did not get one until he/she complained to staff several times about it. The resident said getting showers as scheduled is important to him/her because he/she only has two showers scheduled a week. The resident said when he/she did not get his/her showers as scheduled, he/she felt gross and dirty and did not like feeling that way. Review of the facility shower log, dated 1/1/24 through 2/10/24, on 2/7/24 at 7:36 A.M., showed: -The resident should receive a shower every week on Wednesday and Saturday; -The shower log had blanks indicating the resident did not receive showers on Wednesday 1/10/24, Saturday 1/13/24, and Saturday 2/3/24. During an interview on 2/7/24 at 8:26 A.M., Certified Medication Technician (CMT) H said the resident has complained a few times about not receiving showers on his/her scheduled shower day. CMT H said the resident will tell him/her, Yesterday was my shower day, and I did not get my shower. CMT H said he/she reported that the resident said he/she did not get his/her shower the day before to the CNA. CMT H said the facility had a shower aide until a couple of weeks ago and now showers are hit and miss; they do not always get done because of staffing. CMT H said there was not always enough staff on every weekend to provide showers, Weekends are tough. If showers are not completed, it should be reported to the nurse. 3. During an interview on 2/7/24 at 7:41 A.M., CNA O said CNAs were supposed to follow the shower schedules posted at each nurse's station. The shower log showed staff which resident rooms were assigned for each day. Once a shower or full bed bath is completed, CNAs write their initials next to the resident's room number. If a resident refuses a shower or bed bath, the CNA should offer again. If the resident continues to refuse, the CNA should document the refusal on the shower log and notify the Nurse. Every day, CNAs should provide basic personal care, including washing a resident's face and hands, brushing their hair and teeth, and shaving the resident. CNAs should assess a resident's fingernails and toenails and provide basic nail care, when possible. If a resident's fingernails or toenails are extra long or discolored, the CNA should report it to the Nurse. 4. During an interview on 2/7/24 at 8:13 A.M., CNA P said CNAs provide showers according to the shower log posted at the nurse's station. When a shower is completed, the CNA was supposed to initial the log, next to the resident's room number. If a resident refused a shower, the CNA was supposed to report it to the nurse and document the refusal on the log. While providing personal care or bathing assistance, CNAs should look at a resident's fingernails and toenails. CNAs should provide basic nail care, unless the resident is diabetic. If issues are noted with a resident's fingernails or toenails, the CNA should report it to the nurse. CNAs should offer shaving assistance daily, especially on shower days. 5. During an interview on 2/7/24 at 7:53 A.M., LPN M said CNAs follow the shower schedule posted at the nurse's station. If a resident refuses a shower, the aide should tell the Nurse and the Nurse would verify the resident's refusal. Residents might consider a shower to mean cleaning themselves up at the sink or receiving a bed bath. Staff should provide residents with the bathing options they prefer. Once a resident receives the type of bathing assistance they prefer, the CNA initials the shower log. While providing bathing assistance, staff should assess a resident's fingernails and toenails. Basic nail care is provided by CNAs and nurses provide nail care if the resident is diabetic. If a resident requires more assistance with their toenails than what can be provided by the Nurse, the Nurse should tell the SSD to make a referral for the podiatrist. 6. During an interview on 2/7/24 at 9:06 A.M. and at 12:16 P.M., RN D said CNAs were responsible for providing showers and following the shower schedule at the nurse's station. Upon completion of a shower, the CNA writes their initials next to the resident's room number. The Nurse verifies the shower was completed and then writes their initials next to the resident's room number. If a resident refuses their shower, the CNA should tell the Nurse and the Nurse would go try to resolve the issue by offering different solutions to the resident. If the resident continues to refuse, the Nurse would notify the physician and family, then document the refusal. If a resident does not want to take a shower, a bed bath could be offered. A resident's hair should be washed in the shower or bed bath. If staff notice a resident has dandruff or flaky scalp, the Nurse should be notified so they can tell the doctor and obtain orders for a medicated shampoo. CNAs should offer to shave residents, if that is their preference. CNAs should provide nail care unless the resident is diabetic, and then it is done by the Nurse. If the resident requires more extensive toenail care, the Nurse should tell nursing management a referral is needed for podiatry. RN D said there was not enough staff on the weekends to complete showers. Weekends were really busy, and family comes in to visit residents. If showers do not get completed, the CNAs do not report it to him/her. Sometimes, RN D forgets to look at the shower book. He/She has told the CNAs if they cannot complete showers on Saturday, to make them up on Sunday. 7. During an interview on 2/7/24 at 8:16 A.M., Clinical Supervisor C said the facility had a shower aide that worked Monday through Friday but that employee was recently terminated about a week and a half ago for not performing job duties. There are no residents who are complaining about not receiving showers. If a resident had a complaint that they are not receiving showers, the social worker would handle the grievance and notify nursing. 8. During an interview on 2/7/24 at 12:52 P.M., the Assistant Director of Nurses (ADON) said he expected nursing staff to follow the shower schedule posted at the nurse's station. Residents should be offered or provided showers in accordance with the shower log. Once a shower is completed, the CNA should write their initials next to the resident's name, then the nurse verifies the shower was completed and writes their initials next to the resident's name. If a resident refuses a shower, staff should offer alternatives. If the resident continues to refuse, staff should notify the family and then document the refusal. While providing bed baths or showers, staff should wash the resident's hair. They should assess the resident's fingernails and toenails, and report any issues to the nurse. CNAs provide basic nail care. Nurses provide nail care for diabetic residents, and notify the SSD if a podiatry referral is needed. 9. During an interview on 2/7/24 at 1:17 P.M., the DON said she expected nursing staff to follow the shower schedule at the nurse's station. If a shower or bed bath is provided, the aide should initial the shower log. The Nurse should verify the shower or bed bath was completed, and then they initial the shower log. If a resident refuses a shower, she expected staff to try encourage the resident or reschedule the shower. Staff should try and identify ways to keep the resident clean, dry, and free from odors. When a shower or bed bath is provided, she expected staff to wash the resident's hair. If flakes or dandruff is noted and persists after a resident's hair is washed, she expected the Nurse to obtain orders for a medicated shampoo. CNAs should offer shaving assistance on shower days or as desired by the resident. 10. During an interview on 2/8/24 at 10:17 A.M., the Administrator said she expected nursing staff to follow the shower schedule at the nurse's station. She expected staff to provide showers or bathing assistance to residents in accordance with the resident's needs and preferences. She expected nurses to verify showers and/or bed baths were provided as documented on the shower logs. She expected nursing staff to provide residents with hair and nail care, and to offer and/or provide shaving assistance. CNAs can provide shaving assistance and basic nail care. Nurses provide nail care to residents who are diabetic. If the resident's toenails require additional assistance, Nurses should notify SSD of the need for a podiatry referral. If staff observe a resident has excessive dander in their hair, she expected the Nurse to notify the physician of a need for medicated shampoo.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards and failed to ensure drugs and biologicals were in locked compartments for one medication cart not currently in use and stored on a resident hall. The census was 86. Review of the facility's Medication Storage in the Facility policy, dated November 2012, showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the suppliers. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Observation on 2/5/24 at 10:46 A.M., 2/6/24 at 6:49 A.M., and 2/7/24 at 5:38 A.M., showed a medication cart located near room [ROOM NUMBER]. The cart was locked, but the top three drawers were able to be opened. The top drawer contained a tube Trimethicone cream (a cream used to provide hydration and assist in wound healing) not labeled with a resident's name and visibly squeezed and used. A tube of vanexel cream (moisturizing cream to treat itching) not labeled with a resident's name and visibly squeezed and used. The second drawer contained a bottle of stock vitamin C and vitamin D tablets. During an interview on 2/7/24 at 5:37 A.M., Licensed Practical Nurse (LPN) A said the medication cart near room [ROOM NUMBER] is not in use. During an interview on 2/7/24 at 1:18 P.M., the Director of Nursing (DON) said medications should be locked up. That includes ointments and over the counter medications and vitamins. Observation on 2/8/24 at 10:31 A.M., showed the medication cart located near room [ROOM NUMBER] contained a tube Trimethicone cream and tube of vanexel cream, not labeled with a resident's name and visibly squeezed and used. The second drawer contained a bottle of stock vitamin C and vitamin D tablets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records, including the documentation of administration of medications and transposition of accurate skin assessments, for three of 18 residents sampled (Residents #20, #3, and #37). The facility census was 86. Review of the facility's Episodic and Narrative Documentation Policy, revised 1/5/22, showed: -Documentation will occur in the Nurse's Progress notes to reflect a change in status, event, or notification of a responsible party or physician; -A single narrative entry will occur for the following episodes, including but not limited to: admission, change in condition, body system data collection, departure or return from medical leave, and resident responses to treatment; -Document the facts regarding the resident status as applicable, including vital signs, physical assessment findings, resident response, resident's level of consciousness, and symptoms. 1. Review of Resident #20's medical record, showed: -The resident was admitted on [DATE] and currently resides at the facility; -Medical diagnoses including unspecified paraplegia (loss of motor function in the upper or lower limbs), unspecified fracture of the thoracic vertebra (a break in one of the bones in the spine), and osteomyelitis of the vertebra (swelling or inflammation in the bones of the spine). Review of the resident's electronic Physician Order Sheet (ePOS), in use at the time of the survey, showed: -An order dated 12/14/22, for catheter (flexible tube inserted to drain urine from the bladder) care, to be completed twice daily; -An order dated 12/14/22, for colostomy (a surgical opening in the large intestine to drain fecal matter) care, to be completed twice daily. Review of the resident's January 2024 Medication Administration Record (MAR), showed: -11 out of 62 catheter care entries with blank documentation; -11 out of 62 colostomy care entries with blank documentation. During interview on 2/5/24 at 9:58 A.M. the resident said he/she had no concerns with catheter or colostomy care being done and had encountered no issues in relation to his/her catheter and colostomy care being completed by staff. During an interview on 2/8/24 at 9:18 A.M. the facility Assistant Director of Nursing (ADON) and Clinical Supervisor C said staff should document care was completed each time they complete a resident care procedure, and that staff are expected to document each time catheter and/or colostomy care are completed, to ensure the resident is receiving consistent treatment in line with the resident's treatment plan. 2. Review of Resident #3's medical record, showed: -The resident was admitted on [DATE] and currently resides at the facility; -Medical diagnoses including paranoid schizophrenia (a chronic brain disorder causing hallucinations and delusions), unspecified dementia, and chronic heart failure. Review of the resident's progress notes, showed: -A note from 1/25/24 at 3:23 P.M. entered by the on-duty Nurse, stating a Certified Nursing Assistant (CNA) had noticed a skin tear to the resident's right shin due to the resident reporting bumping it against a furniture item earlier in the day. The nurse applied a wound dressing and notified the wound nurse and the facility physician in regards to the skin tear. Review of a skin assessment performed on 1/26/24 at 6:54 A.M. by the Wound Nurse, showed the Nurse documented no new skin issues were present and no skin issues were noted upon assessment. During an interview on 2/8/24 at 9:18 A.M., the facility ADON and Clinical Supervisor C said the Wound Nurse is in charge of conducting and keeping records of skin assessments, but charge nurses on the floor can do them if necessary. Skin assessments should be completed weekly for residents unless otherwise indicated. They would expect a skin assessment conducted the day after a skin tear was observed to reflect the new injury. 3. Review of Resident #37's ePOS, in use at the time of the survey, showed: -Diagnosis of an acute infection; -An order dated 1/1/24, for cefazolin sodium (antibiotic) injection 2 grams (GM). Use 2 GM intravenously every eight hours for sepsis (complication of an infection). Review of the resident's January 2024 MAR, showed 23 out of 93 scheduled cefazolin sodium medication doses with blank entries. Review of the resident's February 2024 MAR, showed four out of 15 scheduled cefazolin sodium medication doses blank. During an interview 2/7/24 at 2:47 P.M., the Director of Nursing (DON) said nursing staff should document when medications are administered to the residents, and she would expect the documentation to be complete and accurate. 4. During interview on 2/8/23 at 1:17 P.M. the facility DON and Administrator said they would expect staff to document all care provided to residents and would expect documentation of skin assessments to be complete and accurate to reflect the residents' true skin conditions. Staff were also expected to document medications administered to each resident in each resident's MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to adhere to general infection control principles when staff provide resident care. Facility staff failed to maintain proper and effective infection control practices while providing incontinence care for one resident (Resident #19), and by exposing a wound dressing to possible infectious organisms for another resident (Resident #37). The resident sample was 18. The facility census was 86. Review of the facility's Care of Incontinent Resident Policy and Procedures, dated 1/2022, showed: -Purpose: To have residents clean and dry. -Procedure: Wash hands. Apply gloves. Remove excess feces and urine with brief, pad, or tissue as indicated. Remove gloves and wash hands or use alcohol-based gel. Apply clean gloves. Spray perineal wash on wet washcloth and cleanse with wet washcloth, or cleanse with wet, soapy washcloth. 1. Review of Resident #19's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/17/24, showed: -Severe cognitive impairment; -Diagnoses included stroke, dementia, and hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body). Review of the resident's care plan, in use at the time of the survey, showed the resident has an Activity of Daily Living (ADL) self-care performance deficit related to overall decline in functioning ability with toilet use, and is dependent on staff for assistance with toileting. Observation on 2/7/24 at 6:20 A.M., showed Certified Nursing Assistant (CNA) G entered the resident's room to provide personal care. CNA G washed his/her hands and placed on gloves. CNA G pulled down the sheet and exposed the residents brief, pulled the tabs that secured the brief, and pushed the soiled brief between the resident's legs, which was heavily soiled with tan-colored urine. CNA G took a wet washcloth and wiped the resident's perineal area (the surface area between the thighs, extending from the pubic bone to the tail bone) front to back, placed the washcloth directly on the bed, and dried the perineal area with the towel. CNA G instructed the resident that he/she would assist him/her to the side, and did so without changing gloves or sanitizing his/her hands. CNA G then exposed the resident's buttocks, and removed the soiled brief. CNA G used the same washcloth used to cleanse the perineal area, to clean the resident's buttocks, dried the perineal area with the same towel, and placed a clean brief under the resident while wearing the same gloves. CNA G then rolled the resident to his/her back. CNA G turned from the resident to retrieve ointment from the nightstand drawer and used his/her soiled gloved hand to open the drawer and grab the ointment. CNA G applied the ointment to the resident's buttocks while wearing the same soiled gloves. CNA G removed the soiled gloves and without sanitizing his/her hands, dressed the resident. During an interview on 2/7/24 at 1:18 P.M., the Director of Nursing (DON) said when staff provide perineal care they should change their gloves when going from soiled to clean, staff should wash their hands when the gloves are changed, and soiled gloves should not be used to touch clean surfaces. 2. Review of Resident #37's significant change MDS dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included diabetes mellitus, heart failure and dementia. Review of the resident's electronic physician order sheet (ePOS), showed an order dated 2/4/24, for wound care to the right lateral ankle. Cleanse area with soap and water, apply collagen powder (used to improve wound healing) and calcium alginate (absorbent dressing used for wounds with drainage) to open site and cover with bordered gauze daily and as needed, every day shift for wounds. Observation on 2/7/24 at 8:31 A.M. showed the Wound Nurse by room [ROOM NUMBER] near the entrance to the dining room, preparing a wound dressing. An opened border gauze dressing dated 2/7 with calcium alginate powder was observed on top of the treatment cart, exposed. The Wound Nurse pushed the treatment cart past 20 resident rooms down the hall to the doorway of Resident #37's room. The Wound Nurse carried the pre-prepped dressing and a clear cup with a soapy substance into the room and applied the treatment to the right lateral ankle as ordered. During an interview 2/8/24 at 2:47 P.M., the DON said nursing staff should not pre-prep the wound dressing, and should not leave the open dressing on the treatment cart to be transported to the resident room. She would expect nursing staff to have supplies that would be needed for wound care to be nearby on a clean surface when prepared. 3. During interview on 2/8/24 at 9:18 A.M., the facility Assistant Director of Nursing (ADON), who also serves as the facility Infection Preventionist (IP), and Clinical Supervisor C said facility staff are inserviced on hand hygiene and infection control policies at least annually, but there have been four inservices on infection control in the past six months. The ADON and Clinical Supervisor C said staff were expected to change gloves during perineal care between dirty and clean areas to prevent infection, and that staff should perform hand hygiene before and after each glove change. The ADON and Clinical Supervisor C would expect staff to change gloves after discarding a soiled brief before applying a clean brief, and would expect staff to change gloves and perform hand hygiene prior to touching any resident furniture item or resident personal care item in the room. 4. During interview on 2/8/24 at 1:17 P.M. the facility DON and Administrator said facility staff are inserviced on hand hygiene and infection control practices at minimum upon hire, annually, and with identified concerns as applicable. The DON and Administrator said staff providing perineal care to residents should change gloves and perform hand hygiene after discarding a soiled brief and before applying a new brief to a resident during perineal care. The DON and Administrator would expect staff to change gloves after discarding a soiled brief before touching resident furniture items or resident personal care items.

Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to follow up on outstanding checks during monthly resident trust fund (RTF) reconciliations. This facility identified 77 residents with funds handled by the facility. The census was 86. Review of the facility's Resident Fund Management Service (RFMS) policy, revised 5/1/20, showed: -Protocol: The facility will safeguard and manage resident funds in accordance with state regulation; -Procedure included: -All written accounts of the residents' funds shall be reconciled monthly and a written statement showing the current balance and all transactions shall be given to the resident, his/her designee, guardian and conservator, or conservator on a quarterly basis; -The policy did not provide guidance for follow-up on outstanding checks. Review of the facility's monthly RTF reconciliations from February 2023 through January 2024, showed outstanding checks as follows: -Check #1125, dated 7/1/20: $100.00; -Check #1265, dated 11/4/20: $1,000.00; -Check #1266, dated 11/4/20: $1,000.00; -Check #1277, dated 11/18/20: $0.38; -Check #1323, dated 1/7/21: $150.00; -Check #1449, dated 4/13/21: $30.15; -Check #1466, dated 4/28/21: $24.17; -Check #1504, dated 5/17/21: $0.02; -Check #1702, dated 1/13/22: $0.01; -Check #1766, dated 3/31/22: $58.00; -Check #1777, dated 4/19/22: $25.00; -Check #1787, dated 4/28/22: $25.58; -Check #1927, dated 10/18/22: $20.01; -Check #1984, dated 12/21/22: $100.00; -Check #2036, dated 2/23/23: $50.00. During an interview on 2/8/24 at 7:47 A.M., the Business Office Manager (BOM) said she is responsible for reconciling the RTF account monthly. The account has outstanding checks dating back to 7/1/20 that have not cleared, and the money is factored into the monthly reconciliation. She has not followed up on checks that have not cleared. There should be some follow up on outstanding checks within a reasonable timeframe. During an interview on 2/8/24 at 8:08 A.M., the Administrator said during the BOM's monthly reconciliation of the RTF account, she expects the BOM to investigate outstanding checks that have not cleared after an extended period. She expects the facility's policy to provide guidance on timeframes for investigating outstanding checks in the RTF account.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to make prompt efforts to resolve grievances when the facility did not file the grievance and/or the resolution for two residents (Resident #17 and Resident #16). The facility failed to make information on how to file a grievance available to the residents, notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in writing, the right to file grievances anonymously, and the contact information of the Grievance Official with whom a grievance can be filed. In addition, the facility failed to have access to the grievance box that was locked and located in the dining room with grievances in the box. The sample was 18. The census was 86. Review of the facility's undated Grievance Committee Policy and Procedure, showed: -Purpose: The facility Grievance Committee is established for the sole purpose of resolving complaints, which are referred to the committees by residents, sponsors, family members or other interested parties on behalf of the resident. The Grievance Committee will also receive and respond to complaints referred by the Ohio Department of Health. The resident and/or responsible party has the right to file a grievance anonymously, orally or in writing; -Committee Composition: -The Grievance Committee shall be composed of six members. The facility representative will be the Director of Nursing or assigned designee and the facility Social Worker. The remaining four members will be residents, sponsors and/or outside representatives; -Staff members will serve on the Committees as permanent members. Residents, sponsors, and/or outside representatives will be selected for the Committee by the facility Administrator. These members shall serve on the Committee until their participation becomes impractical or a resignation occurs. The Grievance Committee Chairperson will be the facility Administrator or assigned designee. You may contact the grievance official at (information for Administrator listed); -Committee meetings and documentation: -The Committee will meet at least annually to review any policies or activities deemed necessary by the Committee Chairperson. Meetings will be held on an as needed basis when complaints or grievances are received from residents, sponsors, or the Missouri Department of Health and Senior Services. The facility will first try to resolve concerns or complaints by residents or resident sponsors through meeting with facility administration. If the concern or complaint cannot be resolved through the facility administration, the full committee will meet within two business days to review and resolve the complaint. Whenever necessary, the Committee Chairperson will select temporary substitute representatives and assure the proper ratio of Committee members. The ratio will be maintained at one facility member per two residents or sponsors; -Committee Documentation: -Whenever possible, residents or sponsors will be encouraged to make complaints in writing to the Committee utilizing a standard Resident Concern Form. Meetings will be documented, and records will be maintained on file for three years; -Complaint Resolution: -The Grievance Committee will determine if a violation of Residents Rights has occurred. If a violation is found, the Committee will attempt to resolve the complaint. The facility Administrator will be notified of the steps the Committee will take to resolve the issue. If the Grievance Committee is unable to resolve a complaint referred by the Missouri Department of Health and Senior Services within ten days, the complaint will be returned to the Missouri Department of Health and Senior Services for further documentation. All actions taken by the Grievance Committee on complaints referred by the Missouri Department of Health and Senior Services will be documented on the form issued by the Missouri Department of Health and Senior Services and returned to them within 30 days from the date of notice. Any issues or concerns regarding violation of Resident Rights that is discussed in Resident Council will be referred to the Grievance Committee. All actions taken by the Grievance Committee that directly affect the residents of the home will be followed up on and discussed in Resident Council. The resident and/or responsible party also may contact the Missouri Department of Health and Senior Services and the State Long Term Care Ombudsman Program. 1. Review of Resident #17's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/21/23, showed: -Cognitively intact; -Hearing: adequate, no difficulty in normal conversation, social interaction; -Rejection of care not exhibited; -Activity preference: How important is it to you to do your favorite activities: very important; -Diagnoses included stroke, high blood pressure, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild loss of strength to one side of the body) flowing stroke. Review of the resident's current care plan, showed: -Focus: Resident participates in activity program; -Goal: Resident will attend/participate in activities of choice three to five times weekly by next review date, resident will help lead some activities by next review date; -Interventions: -Resident is a big bingo player and plays bingo every Tuesday, Thursday and Saturday; -Resident participates in morning chat, arts and crafts, bingo and entertainment parties of choice. During an interview on 2/5/24 at 12:39 P.M., the resident said he/she spoke to the Administrator last week regarding playing bingo in the dining room. The resident said he/she told the Administrator that he/she and other residents could not hear the numbers being called because of all the other noise in the dining room such as people talking, dietary staff pushing carts through the dining room to set up for lunch, and other noise. The resident said the Administrator told him/her that she wanted the activity room full and if there are not enough residents participating in activities that she will close the activity room and move all activities to the dining room. The resident said he/she normally helps Resident #16 with bingo because Resident #16 cannot hear or see well. Resident #17 said he/she cannot help Resident #16 while playing bingo in the dining room because Resident #17 cannot hear well in the dining room himself/herself. Resident #16 told Resident #17 he/she will not go to the dining room to play bingo anymore because of how loud it is in the dining room. The resident also said there are three or four residents who will not go to the dining room to play bingo anymore. The resident said when playing bingo in the activity room, if it gets loud in the hallway outside the activity room, they can close the door to limit distractions and noise. The resident said in the dining room there is not a door to close to limit distractions and noise. During an interview on 2/6/24 at 6:55 A.M., the resident said he/she might go play bingo today but he/she does not want to go because it is in the dining room. During an interview on 2/7/24 at 9:50 A.M., the resident said the experience of playing bingo in the dining room yesterday was quieter than it normally is. The resident said he/she still had problems hearing during bingo because of the carts going back and forth and people talking all the time. The resident said he/she did not hear all the numbers being called and did not even know he/she had a bingo until the Activity Director checked his/her bingo card. The resident said he/she made a verbal grievance to the Administrator on 2/1/24. The resident said the Administrator did not follow up with the resident after the grievance was voiced for him/her and other residents. The Administrator only told the resident that if more people did not start showing up for activities, the activity room would be closed and all activities would be done in the dining room. The resident said some residents just did not show up for bingo in the dining room. 2. Review of Resident #16's annual MDS, dated [DATE], showed: -Cognitively intact; -Hearing: minimal difficulty in some environments when person speaks softly or setting in noisy; -Rejection of care not exhibited; -Activity preference: How important is it to you to do your favorite activities: very important; -Diagnosis included high blood pressure, neuropathy (abnormality of the nervous system), peripheral vascular disease (PVD, poor circulation), herpes zoster eye disease (HZO, a viral infection of the nerve that supplies sensation (touch and pain) to the eye surface, eyelids, skin of the forehead and nose (trigeminal nerve)). Review of the resident's care plan, showed: -Focus: Resident is social and enjoys interacting with others. Resident prefers to choose his/her own level of participation; -Goal: Resident will attend/participate in activities of choice through review date; -Interventions: -Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. -The resident's preferred activities are: bingo, morning chat, chair exercise, happy hours and some arts and crafts. During an interview on 2/5/24 at 10:55 A.M., the resident said bingo has been recently changed from the activity room to the dining room. The resident said this changed when the new Administrator came. The resident said that bingo is one of the only activities that he/she can do on his/her own. The resident said he/she went to play bingo last week in the dining room because Resident #17 said he/she would help him/her. The resident said the Activity Director knows how the residents feel but the Activity Director is obligated to do what she is told by the Administrator. The resident said he/she has never seen or spoken to the new Administrator. The resident said he/she will not be attending bingo if it is held in the dining room. During an interview on 2/6/24 at 10:32 A.M., the resident said he/she would not attend bingo because it is being held in the dining room and he/she cannot see or hear in the dining room. During an interview on 2/7/24 at 10:14 A.M., the resident said he/she voiced his/her concern about playing bingo in the dining room to the Activity Director last week after playing bingo in the dining room. The Activity Director said she understood but the Administrator said bingo is to be done in the dining room. 3. Observations on 2/6/24 showed: -10:25 A.M., overhead announcement made that bingo will be held in the dining room at 10:30 A.M., floors in the dining room actively being cleaned with large machine, one resident playing piano in dining room, TV on in dining room; -10:35 A.M., Activity Director asked the resident playing the piano to stop playing because they were getting ready to play bingo, and Activity Director also turned off the TV in dining room; -10:38 A.M., two residents in the dining room talking to each other from one table to another table and then responding, I can't hear you. One resident left the table he/she was sitting at and propelled self to the other table to speak with the other resident; -10:43 A.M., Activity Director announced getting ready to start and then began calling numbers; -10:44 A.M., resident asked Activity Director to repeat number called; -10:46 A.M., soda machine in dining room making a loud humming sound, staff talking and laughing at receptionist desk, Maintenance Director working on reception desk using a power drill; -10:48 A.M., Resident #54 looking at the receptionist desk with scowl on his/her face; -10:49 A.M., Maintenance Director continuing to use power drill on receptionist desk; -10:50 A.M., resident entering the dining room area walking to smoking area door and exiting through the door; -10:53 A.M., staff getting soda out of vending machine, soda loud when dispensed and echoing in dining room; -10:54 A.M., second staff member getting soda out of the vending machine, soda loud when dispensed and echoing in dining room; -10:56 A.M., Director of Nursing (DON) walking through dining room and speaking to a resident; -10:57 A.M., resident propelling self to soda machine; -10:59 A.M., receptionist paging on the overhead intercom; -11:00 A.M., staff at soda machine talking and assisting a resident with getting a soda, soda loud when dispensed and echoing in dining room, another resident entered the dining room and exited through the smoke area door; -11:02 A.M., staff assisting a resident at the vending machine next to soda machine to purchase snacks, phone ringing at receptionist desk and people talking at receptionist desk; -11:04 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, Maintenance Director using hammer at receptionist desk, when hammer is struck it echoes loudly through the dining room, receptionist talking to people at the desk; -11:06 A.M., resident asking what Activity Director said; -11:06 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:07 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, staff talking to receptionist desk and laughing, phone ringing at receptionist desk, door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:08 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room; -11:09 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking at the entrance, phone ringing from receptionist desk; -11:10 A.M., dietary staff rolling cart of dishes through the dining room, loud clanging of dishes as dietary rolled the cart through the dining room; -11:11 A.M., loud talking at the receptionist desk, door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:11 A.M., dietary staff loading dishes off cart onto table in dining room, dishes loudly clanging together and echoing through the dining room; -11:12 A.M., staff at vending machine purchasing snack then at soda machine purchasing soda, when soda dispenses echoes loudly though dining room; -11:13 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:13 A.M., Maintenance Director using air nail hammer on receptionist desk very loud and echoing through the dining room, alarm sounding at door next to Administrator's office, all noises echoing through the dining room; -11:14 A.M., Maintenance Director continuing to use air nail hammer on receptionist desk, noise very loud and echoing in dining room, resident at soda machine; -11:15 A.M., Maintenance Director continuing to use air nail hammer on receptionist desk; -11:16 A.M., resident at soda machine purchasing soda, soda loud when dispensed and echoing in dining room; -11:19 A.M., door next to Administrator's office leading to administrative offices opening and then closing loudly and echoing through the dining room; -11:21 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:22 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking loudly at receptionist desk, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:23 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:24 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:26 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:27 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:29 A.M., resident having a conversation with someone walking through the dining room; -11:30 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, resident entering the dining room and walking to smoking area door and exiting out the door; -11:31 A.M., Resident #17 asking Activity Director if she called number 58, Activity Director said yes and walked over to Resident #17 and checked his/her bingo card and Resident #17 said I have a bingo too; -11:32 A.M., several people around receptionist desk and talking loudly, resident at the soda machine to purchase a soda, resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:33 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:35 A.M., soda machine making loud buzzing noise again; -11:36 A.M., resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot, door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking at the receptionist desk; -11:37 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:38 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room; -11:39 A.M., staff rolling computer stand cart with computer through the dining room, cart wheels echoing in dining room; -11:40 A.M., resident getting ice out of cooler at hydration station in dining room, when ice is moved crunching sound loudly echoes through dining room, resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:41 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, staff brining residents into the dining room for lunch and asking the residents where they would like to sit; -11:42 A.M., dietary staff moving plates around and clinking the plates together while moving them; -11:43 A.M., staff asking residents who were brought into the dining room what they would like to drink; -11:44 A.M., staff putting ice into cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cup, staff putting ice into second cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cup; -11:45 A.M., resident speaking loudly to receptionist at receptionist desk, staff putting ice into cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cup; -11:46 A.M., resident who was brought in for lunch by staff began yelling out help in dining room, while sitting in broda chair (a specialized reclining chair propelled by staff) in front of dining table, door next to Administrator's office opening and then closing loudly two times, echoing through the dining room; -11:47 A.M., visitor walking through dining room with keys hanging on side and clanking together as walking through dining room; -11:48 A.M., resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:49 A.M., people talking at the receptionist desk, door next to Administrator's office opening and then closing loudly two times, echoing through the dining room, resident called bingo for cover all game. 4. During an interview on 2/6/24 at 12:10 P.M., the Activity Director said examples of activities that are normally done in the dining room are when entertainment comes, and events with parties. The Activity Director said bingo has not always been played in the dining room and the Administrator told the Activity Director right before the February activity calendar came out that bingo needs to be done in the dining room. The Administrator said if activities did not start incorporating more activities in the dining room that she was going to move the Activity Director's office to a smaller office and have all activities preformed in the dining room. The Activity Director said the Administrator did not say why but she thought the Administrator was trying to get more residents to participate in activities. The Activity Director said there are problems with the noise level in the dining room when playing bingo and several residents have complained about the noise level. Resident # 16 came to the bingo game on 2/1/24 and stayed the entire game and at the end of the game Resident #16 said he/she cannot hear or see in the dining room. Resident #16 usually sits next to Resident #17 and Resident #17 helps Resident #16 while playing bingo. Resident #16 declined to come to bingo today and that is abnormal for him/her to decline. Resident #16 attended every bingo prior to changing it to the dining room. Resident #16 told the Activity Director he/she cannot see in the dining room due to the light in the dining room. Resident #16 said the lighting makes it hard for him/her to see. The Activity Director said that Resident #16 has some issues when playing bingo in the activity room but in the dining room it is a lot worse for Resident #16. Resident #16 also had complaints of not being able to hear while playing bingo in the dining room. The Activity Director said the Administrator is aware residents have complaints about the noise level in the dining room. Resident #17 went and spoke to the Administrator on 2/1/24 and told the Administrator that residents do not like going to the dining room for bingo due to the noise and distractions. The Activity Director said she gets more participation in the activity room for bingo than in the dining room. The Activity Director said there is nothing that can be done in the dining room to decrease the noise levels. The Activity Director said staff will bring residents into the dining room who are not participating in bingo and some of those residents will yell out things like help. There have been other times when residents have come into the dining room themselves and they are not participating in bingo and will yell out bingo or call out numbers after the Activity Director has called out a number. This confuses and frustrates the residents who are participating in the bingo activity. There is also a resident who likes to play the piano in the dining room and that resident sometimes goes to the piano and plays while bingo is being played. Family members will walk in and talk at the receptionist desk, employees will pass through the dining room and talk to people in the front receptionist area. The Activity Director said there is no way to shut the dining room off from the noise because there is no door to close the dining room off from the front receptionist area. The Activity Director said most of the noise comes from the front receptionist area and there is nothing that can be done about that. The Activity Director said she is aware some residents are not attending bingo due to it being held in the dining room. The Activity Director said residents will voice to her after bingo is over in private that they are having problems hearing. Some residents may ask during bingo for a number to be repeated but some will wait and talk to her afterwards in private. 5. During an interview on 2/6/24 at 12:11 P.M., the DON said there have been no grievances filed to date in 2024. She attended the last Resident Council and there were no concerns. 6. During an interview on 2/7/24 at 9:06 A.M., Registered Nurse (RN) D said several residents have voiced concerns about going to the dining room for bingo. RN D said he/she is not sure of the resident's names from the other hall but Resident #17 says it is too loud in the dining room and they cannot hear. People that are not doing activities such as a resident that yells out and sits in a broda chair will be brought into the dining room while bingo is being called and the resident will yell out help. Resident #16 said that it is too loud and people that are not participating in activities are in the dining room yelling, the TV will be on and can't hear numbers being called because it is too big of a room, and everything echoes in the room. RN D said that he/she could assist residents in filling out a grievance, but he/she knows the Activity Director and will just go to her and let her know the concerns. RN D said if it was a big deal he/she would imagine he/she would need to fill out a grievance for residents because some of them cannot write. RN D said blank grievances can be located at the nurse's station and looked at the nurse's station and was unable to locate a grievance form. RN D said if he/she needed a grievance form and could not locate one at the nurse's station he/she would ask Clinical Supervisor C for a grievance form. RN D said if he/she filled out a grievance form for a resident, he/she would turn it into the Assistant Director of Nursing (ADON). 7. During an interview on 2/7/24 at 10:23 A.M., Certified Medication Technician (CMT) H said Resident #17 has voiced concerns about playing bingo in the dining room because he/she cannot hear and there are too many people that are talking, and the room is huge, and they cannot hear. CMT H said the residents were playing bingo in the activity room but now they are playing in the dining room. 8. During an interview on 2/7/24 at 10:35 A.M., six Resident Council members, whom the facility identified as alert and oriented, said they do not feel that their grievances are followed up on. The residents said they will file a grievance with staff and will either not hear back or will hear back but not in a timely manner. 9. During an interview on 2/7/24 at 12:13 P.M., the DON knocked on the conference room door that is located directly across from the receptionist desk and then opened the door stating she could not hear if anyone said come in because of the noise outside the conference room. 10. During an observation on 2/8/24 at 8:35 A.M., showed the grievance box located in the dining room. The grievance box looked like a mailbox with a clear window on the front that goes down the middle of the box, there was a lock on the box. Several papers could be visualized through the clear window, that are inside the grievance box that had not been removed. Next to the grievance box was a folder on the wall with blank grievance sheets in it. No postings next to the grievance box or in the folder with information or directions on how grievances can be filed out. No information posted on who the grievance officer was or contact information for the grievance officer. 11. During an interview on 2/8/24 at 8:45 A.M., Certified Nurse Assistant (CNA) K said if a resident has a complaint, he/she would assess it and then would take the concern to the charge nurse. CNA K said he/she would assist a resident with filling out a grievance if needed. CNA K said blank grievance forms can be located at the nurse's station and in the DON's office. CNA K said he/she would turn in the filled out grievance form to the DON or Administrator. 12. During an interview on 2/8/24 at 8:52 A.M., CNA J said if a resident had a complaint, he/she would alert the nurse. CNA J said he/she did not think he/she could fill out a grievance for a resident. CNA J said blank grievance forms can be located in the dining room. CNA J said he/she would direct the resident to turn in the grievance form they filled out to the charge nurse or the DON. 13. During an interview on 2/8/24 at 9:10 A.M., CMT H said if a resident had a complaint, he/she would start by talking to the resident and see if he/she could help with the complaint. If CMT H could not help with the complaint he/she would refer the resident to the person that could help them. CMT H said he/she would fill out a grievance for a resident, but CMT H said he/she has never filled one out for a resident. CMT H said he/she would only fill one out if the resident could not write. CMT H said blank grievance forms can be located in the ADON office, DON office, and in the cubby next to the Human Resources (HR) office. CMT H said he/she is unsure on the exact person to turn in a grievance form that has been filled out. He/She would give the grievance form that has been filled out to the Social Worker, DON, or Clinical Supervisor C. 14. During an interview on 2/8/24 at 11:20 A.M., the DON said she expected staff to fill out a grievance for a resident if the resident voices a concern that staff cannot resolve themselves. After filling out the grievance for the resident, the staff member should let the resident read the grievance and make sure it is correct and have the resident sign or initial the grievance, if possible, to show that the grievance is correct. Grievances can be located at the front desk and at the nurse's station. The grievance process is the Social Worker and the Administrator keep the grievance book. If someone turns in a grievance the grievance is discussed with the interdisciplinary team (IDT) to find a solution. The DON said there have not been any grievances in the month of January. The DON said if a resident voices a verbal concern and she cannot fix the concern, it would become a grievance and the DON would offer to help the resident write the grievance if he/she could not write. Grievances should be turned into the Social Worker or Administrator. The DON also said she believes there is also a grievance box in the dining room where they can be turned into, but she would personally take it to the Social Worker or Administrator. The Social Worker is responsible for following up with the person filling out the grievance. Anyone on the management team can also follow up with a person filling out a grievance. The DON said she is not sure on what the timeframe is that the grievance needs to be followed up on. If there are grievances, they are discussed daily in morning meeting and during the weekly risk meeting on Thursdays. 15. During an interview on 2/8/24 at 12:09 P.M., the Administrator said if a grievance was vocalized, she would fill out a grievance for the resident. The Administrator said that she has asked residents before if they want to file a grievance and she will if the resident wants one filled out and sometimes the residents say no, they do not want a grievance filled out. They just wanted to talk. The Administrator said she would follow up with the resident regarding any concerns they have. The Administrator said anyone can file a grievance. The Administrator said the Social W

Based on interview and record review, the facility failed to check for a federal indicator (identifies when an employee who has ever held a Certified Nurse Aide (CNA) certificate has ever been found to have abused, neglected, or misappropriated resident property) through the state Nurse Aide (NA) registry prior to hiring a new employee, in accordance with the facility's abuse policies, for four of 10 employee files reviewed. The census was 86. Review of the facility's Abuse, Neglect, Exploitation, Misappropriation of Resident Property policy and procedure, revised 9/12/18, showed: -Policy: The facility will follow state and federal guidelines on abuse, neglect; -Screenings included: -1. Prior to hiring a new employee, the facility will: -a. Check with the nurse assistant registry and any other nurse assistant registries that the facility has reason to believe contain information on an individual, prior to using the individual as a nurse assistant; -The policy did not specify that the NA registry check should be performed for employees hired in positions other than nurse assistants. 1. Review of Licensed Practical Nurse (LPN) M's employee file, showed: -Date of hire: 11/2/22; -No NA registry federal indicator check. 2. Review of Receptionist S's employee file, showed: -Date of hire: 8/14/22; -NA registry federal indicator check completed 10/9/23. 3. Review of Housekeeper Q's employee file, showed: -Date of hire: 5/20/23; -NA registry federal indicator check completed 10/9/23. 4. Review of Housekeeper R's employee file, showed: -Date of hire: 5/22/23; -NA registry federal indicator check completed 10/9/23. 5. During an interview on 2/7/24 at 8:23 A.M., the Human Resources (HR) said she runs background checks, including the NA registry check on all prospective new hires, before they are extended a job offer. The background checks should be completed before an employee begins working in the facility as part of the facility's abuse prevention program. 6. During an interview on 2/8/24 at 10:17 A.M., the Administrator said she expected pre-employment background screening to include checking the NA registry for all new hires. The NA registry check should be completed by the HR Manager before the employee starts working in the facility, which is part of the facility's abuse prevention policy. All pre-employment background screenings should be retained in the employee files.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing activity program based on resident preferences, to support residents in their choice of activities and meet the needs of the residents. The facility failed to accommodate resident preferences and accommodate the residents' physical needs, to include hearing and vision difficulties. When concerns were brought to administration regarding the noise level in the dining room, no interventions were put in place and activities were continued in the dining room. The resident council representatives reported when activities are held in the dining room, it is too loud and it is hard to hear, and some residents have stopped going to activities when they are held in the dining room due to the noise level. In addition, two residents (Residents #17 and #16) reported concerns with the activities being held in the dining room. The sample was 18. The census was 86. 1. Review of Resident #17's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/21/23, showed: -Cognitively intact; -Hearing: adequate, no difficulty in normal conversation, social interaction; -Rejection of care not exhibited; -Activity preference: How important is it to you to do your favorite activities: very important; -Diagnosis included stroke, high blood pressure, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild loss of strength to one side of the body) flowing stroke. Review of the resident's current care plan, showed: -Focus: Resident participates in activity program; -Goal: Resident will attend/participate in activities of choice three to five times weekly by next review date, resident will help lead some activities by next review date; -Interventions: -Resident is a big bingo player and plays bingo every Tuesday, Thursday and Saturday; -Resident participates in morning chat, arts and crafts, bingo and entertainment parties of choice. During an interview on 2/5/24 at 12:39 P.M., the resident said he/she spoke to the Administrator last week regarding playing bingo in the dining room. The resident said he/she told the Administrator he/she and other residents could not hear the numbers being called because of all the other noise in the dining room such as people talking, dietary staff pushing carts through the dining room to set up for lunch, and other noise. The resident said the Administrator told him/her that she wanted the activity room full and if there are not enough residents participating in activities that she will close the activity room and move all activities to the dining room. The resident said he/she normally helps Resident #16 with bingo because Resident #16 cannot hear or see well. Resident #17 said he/she cannot help Resident #16 while playing bingo in the dining room because Resident #17 cannot hear well in the dining room himself/herself. Resident #16 told Resident #17 he/she will not go to the dining room to play bingo anymore because of how loud it is in the dining room. The resident also said there are three or four residents who will not go to the dining room to play bingo anymore. The resident said when playing bingo in the activity room, it gets loud in the hallway outside the activity room, and they can close the door to limit distractions and noise. The resident said in the dining room, there is not a door to close to limit distractions and noise. During an interview on 2/6/24 at 6:55 A.M., the resident said he/she might go play bingo today but he/she does not want to go because it is in the dining room. During an interview on 2/7/24 at 9:50 A.M., the resident said the experience of playing bingo in the dining room yesterday was quieter than it normally is. The resident said he/she still had problems hearing during bingo because of the carts going back and forth and people talking all the time. The resident said he/she did not hear all the numbers being called and did not even know he/she had a bingo until the Activity Director checked his/her bingo card. The resident said he/she did a verbal grievance to the Administrator on 2/1/24. The resident said the Administrator did not follow up with the resident after the grievance was voiced for him/her and other residents. The Administrator only told the resident if more people did not start showing up for activities that the activity room would be closed and all activities would be done in the dining room. The resident said some residents just did not show up for bingo in the dining room. 3. Review of Resident #16's annual MDS, dated [DATE], showed: -Cognitively intact; -Hearing: minimal difficulty in some environments when person speaks softly or setting in noisy; -Rejection of care not exhibited; -Activity preference: How important is it to you to do your favorite activities: very important; -Diagnosis included high blood pressure, neuropathy (abnormality of the nervous system), peripheral vascular disease (PVD, poor circulation), herpes zoster eye disease (HZO, a viral infection of the nerve that supplies sensation (touch and pain) to the eye surface, eyelids, skin of the forehead and nose (trigeminal nerve)). Review of the resident's current care plan, showed: -Focus: Resident is social and enjoys interacting with others. Resident prefers to choose his/her own level of participation; -Goal: Resident will attend/participate in activities of choice through review date; -Interventions: -Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. -The resident's preferred activities are: bingo, morning chat, chair exercise, happy hours and some arts and crafts. During an interview on 2/5/24 at 10:55 A.M., the resident said bingo has been recently changed from the activity room to the dining room. The resident said this changed when the new Administrator came. The resident said that bingo is one of the only activities that he/she can do on his/her own. The resident said he/she went to play bingo last week in the dining room because Resident #17 said he/she would help him/her. The resident said the Activity Director knows how the residents feel but the Activity Director is obligated to do what she is told by the Administrator. The resident said he/she has never seen or spoken to the new Administrator. The resident said he/she will not be attending bingo if it is held in the dining room. During an interview on 2/6/24 at 10:32 A.M., Resident #16 said he/she would not attend bingo because it is being held in the dining room and he/she cannot see or hear in the dining room. During an interview on 2/7/24 at 10:14 A.M., the resident said he/she voiced his/her concern about playing bingo in the dining room to the Activity Director last week after playing bingo in the dining room. The Activity Director said she understood but the Administrator said bingo is to be done in the dining room. 4. Observations on 2/6/24 showed: -10:25 A.M., overhead announcement made that bingo will be held in the dining room at 10:30 A.M., floors in the dining room were actively being cleaned with a large machine, one resident playing piano in the dining room, TV on in the dining room; -10:35 A.M., Activity Director asked the resident playing the piano to stop playing because they were getting ready to play bingo, and the Activity Director also turned off the TV in the dining room; -10:38 A.M., two residents in the dining room talking to each other from one table to another table and then responding, I can't hear you. One resident left the table he/she was sitting at and propelled him/herself to the other table to speak with the other resident; -10:43 A.M., Activity Director announced getting ready to start and then began calling numbers; -10:44 A.M., resident asked Activity Director to repeat the number called; -10:46 A.M., soda machine in dining room making a loud humming sound, staff talking and laughing at receptionist desk, Maintenance Director working on reception desk using a power drill; -10:48 A.M., Resident #54 looking at the receptionist desk with a scowl on his/her face; -10:49 A.M., Maintenance Director continuing to use power drill on receptionist desk; -10:50 A.M., resident entering the dining room area walking to smoking area door and exiting through the door; -10:53 A.M., staff getting soda out of vending machine, soda loud when dispensed and echoing in dining room; -10:54 A.M., second staff member getting soda out of the vending machine, the soda was loud when dispensed and echoing in dining room; -10:56 A.M., Director of Nursing (DON) walking through the dining room and speaking to a resident; -10:57 A.M., resident propelling self to the soda machine; -10:59 A.M., receptionist paging on the overhead intercom; -11:00 A.M., staff at soda machine talking and assisting a resident with getting a soda, soda loud when dispensed and echoing in the dining room, another resident entered the dining room and exited through the smoke area door; -11:02 A.M., staff assisting a resident at the vending machine next to the soda machine to purchase snacks, phone ringing at receptionist desk and people talking at receptionist desk; -11:04 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, Maintenance Director using a hammer at receptionist desk, when hammer is struck it echoes loudly through the dining room, receptionist talking to people at the desk; -11:06 A.M., resident asking what Activity Director said; -11:06 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:07 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, staff talking at the receptionist desk and laughing, phone ringing at the receptionist desk, door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:08 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room; -11:09 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking at the entrance, phone ringing from receptionist desk; -11:10 A.M., dietary staff rolling cart of dishes through the dining room, loud clanging of dishes as dietary rolled the cart through the dining room; -11:11 A.M., loud talking at the receptionist desk, door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:11 A.M., dietary staff loading dishes off cart onto a table in the dining room, dishes loudly clanging together and echoing through the dining room; -11:12 A.M., staff at vending machine purchasing snack then at soda machine purchasing soda, when soda dispenses echoes loudly though dining room; -11:13 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:13 A.M., Maintenance Director using air nail hammer on receptionist desk, very loud and echoing through the dining room, alarm sounding at door next to Administrator's office, all noises echoing through the dining room; -11:14 A.M., Maintenance Director continuing to use air nail hammer on receptionist desk, noise very loud and echoing in the dining room, resident at soda machine; -11:15 A.M., Maintenance Director continuing to use air nail hammer on receptionist desk; -11:16 A.M., resident at soda machine purchasing soda, soda loud when dispensed and echoing in dining room; -11:19 A.M., door next to Administrator's office leading to administrative offices opening and then closing loudly and echoing through the dining room; -11:21 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room, alarm sounding at door next to the Administrator's office that leads to administrative offices and echoing through dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:22 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking loudly at receptionist desk, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:23 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:24 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:26 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room; -11:27 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:29 A.M., resident having a conversation with someone walking through the dining room; -11:30 A.M., door next to the Administrator's office opening and then closing loudly, echoing through the dining room, resident entering the dining room and walking to smoking area door and exiting out the door; -11:31 A.M., Resident #17 asking Activity Director if she called number 58, Activity Director said yes and walked over to Resident #17 and checked his/her bingo card and Resident #17 said he/she had a bingo too; -11:32 A.M., several people around receptionist desk and talking loudly, resident at the soda machine to purchase a soda, resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:33 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:35 A.M., soda machine making loud buzzing noise again; -11:36 A.M., resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot, door next to Administrator's office opening and then closing loudly, echoing through the dining room, people talking at the receptionist desk; -11:37 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room, alarm sounding at door next to Administrator's office that leads to administrative offices and echoing through dining room, door next to Administrator's office opening and then closing loudly second time, echoing through the dining room; -11:38 A.M., door next to Administrator's office that leads to administrative offices opening and then closing loudly, echoing through the dining room; -11:39 A.M., staff rolling computer stand cart with computer through the dining room, cart wheels echoing in dining room; -11:40 A.M., resident getting ice out of cooler at hydration station in dining room, when ice is moved crunching sound loudly echoes through dining room, resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:41 A.M., door next to Administrator's office opening and then closing loudly, echoing through the dining room, staff brining residents into the dining room for lunch and asking the residents where they would like to sit; -11:42 A.M., dietary staff moving plates around and clinking the plates together while moving them; -11:43 A.M., staff asking residents who were brought into the dining room what they would like to drink; -11:44 A.M., staff putting ice into cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cup, staff putting ice into second cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cups; -11:45 A.M., resident speaking loudly to receptionist at receptionist desk, staff putting ice into cup from cooler at hydration station, ice crunching loudly as retrieving the ice then clinking loudly when placed into cups; -11:46 A.M., resident who was brought in for lunch by staff began yelling out help in dining room, while sitting in broda chair (a specialized reclining chair propelled by staff) in front of dining table, door next to Administrator's office opening and then closing loudly two times, echoing through the dining room; -11:47 A.M., visitor walking through dining room with keys hanging on side and clanking together as walking through dining room; -11:48 A.M., resident placing change into the soda machine and change falling through soda machine and clinging loudly into the change slot; -11:49 A.M., people talking at the receptionist desk, door next to Administrator's office opening and then closing loudly two times, echoing through the dining room, resident called bingo for cover all game. 5. During an interview on 2/6/24 at 12:10 P.M., the Activity Director said examples of activities that are normally done in the dining room are when entertainment comes, and events with parties. The Activity Director said bingo has not always been played in the dining room and the Administrator told the Activity Director right before the February activity calendar came out that bingo needs to be done in the dining room. The Administrator said if activities did not start incorporating more activities in the dining room, she was going to move the Activity Director's office to a smaller office and have all activities performed in the dining room. The Activity Director said the Administrator did not say why but she thought the Administrator was trying to get more residents to participate in activities. The Activity Director said there are problems with the noise level in the dining room when playing bingo and several residents have complained about the noise level. Resident #16 came to the bingo game on 2/1/24 and stayed the entire game and at the end of the game Resident #16 said he/she cannot hear or see in the dining room. Resident #16 usually sits next to Resident #17 and Resident #17 helps Resident #16 while playing bingo. Resident #16 declined to come to bingo today and that is abnormal for him/her to decline. Resident #16 attended every bingo prior to changing it to the dining room. Resident #16 told the Activity Director that he/she cannot see in the dining room due to the light in the dining room. Resident #16 said the lighting makes it hard for him/her to see. The Activity Director said that Resident #16 has some issues when playing bingo in the activity room but in the dining room it is a lot worse for Resident #16. Resident #16 also had complaints of not being able to hear while playing bingo in the dining room. The Activity Director said the Administrator is aware that residents have complaints about the noise level in the dining room. Resident #17 went and spoke to the Administrator on 2/1/24 and told the Administrator that residents do not like going to the dining room for bingo due to the noise and distractions. The Activity Director said she gets more participation in the activity room for bingo than in the dining room. The Activity Director said there is nothing that can be done in the dining room to decrease the noise levels. The Activity Director said staff will bring residents into the dining room who are not participating in bingo and some of those residents will yell out things like help while the other residents are participating in bingo. There have been other times when residents have come into the dining room themselves and they are not participating in bingo and will yell out bingo or call out numbers after the Activity Director has called out a number. This confuses and frustrates the residents who are participating in the bingo activity. There is also a resident who likes to play the piano in the dining room and that resident sometimes goes to the piano and plays while bingo is being played. Family members will walk in and talk at the receptionist desk, employees will pass through the dining room and talk to people in the front receptionist area. The Activity Director said there is no way to shut the dining room off from the noise because there is no door to close the dining room off from the front receptionist area. The Activity Director said most of the noise comes from the front receptionist area and there is nothing that can be done about that. The Activity Director said she is aware that some residents are not attending bingo due to it being held in the dining room. The Activity Director said residents will voice to her after bingo is over, in private, that they are having problems hearing. Some residents may ask during bingo for a number to be repeated but some will wait and talk to her afterwards in private. 6. During an interview on 2/7/24 at 9:06 A.M., Registered Nurse (RN) D said several residents have voiced concerns about going to the dining room for bingo. RN D said he/she is not sure of the resident's names from the other hall but Resident #17 says it is too loud in the dining room and they cannot hear. People that are not doing activities such as a resident that yells out and sits in a broda chair will be brought into the dining room while bingo is being called and the resident will yell out for help. Resident #16 said that it is too loud and people that are not participating in activities are in the dining room yelling, the TV will be on and can't hear numbers being called because it is too big of a room, and everything echoes in the room. 7. During an interview on 2/7/24 at 10:23 A.M., Certified Medication Technician (CMT) H said Resident #17 has voiced concerns about playing bingo in the dining room because he/she cannot hear and there are too many people who are talking, and the room is huge, and they cannot hear. CMT H said the residents were playing bingo in the activity room but now they are playing in the dining room. 8. During an interview on 2/7/24 at 10:35 A.M., six Resident Council members, whom the facility identified as alert and oriented, said they like activities to be held in the activity room. The residents said the dining room is too loud and it is hard to hear. The residents said some residents have stopped going to activities when they are held in the dining room due to the noise level. 9. During an interview on 2/8/24 at 1:30 P.M., the Administrator said that Resident #17 came into her office and voiced a concern about having bingo in the dining room and said he/she wanted bingo to be moved back into the activity room. The Administrator said Resident #17 came in the first time bingo was played in the dining room and said that him/her and a couple of other residents wanted bingo to be in the activity room instead of the dining room. The Administrator said she told Resident #17 that she wants a bigger crowd to come to bingo. The Administrator said bingo is a popular activity and she wanted more people to come. The Administrator said she was hoping he/she might like it after a couple more times of playing in the dining room. The Administrator felt like this was something Resident #17 was not willing to give a chance and that he/she did not like change and the Administrator was asking for him/her to give it a chance. The Administrator said the reason Resident #17 gave for not wanting bingo in the dining room was because it is loud in the dining room, and it makes it hard to hear. The Administrator said she has not followed up with Resident #17 related to the concern of it being loud in the dining room and that it is hard to hear. The Administrator also said no adjustments have been made while playing bingo in the dining room related to the noise level. The Administrator said she was not aware that several residents did not like having bingo in the dining room because of the noise level and not being able to hear well. The Administrator was also not aware that one resident was no longer attending bingo because it was being held in the dining room and the resident was having problems seeing due to the lighting in the dining room and hearing in the dining room due to it being loud. The administrator said activities should accommodate resident's preferences and accommodate the residents physical needs to include hearing and vision difficulties.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident receives assistance to prevent accidents, for three residents observed to be propelled down the hall in a wheelchair with their feet dragging (Residents #37, #14, and #86). In addition, the facility failed to use a gait belt to transfer one resident observed to be transferred from the bed to wheelchair (Resident #19). 1. Review of Resident #37's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/23/23, showed: -Severe cognitive impairment; -Does the resident use a wheelchair or a scooter: Yes; -Diagnoses included dementia. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident has an activity of daily living (ADL) self-care performance deficit related to overall decline in functioning ability; -Goal: Improve current level of function; -Interventions: The resident requires moderate to total assistance by staff to move between surfaces. Observation on 2/6/24 at 7:39 A.M., showed a staff person propelled the resident down the hall, past 17 rooms and into the dining room. No footrests were in place on the wheelchair and the resident held his/her feet up. The resident wore socks and his/her right heel drug on the ground as staff propelled the resident down the hall. 2. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Mobility devices: Wheelchair; -Diagnoses included traumatic brain dysfunction. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Moderate assist with ADLs. Weakness and history of traumatic brain injury and decreased mobility; -Goal: Maintain participation in functioning in ADLs; -Resident requires moderate assistance with bed mobility and transfer. Observation on 2/7/24 at 1:18 P.M., showed Occupational Therapist E propelled the resident down the hall. His/Her feet lightly touched the floor with a shuffle sound while his/her feet drug. The resident's feet suddenly dropped, causing an abrupt stop of the wheelchair. The resident's upper body flexed forward then fell back gently against back of the chair. Occupational Therapist E then proceeded to propel the resident into his/her room. 3. Review of Resident #86's admission MDS, dated [DATE], showed: -Cognitively intact; -Does the resident use a wheelchair or scooter: No; -Diagnoses included other neurological conditions. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: ADL self-care performance deficit related to impaired balance; -Goal: Improve current level of function in ADLs; -Interventions: The resident requires partial assistance by staff to move between surfaces. Observation on 2/6/24 at 8:01 A.M., showed a staff person transferred the resident down the hall in a wheelchair from the dining room to his/her room. No footrests were on the wheelchair. The resident wore socks and held his/her feet up. The resident's feet hung only a half of an inch from the floor. As the staff turned the resident into his/her room, his/her left foot dropped and drug the floor. 4. During an interview on 2/7/24 at 1:18 P.M., the Director of Nursing (DON) said when propelling a resident in a wheelchair, the resident's feet should be placed on foot pedals. They should not drag on the ground. The facility purchased bags for the wheelchair for the foot pedals to be stored when not in use. The risk of the resident's feet dragging is a possible fall from the wheelchair. 5. Review of the facility's Gait Belt Transfer policy, dated 10/2023, showed: -Purpose: Minimize the risk of injury to caregiver while performing transfers; -Procedure included: Fasten the gait belt securely around the resident's waste with the buckle at the side. The belt should not come in contact with the resident's skin; -Position one hand under the buckle; -Position the other hand under the belt, The belt should be snug; -Transfer the resident using proper body mechanics. Review of Resident #19's medical record, showed diagnoses included: stroke, hemiplegia (paralysis on one side of the body) or hemiparesis (weakness to one side of the body), and thoracic 7-8 vertebra fracture (a fracture of the mid back). Review of the resident's care plan, in use at the time of the survey, showed the resident had an ADL self-care performance deficit related to overall decline in functioning, transferring requires moderate assist of one staff to move between surfaces. Review of the resident's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Impairment on one side for functional limitation in range of motion; -Partial/moderate assistance to roll left and right for mobility; -Substantial/maximal assistance - helper does more than half the effort for chair/bed to chair transfer; Lying to sitting on side of bed: The ability to move form lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Observation on 2/7/24 at 6:20 A.M., showed Certified Nursing Assistant (CNA) G announced to the resident that he/she was going to transfer the resident to the wheelchair. He/She assisted the resident from a laying position, to sitting on the side of the bed. The CNA then positioned his/her arms under each of the resident's arms, in the armpits. The CNA then lifted the resident and pivoted the resident to the wheelchair. No gait belt was used. During an interview on 2/7/24 at 1:18 P.M., the DON said residents should be transferred with a gait belt if they are a moderate assist of one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents (Residents #16, #31, #56, #69, and #82) received room trays with food that was palatable and at the required temperatures for safe consumption. The sample was 18. The census was 86. Review of the facility's Meal Service Temperatures policy, revised 1/2019, showed: -Purpose: To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing food meal service; -Policy: Meal temperatures shall be monitored by the Director of Dietary and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees, food which does not meet the appropriate temperatures shall be removed and reheated or rechilled prior to meal service, foods which are requested by residents/patients to be reheated shall be reheated or replated to ensure satisfaction; -The policy did not address the serving temperatures of food. 1. Observation on 2/6/24 at 8:32 A.M., of a 200 hallway breakfast tray, showed: -Biscuits and gravy measured at 114.2 degrees Fahrenheit (F) and was cold to taste. 2. Observation on 2/7/24 at 8:33 A.M., of a 200 hallway breakfast tray, showed: -Pancakes measured at 111.2 degrees F and were cool to taste; -Bacon measured at 91.5 degrees F and was cold to touch. 3. Observation on 2/8/24 at 8:15 A.M., of a 200 hallway breakfast room tray, showed: -Scrambled eggs measured at 105.6 degrees F and were cold to taste; -Hash browns measured at 116.9 degrees F and were cold to taste. 4. Review of Resident #16's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/24, showed: -Cognitively intact; -Setup or clean-up assistance with eating; -Diagnoses included high blood pressure, neuropathy (abnormality of the nervous system), peripheral vascular disease (PVD, poor circulation), herpes zoster eye disease (HZO, a viral infection of the nerve that supplies sensation (touch and pain) to the eye surface, eyelids, skin of the forehead and nose (trigeminal nerve)). During an interview on 2/5/24 at 10:55 A.M., the resident said the food is terrible, the food is cold and the coffee is always cold. The resident said the food and coffee must be hot to be good. During observation and interview on 2/6/24 at 8:26 A.M., the resident had his/her breakfast tray and was attempting to stir the oatmeal. The resident said the oatmeal was so thick, the resident could hardly stir it. Observation of the resident attempting to stir the oatmeal showed one solid lump moving around in the bowl, as the resident moved the spoon in the bowl. The resident said the oatmeal was barely warm, and the eggs were cold. 5. Review of Resident #31's admission MDS, dated [DATE], showed: -Usually understood and usually understands others; -Partial/moderate assistance required for eating; -Diagnoses included stroke and aphasia (language disorder). Observation on 2/6/24 at 1:44 P.M., showed the resident seated in front of a bedside table with a plate of chopped ham, coleslaw and a slice of pie. During an interview, the resident was unable to speak and nodded his/her head in response to questions. The resident indicated his/her food was served cold and should have been hot. 6. Review of Resident #56's MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, hypertension (high blood pressure), chronic atrial fibrillation (a cardiac arrythmia caused by rapid beating in the upper chambers of the heart) and the presence of a cardiac pacemaker; -The resident required set-up assistance for meals and staff supervision for all other care areas. During an interview on 2/5/24 at 10:16 A.M., the resident said meals were often served to the resident rooms cold, and this morning's meal was served on Styrofoam plates, which has not happened before. The resident said all meals at the facility were served late and almost always come to the resident rooms cold. During an interview on 2/7/24 at 11:48 A.M., the resident said his/her breakfast was served cold this morning. In particular the bacon and pancakes were cold to the touch when they arrived. 7. Review of Resident #69's annual MDS, dated [DATE], showed: -Cognitively intact; -Independent for eating; -Diagnoses included high blood pressure, unstable burst fracture (breaks in multiple directions) of fourth lumbar vertebra, rheumatoid arthritis (RA, chronic joint disease that causes pain and swelling) and weakness. During an interview on 2/5/24 at 11:57 A.M., the resident said the food was terrible, unseasoned and always cold. 8. Review of Residents #82's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia (low red blood cell count), high blood pressure, renal (kidney) failure, and end stage renal disease (ESRD); -Eating: Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as resident completes activity. During an interview on 2/6/24 at 6:54 A.M., the resident said the temperature of the food was hit or miss and there was no microwave to heat up food. Observation and interview on 2/6/2024 at 8:32 A.M., showed the breakfast meal hall tray delivered by staff to the resident's room. The resident said the biscuits were like rocks and not hot. Observation and interview on 2/6/24 at 1:36 P.M., showed staff delivered the lunch meal hall tray to the resident's room. The resident said the ham was really salty, and he/she would rather have had the chicken, but staff said there was no more chicken. The food was cold. Observation and interview on 2/7/24 at 8:27 A.M., showed staff delivered the breakfast meal hall tray to the resident's room. The resident said the pancakes were cold. 9. During an interview on 2/8/24 at 9:03 A.M., Certified Nurse's Assistant (CNA) K said if a resident complained their food was cold, he/she was supposed to go to the kitchen to get a new tray for the resident. He/She expected food to be served at a safe and palatable temperature. 10. During an interview on 2/8/24 at 8:35 A.M., the Director of Dietary said she expected food to be served at the safe and required temperature. She said if a resident complained of cold food on a hall tray, nursing staff should come to the kitchen to get a new tray for the resident. 11. During an interview on 2/8/24 at 11:31 A.M., the Administrator said she expected all staff to ensure residents are served food at the required temperatures.

Based on observation and interview, the facility failed to ensure staff were following proper hand hygiene procedures when serving food and assisting residents with meals. Further, the facility failed to ensure oversight when a resident used a drink cup to scoop ice from a community ice bucket in the dining room. The sample was 18. The census was 86. 1. Observation of the main dining room during the lunch meal on 2/5/24 at 12:24 P.M., showed Clinical Supervisor C and the Wound Nurse helping to make up and pass meal trays to residents in the dining room. Clinical Supervisor C and the Wound Nurse repeatedly served multiple resident trays with no hand hygiene in between serving the residents. Neither the Clinical Supervisor nor the Wound Nurse wore gloves as they touched the residents' plates to put them on the table. 2. Observation of the main dining room during the dinner meal on 2/5/24 at 5:56 P.M., showed the Dietary Director and [NAME] T making up and serving trays for staff to pass to residents. Neither the Dietary Director nor [NAME] T wore gloves while serving trays, touching resident plates and silverware, and placing food items on resident trays. [NAME] T repeatedly wiped his/her hands on a towel slung across the shoulder, wiped his/her nose, and adjusted his/her pants, with no hand hygiene performed between these actions and touching resident food items. 3. Observation of the main dining room during the breakfast meal on 2/6/24 at 8:19 A.M., showed the Dietary Director and [NAME] T making up and serving trays for staff to pass to residents in the dining room. Neither the Dietary Director nor [NAME] T wore gloves while serving trays, touching resident plates and silverware, and placing food items on trays. 4. Observation of the main dining room during the breakfast meal on 2/7/24 at 7:33 A.M., showed [NAME] T helping to serve trays to residents in the dining room with ungloved hands. [NAME] T cut up a resident's food with the resident's fork, wiped his/her hands on a rag at his/her shoulder, adjusted his/her pants, wiped his/her face, and then grabbed a meal ticket and served the next tray. [NAME] T did not perform hand hygiene between resident trays or before and after touching resident food items. 5. Observation on 2/6/24 at 12:01 P.M., showed an ice bin in the main dining room located on top of a table, with the lid of the ice bucket opened. A resident propelled up in a wheelchair and used a coffee cup to dip into the ice bucket and fill the cup with ice. Staff present in the dining room and did not redirect the resident. At 12:08 P.M., a staff person used the ice scoop, located in an ice scoop cup, to get ice for a resident. He/She left the ice bucket opened. During an interview on 2/7/24 at 1:18 P.M., the Director of Nursing (DON) said the ice bin should only be accessed by staff. The lid should be down when not in use. A drink cup cannot be used to get ice from the ice bin. 6. During an interview on 2/8/24 at 8:29 A.M., Dietary Aide U said he/she was expected to wash his/her hands every time they touch a surface or change their gloves. He/She said proper hand washing should be done to prevent residents from getting sick. 7. During an interview on 2/8/24 at 8:35 A.M., the Dietary Director said she would expect for staff to be following hand washing procedures when handling food and assisting residents during meal times. The Dietary Director would expect for staff to be washing their hands every time they enter and exit the kitchen, when preparing and serving food, and whenever staff touch something.

Based on interview and record review, the facility failed to designate a person to serve as the Director of Dietary with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. This had the potential to affect all residents who consume meals at the facility. The census was 86. Review of the facility's director of dietary job requirements showed: -Qualifications: Certified Dietary Manager(CDM), Certified Food Protection Professional (CFPP) certification or registration as dietetic technician. During an interview on 2/8/24 at 11:21 A.M., the Administrator said the RD is not employed full time and is contracted. The Director of Dietary does not have the required qualifications. She would expect for the Director of Dietary to be certified for food handling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure their policy regarding the provision of basic life support and cardiopulmonary resuscitation (CPR, a lifesaving technique useful in which someone's breathing or heartbeat has stopped) provided guidance for staff in the event of a resident showing obvious clinical signs of irreversible death, and to provide guidance to ensure staff who provided CPR were certified in performance of CPR. The facility failed to ensure staff followed the facility's policy to correctly identify a resident's code status and to initiate CPR when one resident was found unresponsive with clinical signs of irreversible death (Resident #2). The sample was 13. The census was 83. Review of the facility's Initiating and Identifying CPR policy, undated, showed: -Purpose: To correctly identify code status for all residents to determine if the resident requires CPR; -Policy: Upon finding any resident unresponsive code status will be determined. When applicable CPR will be initiated; -Procedure: -1. Each resident will have a code status in the medical record; -2. If CPR, life saving measures will be administered. When in doubt or unknown CPR must be initiated; -3. Upon finding a resident unresponsive, summon staff by calling for help; -4. Call a code blue on the overhead speaker with room number/location; -5. If CPR certified, begin CPR; -6. If NOT CPR certified, remain with the resident until help arrives; -7. Obtain crash cart; -8. The nurse will direct staff to call 911 and any other necessary parties; -9. CPR will continue until Emergency Medical Services (EMS) arrives; -The policy failed to provide guidance for staff regarding the provision of CPR unless a resident shows obvious clinical signs of irreversible death and to ensure staff who provide CPR are certified in performance of CPR. Review of Resident #2's medical record, showed: -Diagnoses included multiple sclerosis (MS, nervous system disease affecting the brain and spinal cord) and history of pulmonary embolism (sudden blockage in a lung artery); -A physician order, dated [DATE], for CPR. Review of the resident's nurse's note, dated [DATE] at 8:20 P.M., showed Registered Nurse (RN) A documented at 6:20 A.M. this morning, a Certified Nurse Aide (CNA) came to RN A and reported he/she believed the resident passed away. RN A unable to hear any heartbeats (by) auscultation (listening to the internal sounds of the body, usually using a stethoscope) and had no respiration. When touched, his/her skin felt cold. No documentation regarding the resident's code status or performance of CPR. During an interview on [DATE] at 3:22 P.M., CNA C said on [DATE] around 6:30 A.M., he/she entered the resident's room and saw the resident looked pale and weird, and CNA C believed the resident was dead. CNA C called the resident's name and there was no response. CNA C left the resident's room and found the nurse. CNA C told the nurse the resident was dead and both CNA C and the nurse went back to the resident's room. The nurse physically assessed the resident and agreed he/she was deceased . The nurse told CNA C to get the nurse on the other hall. The nurse from the other hall looked at the resident and agreed he/she was deceased . Neither nurse said anything about the resident's code status. CNA C does not think anyone checked the resident's chart and he/she did not see anyone check the resident's chart. When CNAs find residents unresponsive, they are supposed to leave and go find the nurse to report it. During an interview on [DATE] at 12:41 P.M., Licensed Practical Nurse (LPN) B said on the day the resident passed, he/she worked on the 200 hall. The CNA from the resident's hall, the 100 hall, came over and said RN A wanted LPN B to check the resident and confirm he/she was deceased . LPN B went to the resident's room and saw he/she was dead. LPN B did not check the resident's chart and does not know if RN A checked the chart. When a resident is found unresponsive, staff need to check the resident's code status by looking up their electronic medical record (EMR). If the resident is CPR, staff should initiate CPR, get the crash cart, have someone call 911, and continue performing life saving measures until EMS arrives. During an interview on [DATE] at 12:30 P.M., Certified Medication Technician (CMT) E said on the day the resident passed, he/she worked on the 200 hall. The CNA from the 100 hall came over and told LPN B that RN A wanted him/her to come to the resident's room. LPN B and CMT E went to the resident's room and CMT E saw the resident appeared to have passed away. He/She exited the room and is not sure if anyone performed CPR. If he/she was the person to find a resident was unresponsive, he/she would check the resident's medical record on the computer to see if they are full code or not. After identifying code status, he/she would notify the nurse, who would instruct staff on what to do. During an interview on [DATE] at 1:28 P.M., RN A said on [DATE] around 6:20 A.M., the night shift aide came and got him/her, stating the resident was dead. RN A entered the resident's room and found the resident had no respirations, no heartbeat, and no signs of life. The resident had no color and his/her eyes were dry. He/She was stiff and ice cold to the touch. RN A did not know the resident's code status upon entering the resident's room. RN A told the aide to get the other nurse, LPN B. LPN B entered the resident's room and based on visually looking at the resident, he/she agreed the resident was deceased . Neither RN A nor LPN B checked the resident's medical record for code status while determining the resident was deceased . CPR was not initiated. In the event that a resident is found unresponsive, the facility's protocol is to for staff to follow a resident's code status. Staff should check the resident's EMR to find out the resident's code status. After RN A and LPN B determined the resident was deceased , RN A pulled the resident's EMR to locate the physician's phone number for notification. While he/she looked at the resident's EMR, he/she saw the resident's code status was CPR. He/She called the resident's physician and didn't really know what else to do regarding the resident's code status. When RN A assessed the resident, he/she was cold and stiff so RN A knew CPR would not have worked. If the resident had been warm, RN A would have called 911 and performed CPR until EMS arrived at the facility. During an interview on [DATE] at 12:21 P.M., CNA D said if he/she walked into a resident's room and found the resident was unresponsive, he/she would check the resident for signs of life, then he/she would leave the room and go find the Charge Nurse. The nurse decides what to do next. During an interview on [DATE] at 12:51 P.M., CNA F said if he/she walked into a resident's room and found the resident was unresponsive, he/she would leave to go get the nurse. The nurse checks the resident's medical record for the resident's code status. The nurse decides what staff should do next. During an interview on [DATE] at 2:53 P.M., CNA J said if he/she found a resident was unresponsive, he/she would go find the nurse and tell them. He/She would not perform CPR until the nurse looks at the resident. During an interview on [DATE] at 12:58 P.M., CNA H said if he/she found a resident was unresponsive, he/she would check the resident's vital signs and report them to the nurse. The nurse should check the resident's chart and tell staff what to do next. During an interview on [DATE] at 1:04 P.M., LPN G said if an employee finds a resident is unresponsive, they should tell the nurse. The nurse will assess the resident and have someone grab the crash cart immediately. Someone would check the resident's record for their code status. If the resident's code status was CPR, a CPR-certified employee would initiate life saving measures while staff notify the other nurse in the building and someone calls 911. Life saving measures would continue until EMS arrives. During an interview on [DATE] at 3:38 P.M., the Director of Nurses (DON) said when RN A assessed the resident, the resident was cold and stiff with rigor mortis (temporary rigidity of muscles occurring after death). Based on the resident's condition, she does not believe CPR would have resulted in a different outcome. RN A used his/her clinical judgment to make a determination on how to proceed after finding the resident. Regardless of the resident's condition, staff should have checked the resident's chart for code status. Anytime a resident is found unresponsive, staff should initiate CPR until the resident's code status is identified. A resident's code status is located in the EMR. If the resident's code status is full code/CPR, staff should continue performing CPR until EMS arrives. During an interview on [DATE] at 9:52 A.M., the DON said when staff find a resident is unresponsive, she expected the employee to stay with the resident and call for help. If the employee is CPR-certified, she expected them to start CPR while another employee checks the resident's chart. CPR should only be performed by CPR-certified staff. If an employee is in doubt about whether or not to perform CPR, they should start CPR. Rigor mortis is a clinical sign of irreversible death. She expected the facility's policy to include guidance for staff to follow if a resident presents with rigor mortis or other clinical signs of irreversible death, but their code status is CPR. She expected the policy to include guidance for staff performing CPR to be CPR-certified. During an interview on [DATE] at 10:12 A.M., the Administrator said when a resident is found unresponsive, she expected staff to start CPR if the resident is full code. She expected the facility's policy to include guidance for staff in the event that a resident is found unresponsive with signs of irreversible death, such as stiffness/rigor mortis. CPR should be performed by CPR-certified staff. She expected the facility's policy to specify that CPR must be performed by CPR-certified staff. MO00228114

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain temperatures in resident rooms at or below 81 degrees Fahrenheit (F) and/or meet the comfort needs of resident rooms for four out of four residents (Residents #2, #3, #4 and #7). The facility's air conditioner unit for the 200 unit was under repair for approximately one month. The census was 87. 1. Review of the facility's undated evacuation policy and procedure related to temperature regulation, showed: -Purpose: Evacuation to ensure that the residents remain at a safe and comfortable temperature; -Policy: The maintenance department will monitor and record temperatures levels in resident areas when indicated at various times. The maintenance department will inform the Administrator if the temperatures are outside of the temperature range; -Procedure: Temperature range means between 71 degrees Fahrenheit (F) and 81 degrees F; -The facility will provide alternate means to cool/heat the facility if indicated; -The facility will first evacuate residents to alternate areas within the facility as needed, then to an alternate location if alternate means to correct the temperatures cannot be obtained. 2. Review of the facility's heating and cooling invoice, showed: -On 7/27/23: Recover refrigerant. Braze (join two metal pieces, without melting them, using heat and diffusion of a jointing [NAME] of capillary thickness) in a working liquid line service valve so that unit can be pumped down since the existing one does not work; -On 7/28/23: Replace compressor on 30 ton unit. Including both unloader, crank case heater with polyolester ([NAME], synthetic oil used in refrigeration compressors) oil. Triple evacuate system. Charged system with 84 pounds (lbs) of 407C (mixture of hydrofluorocarbons used as a refrigerant). Blew main 200 amp fuse when we got system fully loaded and single phased compressor and fans. Not good; -We had figured up to 75 lbs. and 9 lbs. will be added at 80/lbs. to invoice; -A 200 amp fuse blew in the main disconnect box located in the boiler room. We were able to get a fan blowing on the replacement fuse. Cooled it down from 237 degrees to 136 degrees; -There is an 8 volt drop from the main panel to the compressor. Compressor contractors will need replaced along with corroded electrical connections cleaned up and reassembled. 3. Review of the weather forecast on 7/29/23 between 12:00 P.M. and 6:00 P.M., showed a temperature of 97 degrees F. There was an excessive heat warning. 4. During an interview on 7/28/23 at 3:30 P.M., Family Member (FM) A said his/her family member needs help to get out of bed. It was hot in the resident's room. The air conditioning is broken so they have these tall square units in the hall. FM A opened the privacy curtain to cool the room, but that didn't help a lot anyway. His/Her family member said it's hot, and he/she never says he/she is hot. It is hot everywhere, including the dining room. It's miserable. 5. During an interview on 7/29/23 at 1:30 P.M., Registered Nurse (RN) A said it was hotter than hell in the building. He/She planned to use his/her personal fan. 6. During an interview on 7/29/23 at 1:37 P.M., Certified Nurse Aide (CNA) B and CNA C said it was hotter in the facility on 7/27 and 7/28/23. CNA B saw someone fixing the air conditioner because they were going in and out of the room earlier this week where the air conditioning unit was, but was not sure what they were doing. CNA B said it was so hot that he/she went to the hospital because he/she thought he/she was having a heat stroke. The doctor told CNA B if he/she waited just a couple of hours to go to the hospital, he/she could have had a heat stroke. CNA B and CNA C had not heard of any residents going to the hospital as a result of the heat. 7. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/7/23, showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, coronary artery disease, diabetes and depression. During an interview on 7/29/23 at 1:37 P.M., CNA B said he/she heard the resident was sweating up a storm and threw up the other day because it was so hot. At 3:00 P.M., CNA B said he/she was not informed about any special monitoring, but he/she was not working at the time it happened. He/She was not sure if staff from yesterday was informed about monitoring the resident. During an interview on 7/29/23 at 3:46 P.M., the resident said he/she felt better. He/She was sick and felt there was so much going on. He/She remembered sweating and vomiting yesterday, but was not sure why. He/She just did not have any stamina. He/She could not say if the weather or the temperature was hot or not the day before. 8. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included stroke and depression. During an interview on 7/29/23 at 1:55 P.M., the resident said it had been hot in his/her room. His/Her thermometer on the wall in his/her room read 85 degrees F the other day. It is not homelike and unacceptable to not have air conditioning for over a month. They supposedly fixed it yesterday at 5:00 P.M. and there is not a noticeable difference, but maybe the company will come back. 9. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart failure, paraplegia and seizure disorder. Observation and interview on 7/29/23 at 2:04 P.M., showed the resident was in room [ROOM NUMBER]. He/She was in bed and wore only a brief. His/Her eyes were closed. The room was in the back of the 200 unit and significantly warmer than the rooms on the front of 200 unit. There was an oscillating fan on the dresser approximately two feet from the resident. The fan was turned on and blew air directly on the resident. The resident's roommate said it has been hotter than fiction this week and all month. The air thermometer showed the room was 82.6 degrees F. Review of the facility's hall and room temperature log, dated 7/29/23 at 2:30 P.M., showed: -room [ROOM NUMBER], a temperature of 82.0 degrees F. 10. Review of Resident #6's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included stroke, high blood pressure, diabetes and hemiplegia. Observation and interview on 7/29/23 at 2:07 P.M., showed the resident sat in his/her wheelchair in room [ROOM NUMBER]. The room was in the back of the 200 unit and significantly warmer than the rooms on the front of 200 unit. The resident sat directly in front of a portable air conditioner on his/her side of the room. The resident said he/she was comfortable because of the portable air conditioner. The air thermometer showed the room was 82.0 degrees F. Review of the facility's hall and room temperature log, dated 7/29/23 at 2:30 P.M., showed: -room [ROOM NUMBER], a temperature of 79.2 degrees F. 11. Review of Resident #7's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included cancer, anemia, and high blood pressure. Observation and interview on 7/29/23 at 2:09 P.M., showed the resident sat in room [ROOM NUMBER] and directly in front of a portable air conditioner. The room was in the back of the 200 unit and significantly warmer than the rooms on the front of 200 unit. He/She said the room was more comfortable than what it had been. The air thermometer showed the room was 79.9 degrees F. Review of the facility's hall and room temperature log, dated 7/29/23 at 2:30 P.M., showed: -room [ROOM NUMBER], a temperature of 82.6 degrees F. Observation and interview on 7/29/23 at 3:08 P.M., showed the resident sat in the back hallway by the exit door outside of room [ROOM NUMBER]. There was an oscillating fan in the hall that faced in his/her direction. He/She was comfortable because there was a fan blowing on him/her. The air thermometer showed a temperature of 84.6 degrees F at the end of the hall. 12. During an interview on 7/29/23 at 2:17 P.M., Housekeeper E said the air conditioner had been out for a while. He/She did not hear the air conditioner was fixed. 13. During an interview on 7/29/23 at 3:00 P.M., Maintenance D said room temperatures are taken three times a day. They keep the resident rooms around 77 degrees F to make it more comfortable. The center rooms on the 200 unit are hot. He/She just took the room temperatures. Maintenance D was asked if the air conditioner was repaired and he/she said yes and no. The company has to come back on Monday. 14. During observation and interview on 7/29/23 at 3:06 P.M., the Administrator said the air conditioner was fixed. The portable air conditioners are still used because the company said to leave them on until Monday. The Administrator and surveyor entered Resident #4's room. The air thermometer showed the room was 85.5 degrees F. The Administrator said the room was pretty warm. If the resident rooms exceed 81 degrees F, staff are expected to cool the room or move the residents out. 15. During observation and interview on 7/29/23 at 3:15 P.M., the Administrator said the air conditioner unit was not replaced, only the compressor. The Administrator and Maintenance D were outside of Resident #4's room. The portable air conditioner outside of the room, in the hall, was pointed towards the direction of the resident's room. Maintenance D removed the vent, flipped it over, and re-inserted the vent back into the portable unit. The Administrator said it is going to help the room cool down. 16. During an interview on 7/29/23 at 3:42 P.M., Certified Medication Technician (CMT) F said staff assigned to the 200 unit come over to the 100 unit and tell staff how much nicer and cooler the 100 unit was. 17. Observation and interview on 7/29/23 at 4:20 P.M. and 4:23 P.M., showed the portable air conditioner in the hallway turned toward Resident #4's room. Cool air blew into the room. The resident remained in bed with the oscillating fan that sat on top of the dresser. The oscillating fan was on and faced the resident as he/she was in bed with his/her eyes closed. Housekeeping staff said they are going to put a portable air conditioner inside the room. The air thermometer showed the temperature decreased to 81.5 degrees F. 18. During an interview on 7/29/23 at 5:13 P.M., the Administrator said they are going to move the portable air conditioner from the hall into Resident #4's room. His/Her roommate does not prefer a cooler temperature, so arrangements have been made to move the resident to another room while they can cool the room down. The Administrator said Resident #4 would not be able to verbalize being too hot or cold. The heating and cooling company was at the facility late yesterday. They said they would either return today or tomorrow to check on the compressor and other things. The Administrator said staff are expected to move the residents into another room or attempt to cool the rooms on the back of the 200 unit. 19. Review of the facility's heating and cooling invoice, showed: -On 7/31/23: Returned to complete compressor oils change. Add 3 tubes of sealant and dye. This is in an attempt to locate refrigerant leaks or seal them. Chemically clean condenser coil; -Found system frozen up this morning. The [NAME] controllers (used to control environmental factors such as temperature, humidity, and air pressure) are not working for either A/C system. They are just running 24/7. This is what likely caused the compressor failure in the first place; -We have to leave the 30 unit off until the A/C controls are working. Other than the A/C not having any control right now there is one zone damper that does not seem to be working properly. There are a total of five zones on the main air handler. MO00222175

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See Event ID# WEW412 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies, dated 5/25/23. Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity, in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life when one resident was told to wait their turn to have care provided after the resident told the staff member he/she was wet. Staff did not put clean pants on the resident after incontinence care, and put their urine saturated pants on them after care was provided (Resident #20). In addition, one resident who requested assistance was not spoken to in a dignified manner (Residents #30). The sample was 17. The census was 86. 1. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/23, showed: -Cognitively intact; -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; -Intermittent catheterization (periodic catheterization (a sterile tube inserted into the bladder to drain urine) to remove residual urine) for bladder; -Required supervision with eating; -Occasionally incontinent of bowel; -Diagnoses included anemia (decrease in the number of red blood cells), depression, neurogenic bladder (bladder does not empty properly due to a neurological condition) and paraplegia (paralysis of lower portions of the body and of both legs). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident has a behavior problem, may become belligerent to staff and disrespectful when needs are not taken care of immediately; -Goal: The resident will have fewer episodes by review date; -Interventions: Staff members to go in room when doing care or answering light, anticipate and meet the resident's needs, resident educated on negative behavior, inappropriate comments and behavior. During an interview on 7/6/23 at 9:48 A.M., the resident said he/she put on his/her call light because his/her pants were wet. Certified Nursing Assistants (CNA) G entered the resident's room. The resident informed the CNA he/she needs to be changed. CNA G told the resident he/she needed to wait his/her turn because the CNA was working his/her way down the hall and would take care of the resident when it is his/her turn. The resident then said he/she went to Nurse H to request assistance. The resident said the nurse was rude and did not assist him/her. The Administrator was informed and an investigation started. The resident returned to his/her room and waited for a staff member. Review of a statement, dated 7/6/23, provided by CNA G, showed: he/she answered the resident's call light and asked the resident what was going on, the resident stated he/she needed to be changed. The CNA let the resident know that he/she was working his/her way down the hall and would be with the resident shortly. The resident then got upset and started to tell the CNA how to do his/her job. That is when the CNA went to get the nurse and told the nurse what the resident said. Observation on 7/6/23 at 9:55 A.M., showed Nurse I entered the resident's room to provide care. Nurse I assisted the resident into bed with the slide board, then pulled the resident's pants down to his/her ankles and unfastened the resident's brief. The resident's brief was saturated. Nurse I got the resident's urinal and an intermittent catheterization kit and handed both to the resident. Nurse I informed the resident he/she would give the resident privacy and left the room. The resident opened the kit and applied the sterile gloves. The resident said his/her brief was wet and no one checked on him/her. The resident said he/she does self-catheterization at least three to four times a day. The resident prefers to do the first one in the morning before he/she gets up for the day, which is around 6:30 A.M., then 10:00 A.M. to 10:30 A.M., after lunch which is between 1:30 P.M. and 2:00 P.M., then 5:00 P.M., and bedtime. This is the first time he/she has been able to perform the straight catheterization today. The resident said when he/she has to wait this long, then he/she will start to leak and will leak through the brief and his/her pants, which is what happened today. The resident said he/she just needs the nursing staff to assist him/her to bed with the slide board and help the resident set up, which includes the sterile kit and a urinal. The resident said he/she can feel pressure, but cannot feel touch from the top of his/her ribs down to his/her feet. Nurse I returned to the resident's room, applied gloves, and emptied the urinal into the toilet and threw away the intermittent catheterization kit. Nurse I put a new brief on the resident and rolled the resident to his/her back and felt his/her pants. Nurse I asked the resident if he/she had another pair of pants, and the resident said no. Nurse I pulled up the resident's pants. The resident's pants were black with a visible darker area near the groin. Nurse I adjusted the resident's pants, then assisted the resident to his/her wheelchair. The nurse removed his/her gloves and left the room. During an interview on 7/10/23 at 11:30 A.M., the Administrator and Director of Nursing (DON) said it is not dignified to tell a resident to wait their turn if the resident informs staff they are wet unless there is an immediate safety concern with another resident. The DON said it is not dignified to put a resident's pants wet with urine back on. 2. Review of Resident #30's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Total dependence with bed mobility, transfers, dressing, toilet use and personal hygiene; -Required supervision with eating; -Frequently incontinent of bowel and bladder; -Diagnoses included stroke, dementia, respiratory failure, anxiety and depression. Observation on 7/10/23 at 10:30 A.M., showed CNA E entered the resident's room and informed the resident he/she needed to provide care. CNA E removed the old brief and cleaned the resident's perineal area (area between the hips, including the anus and the genitals). CNA E placed a new brief under the resident. The CNA fastened one side of the resident's brief, then tried to roll the resident to his/her right side. The resident did not understand the directions and tried to swing his/her legs off the bed. CNA E said to the resident, you are fighting against me, you gotta make me look good. The resident said sorry and he/she was scared and worried he/she will fall. CNA E said, I gotta fasten your diaper. CNA E positioned the resident and fastened the other side of the resident's brief. CNA E adjusted the head of the bed and gave the resident his/her call light. CNA E lowered the resident's bed and left the room. During an interview on 7/10/23 at 11:30 A.M., the DON said it is not dignified to call a brief a diaper. Staff should not tell a resident they have to make the staff look good when they are watched providing care to the resident. MO00220340

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See Event ID# WEW412 Based on observation, interview and record review, the facility failed to ensure a resident admitted on [DATE] received orders for peripherally inserted central catheter (PICC, used to administer long-term medications) care and monitoring of the PICC line and failed to obtain blood glucose monitoring orders (Resident #32). Additionally, the facility failed to notify the physician for out of range blood glucose results (Resident #33). The sample size was 17. The census was 86. Review of the pharmacy PICC policy, showed: -PICC: Flush protocols: -Non-valved access: administer 5 milliliters (ml) of normal saline (NS), infuse medication, then administer 5 ml and follow with 5 ml of heparin (used to prevent clotting); -Site maintenance: Transparent dressing changes done weekly and as needed (PRN). Measure upper arm circumference and external catheter length with each dressing change and PRN. 1. Review of Resident #32's discharge hospital records, dated 7/14/23, showed: -Diagnosis included: osteomyelitis (bone infection) and diabetes; -Orders: -Cefepime (antibiotic used to treat infection) administer 2,000 milligrams (mg) intravenously (IV) once daily every 12 hours for 40 days; -Vancomycin (antibiotic used to treat infection) administer 1,750 mg IV every 24 hours for 40 days; -Humalog (short acting) insulin inject 0-9 units three times daily with meals; -Humalog insulin, inject 20 units three times daily with meals; -Novolin N (intermediate acting) insulin, give 15 units twice a day; -OneTouch blood glucose test strips (used to test blood sugar). Review of the resident's medical record, showed: -admitted on [DATE]; -Diagnoses included: infection of the left lower stump and type II diabetes. Review of the progress notes, dated 7/14/23 at 9:20 P.M., showed the resident was admitted at 8:00 P.M. He/She noted with a PICC line to the right upper arm. Review of the Physician Order Sheet (POS), dated 7/14/23, showed: -An order for Cefepime IV solution, infuse 2000 mg/2 grams (gm) every 12 hours until 8/25/23; -An order for Insulin Lispro, inject 20 units subcutaneously (sub-q, under the skin) three times a day for diabetes; -An order for Insulin NPH, inject 15 units twice a day for diabetes; -An order for blood glucose test strips, use two times a day; -An order for Vancomycin IV, administer 1,750 mg by IV every 24 hours for 40 days; -No orders for monitoring, assessment, dressing or flush protocols for the PICC line; -No orders for monitoring blood glucose levels twice daily. Review of the Medication Administration Record (MAR), dated July 2023, showed: -An order, dated 7/14/23, for Cefepime IV solution, administer 2 gm IV every 12 hours for infection for 41 days. Scheduled daily at 8:00 A.M., and 9:00 P.M. Documented as administered; -An order, dated 7/14/23, for Vancomycin IV solution, administer 1,750 mg every 24 hours for infection for 40 days. Documented as administered; -No PICC flushing or site maintenance protocol orders noted; -An order, dated 7/14/23, for NPH insulin, inject 15 units sub-q two times daily. Scheduled daily in the AM and HS (bedtime). Noted as administered; -An order, dated 7/14/23, for Lispro insulin, inject 20 units sub-q, three times a day. Scheduled daily at 8:00 A.M., 4:00 P.M., and 9:00 P.M. Noted as administered; -No orders or documentation of blood glucose testing prior to administration of insulins. Review of the baseline care plan, dated 7/15/23, showed: -Special treatments: IV medications while a resident; -Medications: insulin and antibiotics. Review of a progress note, dated 7/16/23 at 5:15 P.M., showed skilled evaluation: blood glucose: blank, specialty care IV device: PICC line flushes easily, PICC dressing intact. During an observation and interview on 7/19/23 at 8:34 A.M., the resident lay awake in bed, with a PICC to the right upper arm. A clear dressing covered the insertion site and was dated 7/14/23. The resident said the hospital placed the PICC line on the day he/she discharged to the facility. He/She had an infection, had been taking IV antibiotics, and was scheduled to continue the IV antibiotics for a month. He/She had diabetes. The facility did not check his/her blood sugar before giving the ordered insulin. He/She received insulin several times a day. During an observation and interview on 7/19/23 at 12:30 P.M. Licensed Practical Nurse (LPN) B said the resident received IV antibiotics through the PICC line in his/her right upper arm twice daily. The resident is a diabetic and received insulin several times a day. LPN B checked the POS and verified the resident did not have orders for PICC line dressing changes or maintenance. The resident did not have orders for monitoring blood glucose prior to insulin administration. LPN B said the resident had not received blood glucose monitoring or PICC line protocol care. Blood glucose monitoring and PICC line care should be ordered. The nurse is responsible to ensure the PICC line is monitored and flushed. The nurse is responsible to monitor blood glucose levels before administering insulin. 2. Review of Resident #33's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/25/23, showed: -Cognitively intact; -Diagnoses included diabetes; -Received injections seven days a week; -Received insulin seven days a week. Review of the undated care plan, showed: -Focus: the resident has diabetes; -Goal: no complications related to diabetes; -Interventions: dietary consult, insulin as ordered, staff document side effects, blood glucose monitoring as ordered and notify the physician if the blood sugar is over 400 or under 60. Review of the electronic POS, dated 7/2023, showed: -An order, dated 7/2/20: Call the physician for a blood sugar result under 60 or over 400; -An order, dated 9/21/22: Administer Novolog (fast acting) insulin 18 units with meals. Review of the MAR, dated 7/2023, showed: -An order, dated 9/21/22: Novolog insulin, administer 18 units with meals, scheduled daily at 7:00 A.M., 12:00 P.M. and 4:00 P.M. and included blood glucose readings. -On the following dates and times, the blood sugar results measured above 400: -On 7/13/23 at 7:00 A.M., result: 435, and at 12:00 P.M., result: 452; -On 7/14/23 at 12:00 P.M., result: 401; -On 7/16/23 at 12:00 P.M., result: 419; -On 7/17/23 at 12:00 P.M., result: 437; -On 7/19/23 at 12:00 P.M., result: 487. Review of the progress notes, dated 7/13/23 through 7/19/23 at 12:00 P.M., showed no physician contact regarding the out of range blood sugar results. During an interview on 7/19/23 at 12:30 P.M., LPN B said the resident received routine insulin injections and blood glucose monitoring. LPN B said he/she obtained the resident's 12:00 P.M. blood glucose and administered the ordered 18 units. The order to call the physician for a blood sugar over 400 was not reflected on the MAR and said the order was noted on the POS. He/She did not check the resident's POS against the facility's MAR when a high blood sugar result was obtained. A blood sugar over 400 is high and should have been addressed with the physician. During an interview on 7/19/23 at 3:05 P.M., the Administrator and Regional Director of Business Management said all physician orders should be followed. Residents admitted with IV or PICC line access sites should have orders for flushing and site maintenance. Diabetic residents should have orders for blood glucose testing prior to administration of any fast acting insulin and the physician should be notified of results out of range.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See Event ID# WEW412 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies, dated 5/25/23. Based on observation, interview and record review, the facility failed to ensure a resident who admitted into the facility on 7/14/23 with two known wounds did not develop additional skin impairments. The resident admitted from the hospital with orders to turn and reposition every two hours, daily skin assessments and lie on a low air loss mattress (LAL, an air mattress used to prevent the development of pressure injury). During an observation on 7/19/23, the resident was noted to have five additional unidentified skin impairments that consisted of two deep tissue injuries (DTI, purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure) and three open wounds from shearing on the back of the thigh (Resident #32). The sample was 17. The census was 86. Review of the Skin Program policy and procedure, revised 5/10/21, showed: -Purpose: To ensure that every resident's skin condition is assessed on admission and a comprehensive and interdisciplinary care plan is developed and maintained to treat actual and/or prevent potential skin problems; -Policy: All residents are assessed upon admission and as needed (PRN) for actual and/or potential skin problems. All residents will receive an individualized preventative skin plan of care at the time of admission. All residents with skin problems will receive an active skin plan of care at admission. Skin care team meetings will be held weekly to address all ulcers and any other pertinent skin problems; -Procedure: -The nurse will evaluate and assess all residents upon admission. The initial skin assessment is a full body audit and completion of the Braden skin risk assessment (used to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status). After admission the Braden skin risk assessment will be completed weekly for three weeks and then a quarterly, a significant change of condition and annually; -A plan of care is initiated and individualized by the nurse on the day of admission; -The Director of Nursing (DON) or designee will review all residents weekly with skin ulcers for condition of wound treatment changes, and additional barriers to healing and will document weekly; -The DON/designee will conduct regular in-servicing on skin care, condition, aseptic (sterile) technique, and wound care; -Performance improvement monitoring is conducted by the DON/designee and reported at the QAPI (Quality Assurance Performance Improvement); -Certified nurse aides (CNA) will complete the bath/shower report sheet with each resident's scheduled bath/shower. Each resident will be assessed/evaluated a minimum of weekly by the nurse. The bath/shower sheets become part of the QAPI; -If during the care the CNA notices that a dressing is off/soiled they should notify the charge nurse immediately; -The nurse/designee will notify the resident's responsible party if the resident is admitted /readmitted from the hospital or another healthcare facility with a skin ulcer and document notification in the record. The nurse/designee will continue to notify/update the physician, resident/sponsor weekly of the progress/lack of progress of healing of all the Stage III (wounds that extend through the skin into deeper tissue and fat), Stage IV (wound extend to muscle, tendon, or bone) ulcers and surgical wounds. The resident/sponsor will be educated by the nurse to skin care and the prevention of skin injury as needed. All education as well as the resident/sponsor response will be documented in the clinical record; -The nurse will assess the resident pain originating from skin areas during assessment and treatment and care plan accordingly. Review of Resident #32's hospital Discharge summary, dated [DATE], showed: -Admitting diagnosis: osteomyelitis (bone infection); -Discharge diagnoses included: osteomyelitis of the left leg and pressure injury to the left hip; -Hospital course: -admitted with a left below the knee amputation (BKA) and is wheelchair bound. Noted to have a non-healing ulcer at the site. Also noted is a chronic left hip ulcer. The patient is wheelchair bound and diagnosed with congenital multiple arthrogyroposis (conditions that are characterized by multiple joint contractures (stiffness) and involves muscle weakness found throughout the body at birth); -Skin/wound orders: assess skin every shift, turn and reposition every two hours and PRN, continue LAL mattress; -Braden score: 13, moderate risk to develop skin injury. Review of the admission Physician Order Sheet (POS), dated 7/14/23, showed: -Weekly skin assessments; -Treatment orders for wounds to the left BKA and the left hip; -No orders noted for a LAL mattress. Review of the admission progress notes, showed: -On 7/14/23 at 9:20 P.M., the resident admitted to the facility at approximately 8:00 P.M. He/She is incontinent of urine and is able to make needs/wants known. He/She admitted with wounds to the hip and buttock; -On 7/15/23 at 9:46 A.M., a clinical admission evaluation note: alert and orientated to person, place and time (x 3). He/She is incontinent of urine, he/she is on a turn and reposition schedule. The resident's skin is intact except an area to the left upper hip and the left BKA site. Treatment orders in place. Review of the skin evaluation, dated 7/15/23 at 10:47 A.M., showed: -Skin impairment to the left BKA and left hip; -No additional skin impairments documented. During an observation and interview on 7/19/23 at 8:34 A.M., the resident lay on his/her back in the bed on a standard mattress. He/She said his/her buttocks hurt and he/she would like to be moved onto his/her side. Certified Nurse Aide (CNA) A entered the room and said he/she started the shift at 7:00 A.M. The resident received personal care at that time and the resident's buttocks were red and he/she told the nurse about an open area to the back of the resident's thigh. CNA A assisted the resident onto his/her side, unfastened the brief and exposed the buttocks. The resident noted to have redness and chaffing to the back of the thighs from the bottom of the buttocks to the top of the back of the knees. Three small open areas noted to be caused from shearing on the right thigh. A deep tissue injury (DTI) was noted to the coccyx (tailbone) and to the right upper buttock. CNA A applied barrier ointment to the buttocks and the back of both thighs. He/She repositioned the resident on his/her side. CNA A said the resident is at risk to get wounds. He/She depended on staff for movement and personal hygiene needs. The resident did not have an LAL mattress in use. The staff do not turn him/her in bed often, he/she often lied on his/her back and his/her buttocks is now painful. The staff provide care and had not informed him/her of any additional skin areas. Staff apply a cream to his/her buttocks at times. During an interview on 7/19/23 at 10:20 A.M., the resident said his/her right buttock hurt and would like to be turned onto his/her left side. He/She needed the staff to reposition him/her in bed. Observations of the resident's room on 7/19/23 at 11:19 A.M., showed a coiled LAL mattress leaned against the open bed room door. Observation and interview at 12:08 P.M., showed the resident rested on a standard mattress. The LAL remained coiled and leaned against the open doorway. He/She turned onto his/her left side. The resident said it felt good to be off his/her back and he/she had been staring at the air mattress against the door, it was going to be nice to have it on the bed. Observations of the resident's room on 7/19/23 at 12:30 P.M., showed a coiled LAL mattress leaned against the open bed room door. During an interview on 7/19/23 at 12:32 P.M., Licensed Practical Nurse (LPN) B said he/she had not been notified the resident's skin had open areas in addition to the hip and left BKA. CNA A informed LPN B the resident was in pain, and LPN B administered a pain pill. The Charge Nurse is responsible to assess each resident's skin weekly. The CNAs are responsible to notify the nurse if any changes in skin occur. During an interview on 7/19/23 at 1:10 P.M., CNA A said someone brought the LAL mattress to the resident's room and leaned it against the door. He/She did not know which staff placed the mattress in the doorway. CNA A told LPN B about the open areas and that the resident complained of pain after the observation with the surveyor. He/She provided care to the resident at approximately 12:15 P.M., and the resident did not have any new treatments to the open areas to the back of the thigh. CNA A did not inform the facility Wound Nurse of the open areas, only LPN B. During an interview on 7/19/23 at 1:33 P.M., the Wound Nurse said the resident admitted into the facility with wounds to the left BKA and the left upper hip. The resident is seen by the wound care physician weekly for the wounds and was seen on 7/18/23. The wound physician does not conduct full skin assessments at a visit and relies on staff to report any skin changes. He/She had not been notified of any additional skin concerns. The resident is at risk to develop additional wounds. The resident relied on staff for mobility in the bed and from the bed, is incontinent of urine and is a diabetic. CNAs inspect the skin with care and should notify the charge nurse immediately with changes, the nurse should immediately assess the skin, provide a temporary treatment until the physician is contacted or the wound nurse assessed the skin. At 2:14 P.M., the wound nurse conducted a skin assessment, with the following findings: -Back right upper thigh, shearing injury, measured 1.6 centimeters (cm) x 1.4 cm x 0.1 cm; -Back right lower thigh, shearing injury, measured 2.8 cm x 2.5 cm x 0.1 cm; -Back side right thigh, shearing injury, measured 1.0 cm x 1.0 cm x 0.1 cm; -DTI to the coccyx, measured 1.2 cm x 1.0 cm x 0.0 cm; -DTI to the right upper buttock, measured 1.0 cm x 1.0 cm x 0.0 cm. The wound nurse said she was not notified of any skin changes. The resident was placed on a LAL mattress immediately prior to her assessment. The resident did not have a LAL mattress since his/her admission. The resident is dependent on staff for repositioning in the bed, the resident did not have a pull sheet in use for repositioning. Staff used the incontinence pad for repositioning and could have caused shearing injury with movement. The resident's skin is fragile. The DTI are related to pressure. The wound nurse applied treatments to the observed open areas and stated she would call the physician for orders. The observed sites would be assessed by the wound physician at next weeks visit. During an interview on 7/19/23 at 3:05 P.M., the Administrator and Regional Director of Business said the CNAs are responsible to report changes in skin immediately to the Charge Nurse. The nurse should assess the skin, apply a temporary treatment until the physician is notified and/or the wound nurse assessed the resident. The Charge Nurse should document changes in the skin. All residents at risk for skin breakdown should be placed on a LAL mattress. During an interview on 7/27/23 at 11:51 A.M., the resident's physician said the resident should have been placed on a LAL mattress upon admission. The LAL could have helped to prevent the development of skin wounds, but what was most important was to perform the frequent turning and repositioning. The resident was at risk for skin impairment upon admission and was being treated for a chronic wound to the left hip.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See Event ID# WEW412 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies, dated 5/25/23. Based on observation, interview and record review, the facility failed to follow infection control protocols during personal care for two residents (Resident #30 and Resident #25). The sample was 17. The census was 86. Review of the facility's policy, entitled Perineal Care, revised 9/1/22, showed: -Purpose: To promote cleanliness and prevent infection, to remove irritating and odorous secretions, to prevent extended skin exposure to incontinence of urine/feces. -Procedure included: -Gather equipment; -Identify resident/patient, explain procedure, and provide privacy; -Wash hands and apply gloves; -Adjust the bed to a comfortable working height to prevent back strain; -Assist the resident/patient to a supine position; -Place a linen-saver pad under the buttocks; -Cover resident/patient with a bath blanket, exposing only the genitalia area; -Apply skin barrier to prevent breakdown as needed; -Remove soiled linen and place in linen hamper; -Clean and return the basin to appropriate storage; -Remove gloves and wash hands. Place gloves in plastic bag. Discard in soiled utility room; -Assist resident/patient to a position of comfort and place call light within reach; -Standard Precautions will be observed throughout the procedure. 1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/29/23, showed: -Cognitively intact; -Total dependence with bed mobility, transfers, dressing, toilet use and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses included stroke, dementia, respiratory failure, anxiety and depression. Observation on 7/10/23 at 10:30 A.M., showed Certified Nurse Aide (CNA) E entered the resident's room and informed the resident he/she needed to provide care to the resident. CNA E washed his/her hands, applied gloves, and removed the resident's brief. CNA E used packaged wipes to wipe the resident's genitals and perineal area (the area between the hips, including the anus and genitals). CNA E pulled out more wipes from the package with the same gloves. The CNA rolled the resident to his/her left side and pulled out the old brief from under the resident. The CNA removed his/her gloves, washed his/her hands, and applied new gloves. CNA opened a new brief next to the resident and placed a container of barrier cream on top of the brief. CNA E applied cream on the resident's buttock area and removed his/her gloves. CNA E tucked the brief under the resident and rolled the resident to his/her back. CNA E fastened the right side of the resident's brief and attempted to roll the resident to his/her right side. The CNA still had no gloves on. The resident did not understand the directions and tried to swing his/her legs off the bed. CNA E repositioned the resident with the reusable pad, by rolling the resident to his/her right. The CNA fastened the other side of the resident's brief and laid the resident on his/her back. CNA E adjusted the head of the bed, gave the resident his/her call light, and lowered the resident's bed. CNA E covered the resident with a blanket that had a large dark stain on it. CNA E moved the bed side table closer to the resident, grabbed the trash and put it in the trash bag. During an interview on 7/10/23 at 11:30 A.M., the Administrator and Director of Nursing (DON) said staff should change gloves and perform hand-hygiene when gloves are visibly dirty or when they go from dirty to clean. Staff should wear gloves when they are providing perineal care. If there is a visible stain on a pad or blanket, those should be removed and replaced. Those should not be left on or under the resident. 2. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; -Intermittent Catheterization (Periodic catheterization (a sterile tube inserted into the bladder to drain urine) to remove residual urine) for bladder; -Supervision with eating; -Occasionally incontinent of bowel; -Diagnoses included anemia (decrease in the number of red blood cells), depression, neurogenic bladder (bladder does not empty properly due to a neurological condition) and paraplegia (paralysis of lower portions of the body and of both legs). Observation on 7/6/23 at 9:58 A.M., showed Nurse I entered the resident's room and applied gloves. Nurse I did not wash his/her hands first. Nurse I assisted the resident into bed with the slide board, then pulled the resident's pants down to his/her ankles and unfastened the resident's brief with the same gloves. Nurse I set a new brief on the counter. The nurse removed his/her gloves and handed the resident an unopened intermittent catheter kit and urinal, then washed his/her hands. Nurse I informed the resident he/she would give the resident privacy and left the room. At approximately 10:10 A.M., Nurse I returned to the resident's room and did not wash or sanitize his/her hands. Nurse I applied gloves, emptied the urinal into the toilet and threw away the intermittent catheterization kit. The nurse sprayed perineal cleanser on the resident's genitals and wiped the area. The nurse did not wash his/her hands of change his/her gloves. The nurse assisted the resident to his/her right side and wiped the resident's buttocks area. Nurse I pulled out the old brief and, without washing hands or changing his/her gloves, placed a new one under the resident. The resident was rolled to his/her back and the nurse felt the resident's pants with his/her soiled gloved hand. Nurse I asked the resident if he/she had another pair of pants and the resident said no. Nurse I pulled up the resident's pants. The resident's pants were black with a visible darker area near groin. The nurse rolled the resident to his/her left side and fixed the resident's pants pocket with the same gloves. While the resident used the bed controls to sit up, the nurse, with the same gloves, picked the resident's phone off the floor and placed on the bed side table. Nurse I grabbed the dirty brief and dirty washcloth used to clean the resident and placed in a trash bag. The nurse assisted the resident with his/her feet and touched the controls on the wheelchair to move the wheelchair forward, while wearing the same gloves. Nurse I assisted the resident to his/her wheelchair from the bed and adjusted the resident's pants again. The resident informed the nurse he/she needed his/her sheets changed. Nurse I removed the gait belt from the resident and placed it on the bed side table. The nurse grabbed the trash bag with dirty linen, handed the resident her/his eyeglasses and then removed and placed the dirty sheets into the trash bag. Nurse I removed his/her gloves and did not wash hands or use sanitizer before he/she applied new gloves. Nurse I placed a new fitted sheet and two disposable pads on the bed and said he/she needed to get pillow cases. Nurse I removed his/her gloves tied up the trash bag, washed his/her hands, picked up the trash bag and left the room. During an interview on 7/6/23 at 12:40 P.M., Nurse I said handwashing/hand hygiene should be performed when entering a room, when leaving a room, and in-between when going from dirty to clean. During an interview on 7/10/23 at 11:30 A.M., the Administrator and DON said staff should perform hand hygiene when they enter a room and in-between glove changes. The DON said staff should change gloves when they are visibly dirty or when they go from dirty to clean.

See Event ID# WEW412 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies, dated 5/25/23. Based on interview and record review, the facility failed to follow their Controlled Substance storage policy by not counting inventory at each shift change for controlled substances for three out of three sampled narcotic count sheets. The sample was 17. The census was 86. Review of the Medication Storage in the Facility Policy, dated November 2021, showed: -Medications included in the Drug Enforcement Administration (DEA) Classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerated items is conducted by two licensed nurses and is documented on the shift change form; -Any discrepancy in controlled substance counts is reported to the Director of Nursing (DON) immediately, or in compliance with facility policy and procedure. 1. Review of the facility's narcotic count sheets, showed the facility divided the count sheets for each hall into two groups for each of the two halls: -100 hall top, 100 hall back, 200 hall top, and 200 hall back. 2. Review of the Shift Change Narcotic Sheet for 100 hall top, on 7/6/23, showed: -6/30/23: 7:00 A.M. to 3:00 P.M. shift-No off-going signature and no total narcotic count; -7/1/23: 7:00 A.M. to 3:00 P.M. shift-No total narcotic count; -7/2/23: 11:00 P.M. to 7:00 A.M. shift-No off-going signature and no total narcotic count; -7/4/23: 11:00 P.M. to 7:00 A.M. shift-No oncoming signature; -7/6/23: 7:00 A.M. to 3:00 P.M. shift-No total narcotic count. Review of the Shift Change Narcotic Sheet for 100 hall top, on 7/7/23, showed: -7/1/23: 7:00 A.M. to 3:00 P.M. shift-No total narcotic count; -7/2/23: 11:00 P.M. to 7:00 A.M. shift-No off-going signature and no total narcotic count; -All other blanks had been signed by the Certified Medical Technician (CMT) or nurse. 3. Review of the Shift Change Narcotic Sheet for 100 hall back, on 7/6/23, showed: -6/30/23: 7:00 A.M. to 3:00 P.M. shift-No off-going signature; -7/2/23: 11:00 P.M. to 7:00 A.M. shift-No total narcotic count; -7/3/23: 11:00 P.M. to 7:00 A.M. shift-No off-going signature; -7/4/23: 3:00 P.M. to 11:00 P.M. shift-No oncoming signature; -7/4/23: 11:00 P.M. to 7:00 A.M. shift-No off-going signature and no total narcotic count; -7/5/23: 11:00 P.M. to 7:00 A.M. shift-No oncoming signature; -7/6/23: 7:00 A.M. to 3:00 P.M. shift-No off-going signature; Review of the Shift Change Narcotic Sheet for 100 hall back, on 7/7/23, showed: -No blank signature areas for on-coming or off-going shift change; -No blank total counts. 4. Review of the Shift Change Narcotic Sheet for 200 hall top, on 7/6/23, showed: -7/3/23: 7:00 A.M. to 3:00 P.M. shift-No off-going signature; -7/3/23: 11:00 P.M. to 7:00 A.M. shift-No on-coming signature; -7/4/23: 7:00 A.M. to 3:00 P.M. shift-No off-going signature. Review of the Shift Change Narcotic Sheet for 200 hall top, on 7/7/23, showed: -No blank signature areas for on-coming or off-going shift change. 5. During an interview on 7/7/23 at 3:55 P.M., the DON said the reason the count sheets are different on 7/7/23 than 7/6/23, is because the Assistant Director of Nursing (ADON) had staff who were scheduled but did not sign, come back into the facility to sign the narcotic count log. The DON said it should be done at shift change. During an interview on 7/7/23 at 4:10 P.M., the Administrator said she was not aware the ADON called staff who did not sign, to come back to the facility several days after their shift to sign the narcotic count sheet. She is not sure if it was counted and not signed or not counted and not signed. The Administrator said she expected it to be signed after the count is completed. During an interview on 7/10/23 at 11:30 A.M., the Administrator and DON said it is not acceptable to have staff come back in to sign the narcotic count sheet. The count may not have been accurate at the end of their shift. There is also a chance they may not count when they come back in to sign the narcotic count sheet.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity, in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life when one resident was left exposed during personal care (Resident #1). Staff also talked with the resident about his/her roommate's hygiene while the roommate was present. The sample was 16. The census was 91. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/23, showed: -Cognitively intact; -Total dependence with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses included heart failure, end stage renal disease (ESRD), anxiety, depression, and chronic obstructive pulmonary disease (COPD, lung disease). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident had an activities of daily living (ADL, self-care activities) self-care performance deficient related to impaired balance and limited mobility; -Goal: The resident will maintain current level of function in ADLs through the review date; -Intervention: The resident required total assistance of staff with bathing/showering two times weekly and as necessary. The resident required maximum staff assist for personal hygiene/oral care. Observation on 5/11/23 at 9:20 A.M., showed Certified Nursing Assistant (CNA) D entered the resident's room and gathered supplies. He/She uncovered the resident and raised the gown above the resident's brief. CNA D unsecured the resident's brief and provided care to the resident. CNA D did not close the privacy curtain. The resident's roommate sat on the side of his/her bed and faced the resident. CNA D removed the resident's gown and the resident was fully naked. The privacy curtain remained open with the roommate in the same location. Resident #1 told the CNA his/her roommate needed a bath and stunk up the room. CNA D looked at the roommate and asked if he/she wanted a bath. The roommate said no because he/she was cold. Resident #1 said the roommate had not had one in over a week. CNA D asked Resident #1 if the roommate had family. Resident #1 said no. CNA D said when a resident refused to take a bath, staff would use the family. CNA D said if a resident refused, there was nothing staff could do. Resident #1 remained fully exposed during this conversation. The roommate got up and opened the door to the room and poked his/her head out of the door. Resident #1 asked the CNA to pull the privacy curtain because the roommate had the door cracked. CNA D stood at the sink and did not close the curtain. CNA D told the roommate to shut the door. The roommate said he/she thought someone knocked. The roommate then shut the door, walked back and sat on his/her bed and faced Resident #1. He/She remained exposed and the privacy curtain remained open. At approximately 9:45 A.M., CNA D finished care. The roommate was heard talking to himself/herself. CNA D asked Resident #1 what the roommate was talking about. Resident #1 said the roommate needed a shower bad. CNA D laughed. CNA D finished up care, raised the resident up in bed, gathered trash and left the room. During an interview on 5/11/23 at 9:55 A.M., the resident said he/she would have preferred CNA D pull the privacy curtain closed. He/She was ok with the roommate but did not really like being exposed. During an interview on 5/11/23 at 3:00 P.M., the Director of Nursing said it was not acceptable for a resident to be left exposed during care. She expected staff to close the curtain. She also said it was unacceptable for staff to talk to a resident about another resident's hygiene, especially when the other resident was present.

Based on observation, interview and record review, staff failed to answer call lights for extended periods of time (Resident #20). The sample size was 16. The census was 91. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/23, showed: -Cognitively intact; -Required extensive assistance with bed mobility, transfers, dressing and toilet use: extensive assistance- resident involved in activity and staff provide weight-bearing support with one person physical assistance. Review of the nurse's note, dated 4/7/23 at 2:52 P.M., showed the nurse asked why resident was trying to get out of bed without assistance. Resident response, the call light has been on for an hour, the aide came by and asked what was needed and said (he/she) would be back. (He/she) hasn't come back. Review of the Grievance report for the resident, dated 5/16/23, showed: -Description of concern in detail: Could not get call light answered when it was turned on because my aide left the premises with another aide and then dinner trays came; -Results of investigation: Camera evidence was reviewed, and resident put on call light at 5:30 P.M. on 5/16/23. The dinner trays were being passed during this time. Resident's call light was answered after dinner service at 7:15 P.M. Aides did not leave premises during time viewed on camera; -Resolution: CNA's will be in serviced on call light response times. Observation on 5/23/23 at 10:23 A.M., 10:30 A.M. and 10:58 A.M., showed the resident's call light on and Certified Nurse Aide (CNA) B walked past the resident's room without going in. He/She continued to walk to the nurse station, where he/she took a sip from his/her drink. Observation on 5/23/23 at 10:26 A.M., showed three staff sitting/standing around the nurse desk in the back of 100 hall while resident call lights were on above their room doors. Observation on 5/23/23 at 10:58 A.M., showed a CNA went into the resident's room, after his/her call light had been on for approximately thirty minutes. Observation on 5/23/23 at 2:07 P.M., showed two aides got up from the nurse area to answer resident call lights after hearing questions to Licensed Practical Nurse (LPN) E regarding the meaning of red dots that were lit up on the call light system, located behind the nurse desk. During an interview on 5/22/23 at 10:05 A.M., the resident said when staff do not come to answer his/her call light, he/she ended up soiling his/her brief. He/She said it makes him/her angry when staff do not answer his/her call light. The resident said he/she would try to put him/herself into bed when staff didn't come. His/Her body would be half in/half out of the bed. During an interview on 5/23/23 at 2 P.M., LPN E said staff know when the resident call light is on by the call light system located behind the nurse desk. He/she pointed to a board behind the nurse desk that was lit up with greater than ten dots. He/She said red dots meant a resident call light was on. It was not appropriate for staff to be sitting around the nurse station when the call light system was lit up. During an interview on 5/22/23 at 2:25 P.M., the Social Worker said the resident's call light was not answered for two hours on 5/16/23 because it was dinner time. She said it should not have taken that long to answer the call light. During an interview on 5/22/23 at 2:00 P.M., the Assistant Director of Nursing (ADON) said the resident's call light was turned on at 5:30 P.M. on 5/16/23 and wasn't answered until 7:15 P.M. He said the two hour time delay was unacceptable for a resident's request for help to go unanswered. He didn't know why it took so long for the resident's call light to be answered. He didn't think it should have taken that long. During an interview on 5/23/23 at approximately 2:10 P.M., CNA D said he/she knew when a resident's call light was on if he/she sat at the nurse station because he/she would see the call light panel system light up. During the same interview, CNA D said he/she walked the hallway or sat in the hallway such that he/she could see the light illuminated above the doors of his/her assigned rooms. He/She would answer the call light even if not his/her resident. During an interview on 5/25/23 at approximately 2:10 P.M., the Director of Nursing, (DON) said when the call light is on, it makes a dinging noise and the panel behind the nurse desk is lit up. It was not appropriate for staff to be sitting around the nurses' desk when resident call lights were going off or pass a resident room who had their call light on. She expected staff to answer the call light within five to ten minutes, but the wait time could be more based on the resident's need or if that particular staff answering the light was able to meet the resident's need. Answering resident call lights should be a priority. She also said during meal time, staff who are assigned to pass hall trays are also responsible to answer resident call lights. There was always staff available to answer call lights, even during meal time service. She expected staff to answer resident call lights during meal time. MO00218511

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice when staff failed to honor two residents' choices to get out of bed, resulting in the residents remaining in bed and unable to go about their day (Resident #1 and Resident #7). The sample size was 16. The census was 91. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/12/23, showed: -Cognitively intact; -Interview for activity preferences: -How important is it to you to choose what clothes to wear: Very important; -How important is it to you to take care of personal belongings: Very important; -How important is it to you to choose between tub bath, shower, bed bath, or sponge bath: Very important; -How important is it to you to choose your own bedtime: Very important. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Total dependence with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Supervision with eating; -Frequently incontinent of bowel and bladder; -Diagnoses included heart failure, end stage renal disease (ESRD), anxiety, depression, and chronic obstructive pulmonary disease (COPD, lung disease). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident had an activities of daily living (ADL) self-care performance deficit related to impaired balance and limited mobility; -Goal: The resident would maintain current level of function in ADLs through the review date; -Intervention: The resident required total assistance by staff with bathing/showering two times weekly and as necessary. The resident required maximum staff assist for personal hygiene/oral care. During an interview on 5/11/23 at 9:00 A.M., the resident said he/she asked to go back to bed at 2:00 P.M. yesterday. He/She was told he/she would have to wait until 3:00 P.M. when shift change occurred. The resident said that morning he/she asked for care to be provided before 9:00 A.M. A Certified Nursing Assistant (CNA) told the resident he/she had to feed another resident and would be back. The resident was told he/she would be first on the CNA's list for care. Observation on 5/11/23 at 9:20 A.M., showed CNA D told the resident two other residents wanted to get up. He/She could not get either resident up out of bed because CNA D was not sure if he/she would be able to put them back to bed when the residents wanted. This was because there was not enough help. CNA D entered the resident's room at that time to provide care. CNA D said he/she asked for assistance from other CNAs on the floor, but was told no. Observation on 5/11/23 at 2:20 P.M., showed Resident #1 remained in bed. 2. Review of Resident #7's annual MDS, dated [DATE], showed: -Cognitively intact; -Total dependence with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Resident had a supra pubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) and colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall); -Diagnoses included Multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue), neurogenic bladder (the bladder does not empty properly due to a neurological condition), seizure disorder, anxiety and depression. Review of Resident #7's quarterly MDS, dated [DATE], showed: -Interview for activity preferences: -How important is it to you to choose what clothes to wear: Very important; -How important is it to you to take care of personal belongings: Very important; -How important is it to you to choose between tub bath, shower, bed bath, or sponge bath: Very important; - How important is it to you to choose your own bedtime: Very important. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Resident had an ADL self-care performance deficit related to MS. Resident required total care form staff; -Goal: The resident would maintain current level of function in ADLs through next review date; -Intervention: The resident was totally dependent on staff for personal hygiene and oral care. The resident was totally dependent on staff for dressing. The resident wished to pick out his/her own clothes. During an interview on 5/11/23 at 1:40 P.M., Licensed Practical Nursing (LPN) H said CNA D just told him/her that Resident #7 wanted to get up. LPN H said CNA D was to put lunch trays away first. Observation and interview on 5/11/23 at 2:20 P.M., showed Resident #7 still in bed. Resident #7 was told he/she would get up but that was over an hour ago. 3. During an interview on 5/11/23 at 3:00 P.M., the Director of Nursing (DON) said it is not acceptable to tell a resident they are not going to get out of bed because they are not sure when they would be able to get back to bed. She said a resident should not have to wait for personal care or told they have to wait for personal care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident admitted on [DATE] received orders for peripherally inserted central catheter (PICC, used to administer long-term medications) care and monitoring of the PICC line and failed to obtain blood glucose monitoring orders (Resident #32). Additionally, the facility failed to notify the physician for out of range blood glucose results (Resident #33). The sample size was 17. The census was 86. Review of the pharmacy PICC policy, showed: -PICC: Flush protocols: -Non-valved access: administer 5 milliliters (ml) of normal saline (NS), infuse medication, then administer 5 ml and follow with 5 ml of heparin (used to prevent clotting); -Site maintenance: Transparent dressing changes done weekly and as needed (PRN). Measure upper arm circumference and external catheter length with each dressing change and PRN. 1. Review of Resident #32's discharge hospital records, dated 7/14/23, showed: -Diagnosis included: osteomyelitis (bone infection) and diabetes; -Orders: -Cefepime (antibiotic used to treat infection) administer 2,000 milligrams (mg) intravenously (IV) once daily every 12 hours for 40 days; -Vancomycin (antibiotic used to treat infection) administer 1,750 mg IV every 24 hours for 40 days; -Humalog (short acting) insulin inject 0-9 units three times daily with meals; -Humalog insulin, inject 20 units three times daily with meals; -Novolin N (intermediate acting) insulin, give 15 units twice a day; -OneTouch blood glucose test strips (used to test blood sugar). Review of the resident's medical record, showed: -admitted on [DATE]; -Diagnoses included: infection of the left lower stump and type II diabetes. Review of the progress notes, dated 7/14/23 at 9:20 P.M., showed the resident was admitted at 8:00 P.M. He/She noted with a PICC line to the right upper arm. Review of the Physician Order Sheet (POS), dated 7/14/23, showed: -An order for Cefepime IV solution, infuse 2000 mg/2 grams (gm) every 12 hours until 8/25/23; -An order for Insulin Lispro, inject 20 units subcutaneously (sub-q, under the skin) three times a day for diabetes; -An order for Insulin NPH, inject 15 units twice a day for diabetes; -An order for blood glucose test strips, use two times a day; -An order for Vancomycin IV, administer 1,750 mg by IV every 24 hours for 40 days; -No orders for monitoring, assessment, dressing or flush protocols for the PICC line; -No orders for monitoring blood glucose levels twice daily. Review of the Medication Administration Record (MAR), dated July 2023, showed: -An order, dated 7/14/23, for Cefepime IV solution, administer 2 gm IV every 12 hours for infection for 41 days. Scheduled daily at 8:00 A.M., and 9:00 P.M. Documented as administered; -An order, dated 7/14/23, for Vancomycin IV solution, administer 1,750 mg every 24 hours for infection for 40 days. Documented as administered; -No PICC flushing or site maintenance protocol orders noted; -An order, dated 7/14/23, for NPH insulin, inject 15 units sub-q two times daily. Scheduled daily in the AM and HS (bedtime). Noted as administered; -An order, dated 7/14/23, for Lispro insulin, inject 20 units sub-q, three times a day. Scheduled daily at 8:00 A.M., 4:00 P.M., and 9:00 P.M. Noted as administered; -No orders or documentation of blood glucose testing prior to administration of insulins. Review of the baseline care plan, dated 7/15/23, showed: -Special treatments: IV medications while a resident; -Medications: insulin and antibiotics. Review of a progress note, dated 7/16/23 at 5:15 P.M., showed skilled evaluation: blood glucose: blank, specialty care IV device: PICC line flushes easily, PICC dressing intact. During an observation and interview on 7/19/23 at 8:34 A.M., the resident lay awake in bed, with a PICC to the right upper arm. A clear dressing covered the insertion site and was dated 7/14/23. The resident said the hospital placed the PICC line on the day he/she discharged to the facility. He/She had an infection, had been taking IV antibiotics, and was scheduled to continue the IV antibiotics for a month. He/She had diabetes. The facility did not check his/her blood sugar before giving the ordered insulin. He/She received insulin several times a day. During an observation and interview on 7/19/23 at 12:30 P.M. Licensed Practical Nurse (LPN) B said the resident received IV antibiotics through the PICC line in his/her right upper arm twice daily. The resident is a diabetic and received insulin several times a day. LPN B checked the POS and verified the resident did not have orders for PICC line dressing changes or maintenance. The resident did not have orders for monitoring blood glucose prior to insulin administration. LPN B said the resident had not received blood glucose monitoring or PICC line protocol care. Blood glucose monitoring and PICC line care should be ordered. The nurse is responsible to ensure the PICC line is monitored and flushed. The nurse is responsible to monitor blood glucose levels before administering insulin. 2. Review of Resident #33's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/25/23, showed: -Cognitively intact; -Diagnoses included diabetes; -Received injections seven days a week; -Received insulin seven days a week. Review of the undated care plan, showed: -Focus: the resident has diabetes; -Goal: no complications related to diabetes; -Interventions: dietary consult, insulin as ordered, staff document side effects, blood glucose monitoring as ordered and notify the physician if the blood sugar is over 400 or under 60. Review of the electronic POS, dated 7/2023, showed: -An order, dated 7/2/20: Call the physician for a blood sugar result under 60 or over 400; -An order, dated 9/21/22: Administer Novolog (fast acting) insulin 18 units with meals. Review of the MAR, dated 7/2023, showed: -An order, dated 9/21/22: Novolog insulin, administer 18 units with meals, scheduled daily at 7:00 A.M., 12:00 P.M. and 4:00 P.M. and included blood glucose readings. -On the following dates and times, the blood sugar results measured above 400: -On 7/13/23 at 7:00 A.M., result: 435, and at 12:00 P.M., result: 452; -On 7/14/23 at 12:00 P.M., result: 401; -On 7/16/23 at 12:00 P.M., result: 419; -On 7/17/23 at 12:00 P.M., result: 437; -On 7/19/23 at 12:00 P.M., result: 487. Review of the progress notes, dated 7/13/23 through 7/19/23 at 12:00 P.M., showed no physician contact regarding the out of range blood sugar results. During an interview on 7/19/23 at 12:30 P.M., LPN B said the resident received routine insulin injections and blood glucose monitoring. LPN B said he/she obtained the resident's 12:00 P.M. blood glucose and administered the ordered 18 units. The order to call the physician for a blood sugar over 400 was not reflected on the MAR and said the order was noted on the POS. He/She did not check the resident's POS against the facility's MAR when a high blood sugar result was obtained. A blood sugar over 400 is high and should have been addressed with the physician. During an interview on 7/19/23 at 3:05 P.M., the Administrator and Regional Director of Business Management said all physician orders should be followed. Residents admitted with IV or PICC line access sites should have orders for flushing and site maintenance. Diabetic residents should have orders for blood glucose testing prior to administration of any fast acting insulin and the physician should be notified of results out of range.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their fall programs policy and procedure by not documenting a fall and failing to report the fall to the next shift (Resident #23). The facility staff also did not know the procedure when a resident was found on the floor (Resident #4). The sample was 16. The census was 91. Review of the Falls Programs Policy and Procedures policy, undated, showed: -Purpose: To identify all residents who have a high risk for falls and to ensure adequate interventions are in place to prevent a major injury; -Policy: All residents will be evaluated to assess for fall risk on admission/readmission. An investigation of all falls will be completed by the Director or Nursing (DON)/Designee and submitted to the Interdisciplinary Team (IDT) committee for review; -Procedure: -1. The Fall Risk Evaluation will be completed on every resident upon admission/re-admission by the nurse on the shift that the resident is admitted on ; -2. When a resident is identified as being at a high risk for fall, an Initial Plan of Care when the Comprehensive Plan of Care is completed; -3. The Minimum Data Set ((MDS), a federally mandated assessment instrument completed by facility staff) nurse will be responsible for discontinuing the Initial Plan of Care when the Comprehensive Plan of Care is completed; -4. When a resident within the facility falls, the nurse will assess/evaluate the resident and document in the electronic medical record. Neurological checks (neuro-checks, an assessment completed by nursing staff to monitor for changes in the resident's neurological (nervous system) status) will be initiated for all un-witnessed falls, residents on anti-coagulant, or anti-platelet medication or hit their head and as ordered by the physician/practitioner; -5. The nurse will complete a new Fall Risk Evaluation in the electronic medical record; -6. The nurses document post fall for 72 hours completing the Fall Follow up 72 hour in the electronic medical record; -7. The DON/Designee will complete the Fall Risk Evaluation within 24 hours and/or the next business day in the electronic medical record; -8. Fall tracking/incident reports are completed in the electronic Risk Management Program; -9. Fall tracking is reviewed monthly during monthly Quality Assurance and Performance Improvement (QAPI) for patterns and trends. 1. Review of Resident #23's admission MDS, dated [DATE], showed: -Cognitively impaired; -Total dependence with dressing, toilet use and personal hygiene -Extensive assistance with bed mobility and transfers; -Occasionally incontinent of bladder, frequently incontinent of bowel; -Diagnoses included end stage renal disease (ESRD), dementia and high blood pressure. Review of the resident's care plan, undated and in use at the time of the survey, showed the resident's risk for falls was not identified. Review of the resident's progress notes, showed: -5/8/23 at 10:12 P.M., Resident admitted to the facility from the hospital; -5/10/23 at 5:45 P.M., Resident was found unresponsive upon entering the room around 5:45 P.M. in wheelchair. Resident was not responding to any verbal communication, physical stimuli or sternal rub (a commonly used method of assessing response to painful stimuli in assessing the neurological status of an individual). Upon obtaining vitals, resident stopped breathing and a code was called. Chest compressions were administered with oxygen until emergency medical services (EMS) arrived around 5:52 P.M. Family has been called with no answer, physician also notified; -5/11/23 at 3:08 P.M., This nurse called the hospital for an update. The resident was admitted to the cardiac floor and is waiting on further evaluation; -5/18/23 at 11:18 A.M., Resident returned to the facility. Review of the resident's fall risk evaluation, dated 5/18/23, showed: -Level of consciousness/mental state: Intermittent confusion; -History of falls (past 3 months): No falls in the past 3 months; -Ambulation status: Chair bound-requires restraints and assist with elimination; -Vision status: Adequate (with or without glasses); -Gait/balance: Balance problem while standing and walking, decreased muscular coordination; -Blood pressure: No noted drop between lying and standing. Review of the resident's progress notes, showed: -No documentation of a fall on 5/20/23 or 5/21/23; -5/22/23 at 12:29 A.M., Heard the resident calling help me, help me God, hello. Went to room and call light was placed on side rail for ease of access. Resident complains of sub diaphragmatic (area located under the diaphragm (a muscle located just below the lungs and heart, which helps to breathe)) pain that does not radiate. Denies chest pain. Resident is alert, very anxious. Encouraged resident to be calm. Gave the resident Tylenol. When this nurse left and checked back 15 minutes later, the resident was asleep. Plans to continue to check frequently; -5/22/22 at 2:40 A.M., Resident requested calcium carbonate tablet for gas and discomfort; -5/22/23 4:02 A.M., Resident is having increasing sub diaphragmatic abdominal pain. Resident received doctor ordered Tylenol and this medication cannot be given again until 6:00 A.M. Resident requested more Tylenol around 3:00 A.M. and this nurse gave resident calcium carbonate which is not working well. Resident is not wearing oxygen and says he/she has never had it. Pain does not radiate to the chest or the arms. Discussed cardiac history and the resident has had chest pain in the past and this is not it. Resident informed that he/she cannot have Tylenol until after 6:00 A.M. called the resident's doctor and left a message asking for a call back; -5/22/23 at 9:38 P.M., X-ray completed. Result reported to physician and received new order for Levaquin (antibiotic) 500 milligram (mg) by mouth for 7 days for pneumonia (infection that affects one or both lungs) received and entered into electronic medical record. During an interview on 5/23/23 at 11:57 A.M., Certified Nursing Assistant (CNA) L said there were two falls on the overnight shift of 5/20/23 to 5/21/23. There was a fall on each side of the building. He/She was not sure if the nurse reported the fall for this resident but believes the other fall was reported. CNA L said he/she was not working on that side when the resident fell but assisted the staff so the nurse could assist the resident and get back to bed. During an interview on 5/23/23 at 1:30 P.M., Registered Nurse (RN) M said he/she worked the morning after the fall on 5/21/23. RN M was not aware of anyone that fell overnight or when he/she came on the floor for his/her shift. During an interview on 5/23/23 at 2:20 P.M., the DON was informed of the fall that was not reported. She said she would look into it and start an investigation. She expected staff to follow the facility's policy and report the fall to the next shift as well as complete any documentation that is to be done. 2. Review of Resident #4's discharge MDS, dated [DATE], showed: -Cognitively impaired; -Total dependence with bed mobility, eating, dressing, toilet use, transfers, and personal hygiene; -Always incontinent of bowel and bladder, -Diagnoses included diabetes and malnutrition. Review of the resident's care plan, undated, showed: Focus: Resident is at risk for falls related to deconditioning; Goals: Resident will not sustain serious injury through review date; Interventions: Fall mat on left side of the bed, be sure the resident's call light is within reach. Observation on 5/11/23 at 12:18 P.M., showed the resident lay in bed asleep. The resident's tube feeding was visibly dried on the floor. The resident's call light is on the floor. The resident has a fall mat on the left side of his/her bed. The tube feeding pump showed a flow error. The resident's food tray was in front of the resident on the bedside table. Observation on 5/11/23 at 1:30 P.M., showed the resident sat up in bed. The resident had a cup in his/her hand and red juice from the cup was all over the blanket. The resident's call light was on the floor wrapped up in the phone cord and out of reach. The resident's tube feeding pump still showed a flow error and dried tube feeding remained on the floor. At 1:35 P.M., a housekeeping staff member entered the room with a mop and bucket and started to clean the tube feeding off the floor. Observation on 5/11/23 at 2:37 P.M., showed the resident sat on the floor. The resident had his/her back against his/her bed and held the side rail with his/her left hand. CNA O was observed in the hallway and was informed the resident was on the floor. CNA O went in the room and saw the resident. The CNA came out of the room looked at the surveyor, and asked, What do I do? Can I get the resident up or do I need to get the nurse? CNA O walked out of the room and down the hall to the nurses' station. CNA O returned with a nurse. The nurse assessed the resident and both staff placed the resident back in bed. During an interview on 5/11/23 at 3:00 P.M., the DON said she expected staff to know what to do after a fall or after a resident is found on the floor. The resident should be assessed by a nurse before the resident is moved. The resident should not be left alone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff followed physician orders regarding tube feeding administration for two residents (Resident #4 and Resident #3). The sample size was 16. The census was 91. Review of the facility's Enteral Tube Medication Administration policy, revised January 2018, included: -Policy: The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes, and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietician, and consultant pharmacist. -Procedures: -The physician order must specify the route of administration of any medication via feeding tube; -Elevate head of bed to 30-45 degrees and leave in this position at least 30 minutes after administration of medications; -With gloves on, check for proper tube placement using and auscultation (the action of listening to sounds from the body with a stethoscope) only. Never check placement with water; -Check gastric content for residual feeding. Return to the stomach. Report any residual above 100 milliliters (ml); -If pump is used for feedings, turn it off; -Restart pump and feeding if appropriate. 1. Review of Resident #4's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/26/23, showed: -Cognitively impaired; -Total dependence with bed mobility, eating, dressing, toilet use, transfers and personal hygiene; -Diagnoses included diabetes and malnutrition. Review of the resident's undated care plan, showed: -Focus: Resident requires tube feeding related to dysphasia (difficulty swallowing); -Goal: Resident will be free of aspiration through the review date; -Interventions: Check for tube placement per facility protocol and record, Resident needs to be up in a chair for all oral intake, add pureed diet per speech therapy. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR), showed: -An order, dated 4/18/23, to check gastronomy tube (g-tube, a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication) placement and residual before medications and every shift every day and night shift; -April, 2023: -No documentation: Night 4/21/23; -May 1-May 11, 2023: -No documentation: Day: 5/2/23; -No documentation: Night: 5/1/23. -An order dated, 4/18/23 through 5/3/23, for Jevity 1.5 (calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 45 ml/hour (hr) via pump with 150 ml water flush every 4 hours every shift; -April 2023: -No documentation: Evening: 4/27/23; -May 1 through May 11, 2023: -No documentation: Evening: 5/1/23; -No documentation: Day: 5/2/23. -An order, dated 4/18/23, for g-tube care every day and night shift; -April, 2023: -No documentation: Days: 4/20, 4/23, 4/25, 4/26, 4/27 and 4/28/23; -No documentation: Nights: 4/18, 4/20, 4/21, 4/25 and 4/29/23. -May 1 through May 11, 2023: -No documentation: Day: 5/1, 5/2, 5/4, 5/6 and 5/7/23; -No documentation: Evening: 5/1/23; -No documentation: Nights: 5/1, 5/3 and 5/7/23. -An order dated, 5/3/23, for Jevity 1.5 at 45 ml/hr via pump with 150 ml water flush every 6 hours every shift; -May 1 through May 11, 2023: -No documentation: Evening: 5/5/23; -No documentation: Night: 5/5/23. Review of the resident's progress notes, dated 4/26/23 12:03 P.M., showed an initial dietary assessment. Resident has no skin breakdown. Current regimen exceeds fluid needs. Would change water flush to 150 ml four times a day. This would provide 1387 ml fluid daily. Would add nothing by mouth (NPO) to physician order sheet (POS). Will monitor status. Goals: Adequate nutrition and hydration, weight stability. Plan: Change water flush to 150 ml four times a day; Add NPO to POS; Monitor weights, labs, and skin. Review of the Nutrition/Dietary note, dated 5/23/23 at 11:11 A.M., Current body weight 102 pounds (1 mo 103). Stable weight over 1 month. Skin intact. Diet order is Puree, Jevity 1.5 at 70 ml/hr with 150 every 4 hours water flush. Would continue with previous recommendation to change water flush to four times a day. Will monitor status. Observation on 5/10/23 at 10:30 A.M. showed the resident lay in bed. The resident's tube feeding pump showed a flow error. The water bag was empty. Licensed Practical Nurse (LPN) P entered the room and attempted to fix the error. LPN P said he/she will come back to get that straightened out and get a new tube feeding bottle and water bag for the resident. Observation on 5/11/23 at 12:18 P.M., showed the resident lay in bed asleep. The resident's tube feeding was on the floor, dried. The tubing was tangled with the phone cord and next to the bed. The resident's call light was on the floor and out of reach. The tube feeding pump showed a flow error. A Jevity 1.5 bottle hung and was dated 5/10/23 at 10:30 A.M. with approximately 300 ml left in the bottle. A water flush bag hung and was dated 5/10/23 at 10:30 A.M. with approximately 25 ml left in the bag. Observation on 5/11/23 at 1:30 P.M., showed the resident sat up in bed. The resident's tube feeding pump showed a flow error. Dried tube feeding was on the resident's floor. During an interview on 5/11/23 at 4:30 P.M., LPN N said the Jevity bottle was over 24 hours old and the pump showed flow error because they are trying to discontinue the order. The physician just did rounds and changed the order to Jevity 1.5 at 70 ml/hr from 9:00 P.M. to 5:00 A.M. with 150 ml water flush every 4 hours. LPN N informed the Jevity was the same yesterday and LPN N replied, oh. 2. Review of Resident #3's discharge MDS, dated [DATE], showed: -Cognitive impairment; -Total dependence for bed mobility, transfers, dressing, eating, toilet use and personal hygiene; -Diagnosis of obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). Review of the resident's care plan, undated, showed: Focus: The resident requires tube feeding related to dysphagia; Goal: The resident will maintain adequate nutritional and hydration status. The resident will remain free of side effects or complications related to tube feeding through the review date; Interventions: Staff to administer tube feeding and flushes per physician orders. The resident needs the head of bed elevated 45 degrees during and thirty minutes after tube feed. The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. Review of the resident's MAR/TAR, showed: -An order, dated, 2/27/23, Every night shift change syringe daily and as needed; -April, 2023: -No documentation: 4/1, 4/3, 4/5, 4/11, 4/12, 4/14, 4/20, 4/21, 4/25 and 4/29/23; -May 1 through May 8, 2023; -No documentation: 5/3 and 5/7/23. -An order, dated 2/27/23, Every shift check tube placement before initiation of formula, medication administration, and flushing tube; -April, 2023: No documentation per shift; -Day: 4/1, 4/3, 4/4, 4/5, 4/13, 4/14, 4/20, 4/25, 4/26, 4/27, and 4/28/2;3 -Evening: 4/1, 4/3, 4/5, 4/14, and 4/20/23; -Night:: 4/3 and 4/12/23. -May 1 through May 8, 2023: No documentation per shift: -Day: 5/1, 5/2, and 5/7/23; -Evening: 5/7/23. -An order, dated 2/27/23, Every day and every night shift. Flush tube with 20 ml-0 ml of water before and after administration of medication pass; -April, 2023: No documentation per shift; -Days: 4/13; -Nights: 4/5, 4/14, and 4/21. -May 1 through May 8, 2023: Blank dates per shift: -Days: 5/2; -Nights: 5/1. -An order, dated 2/27/23, Elevate head of bed 30-45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding has stopped every shift. -May 1 through May 8, 2023: -Day shift: 5/2/23 Blank. -An order, dated 4/2/23, Jevity 1.5 at 70 ml/hr with 150 ml water flush every 4 hours continuously; -April, 2023: -12:00 A.M. 4/6, 4/15 and 4/22/23 Blank; -May 1 through May 8, 2023 -12:00 A.M. 5/2 and 5/4/23 Blank. 3. During an interview on 5/11/23 at 3:00 P.M., the Director of Nursing (DON) said the Jevity bottle and tubing should be changed if it is over 24 hours old. She expected staff to check on residents every two hours. She expected staff to follow physician orders for medications and treatments. MO00218101 MO00218164

Based on observation, interview and record review, the facility failed to follow infection control protocols during personal care for one resident (Resident #1). The sample was 16. The census was 91. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/23, showed: -Cognitively intact; -Total dependence with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses included heart failure, end stage renal disease (ESRD), anxiety, depression, and chronic obstructive pulmonary disease (COPD, lung disease). Review of the resident's care plan, undated, showed: -Focus: The resident had an activities of daily living (ADL, self-care activities) self-care performance deficient related to impaired balance and limited mobility; -Goal: The resident will maintain current level of function in ADLs through the review date; -Intervention: The resident required total assistance by staff with bathing/showering two times weekly and as necessary. The resident required maximum staff assist for personal hygiene/oral care. Observation on 5/11/23 at 9:20 A.M., showed Certified Nursing Assistant (CNA) D entered the resident's room with supplies. CNA D put on gloves, then uncovered the resident and raised the gown above the resident's brief. CNA D unsecured the resident's brief and provided perineal care (washing of the pubic area, buttocks and thighs) to the resident. CNA D went to the sink with a basin and filled the basin with soap and water with the same gloves. CNA D wiped the resident's chest and breast under folds with a wet towel, then used a dry towel on the resident while wearing the same gloves. CNA D went through the resident's personal items in his/her dresser to search for lotion, deodorant and cream. CNA D, while still wearing the same gloves, applied the personal care items on the resident. Still wearing the same gloves, he/she went back to the resident's personal items to get powder. CNA D applied powder and lotion on the resident then placed the basin by the television. CNA D went to the resident's right side and helped the resident roll over, then removed the brief. CNA D did not change gloves or perform hand hygiene. CNA D washed the resident's back and buttocks and the back of the resident's legs. CNA D applied lotion to the resident's back and petroleum jelly to the resident's buttock area. He/She put a new brief under the resident and the resident rolled over to secure the brief. CNA D helped the resident don a gown and went back to the dresser for body spray. CNA D saw food under the resident's chin and used a cloth off the resident's tray to remove it from his/her chin. He/She, while still wearing the same gloves, covered the resident with his/her sheet. CNA D washed the basin in the sink, while still wearing the same gloves, then dried the basin and placed it under the sink. CNA D wiped the sink down with a towel. He/She then went back to the resident to assist with a position change, per the resident's request. CNA D used the bed control remote to lay the resident flat, then assisted the resident to a different position. CNA D picked up the brief and disposable pads off the floor and placed them in a trash can. He/She pulled out the trash bag and put on them on the floor, then left the room. CNA D returned to the room with trash bags. CNA D gathered up trash and left the room. He/She disposed of the trash and removed his/her gloves outside of the room. During an interview on 5/11/23 at 3:00 P.M., the Director of Nursing (DON) said when nursing staff provide care, their gloves should be changed between dirty and clean. They should also wash their hands after gloves are removed. Dirty linens and briefs should not be thrown on the floor. Staff should remove gloves and wash hands after a bed bath is given and before any of the resident's personal items are touched.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a clean, comfortable, home-like environment when staff did not keep one resident's (Resident #9) floor free of food debris and keep the outside of the commode clean, and change the bedsheets of another resident (Resident #10) who experienced a bleedout after dialysis. Additionally, the facility failed to repair cracks in the ceilings in two resident rooms which led to leaking in the room near the residents' beds (Residents # 9 and 12) when it rained. The census was 91. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/23, showed the following: -Severe cognitive impairment; -Diagnoses included anemia, non-traumatic brain dysfunction (injuries to the brain not caused by an external blow to the head), Alzheimer's disease, renal insufficiency (poor kidney functioning), atrial fibrillation (an abnormal heart rhythm (quivering or irregular) characterized by rapid and irregular beating), gastro-esophageal reflux disease without esophagitis (a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach) but does not include inflammation of the esophagus), irritable bowel syndrome (a disorder that leads to abdominal pain and cramping, changes in bowel movements and other symptoms) with diarrhea, anxiety disorder, depression; -Wheelchair mobility; -Required limited assistance of one with bed mobility, transfers, ambulation in room and bathing; -Required extensive assistance of one with dressing, toilet use and personal hygiene. Observations of the resident's room on 5/10/23 at 11:15 A.M. and 5/11/23 at 9:30 A.M., showed a long T-shaped crack in the resident's ceiling to the left of his/her bed. To the right of the bed, in front of the window, was a line of caulk sealing a crack in the ceiling. The resident's floor had black scuff marks/grime in the area to the left of the resident's bed. Food debris and three discarded lollipop sticks were scattered around the floor along with one partially eaten lollipop partially concealed by the resident's blanket draped over the left side of the bed. Black scuff marks were visible along the wall opposite from the bed extending from the side near the sink across to the bathroom door. The commode in the resident's bathroom had liquid feces which had dripped down from the seat and dried. The bathroom trash contained a used protective gown and soiled bandage, dated 5/9/23. During an interview on 5/17/23 at 9:50 A.M., the Housekeeping Supervisor said that housekeeping staff was expected to clean resident rooms daily. Some residents periodically refused cleaning. She was going to start keeping a sheet on which staff was to document those refusals. Resident #9's floor tended to be sticky, because he/she liked candy. Staff had to clean his/her floor all day. The Housekeeping Supervisor was trying to get the housekeeping department up to state standards, but the department was short-staffed. 2. Review of Resident #12's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnoses included atrial fibrillation, heart failure, high blood pressure, renal insufficiency, diabetes mellitus, anxiety disorder, depression and presence of cardiac pacemaker; -Required physical help by one in part of bathing activity; -Required extensive assistance of one with bed mobility, transfers, locomotion off unit, dressing and toilet use; -Wheelchair mobility. Observations of the resident's room on 5/10/23 at 12:00 P.M. and 5/11/23 at 9:00 A.M., showed water damage (indicated by bubbled paint) to the ceiling, near the window and air conditioner which was placed high on the wall. During an interview on 5/11/23 at 9:00 A.M., the resident said that section of the ceiling had leaked the night before and the air conditioner blew the steady drip of water onto the resident in bed. He/She was cold all night. The ceiling always leaked when it rained. Review of the facility's roof repair estimate, dated 12/16/22, showed the cost of labor and material necessary for tearing out shingles, repairing damaged step flashing (a piece of metal, bent at 90 degrees, placed between the shingles and a sidewall, [NAME] or chimney to prevent water from getting under roof shingles and destroying the roof structure, by directing the water back to the shingles below and off the roof), installing ice and water shield and new shingles similar to existing at area of leakage. During an interview on 5/10/23 at 10:45 A.M., the Maintenance Supervisor said the cracked ceiling in the resident's room did leak over by the window approximately a month prior, but had been repaired. Afterwards, there was another big rain and the second (T-shaped) crack formed. He checked it every time it rained and did not see any leaking. No one had reported any issues with leaking to him. That was the only resident area of the facility he knew of that leaked. The ceiling would be repaired, once a delivery of drywall arrived. There was no estimated time of arrival for the drywall. 3. Review of Resident #10's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Received dialysis; -Diagnoses included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis, heart failure, high blood pressure, diabetes mellitus, depression, insomnia, COVID-19, restless leg syndrome (a disorder characterized by the occurrence of uncomfortable sensations in the legs and the urge to move them in order to relieve the sensations) and muscle weakness; -Required set up and supervision for eating; -Required limited assistance of one with bed mobility, transfers, ambulation, locomotion, personal hygiene and bathing; -Required extensive assistance of one with toilet use; -Walker and wheelchair mobility. Review of the resident's grievance/concern form, dated 4/11/23, showed sometimes housekeeping won't come in for 2-3-4 days, dirty diapers will stink by then. When they do come in, they barely sweep/mop around things then leave. The resident had to ask them to take the trash or push the can to the hallway. On 4/11/23, the social worker's note showed the resident's floors were sticky and it has been noted that housekeeping has seen and disposed of used peri care items left in trash cans. Review of the resident's progress note, dated 4/26/23 at 4:54 P.M., showed status post dialysis bleeding from fistula (how patients are connected to a dialysis machine). The resident needed to see the nephrologist (physician who specializes in kidney disease). Observations of the resident's room on 5/10/23 at 11:30 A.M. and 5/11/23 at 9:45 A.M., showed an area of dried blood, measuring 4 1/2 inches long and 2 inches wide near the foot of the right side of the resident's bed next to the resident's pillow. During an interview on 5/11/23 at 9:45 A.M., the resident said the issues he/she documented via a grievance on 4/11/23, had only improved slightly. Staff never changed his/her bed sheets. The blood stain was from a bleedout after dialysis. During an interview on 5/17/23 at 10:00 A.M., the Director of Nursing said the Certified Nurse Aides were expected to strip sheets off of resident beds on their shower days and as needed, when they were visibly soiled. 4. During interviews on 5/10/23 at 10:20 A.M. and 5/30/23 11:57 A.M., the Administrator said she was only aware of an issue with the ceiling leaking in the office. She was not aware of cracks in the ceilings of any resident rooms. The expectation was that maintenance inform her of any cracks in the ceiling, so that she could monitor and ensure timely repairs. The Administrator also was not aware of any issues of resident rooms not being adequately cleaned. She expected resident rooms to be deep cleaned once a week and swept daily. Resident sheets were to be changed immediately when soiled or saturated with urine, on the residents' shower days and upon request. MO00218179

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with suprapubic catheters (a sterile tube inserted into the bladder through the abdominal wall to drain urine) receive appropriate treatment and services to prevent urinary tract infections (UTIs) for three of three residents sampled with suprapubic catheters (Resident #7, Resident #3 and Resident #5). Additionally, one of the residents (Resident #7) developed a UTI. The sample size was 16. The census was 91. Review of the facility's Foley Catheter Care policy, undated, showed: -Equipment: Soap and warm water, washcloths and towels, gloves; -Procedure: -1. Assemble equipment; -2. Explain procedure to the resident; -3. Provide privacy; -4. Wash Hands thoroughly; -5. Apply gloves; -6. Provide perineal care first prior to catheter care; -Note: If resident is soiled with feces, takes every precaution to keep feces away from the urinary meatus (an opening in the body) as bacteria found in the bowel will cause urinary tract infection; -7. Remove gloves; -8. Wash hands thoroughly; -9. Apply gloves; -10. Stabilize catheter at the insertion site, cleanse with warm soap and water and clean wash cloth, starting at the site of insertion downward; -11. Check catheter to make sure positioning promotes proper flow of urine, no pulling is present, and catheter bag is below level of bladder. Bag should not be on the floor; -12. Leave resident dry and comfortable; -13. Place dirty reusables in one plastic bag and place dirty disposables in another bag for proper disposal; -14. Remove gloves; -15. Wash hands thoroughly; -16. Notify physician of any concerns; -17. Document all changes. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/23, showed: -Cognitively intact; -Total dependence for bed mobility, transfers, dressing, eating, toilet use and personal hygiene; -Indwelling catheter and colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) for bowel; -Diagnoses include Multiple Sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue), neurogenic bladder (the bladder does not empty properly due to a neurological condition), seizure disorder, depression and anxiety. Review of the resident's care plan, undated, showed: -Focus: Resident has a suprapubic catheter. Resident has diagnosis neurogenic bladder. Resident has history of catheter leaking related to bladder spasms; -Goal: The resident will be/remain free from catheter-related trauma through the review date; -Interventions: Monitor/document for pain/discomfort due to catheter. Monitor/record/report to physician for signs/symptoms of UTI: pain, burning, no output, altered mental status, change in behavior. Catheter care every day and night shift. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated 11/10/19, suprapubic catheter care every day and night shift; -An order, dated 8/27/22, cleanse periwound around suprapubic catheter and apply Silvadene (topical cream used to prevent infections) daily and as needed. Cover with gauze; -An order, revised 5/4/23, may flush suprapubic catheter with 30 milliliters (ml) sterile water as needed for occlusion every day and night shift; Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR), showed: -March, 2023: -Suprapubic catheter care every day and night shift: -Day shift blank: 3/9, 3/10, 3/13, 3/15, 3/16, 3/18, 3/20, 3/22, 3/27 and 3/30/23; -Night shift blank: 3/3 and 3/15/23; -Cleanse peri-wound around suprapubic catheter and apply Silvadene (topical cream used to prevent infections) daily and as needed; -Day shift blank: 3/9, 3/20, 3/13, 3/15, 3/16, 3/18, 3/20, 3/27 and 3/30/23. -April, 2023: -Suprapubic catheter care every day and night shift: -Day shift blank: 4/4, 4/5, 4/6, 4/8, 4/9, 4/11, 4/14, 4/15, 4/16, 4/18, 4/21, 4/24, 4/25, 4/26 and 4/29/23; -Night shift blank: 4/17, 4/18, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29/23; -Cleanse peri-wound around suprapubic catheter and apply Silvadene daily and as needed; -Day shift blank: 4/4, 4/5, 4/6, 4/8, 4/9, 4/11, 4/14, 4/15, 4/16, 4/18, 4/21, 4/24, 4/25, 4/26 and 4/29/23. -May 1 through May 21, 2023: -Suprapubic catheter care every day and night shift: -Day shift blank: 5/1, 5/4, 5/5, 5/7, 5/8, 5/9, 5/10, 5/12, 5/19 and 5/20/23; -Night shift blank: 5/1, 5/6, 5/7, 5/9, 5/10, 5/11, 5/15, 5/16, 5/19 and 5/20/23; -Cleanse peri-wound around suprapubic catheter and apply Silvadene daily and as needed; -Day shift blank: 5/1, 5/4, 5/5/, 5/7, 5/8, 5/9, 5/10, 5/12, 5/19, and 5/20/23. Review of the resident's progress notes, showed: -5/8/23 at 9:28 A.M., resident stated he/she was not feeling well. This nurse assessed resident and resident stated his/her stomach hurts and feels like he/she has a UTI. This nurse also observed resident's mouth related to bleeding and noticed a spot on the inner right cheek that appears to have been bitten. No other concerns observed. A call placed to physician and hospice pertaining to resident's concerns. This nurse advised resident to stay in bed related to not feeling well and being weak. Resident agreed with staying in bed; -5/15/23 at 12:26 P.M., Resident begins skilled observation due to antibiotic for UTI, he/she is receiving Cefdinir (antibioltic) by mouth, resident displays no signs/symptoms adverse reactions to therapy. Resident is without fever, catheter care administered, perineal care performed. By mouth fluids offered and encouraged. -5/15/23 at 12:31 P.M., Resident's spouse called and notified of resident's UTI diagnosis and new antibiotic prescription. -5/16/23 at 9:06 A.M., Resident remains on antibiotic for UTI. Temperature 97.0 temporal. No signs/symptoms of adverse reactions. No complaints of pain. Encouraging fluids, will continue to monitor. -5/16/23 9:19 A.M., Cefdinir Capsule 300 milligrams (mg). Give one capsule by mouth two times a day for UTI for 7 days. On order with the pharmacy, nurse on duty notified; -5/16/23 6:20 P.M., Resident is using one antibiotic for UTI. No side effects noted. Encouraged to drink plenty of fluids. End date for medication is 5/22/23. 5/17/23 10:09 A.M., Remains on antibiotic for UTI. Denies any complaints or pain when urination. Encourage extra fluids. Call light within reach. Temp 96.8 (degrees Fahrenheit); 5/17/23 10:29 P.M. Resident remains on antibiotic for UTI. No signs/symptoms of adverse reactions noted. Encouraged increased by mouth fluid intake; 5/19/23 7:24 A.M., Resident remains on antibiotic for UTI. Displays no signs/symptoms of adverse reactions to therapy, no fever with temperature-98.5. Catheter patent, draining dark amber urine to gravity, by mouth fluids encouraged; -5/21/23 1:27 A.M., Resident continues to take antibiotic Cefdinir for urinary tract infection. Tolerating medication without difficulty, encouraged to drink plenty of fluids. Stop date 5/22/23; -5/21/23 1:47 A.M., This nurse has made multiple trips to the resident's room to answer lights. Told resident he/she could not take Sorbitol (sweetener) because it was a rectal medication. He/She took milk of magnesia (a laxative to relieve occasional constipation). Resident received eye ointment. Told him/her that this nurse was not going to irrigate his/her catheter because the urine was flowing freely in the bag. 2. Review of Resident #3's discharge MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Indwelling catheter and always incontinent of bowel; -Diagnosis included obstructive uropathy (urinary tract disorder due to obstruction of urinary flow). Review of the resident's care plan, undated, showed: -Focus: Resident has a suprapubic catheter. Resident has diagnosis neurogenic bladder; -Goal: The resident will be/remain free from catheter-related trauma through the review date. The resident will show no signs/symptoms of urinary infections through the review date; -Interventions: Monitor/document for pain/discomfort due to catheter. Monitor/record/report to physician for signs/symptoms of UTI: pain, burning, no output, altered mental status, change in behavior. Change catheter per order. Review of the resident's ePOS, showed: -An order dated 12/1/22, suprapubic catheter care every shift; -An order, dated 12/1/22, may flush suprapubic catheter with 30 ml sterile water as needed occlusion every day and night shift; -An order, dated 12/3/22, wound care to suprapubic catheter site, cleanse area with saline or wound cleanser, apply clean dressing to site daily and as needed; Review of the resident's MAR/TAR, showed: -March 2023: -Suprapubic catheter care every day and night shift: -Day shift blank: 3/5, 3/6, 3/8, 3/13, 3/21, 3/18, 3/24, 3/28 and 3/29/23; -Night shift blank: 3/7, 3/25 and 3/30/23. -Wound care to suprapubic catheter site:; -Day shift blank: 3/5, 3/6, 3/8, 3/13, 3/21, 3/24, 3/28 and 3/29/23. -April 2023: -Suprapubic catheter care every day and night shift: -Day shift blank: 4/1, 4/3, 4/4, 4/5, 4/13, 4/14, 4/20, 4/25, 4/26 and 4/27/23; -Night shift blank: 4/1, 4/3, 4/5, 4/11, 4/12, 4/14, 4/15, 4/20, 4/21 and 4/29/23. -Wound care to suprapubic catheter site: -Day shift blank: 4/1, 4/3, 4/4, 4/5, 4/13, 4/14, 4/20, 4/23, 4/25, 4/26 and 4/27/23. -May 1 through May 8, 2023: -Suprapubic catheter care every day and night shift: -Day shift blank: 5/1, 5/2 and 5/7/23; -Night shift blank: 5/3 and 5/7/23. -Wound care to suprapubic catheter site: -Day shift blank: 5/1, 5/2, and 5/7/23. 3. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Total dependence for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Indwelling catheter and always incontinent of bowel; -Diagnoses include neurogenic bladder, anemia (decrease in the number of red blood cells) dementia, depression, and schizophrenia (a chronic brain disorder which affects how a person thinks, feels and acts). .Review of the resident's care plan, undated, showed: -Focus: Resident has a suprapubic catheter related to neurogenic bladder; -Goal: The resident will show no signs/symptoms of urinary infection through the review date; -Interventions: Document output every shift, record urinary output every shift, suprapubic catheter change monthly. Review of the resident's ePOS, showed an order, dated 2/27/23, Foley catheter care two times a day; Review of the resident's MAR/TAR, showed: -March, 2023: Foley catheter care two times a day: -Day shift blank: 3/6, 3/9, 3/10, 3/15, 3/16, 3/18, 3/20, 3/22, 3/23, 3/24, 3/27, 3/28, 3/30 and 3/31/23. -April, 2023: Foley catheter care two times a day: -Day shift blank: 4/3, 4/5, 4/6, 4/8, 4/9, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/18, 4/21, 4/25 and 4/29/23; -Night shift blank: 4/14, 4/17, 4/18, 4/22, 4/23, 4/24, 4/25, 4/27, 4/28 and 4/29/23. -May 1 through May 20, 2023: Foley catheter care two times a day: -Day shift blank: 5/1, 5/2, 5/4, 5/7, 5/8, 5/9, 5/10, 5/12, 5/18 and 5/20/23; -Night shift blank: 5/1, 5/6, 5/7, 5/9, 5/10, 5/11, 5/16, 5/18, 5/19, and 5/20/23. 4. During an interview on 5/11/23 at 2:20 P.M., the Director of Nursing (DON) said she expected staff to follow physician orders. She said a blank spot on the MAR/TAR indicates the item was not completed. If something is not signed, then it is not done. On 5/25/23 at 2:00 P.M., the DON said she expected catheter care to be completed as ordered. She would expect treatments to be given as ordered and staff to chart in the electronic medical record when treatments or medications are given. MO00218511

Based on observation, interview and record review, the facility failed to follow their Controlled Substance storage policy by not counting inventory at each shift change for controlled substances for two out of two sampled narcotic count sheets. The sample was 16. The census was 91. Review of the Medication Storage in the Facility Policy, dated November 2021, showed: -Medications included in the Drug Enforcement Administration (DEA) Classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances including refrigerated items is conducted by two licensed nurses and is documented on the shift change form; -Any discrepancy in controlled substance counts is reported to the Director of Nursing (DON) immediately, or in compliance with facility policy and procedure. 1. Review of the On-Coming/Off-going Nurse Count Sheet, on 5/22/23, for the 100 hall, showed the following: -Two sheets in the book for May 2023; -Sheet one started 5/1/23 and ended 5/13/23; -Starts on 5/1/23 6:00 A.M. to 6:00 P.M., no off-going signature; -5/1/23 6:00 P.M. to 6:00 A.M., no on-coming signature; -5/2/23 no time, with no off-going signature; -5/2/23 no time, with no on-coming signature; -5/3/23 6:00 A.M. to 6:00 P.M., no on-coming or off-going signature; -5/4/23 6:00 P.M. to 6:00 A.M., no on-coming signature; -5/5/23 no time, with no on-coming or off-going signature; -5/6/23 6:00 A.M. to 6:00 P.M., no off-going signature; -5/8/23 6:00 A.M. to 6:00 P.M., count completed by same Certified Medication Technician (CMT); -5/9/23 6:00 A.M. to 3:00 P.M., no off-going signature; -5/10/23 6:00 A.M. to 3:00 P.M., no on-coming signature; -5/10/23 3:00 P.M. to 11:00 P.M., no off-going signature; -5/11/23 6:00 A.M. to 6:00 P.M., no off-going signature; -5/11/23 6:00 P.M. to 6:00 A.M., no on-coming or off-going signature; -Next date listed, 5/12/23 3:00 P.M. to 11:00 P.M., no on-coming signature; -Last date listed, 5/13/23 6:00 P.M. to 6:00 A.M. -Sheet two started 5/14/23 and ended 5/20/23; -Starts on 5/14/23 6:00 A.M. to 6:00 P.M., no on-coming signature; -5/14/23 6:00 P.M. to 6:00 A.M., no off-going signature; -5/15/23 6:00 A.M. to 6:00 P.M., no on-coming signature; -Next date listed, 5/17/23 at 6:00 P.M. to 6:00 A.M. shift -5/18/23 no time and no on-coming or off-going signature; -Next date listed, 5/19/23 6:00 A.M. to 3:00 P.M.; -Next date listed, 5/20/23 7:00 A.M. to 7:00 P.M.; -Next date listed, 5/20/23 7:00 P.M. to 11:00 P.M.; -Last date listed, 5/20/23 11:00 P.M. to 7:00 A.M. 2. Review of the On-Coming/Off-going Nurse Count Sheet, on 5/22/23, for the 200 hall, showed the following: -Three sheets in the book for May 2023; -Sheet one started 5/4/23 and ended 5/16/23; -Starts on 5/4/23 for 11:00 P.M. to 7:00 A.M. shift; -5/5/23 no time specified, and no on-coming signature; -5/5/23 at 12:51 A.M., no on-coming signature; -5/6/23 at 3:00 P.M. to 11:00 P.M., no on-coming nurse signature; -5/7/23 6:00 A.M. to 6:00 P.M., count completed by same CMT; -Next date listed, 5/9/23 at 3:00 P.M. to 11:00 P.M.; -Next date listed, 5/10/23 at 6:00 P.M. to 6:00 A.M.; -Next date listed, 5/10/23 only P.M.-A.M. specified, (no specific time) count was completed; -5/11/23 6:00 A.M. to 6:00 P.M., no on-coming signature; -Next date listed, 5/12/23 6:00 A.M.to 6:00 P.M., no off-going signature; -5/12/23 6:00 P.M. to 6:00 A.M., no on-coming or off-going signature; -Next date listed, 5/13/23 at 2:30 P.M., no off-going signature; -5/13/23 11:00 P.M. to 7:00 A.M., no on-coming signature; -Two 5/15/23 dates listed at bottom of form with no time or signatures; -Two 5/16/23 dates listed at bottom of form with no time or signatures. -Sheet two started 5/10/23 and ended 5/22/23; -5/10/23 7:00 A.M.to 3:00 P.M., no off-going signature; -5/11/23 6:00 A.M. to 6:00 P.M., no on-coming signature; -5/11/23 3:00 P.M. to 11:00 P.M., no off-going signature; -Next date listed, 5/12/23 6:00 A.M.to 3:00 P.M.; -5/12/23 2:30 P.M., no off-going signature; -Next date listed, 5/13/23 6:00 P.M.; -5/13/23 11:00 P.M., no on-going signature; -Next date listed, 5/14/23 6:00 A.M. to 6:00 P.M., count completed by same CMT; -Next date listed, 5/15/23 6:00 A.M. to 6:00 P.M., no on-coming signature; -Next date listed, 5/18/23 6:00 P.M. to 6:00 A.M.; -Next date listed, 5/19/23 6:00 A.M. to 6:00 P.M., no on-coming signature; -Next date listed, 5/20/23 2:45 P.M. to 11:30 P.M., no off-going signature; -Next date listed, 5/20/23 6:00 P.M. to 6:00 A.M., no off-going signature; -Next date listed, 5/21/23 6:00 A.M. to 6:00 P.M.; -Last day listed, 5/22/23 6:00 A.M. to 6:00 P.M., no on-coming signature. -Sheet three started 5/17/23 and ended 5/22/23; -Two 5/17/23, 5/18/23 and 5/19/23 dates listed at top of form with no time or signatures; -Next date listed, 5/20/23 6:00 A.M. to 6:00 P.M., no off-going signature; -5/20/23 6:00 P.M. to 6:00 A.M., no on-coming or off-going signature; -Next date listed, 5/20/23 6:00 A.M. to 3:00 P.M., no off-going signature; -Next date listed, 5/20/23 3:00 P.M. to no time listed, no off-going signature; -Next date listed, 5/20/23 11:00 P.M. to 7:00 A.M., no off-going signature; -5/21/23 6:00 A.M. to 6:00 P.M. listed two times. The second has no on-coming signature; -5/21/23 6:00 P.M. to 6:00 A.M., no off-going signature; -5/22/23 6:00 A.M. to 6:00 P.M., no on-coming signature (off-going signed with a count before end of shift). During an interview on 5/25/23 at 2:00 P.M., the DON said she expected staff to count before and after each shift and to report any discrepancies to management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete an accurate documentation for seven residents of seven sampled residents with catheters (Residents #19, #21, #26, #17, #29, #8 and #33). The census was 65. Review of the facility's policy, Foley Catheter Care, reviewed 1/2020, showed: -Procedure: --Assemble equipment; --Explain procedure to the resident; --Provide Privacy; --Wash Hands thoroughly; --Apply gloves; --Provide perineal care (peri care, involves washing the external genitalia and surrounding area) first prior to catheter care; --Female resident - Spread the labia and wash from front to back; --Male resident - Cleanse moving from the meatus to the base of the penis. If uncircumcised, retract the foreskin and clean thoroughly; --NOTE: if the resident is soiled with feces, take every precaution to keep feces away from the urinary meatus as bacteria found in the bowel will cause urinary tract infections; --Remove gloves; --Wash hands thoroughly; --Apply gloves; --Stabilize catheter at the insertion site, cleanse with warm soap and water and clean washcloth, starting at the site of insertion downward; --Check catheter to make sure positioning promotes proper flow of urine, no pulling is present, and catheter bag is below level of bladder. Bag should not be on floor; --Leave resident dry and comfortable; --Place dirty reusables in one plastic bag and place dirty disposables in another bag for proper disposal; --Remove gloves; --Wash hands thoroughly; --Notify MD of any concerns; --Document all changes. 1. Review of Resident #19's face sheet, showed he/she was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia without behaviors, neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) of unspecified stage and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/8/22, showed: -Severe cognitive impairment; -Understood others and made his/her needs known; -Total dependence of one staff member for bed mobility, mobility on and off the unit, dressing, toileting, personal hygiene and bathing; -Total dependence of two staff members for transfers; -Had an indwelling catheter. Review of the resident's care plan, revised on 2/18/22, showed: -Focus: the resident had an activities of daily living (ADLs, the tasks of everyday life, include eating, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet) self-care performance deficit related to overall decline in functioning ability and limited mobility; -Goal: the resident will improve current level of function in ADLs through next review date; -Interventions: --Personal hygiene/oral care: the resident is totally dependent on one staff for personal hygiene and oral care; --Toilet use: the resident is totally dependent on one staff with incontinence care; --Transfer: the resident is totally dependent with a Hoyer lift (a mechanical mobility tool used to help those with mobility challenges get in/out of bed and/or wheelchair and on/off the toilet) and two staff for transfers; -Focus: suprapubic catheter (a device that is inserted through a hole in your abdomen and then directly into your bladder to drain urine); -Goal: the resident will show no signs or symptoms of urinary tract infection (UTI) through review date; -Interventions: --Complex suprapubic catheter change monthly; --Document urinary output each shift; --Resident refuses a simple suprapubic catheter; --Staff educated to prevent current leakage of catheter bag; --Staff will place an incontinence pad in a basin on the floor at the foot of the bed. Review of the resident's physician orders, showed: -Monitor urinary output every shift for output, document on intake and output (I&O) sheet, dated 6/29/22; -Suprapubic catheter care every day and night shift for Foley (brand of catheter) catheter, dated 7/7/22; -Place traditional suprapubic catheter that will accommodate a traditional catheter bag, dated 10/31/22. Review of the resident's Treatment Administration Record (TAR), dated 10/1/22 to 10/31/22, showed: -Monitor urinary output every shift every day and night shift for output document on I&O sheet, start date 6/29/22. Thirteen blanks were noted with no staff initials to document urinary output was performed for 13 out of 26 opportunities; -Suprapubic catheter care every day and night shift for Foley catheter, start date 7/7/22. Eight blanks were noted with no staff initials to document catheter care was performed for eight out of 26 opportunities. Review of the resident's TAR, dated 11/1/22 to 11/7/22, showed: -Monitor urinary output every shift every day and night shift for output document on I&O sheet, start date 6/29/22. Seven blanks were noted with no staff initials to document urinary output was performed for seven out of 13 opportunities; -Suprapubic catheter care every day and night shift for Foley catheter, start date 7/7/22. Five blanks were noted with no staff initials to document catheter care was performed for five out of 13 opportunities. During an interview on 11/2/22 at 2:28 P.M., the resident said staff never empty his/her urine collection bag and never clean the catheter insertion site. Staff had not performed catheter care nor looked at his/her catheter insertion site that shift. 2. Review of Resident #21's face sheet, showed he/she was admitted to the facility on [DATE] with diagnoses of diabetes mellitus II, dementia without behaviors, Stage IV pressure ulcer (Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.) of the sacrum (triangular bone located above the coccyx) and hereditary and idiopathic (unknown cause) neuropathy (abnormality of the nervous system). Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Understood others and made his/her needs known; -Required extensive assistance of one or two staff members for bed mobility, transfers and dressing; -Total dependence with assistance of one staff member for toileting, personal hygiene and bathing; -Required a wheelchair for mobility; -Had an indwelling catheter. Review of the resident's care plan, initiated 9/8/22, showed: -Focus: the resident admitted with indwelling catheter; -Goal: the resident will be/remain free from catheter related trauma through next review; -Interventions: --Catheter: 16 French (size). Change the catheter on the 15th day of each month; --Check tubing for kinks each shift; --Monitor and document intake and output as per facility protocol; --Monitor, record and report to the resident's physician, any signs or symptoms of a UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in eating patterns and change in behavior. Review of the resident's physician orders, showed: -Foley catheter care every day and night shift for Foley catheter, dated 8/26/22; -Monitor urinary output every shift and document on I&O sheet, dated 10/10/22; -Change Foley catheter every month on the 15th with a 16 French (fr)/10 milliliter (ml) balloon catheter for wound, dated 10/12/22. Review of the resident's TAR, dated 9/1/22 to 9/30/22, showed: -Foley catheter care every day and night shift for Foley catheter, start date 8/26/22. Eleven blanks were noted with no staff initials to document catheter care was performed for eleven out of 60 opportunities. Review of the resident's TAR, dated 10/1/22 to 10/15/22, showed: -Foley catheter care every day and night shift for Foley catheter, start date 8/26/22. Thirteen blanks were noted with no staff initials to document catheter care was performed for 13 out of 28 opportunities; -Monitor urinary output every shift and document on I&O sheet, start date 10/10/22. Four blanks were noted with no staff initials to document urinary output was performed for four out of nine opportunities. During an interview on 11/7/22, the resident's physician said he/she expected staff to follow all physician orders. 3. Review of Resident #26's face sheet, showed he/she was readmitted to the facility on [DATE] with diagnoses of multiple sclerosis (MS, disease in which the immune system eats away at the protective covering of nerves, resulting nerve damage disrupts communication between the brain and the body), quadriplegia (paralysis of all four limbs) and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems). Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Understood others and made his/her needs known; -Total dependence with assistance of one staff member for bed mobility, dressing, toileting, personal hygiene and bathing; -Total dependence with assistance of two staff member for transfers; -Required a wheelchair for mobility; -Had an indwelling catheter. Review of the resident's care plan, initiated 9/8/22, showed: -Focus: the resident had a suprapubic catheter; -Goal: the resident will be/remain free from catheter related trauma through next review; -Interventions: --Catheter care as ordered every day and night shift; --Check for placement of the privacy bag; --Document output every shift; --Cleanse catheter site as ordered; --Catheter to be changed on the 15th of every month; --Monitor and document for pain/discomfort due to catheter; --Monitor/record/report to the physician any signs or symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening in urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating pattern. Review of the resident's physician orders, showed: -Change drain sponge around suprapubic catheter every day shift, dated 6/23/20; -Change suprapubic catheter every month on the 5th with a 16 fr/30 ml balloon catheter, dated 10/24/22; -Suprapubic catheter care every day and night shift, dated 8/26/22; -Monitor urinary output every shift every day and night shift, record output each shift, dated 7/25/20; -Acetic Acid Solution 0.25 % flush catheter with 60 cc via irrigation every day shift for catheter irrigation, dated 5/24/22. Review of the resident's TAR, dated 10/1/22 to 10/30/22, showed: -Acetic Acid Solution 0.25 % flush catheter with 60 cc via irrigation every day shift for catheter irrigation, dated 5/24/22. Fourteen blanks were noted with no staff initials to document the flush was performed for 14 out of 31 opportunities; -Change drain sponge around suprapubic catheter every day shift, dated 6/23/20. Eleven blanks were noted with no staff initials to document the sponge was changed was performed for 11 out of 31 opportunities; -Change suprapubic catheter every month on the 5th with a 16 fr/30 ml balloon catheter, dated 10/24/22. One blank was noted with no staff initials to document catheter change was performed for one out of one opportunities; -Monitor urinary output every shift every day and night shift, record output each shift, dated 7/25/20. Twenty three blanks were noted with no staff initials to document urinary output was performed for 23 out of 62 opportunities; -Suprapubic catheter care every day and night shift, dated 8/26/22. Thirteen blanks were noted with no staff initials to document catheter care was performed for 13 out of 62 opportunities. Review of the resident's TAR, dated 11/1/22 to 11/7/22, showed: -Acetic Acid Solution 0.25% flush catheter with 60 cc via irrigation every day shift for catheter irrigation, dated 5/24/22. Four blanks were noted with no staff initials to document the flush was performed for four out of seven opportunities; -Change drain sponge around suprapubic catheter every day shift, dated 6/23/20. Five blanks were noted with no staff initials to document the sponge was changed was performed for five out of seven opportunities; -Change suprapubic catheter every month on the 5th with a 16 fr/30 ml balloon catheter, dated 10/24/22. One blank was noted with no staff initials to document catheter care was performed for one out of one opportunities; -Monitor urinary output every shift every day and night shift, record output each shift, dated 7/25/20. Six blanks were noted with no staff initials to document urinary output was performed for six out of 13 opportunities; -Suprapubic catheter care every day and night shift, dated 8/26/22. Five blanks were noted with no staff initials to document catheter care was performed for five out of 13 opportunities. During an interview on 11/4/22 at 4:15 P.M., the resident said staff do not provide catheter care every day. He/she does not get his/her acetic acid flush daily. He/she will sometimes go a couple days at a time without catheter care or flushes. Staff will tell him/her they are too busy to do it. He/she would prefer if the catheter care and flushes were performed daily. He/she has a history of UTIs. 4. Review of Resident #17's face sheet, showed he/she was admitted to the facility on [DATE], with diagnoses of quadriplegia and neuromuscular dysfunction of the bladder Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Understood others and made his/her needs known; -Total dependence with assistance of one staff member for bed mobility, dressing, toileting, personal hygiene and bathing; -Total dependence with assistance of two staff member for transfers; -Required a wheelchair for mobility; -Had an indwelling catheter. Review of the resident's care plan, initiated 9/8/22, showed: -Focus: the resident had a suprapubic catheter due to neurogenic bladder; -Goal: the resident will be/remain free from catheter related trauma through next review; -Interventions: --Size 8 fr catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door; --Monitor and document intake and output as per facility policy; --Check tubing for kinks each shift; --Document output every shift; --Monitor/record/report to the physician any signs or symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening in urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating pattern. Review of the resident's physician orders, showed: -Change suprapubic catheter every month on the 13th with an 8 fr catheter every day shift, every month starting on the 13th, start date 7/13/22 and discontinue 10/10/22; -Monitor urinary output every shift at bedtime, start date 8/25/22 and discontinue 10/11/22; -Foley catheter care every day and night shift, dated 8/25/22; -Monitor urinary output every shift one time a day at noon, start date 8/26/22 and discontinued 10/11/22; -Monitor urinary output every shift, once daily in the A.M. and document on I&O sheet, start date 8/26/22 and discontinued 10/11/22; -Change Foley catheter every month on the (blank) with a (blank) fr catheter every day shift, every month starting on the 26th, start date 9/26/22 and discontinue 10/10/22; -Acetic Acid Solution 0.25 % flush catheter with 120 cc via irrigation every other day shift for catheter flush, start date 10/8/22; -Monitor urinary output every shift, two times a day, and document on I&O sheet, start date 10/11/22; -Monitor urinary output every shift at bedtime, start date 10/11/22; -Monitor urinary output every shift at noon, start date 10/12/22. Review of the resident's TAR, dated 9/1/22 to 9/30/22, showed: -Change suprapubic catheter every month on the 13th with an 8 fr catheter every day shift, every month starting on the 13th, start date 7/13/22 and discontinue 10/10/22. One blank was noted with no staff initials to document the catheter change was performed for one out of one opportunities; -Monitor urinary output every shift at bedtime, start date 8/25/22 and discontinue 10/11/22. Two blanks were noted with no staff initials to document urinary output was performed for two out of 18 opportunities; -Foley catheter care every day and night shift, dated 8/25/22. Ten blanks were noted with no staff initials to document catheter care was performed for 10 out of 36 opportunities; -Monitor urinary output every shift one time a day at noon, start date 8/26/22 and discontinued 10/11/22. Seven blanks were noted with no staff initials to document urinary output was performed for seven out of 18 opportunities; -Monitor urinary output every shift, once daily in the A.M. and document on I&O sheet, start date 8/26/22 and discontinued 10/11/22. Seven blanks were noted with no staff initials to document urinary output was performed for seven out of 18 opportunities; -Change Foley catheter every month on the (blank) with a (blank) fr catheter every day shift, every month starting on the 26th, start date 9/26/22 and discontinue 10/10/22. One blank was noted with no staff initials to document the catheter change was performed for one out of one opportunities. Review of the resident's TAR, dated 10/1/22 to 10/31/22, showed: -Foley catheter care every day and night shift, dated 8/25/22. Twelve blanks were noted with no staff initials to document catheter care was performed for 12 out of 52 opportunities; -Monitor urinary output every shift at bedtime, start date 8/25/22 and discontinue 10/11/22. One blank was noted with no staff initials to document urinary output was performed for tone out of eight opportunities; -Monitor urinary output every shift, once daily in the A.M. and document on I&O sheet, start date 8/26/22 and discontinued 10/11/22. Three blanks were noted with no staff initials to document urinary output was performed for three out of eight opportunities; -Acetic Acid Solution 0.25% flush catheter with 120 cc via irrigation one time daily, every other day shift for catheter flush, start date 10/8/22. Five blanks were noted with no staff initials to document the flush was performed for five out of 12 opportunities. -Monitor urinary output every shift at bedtime, start date 10/11/22. One blank was noted with no staff initials to document urinary output was performed for one out of 18 opportunities; -Monitor urinary output every shift, two times a day, and document on I&O sheet, start date 10/11/22. Seven blanks were noted with no staff initials to document urinary output was performed for seven out of 38 opportunities. Review of the resident's TAR, dated 11/1/22 to 11/7/22, showed: -Foley catheter care every day and night shift, dated 8/25/22. One blank was noted with no staff initials to document catheter care was performed for one out of three opportunities; -Monitor urinary output every shift at noon, start date 10/12/22. Two blanks were noted with no staff initials to document urinary output was performed for two out of two opportunities; -Acetic Acid Solution 0.25 % flush catheter with 120 cc via irrigation one time daily, every other day shift for catheter flush, start date 10/8/22. One blank was noted with no staff initials to document the catheter flush was performed for one out of one opportunity. During an interview on 11/4/22 at 4:04 P.M., the resident said staff does not provided catheter care or acetic acid flushes daily. He/she would like to get catheter care and flushes daily. 5. Review of Resident #29's face sheet, showed he/she was admitted to the facility on [DATE] with diagnoses of MS and neuromuscular dysfunction of the bladder. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively impaired; -Understood others and made his/her needs known; -Total dependence with assistance of one staff member for transfers, dressing, toileting, personal hygiene and bathing; -Had an indwelling catheter. Review of the resident's care plan, initiated 9/8/22, showed: -Focus: the resident had a indwelling catheter related to a neurogenic bladder; -Goal: the resident will be/remain free from catheter related trauma through next review; -Interventions: --The resident has (SPECIFY Size) (SPECIFY Type of Catheter); --Position catheter bag and tubing below the level of the bladder and away from entrance room door; --Change catheter per order; --Check tubing for kinks [# TIMES] each shift; --Monitor and document intake and output as per facility policy; --Monitor/record/report to the physician any signs or symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening in urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating pattern. Review of the resident's physician orders, showed: -Foley catheter care every day and night shift, start date 10/24/22; -Monitor urinary output every shift every day and night, document on l&O sheet, start date 10/24/22. Review of the resident's TAR, dated 10/1/22 to 10/30/22, showed: -Foley catheter care every day and night shift, start date 10/24/22. Three blanks were noted with no staff initials to document catheter care was performed for three out of 15 opportunities; -Monitor urinary output every shift every day and night, document on l&O sheet, start date 10/24/22. Five blanks were noted with no staff initials to document urinary output was performed for five out of 15 opportunities. Review of the resident's TAR, dated 11/1/22 to 11/4/22, showed: -Foley catheter care every day and night shift, start date 10/24/22. Two blanks were noted with no staff initials to document catheter care was performed for two out of six opportunities; -Monitor urinary output every shift every day and night, document on l&O sheet, start date 10/24/22. Two blanks were noted with no staff initials to document urinary output was performed for two out of six opportunities. 6. Review of Resident #8's face sheet, showed he/she was admitted to the facility on [DATE] with diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and neuromuscular dysfunction of the bladder. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Understood others and made his/her needs known; -Total dependence with assistance of one staff member for bed mobility, dressing, toileting, personal hygiene and bathing; -Total dependence with assistance of two staff member for transfers; -Required a wheelchair for mobility; -Had an indwelling catheter. Review of the resident's care plan, initiated 3/10/22, showed: -Focus: the resident had an indwelling catheter; -Goal: the resident will be/remain free from catheter related trauma through next review; -Interventions: --Indwelling catheter 16 fr with 10 cc balloon; --Change monthly per physician order and as necessary; --Monitor and document intake and output as per facility policy; --Monitor/document for pain/discomfort due to catheter; --Monitor/record/report to the physician any signs or symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening in urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating pattern. Review of the resident's physician orders showed: -Foley catheter care every day and night shift, start date 9/9/22; -Monitor urinary output every shift every day and night shift for output document on I&O sheet, start date 9/9/22; Review of the resident's TAR, dated 9/1/22 to 9/30/22, showed: -Foley catheter care every day and night shift, start date 9/9/22. Nine blanks were noted with no staff initials to document catheter care was performed for nine out of 26 opportunities; -Monitor urinary output every shift every day and night shift for output document on I&O sheet, start date 9/9/22. Eleven blanks were noted with no staff initials to document urinary output was performed for eleven out of 26 opportunities. Review of the resident's TAR, dated 10/1/22 to 10/30/22, showed: -Foley catheter care every day and night shift, start date 9/9/22. Seven blanks were noted with no staff initials to document catheter care was performed for seven out of 26 opportunities; -Monitor urinary output every shift every day and night shift for output document on I&O sheet, start date 9/9/22. Eight blanks were noted with no staff initials to document urinary output was performed for eight out of 26 opportunities. 7. Review of Resident #33's admission MDS, dated [DATE], showed: -Cognitively intact; -Indwelling catheter; -Diagnoses included neurogenic bladder and UTI. Review of the resident's physician's orders, showed an order, dated 10/12/22, for a suprapubic catheter care, every shift. Review of the resident's care plan, in use during the survey, showed: -Focus: The resident has a urinary tract infection; -Intervention: Give antibiotic therapy as ordered. Monitor/document for side effects. Monitor/document/report to physicians signs/symptoms of UTI: Frequency, urgency, malaise, foul smelling urine, dysuria (painful urination), fever, nausea and vomiting, flank pain, suprapubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes; -Focus: The resident has a suprapubic catheter due to neurogenic bladder; -Intervention: Catheter: Change of on the 15th of each month. Check tubing for kinks each shift. Monitor and document intake and output as per facility policy. Review of the resident's TAR, showed: -Suprapubic catheter care, every shift, day and night shift; -Not initialed as completed/blank, day shift, on 10/13, 10/14, 10/15, 10/20, 10/23, 10/25, 10/28 and 10/30/22; -Not initialed as completed/blank, night shift, on 10/18, 10/24, 10/26 and 10/29/22. During an interview on 11/14/22 at 3:42 P.M., the resident said staff are supposed to wash his/her catheter, but they have not been washing it. 8. During an interview on 11/2/22 at 3:28 P.M., Certified Nurse Aide (CNA) B said: -Catheter care should be performed each shift and as needed; -Catheters should be emptied each shift and as needed; -He/she performs catheter care on his/her residents each shift; -He/she had received education on catheter care. During an interview on 11/7/22 at 8:52 A.M., Nurse A said: -He/she expected CNAs to provide catheter care each shift and as needed with all peri care; -He/she expected CNAs to empty catheter bags every shift and as needed; -Acetic acid flushes should be performed per order; -If there is a blank in the TAR, it means it was not done; -He/she had received education on catheters. During an interview on 11/15/22 at 3:16 P.M., the Director of Nursing (DON) said: -He/she had been the DON for three days prior to the investigation; -He/she expected staff to follow all physician orders; -A blank space on the TAR means staff charted nothing was done. MO00207613 MO00208736

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided complete privacy for residents by failing to close the room door and pull a privacy curtain for one resident exposed during a skin assessment (Resident #45), and by failing to provide a privacy curtain for another resident a semi-private room (Resident# 224). The census was 75. 1. Review of Resident #45's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/12/21, showed: -admission date of 6/28/04; -Adequate hearing/vision; -Clear speech - distinct intelligible words; -Ability to express ideas and wants: Sometimes understood; -Ability to understand others: Sometimes understands; -Brief Interview for Mental Status (BIMS) score of 03 out of a possible 15 (a score of 0-07 indicates severe cognitive impairment); -Total dependence of two (+) persons required for transfers; -Total dependence of one person required for bed mobility, locomotion on/off the unit, dressing, eating, toilet use, personal hygiene and bathing; -Diagnoses of osteoporosis (weak bones), stroke, hemiplegia (paralysis of one side of the body) or hemiparesis (weakness of one side of the body) and multiple sclerosis (a chronic disease affecting the central nervous system (the brain and spinal cord)). Observation on 5/6/21 at 5:18 A.M., showed the resident lay in bed beneath covers, wearing a hospital gown and incontinence briefs. The resident's room was a semi-private room and his/her bed was closest to the door. Certified Nursing Assistant (CNA) R assisted with the resident's skin assessment. The CNA entered the resident's room. Without shutting the room door or pulling the privacy curtain around the resident's bed, the CNA pulled the resident's gown up, exposing the resident's chest, and removed the resident's incontinence brief, exposing the resident's genitalia and buttocks, as the resident was being positioned during the skin assessment. The resident was exposed to the hall during the assessment while other staff walked up and down the hallway in view of the room. 2. Review of Resident #224's medical record, showed: -admitted [DATE]; -Diagnoses included depression; -A BIMS evaluation, dated 4/9/21, showed the resident with moderate cognitive impairment. Observations on 5/3/21 at 8:42 A.M., 9:09 A.M., 10:47 A.M., 11:45 A.M., 12:27 P.M. and 1:06 P.M., showed the resident lay in bed, dressed in a hospital gown. The resident's room was shared with a roommate, and his/her bed was closest to the door. A catheter bag hung on the resident's right side of the bed with pink-tinged urine and thick strings of mucus in the catheter tubing, visible from the doorway to the room. No privacy curtain hung by the resident's bed. At 2:38 P.M. the Assistant Director of Nurses (ADON) and wound nurse entered the resident's room and shut the door. At 3:12 P.M., the wound nurse exited the resident's room. As the resident's door was open, the resident lay on his/her right side in bed with the hospital gown pulled up, leaving his/her stomach and upper pubic area exposed, fully visible from the hallway. Observations on 5/4/21 at 7:02 A.M., 7:48 A.M., 9:11 A.M., 10:10 A.M. and 1:02 P.M., showed the resident lay on his/her back in bed, dressed in a hospital gown. A catheter bag hung on the resident's right side of the bed with pink-tinged urine and thick strings of mucus in the catheter tubing, visible from the doorway to the room. No privacy curtain hung by the resident's bed. Observations on 5/5/21 at 7:35 A.M., 9:47 A.M., 11:27 A.M. and 1:01 P.M., showed the resident lay in bed, dressed in a hospital gown. A catheter bag hung on the resident's right side of the bed with pink-tinged urine and thick strings of mucus in the catheter tubing, visible from the doorway to the room. No privacy curtain hung by the resident's bed. 3. During an interview on 5/14/21 at 12:01 P.M., the Director of Nurses (DON) and administrator said when a resident is receiving care or is going to be exposed, staff should pull the privacy curtain around the resident's bed and close the door to their room. All residents should have their own privacy curtain to maintain the resident's privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints and when restraints were indicated, to document ongoing re-evaluation of the need for restraints for one resident (Resident #59). The sample was 18. The census was 75. Review of the facility's Restraint Alternatives policy, revised 6/3/19, showed: -Protocol: The purpose of the Restraint Alternatives Protocol is to implement individualized interventions for any resident/patient being assessed for or using a physical restraint. The goals of the Restraint Alternatives Protocol are to utilize restraint alternatives instead of or in conjunction with a restraint reduction plan, and optimize dignity and independence; -Procedure: -Review interdisciplinary assessments and documentation; -Include resident/patient/family and/or responsible party in the development of the interdisciplinary plan of care (IPOC); -Identify and implement immediate restraint alternatives. Alternatives include implementing seat belts for residents that are capable of taking or unbuckling; -Communicate interventions to staff on [NAME], individual resident care plan, and in clinical operations morning meeting; -Evaluate effectiveness of restraint alternatives such as each IPOC meeting and as needed (PRN); -Review and revise IPOC to reflect restraint alternative interventions; -Educate resident/patient/family and/or responsible party on restraint alternatives; -Restraint - Least Restrictive: -Protocol: The facility recognizes that a physical restraint may be required when resident/patient's medical symptoms lead to behaviors that threaten their safety or the safety of others, restraint alternatives are determined to be ineffective, or resident has medical conditions that may benefit from short-term use of physical restraints. Restraints include lap cushions, tap trays, or safety belts the resident/patient cannot remove; -Procedure: -Review and update all interdisciplinary documentation; -Reevaluate and verify documentation on restraint alternative interventions used to treat the underlying causes of the medical sign/symptoms; -Complete and review the Assessment Tool; -Obtain physician's order for restraint, including medical symptoms requiring restraint use, type of restraint, length of time restraint is to be used, and plan for resident reduction/elimination; -Do accept orders for as needed (PRN) restraint use; -Provide the Physical Restraint Information sheet to the resident/patient or responsible party. If the resident/patient/family or responsible party refuses to the use of a restraint, document refusal in the medical record; -Check and release resident/patient at least every two hours and according to the IPOC; -Reassess resident/patient status at the IPOC meeting at least monthly and/or with any change in medical symptoms to evaluate effectiveness of restraint or enabler to treat identified medical symptoms, evaluate results of restraint reduction plan, and evaluate effectiveness of interventions to minimize or eliminate the medical symptoms being treated by the restraint. Review of Resident #59's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/21, showed the following: -Diagnosis of multiple sclerosis (MS); -No short/long term memory loss; -Required total staff assistance for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing; -No trunk restraint used. Review of the resident's care plan, updated 4/8/21, showed the following: -Focus: Resident has an ADL self care performance deficit related to (r/t) MS. Requires total care from staff. Uses an electric wheelchair to navigate throughout the facility; -Interventions: Resident requires Hoyer Lift (machine used to transfer dependent residents) with two staff assistance for transfers; -No documentation regarding the use of a seat belt or trunk restraint. Observations and interviews, showed the following: -5/03/21 at 12:26 P.M.: Resident up in electric wheelchair with belt on. He/She couldn't remove it when asked by this surveyor; -5/04/21 at 10:49 A.M.: Resident in his/her electric wheelchair. The resident stated he/she had a fall from the his/her electric wheelchair a while ago. That is when staff put the seat belt on; -5/05/21 at 11:05 A.M.: Resident outside in his/her electric wheelchair with the seatbelt attached, visiting with family; -5/12/21 at 12:30 P.M.: Resident in his/her electric wheelchair with his/her seat belt attached. Certified Medication Technician (CMT) AC in resident's room. This surveyor asked resident to remove his/her seat belt. He/She was unable to do so. During an interview on 5/14/21 at 7:35 A.M., the MDS coordinator said she was unaware the resident wore a seat belt. If she had known he/she was wearing a seat belt, she would have care planned it. Therapy assesses residents for seat belts and once assessed, they give their recommendations to the MDS Coordinator and he/she adds it to the resident's care plan. The MDS Coordinator is responsible for updating care plans. During an interview on 5/14/21 at 11:47 A.M., the Director of Nursing (DON) said residents should be assessed to determine if they can remove seat belts without assistance. If the resident is unable to remove it, it should be care planned as a restraint. The resident's seat belt was not assessed or care planned. It should have been. During interviews on 5/14/21 at 1:06 P.M. and 1:41 P.M., the DON said lap belts/seat belts should be assessed for use and the purpose of use should be documented in the resident's record. Once a resident is determined to need a lap belt, they should be reassessed for use of the device on an ongoing basis. The Therapy Screen Forms completed by the OT therapist, should include a detailed assessment for the use of a seat belt. Staff should also be checking lap belts routinely for safety.

Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) no later than two hours after an allegation was made by one resident's (Resident #15) family member to facility management, on two separate occasions. The census was 75. Review of the facility's abuse prevention policy dated 2/19, showed: -Prevention and reporting: The administrator has primary responsibility in the facility for implementation of the abuse/neglect program; -The facility will follow all state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse, sexual abuse or involuntary seclusion; -The facility encourages and supports all residents, staff and families in feeling free to report any suspected acts of abuse, neglect, misappropriation or injury of unknown origin. The facility takes all measures possible to ensure that residents, staff and families are free from fear of retribution if reports or incidents are filed with the facility; -Reports of abuse will be promptly reported and thoroughly investigated. Additionally the facility should immediately report all such allegations to administrator/designee and to the Department of Health and Senior Services. In cases where a crime is suspected staff should also report the same to local law enforcement; -The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc.; -The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property; -The facility has implemented the following processes in an effort to provide residents/patients and staff a safe and comfortable environment; -The shift supervisor (charge nurse, nurse manager or administrator) is identified as responsible for immediate initiation of the reporting process; -The administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect and/or misappropriation of property standards and procedures: *Implementation; *Ongoing monitoring; *Reporting; *Investigation; *Tracking and trending; -Implementation and ongoing monitoring consist of the following: *Screening; *Training; *Prevention; *Identification; *Protection; *Investigation; *Reporting; -Investigation: When an incident or suspected incident of abuse or neglect is reported, the administrator or designee investigates the incident with the assistance of appropriate personnel; -Initiate the investigation, the investigation should be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation; -The investigation may consist of an interview with the person reporting the incident and witnesses, and interview with the resident if possible, a review of the residents medical record, an interview with staff members having contact with the resident during the period of the alleged event, interviews with resident's roommate, family members and visitors, a review of all circumstances surrounding the incident; -Conclusion must include whether the allegation was substantiated or not and what information supported the decision. The conclusion/summary must take into account an objective overview of the facts and a reason or basis for the decision to substantiate or not substantiate the allegation; -Reporting: Any person witnessing or having knowledge of alleged violation of involving abuse, neglect, misappropriation or injury of unknown origin are to notify the administrator or Director of Nursing immediately; -The administrator or Director of Nursing or designee to report to the regional clinical manager; -Notify the appropriate state agency(s) immediately of allegations or suspicious of abuse, neglect or injury of unknown injury by fax or telephone after identification of alleged/suspected incident. Allegations or suspicion of mistreatment of resident property or exploitation are to be reported to the state agency immediately and no later than 24 hours upon discovery; -Reports of abuse, neglect and injury of unknown origin are to be made to the state agency immediately, but no later than two hours from the allegation being made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hour if the event that cause the allegation do not involve abuse or result in bodily injury; -Follow reporting requirements as outlined by the state agency. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/18/21, showed: -admission date of 10/14/20; -Adequate hearing/vision; -Clear speech - distinct intelligible words; -Ability to express ideas and wants: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to understand others: Usually understands - misses some part/intent of message but comprehends most conversation; -Brief interview for Mental Status (an assessment used to determine cognitive status) score of 7 (a score of 0-7 indicates severely impaired cognition); -No hallucinations or delusions; -No physical, verbal or other behaviors noted; -Wandering: Behavior not exhibited; -Rejection of care: Behavior not exhibited; -Wandering: Behavior not exhibited; -Limited assistance of one person required for bed mobility; -Extensive assistance on one person required for transfers, dressing, toilet use, personal hygiene and bathing; -Supervision - oversight, encouragement or cueing required for eating; -Independent for locomotion on/off the unit; -Functional limitation of both lower extremities; -Mobility device: Wheelchair; -Diagnoses of renal (kidney) insufficiency, diabetes mellitus, stroke, hemiplegia (the complete loss or paralysis on one half of the body) or hemiparesis (minor to severe weakness of one half of the body) and manic depression (alternating moods of abnormal highs (mania) and lows (depression)). Review of a facility self-report to the DHSS, dated 5/12/21 at 10:22 P.M., showed: -Resident's family contacted the admission Coordinator (AC) on 5/12/21 and stated the night shift staff (Night shift hours for Certified Nursing Assistants (CNAs) is 6:00 P.M. until 6:00 A.M.) had been rude to the resident. Administrator arrived on the night shift on 5/12/21 at approximately 7:30 P.M. and interviewed resident. Resident claimed that a staff member had been verbally rude, insulting him/her and had been physical with him/her. He/She claimed a Certified Nursing Assistant had pushed him/her on the night shift of 5/7/21. During an interview on 5/13/21 at 8:45 A.M., the AC said yesterday, 5/12/21 around 3:00 P.M., the resident's family contacted her by phone about sending the resident to another facility. During the conversation, the family member told her the resident stated two CNAs on the night shift threatened to throw the resident out of his/her wheelchair. The resident had fallen once and those same CNAs left him/her on the floor longer than he/she should have been. The AC said she was surprised as she speaks to the resident most every day and he/she had not mentioned that to her. She did not go and speak to the resident after the phone conversation because she went to the daily management meeting and told the Administrator what the family had said. During an interview on 5/13/21 at 9:13 A.M., the resident said an agency staff member, he/she was not sure if they were a CNA or a nurse, but on the night shift was mean to him/her. The staff member hit him/her on his/her head around the mouth. This happened last Friday when he/she wanted to go into Resident #12's room to speak to him/her. Resident #12 was asleep in his/her recliner. The staff member came down the hall and would not allow him/her to go into the room, The staff member called him/her an ignorant bastard. The staff member hit him/her with his/her fist, then pulled Resident #12's door shut. Both he/she and the staff member left Resident #12's room at that time. The resident had no facial bruising noted during the interview. During an interview on 5/13/21 at 10:10 A.M., the Administrator said the AC told him yesterday in their meeting around 3 o'clock. All he heard the AC say was Resident #15 said someone had been rude to him/her so he did not think it had anything to do with abuse at that time. He ended up leaving the facility and going home before returning between 6:00 P.M. and 6:30 P.M. to speak to the resident. He did not designate anyone to speak to the resident before he left to go home. It was not until he returned and spoke to the resident that he learned the resident claimed staff had verbally abused him/her. The resident did not tell him he/she had been struck by staff. He did not know what the facility policy showed in regards to initiating an abuse/neglect investigation, although he did help write the policy. He was aware of the two hour window to report an allegation of abuse to DHSS and acknowledged he failed to initiate an investigation immediately after the AC mentioned a problem in the management meeting and failed to report the resident's allegation of verbal abuse within the required two hour time frame. During a telephone interview on 5/13/21 at 10:48 A.M., the resident's family member confirmed what he/she had told the AC on 5/12/21. He/She added it was not the first time he/she had reported the resident had problems with two night shift staff. Approximately six months ago, he/she spoke to someone at the facility, but was not sure if it was the AC or the Social Service Director regarding the resident alleging two staff members threatened to throw him/her out of his/her bed or wheelchair. The family member said he/she never heard back from the facility after alerting them to his/her concerns. Review of the resident's progress notes, including social service notes on 5/13/21, showed no documentation regarding a family member complaining about the resident's treatment by staff. During an interview on 5/13/21 at 1:49 P.M., the Social Service Director said she did not recall having any previous conversations with that family member, but did recall another family member telling her the resident was having trouble with the night shift staff. It was how they were approaching him/her. The way they were speaking to him/her. The family member did not know the names or titles of the staff. She could not recall how long ago that conversation took place and she did not document it. She did tell the Administrator and Director of Nurses (DON). She did not know if anyone followed up or not. Review of DHSS complaints, showed no other complaint listed for Resident #15. During an interview on 5/14/21 at 10:30 A.M., the Administrator denied being told by the SSD the resident had problems a few months ago with two night shift staff threatening to throw the resident out of his/her wheelchair. He was only aware of the problem the resident told him about on 5/12/21. MO00185248

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident's (Resident #59) bilevel positive airway pressure machine (BiPap, a machine worn during sleep to maintain consistent breathing) was in working order for use during sleep. In addition, the facility failed to ensure staff documented they notified one resident's (Resident #51) physician for an order to remove the resident's indwelling urinary catheter or why it was necessary to remove the indwelling urinary catheter. The census was 75. 1. Review of Resident #59's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/30/21, showed: -Diagnosis of multiple sclerosis (disease in which the immune system destroys the protective covering of nerves interrupting the nerve signals from the body to the spinal cord/brain); -No short/long term memory loss; -Required total staff assistance for bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing; -BiPap not noted. Review of the resident's care plan, updated 4/8/21, showed: -Focus: Resident has altered respiratory status/difficulty breathing related to (r/t) sleep apnea (a potentially serious disorder in which breathing repeatedly stops and starts); -Intervention: BiPap Settings: 6-18 via mask, on at bedtime, off in morning. Elevate head of bed 30 degrees. Monitor for signs and symptoms of respiratory distress. Monitor/document/report abnormal breathing patterns to the physician. Review of the resident's physician's order sheet (POS), dated 5/21, showed an order dated 4/20/21, for an Auto BiPap machine (a device used for sleep apnea that uses two separate pressure settings for inhale and exhale), apply at bedtime and remove in the morning. During on observation and interview on 5/4/21 at 7:02 A.M., the resident said he/she did not sleep all night. There was no BiPap machine in the room. During an interview on 5/12/21 at 8:09 A.M., the resident said he/she has not worn the BiPap in approximately seven months. He/She said it needs to be serviced. Also, agency staff do not know how to put it on at night. It was frustrating, so he/she stopped asking the staff to put it on. During an interview on 5/13/21 at 1:29 P.M., the resident said he/she does not feel different since not wearing the BiPap. He/She asked Certified Nurse Aide W to tell Central Supply staff his/her Bi-pap needed servicing. He/she does not know where the BiPap machine is because he/she has not seen it for several months. During an interview on 5/13/21 at 1:36 P.M., Central Supply staff said the resident's BiPap machine was not in his/her room. His/Her job is to make sure the resident has one and that it is working properly. The resident has not spoken to him/her about the BiPap machine for about seven months. He/She will notify the Assistant Director of Nurses (ADON). During an interview on 5/13/21 at 1:42 P.M., the ADON said Central Supply staff reported the resident does not have his/her BiPap machine. He will have Central Supply order a new BiPap machine. He does not know what happened to it. The resident has an order to wear it at night. The nurse should apply the BiPap machine. He was unaware the resident was not wearing the BiPap machine. During an interview on 5/13/21 at 2:13 P.M., the Director of Nursing (DON), said she did not know the resident was not wearing his/her BiPap machine. She will contact the physician for an evaluation. 2. Review of Resident #51's admission MDS, dated [DATE], showed: -admission date of 3/1/21; -Adequate hearing/vision; -Clear speech - distinct intelligible words; -Ability to express ideas and wants: Understood; -Ability to understand others: Understands; -Brief Interview for Mental Status score of 15 out of a possible 15 (a score of 13-15 indicates cognitively intact); -Rejection of care: Behavior not exhibited; -Total dependence of one person required for bed mobility, toilet use and bathing; -Total dependence of two (+) persons required for transfers; -Extensive assistance of one person required for dressing and personal hygiene; -Functional limitation of both lower extremities (hip, knee, ankle, foot); -Indwelling urinary catheter (thin tube inserted through the urethra into the bladder to drain the bladder of urine); -Diagnoses of anemia (low number of red blood cells), septicemia (Systemic (bodywide) illness with toxicity due to invasion of the bloodstream by virulent bacteria coming from a local site of infection), urinary tract infection (last 30 days), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), anxiety and depression. Review of the resident's care plan, undated, showed: -admitted with indwelling catheter; -Resident will show no signs and symptoms of urinary infection through next review; -Position catheter bag and tubing below the level of the bladder and away from entrance room door; -4/17/21: readmitted with UTI and sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues); -4/17/21: Continue to administer antibiotic therapy as ordered. Review of the resident's current POS, showed an order for the resident to have an indwelling urinary catheter. Observation on the following dates and times, showed: -5/4/21 at 6:50 A.M., 9:30 A.M., and 11:46 A.M., the resident had an indwelling urinary catheter; -5/5/21 at 7:25 A.M., 11:03 A.M. and 12:44 P.M., the resident had an indwelling urinary catheter; -5/6/21 at 7:59 A.M., the resident lay in bed sleeping. His/her indwelling urinary catheter had been removed; During an interview on 5/6/21 at 9:09 A.M., the resident said he/she asked Nurse H to remove his/her indwelling urinary catheter a couple of hours ago because he/she felt he/she had a urinary tract infection and he/she was becoming septic. During an interview on 5/6/21 at 11:40 A.M., Nurse H said earlier this morning, the resident asked him/her to remove the indwelling urinary catheter because he/she felt he/she was getting an infection. The nurse said he/she called the physician around 9:30 A.M. and received an order to remove the indwelling urinary catheter and begin oral antibiotics. Review of the resident's progress notes on 5/6/21 at 1230 P.M., and 5/10/21 at 7:30 A.M., showed no documentation regarding Nurse H contacting the resident's physician, removing the resident's indwelling urinary catheter, or why he/she removed the indwelling catheter. Observation on 5/10/21 at 7:00 A.M., showed the resident lay in bed without an indwelling urinary catheter. During an interview on 5/10/21 7:10 A.M., Nurse I said the resident had a 101.7 (normal 97.6 - 99.6) temperature and the physician ordered the resident to be evaluated at the hospital. During an interview on 5/11/21 at 9:46 A.M., the DON said the resident was admitted to the hospital on [DATE] with a diagnoses of sepsis and septic shock. Review of the resident's progress notes on 5/13/21 at 7:45 A.M., showed no documentation regarding Nurse H contacting the resident's physician, removing the resident's indwelling urinary catheter, or why he/she removed the indwelling catheter. During an interview at that time, Nurse H said 5/6/21 was a hectic day, and he/she failed to document notifying the physician and removing the indwelling urinary catheter. Ideally, he/she should have documented that information in the resident's progress notes on 5/6/21 before leaving for the day. Review of the resident's progress notes on 5/14/21 at 12:00 P.M. showed no documentation regarding Nurse H contacting the resident's physician, removing the resident's indwelling urinary catheter, or why he/she removed the indwelling catheter. During an interview at that time, the DON said she would have expected Nurse H to have documented why the resident's indwelling urinary catheter was removed and contacting the resident's physician in the resident's progress notes. The resident was readmitted yesterday with a new indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and implement resident-specific interventions, including the provision of nutritional supplements, to maintain acceptable parameters of nutritional status for two residents identified with recent weight loss (Residents #69 and #20.). The sample was 18. The census was 75. 1. Review of Resident #69's medical record, showed -admitted [DATE]; -Diagnoses included heart failure, diabetes with diabetic chronic kidney disease, stroke, attention and concentration deficit following stroke, dysphagia (swallowing disorder) following stroke, vitamin B deficiency, vitamin D deficiency, and depression. Review of the resident's active physician order sheet (POS), showed: -An order, dated 6/4/20, to add ice cream daily at lunch; -An order, dated 6/22/20, for med pass (fortified nutritional shake), 120 milliliters (mL) three times a day, four times a day for supplement; -An order, dated 8/4/20, for no added salt (NAS), regular texture diet; -No orders for a nutritional health shake. Review of the resident's weights, showed: -On 12/8/20, weighed 139.2 pounds (lbs); -On 1/13/21, weighed 120.8 lbs; -On 2/11/21, weighed 123.4 lbs; -On 3/5/21, weighed 111 lbs. Review of the resident's nutrition/dietary note, dated 3/16/21, showed staff documented the resident's current weight as 111 lbs. Significant weight loss over 1-6 months. Diet orders: regular NAS, ice cream daily, 120 mL med pass three times daily. No orders for Ensure nutritional health shake. Review of the resident's medication administration record (MAR) for April 2021, showed staff documented administration of 120 mL med pass four times daily. Review of the resident's meal consumption log for April 2021, showed: -Task for staff to document the resident's percentage of meal eaten in morning, afternoon, and evening, for a total of 90 meals in the month; -Staff documented the resident consumed 0-25% of 10 meals; -Staff documented the resident consumed 26-50% of 3 meals; -Staff documented the resident consumed 51-75% of 8 meals; -Staff documented the resident consumed 76-100% of 23 meals; -Staff failed to document the amount of food eaten for 46 meals. Review of the resident's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/21/21, showed: -Severe cognitive impairment; -Rejection of care not exhibited; -Supervision with one person physical assist required for eating; -Upper extremity impaired on one side; -Weight loss of 5% or more in the last month, or 10% or more in the last 6 months. Not on a physician prescribed weight loss regimen; -Weight: 116 lbs. Review of the resident's nutrition/dietary note, dated 4/22/21, showed staff documented the resident with significant weight gain over 1 month after undesired weight loss. Weight stability is desired at this time. Diet orders included: Regular NAS, ice cream daily at lunch. No recommendation for nutritional health shake. Review of the resident's care plan, undated and in use at the time of survey, showed: -Focus: The resident has a mood problem related to stroke with hemiplegia (paralysis to one side of the body). 4/28/21 Resident remains with weight loss over quarter; -Interventions included: ice cream at lunch and dinner each meal; -Focus: The resident has a swallowing problem related to dysphagia. Note: Spitting out food and only drinking. Resident with weight loss. 4/28/21 weight loss over quarter; -Interventions included: add ice cream daily at lunch. Add nutritional shakes with each meal. Resident will be assisted with eating at each meal. Resident needs to be up in chair at mealtime. Document consumption after each meal. Review of the resident's breakfast diet card, undated, showed Ensure supplement listed under Physician Order. Observation on 5/6/21 at 7:53 A.M., showed the resident sat in bed, feeding him/herself breakfast from a divided plate. A container of Ensure and several beverages sat on the resident's over-the-bed table. Review of the resident's lunch diet card, undated, showed no documentation regarding ice cream. Ensure listed under Likes. Observations of the resident during lunch, showed: -On 5/3/21 at 12:38 P.M., the resident sat in bed, with certified nurse aide (CNA) N seated in a chair to the resident's right side. He/she was served chicken, potato salad, and watermelon, and fed him/herself. No ice cream or Ensure was served during the meal; -On 5/4/21 at 1:02 P.M., the resident sat in bed, with staff seated in a chair to the resident's right side. The resident fed him/herself. A carton of whole milk and a container of Ensure sat on the resident's over-the-bed table. No ice cream served during the meal; -On 5/10/21 at 12:25 P.M., the resident sat in bed. He/she was served pork, corn, potato salad, and strawberry shortcake. The resident fed him/herself without staff in the room to assist. No ice cream or Ensure served during the meal; -On 5/12/21 at 12:35 P.M., the resident sat in bed. Staff served served chicken wings, creamed spinach, stuffing, and cake. No ice cream or Ensure served during meal. 2. Review of Resident #20's medical record, showed -admitted [DATE]; -Diagnoses included heart disease, dementia without behavioral disturbance, vitamin deficiency, vitamin B12 deficiency, vitamin D deficiency anemia, folate deficiency anemia, anemia, and depression. Review of the resident's active POS, showed: -An order, revised 4/10/20, for regular diet, mechanical soft texture; -An order, dated 10/21/20, for ice cream at lunch; -An order, dated 3/31/21, for med pass 120 mL, four times a day for weight management; -No orders for an additional nutritional health shake. Review of the resident's weights, showed: -On 12/8/20, weighed 135.8 lbs; -On 1/13/21, weighed 124.6 lbs. Review of the resident's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care exhibited 1-3 days; -Supervision with one person physical assist required for eating; -Weight loss of 5% or more in the last month, or 10% or more in the last 6 months. Not on a physician prescribed weight loss regimen; -Weight: 117 lbs. Review of the resident's nutrition/dietary note, dated 4/22/21, showed the resident's current weight as 113 lbs. Underweight and stable over one month after significant weight loss. Weight stability or health, gradual weight gain is desired at this time related to underweight status. Diet orders included: mechanical soft, 120 mL med pass four times daily, and ice cream at lunch. Review of the resident's meal consumption log for April 2021, showed: -Task for staff to document the resident's percentage of meal eaten in morning, afternoon, and evening, for a total of 90 meals in the month; -Staff documented the resident refused 2 meals; -Staff documented the resident consumed 0-25% of 8 meals; -Staff documented the resident consumed 26-50% of 5 meals; -Staff documented the resident consumed 51-75% of 8 meals; -Staff documented the resident consumed 76-100% of 26 meals; -Staff failed to document the amount of food eaten for 41 meals. Review of the resident's care plan, undated and in use at the time of survey, showed: -Focus: The resident has an ADL self-care performance deficit related to dementia; -Interventions included resident will refuse to get out of bed, resident hard of hearing and needs a positive approach, approach calmly and speak face to face; -Focus: The resident may be at risk for weight loss related to dementia. 2/12/21 resident remains with weight loss; -Interventions included: add health shake, fortified nutritional shake as ordered. Ice cream at lunch. Mechanical diet. Monitor at mealtime in dining room. Document consumption after each meal-report meal refusal. Must get out of bed and go to dining room for breakfast. 8/24/20 resident must go to the dining room in his/her wheelchair for every meal. Review of the resident's breakfast diet card, undated, showed Ensure supplement listed under Physician's Order. Review of the resident's lunch diet card, undated, showed no documentation regarding ice cream per physician order and no documentation to provide Ensure supplement. Observations on 5/3/21, showed: -At 12:19 P.M., the resident lay in bed on his/her right side, with a blanket over his/her head; -At 12:28 P.M., CNA N delivered a lunch tray to the resident's room, called the resident's name several times, and said he/she would be back to check on him/her later; -At 12:42 P.M., the resident remained in bed on his/her right side with the blanket no longer covering his/her head. A plate of uncovered mechanical soft food, sat on the resident's bedside table. Staff did not serve ice cream or Ensure with the resident's meal. CNA N reentered the resident's room and attempted to wake the resident, who did not verbally respond. The CNA exited the room and told the nurse the resident was not eating; -At 1:12 P.M., the resident remained in bed on his/her right side with food on bedside table, untouched. Observation on 5/5/21 at 7:35 A.M., showed the resident sat in his/her wheelchair in the dining room, feeding him/herself without staff assistance. Staff did not provide Ensure. Ten minutes later, the resident had consumed all of his/her breakfast. Observation on 5/12/21 at 12:40 P.M., showed the resident sat in his/her wheelchair in the dining room, staff served a mechanical diet of soft meat, mashed potatoes, creamed spinach, cake, and Ensure supplement. No ice cream was provided. Observation on 5/13/21 at 8:34 A.M., showed the resident lay in bed with a blanket over his/her head. No food on his/her bedside table. During an interview, the CNA II said the resident did not eat breakfast that morning, but did drink half an Ensure. He/she is not a morning person and does not like to get up to eat breakfast. 3. During an interview on 5/13/21 at approximately 7:19 A.M., cook QQ and dietary aide (DA) RR said the Dietary Director (DD) types up the diet cards for all residents, for each meal. She gets her orders from nursing and adds them to the diet cards. Supplemental items, such as ice cream, are ordered for residents who need to gain weight or do not eat as much as they should for whatever reason. Supplemental items, including Ensure, are added to resident meal trays by dietary staff. If a resident is supposed to get these items or other supplements, it should be on their diet card. If an item is not listed on the diet card, dietary staff do not put it on the meal tray. During an interview on 5/13/21 at 2:27 P.M., the Registered Dietician (RD) said nutritional assessments are completed by the dietician upon a resident's admission, readmission, and on a quarterly basis. Some residents are assessed more frequently based on their condition, such as having weight variances. Upon assessment, the dietician might make recommendations for supplemental items, such as ice cream with meals, med pass, or Ensure. She submits her recommendations to the facility's administrator, Director of Nurses (DON), and DD. Recommended supplements should be implemented by the facility. Health shakes like Ensure require an order. Residents #69 and #20 should be getting med pass, as well as ice cream with lunch. She reviewed the physician orders for both residents and observed the recommendation for ice cream under other, instead of dietary, which is probably why the DD did not pull the recommendations over to the resident's diet cards. During an interview on 5/14/21 at 9:51 A.M., the RD and DD said diet cards are generated by information from a program in the electronic medical record, and from diet communication sheets obtained from nursing staff. If a resident requests an item that is not on their diet card, it is acceptable to give them the item unless it is a change in consistency from what they should receive, or Ensure. Ensure must have physician orders. Until today, Ensure was on the resident's diet cards and dietary staff was responsible for putting the Ensure on the resident's meal tray. Now Ensure has been removed from the diet cards and nursing staff will be responsible for providing it to residents. The DD was not aware residents had not been provided with supplemental items as ordered, or that they had been getting Ensure when not ordered. If an item is not on a resident's diet card, dietary staff won't know to put it on the resident's meal tray. During an interview on 5/14/21 at 6:40 A.M., the DON said staff should monitor resident's meal consumption and document their intake in the resident's medical record. She expects staff to notify her if a resident is not eating. All residents should receive the correct meals as ordered by the physician and dietician, and she expects residents to be served supplements as ordered by physician and dietician. During an interview on 5/14/21 at 12:01 P.M., the administrator said residents should be receiving diets in accordance with their physician orders. All staff should reference a resident's diet card during meal service to ensure residents get what they are supposed to. Staff should not pass out other items that are not on the resident's diet card.

Based on observation, interview and record review, the facility failed to ensure one resident received tube feeding (a tube inserted through the abdomen into the stomach to provide medication, nutrition and hydration) as ordered on a consistent basis. The facility identified two residents with tube feeding, one was sampled and problems were identified (Resident #27). The sample was 18. The census was 75. Review of Resident #27's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 2/15/21, showed: -admission date of 7/7/17; -Makes Self Understood: Sometimes understood - responds adequately to simple, direct communication only; -Ability to understand others: Sometimes understands - responds adequately to simple, direct communication only; -Brief Interview for Mental Status score of 00 out of a possible 15 (a score of 00 - 07 indicates severe cognitive impairment); -Total dependence of two (+) persons required for transfers; -Total dependence of one person required for bed mobility, locomotion on/off the unit, dressing, eating, toilet use, personal hygiene and bathing; -Diagnoses of renal (kidney) insufficiency and stroke; -Weight of 141 pounds; -Weight loss: No; -Weight gain: No; -Feeding tube; -Proportion of total calories the resident received through tube feeding: 51% or more. Review of the resident's physician's order sheet, showed: -12/7/19: Jevity 1.5 (liquid nutritional supplement) 50 milliliters (ml) an hour for 21 hours a day; -Tube feeding off from 12:00 A.M. until 3:00 A.M. Review of the resident's care plan, showed: Activity of daily living deficit due to diagnoses of stroke and dementia. Resident has overall decline in functioning ability and is totally dependent on staff; Requires continuous tube feeding related to dysphagia (difficulty swallowing) and history of malnutrition: -Registered Dietician (RD) to evaluate quarterly and as necessary. Monitor caloric intake, estimate needs. Make recommendations for tube feeding as necessary; -Jevity 1.5 at 50 ml and hour for 21 hours a day. Tube feeding off from 12:00 A.M. until 3:00 A.M. Observation on 5/3/21 at 9:25 A.M., showed the resident lay in bed. The tube feeding pump was on and showing Feed Error, but was not audibly alarming. The date a staff member hung the now empty bottle of Jevity (not Jevity 1.5) was dated 5/2/21 at 3:00 A.M. At 10:03 A.M. the tube feeding bottle remained empty and the tube feeding pump had an auditory alarm sounding. At 10:55 A.M. the tube feeding bottle was still empty. At 12:08 P.M., a new bottle of Jevity 1.5 was infusing at 50 ml and hour. Observation on 5/6/21 at 5:15 A.M., showed the resident lay in bed. A 1000 ml bottle of Jevity (not Jevity 1.5) with 950 ml remaining in the bottle was hanging, but the tube feeding pump had been turned off. At 5:26 A.M. during a skin assessment of the resident, the tube feeding pump remained turned off with 950 ml remaining in the bottle. At 9:48 A.M., the tube feeding pump remained turned off with 950 ml remaining in the bottle. Review of the resident's progress notes at that time, show no documentation as to why the tube feeding pump was off. At 11:14 A.M., the tube feeding pump remained turned off with 950 ml remaining in the bottle. During an interview at 11:18 A.M., Certified Nursing Assistant X said he/she helped give the resident a bed bath around 9:00 A.M. that morning and the tube feeding was off. He/she did not know why the tube feeding was off. Nurse PP, said no one had told him/her the resident's tube feeding had been off all morning. There was no reason that he/she knew of for it to be turned off. Nurse PP turned the resident's tube feeding of Jevity back on at that time. During an interview on 5/14/212 at 10:13 A.M., the Director of Nurses said she expects staff to follow the physician's order by providing the resident with Jevity 1.5, not Jevity and to ensure the tube feeding is infusing unless there is a reason which should be documented in the progress notes. The RD, present during the interview stated the difference between Jevity and Jevity 1.5 in a 1000 ml bottle is Jevity is 500 calories less than Jevity 1.5.

Based on observation, interview and record review, the facility failed to develop and implement an appropriate plan through the facility's Quality Assurance and Performance Improvement (QAPI) committee to correct problems they had identified with pressure ulcer assessments, monitoring and treatments. The census was 75. Review of the facility QAPI Plan, undated, showed: Overall description of QAPI Plan: -The QAPI Plan is based upon person centered care with the goal of providing a home like environment where residents can become more independent. We will develop processes to better enable staff to assist residents in becoming independent and living the best quality life possible. The purpose of the QAPI Plan is to improve Quality of Care and services provided to generate to highest quality of life for our residents; -Our QAPI plan is on-going, with continual monitoring and efforts at process and performance improvement; Guiding Principles: -The goal of QAPI in our organization is to improve the quality of care and the quality of life of our residents; -The QAPI process is focused on system and process improvement along with employee development; -The QAPI program addresses all departments, the development of all services provided, and the development of all staff in the vision and mission of the organization; -With the QAPI program, we make decisions utilizing available data including feedback from caregivers, residents, health care practitioners, and families; -Our home sets measurable goals for performance improvement and we track our progress toward those goals; The facility QAPI Plan is a pro-active approach to improving residents' quality of life; -QAPI design and scope: Designed to be on-going and comprehensive. Its purpose is to correct deficiencies in quality of service and put processes in place to consistently improve performance; -Clinical care services are centered on individualized care plans and resident choice. These services include: Individualized care plans, skilled nursing care, fall and pressure sore management, medication management, treatments, reduction in urinary tract infections and weight loss, physician communication, pharmacy consultations and dietician consultations; -Person-centered quality of life focuses on plans to improve resident care tailored to individual needs: Establishment of goals for each resident, assistance with activities of daily living, dining experiences and dietary choices and social services; -The leadership team including the administrator, Director of Nurses (DON) and department heads are responsible for implementing the QAPI program. There will be weekly review of QAPI progress, monthly QAPI team meetings and quarterly meetings; -The coordinator of the QAPI program is the administrator who has the ultimate responsibility to ensure all department heads are aware of their responsibilities and following through with their part of the QAPI Plan; Feedback, Data Systems and Monitoring: -We use data from all available sources such as auditing efforts, data gathered through Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, and from feedback provided by staff, residents and others; Performance Improvement Projects (PIPs): -PIPs establish projects that address a particular concern by investigating, putting into place education and process changes, auditing performance and gathering data on the concern; Systemic Analysis: -The facility will utilize available data and Root Cause Analysis methods to determine the cause(s) behind problems that have been identified. The focus will be on identifying systemic problems and focus on process improvement performance improvement. All staff involved in QAPI PIPs will be trained in Root Cause Analysis. During the survey process, multiple problems associated with the monitoring, assessment, and treatment of pressure ulcers were discovered, including the following: -Unstageable pressure ulcers identified by the survey team; -Treatments not completed as ordered; -Weekly skin assessments not completed by nurses per facility policy; -Bath/shower sheets not completed by Certified Nursing Assistants (CNAs) and co-signed by nurses in accordance with the facility's policy; -Residents not turned and repositioned every two hours in accordance with the facility's policy; -Resident left soiled for prolonged periods; -A lack of staff inservicing for the identification, assessment, reporting and treatment of pressure ulcers; -Due to the significance of the above concerns, the facility was issued an immediate jeopardy citation at F686 for pressure ulcers during the survey process. During an interview on 5/10/21 at 8:32 A.M., the facility wound nurse said she was hired last July and became the wound nurse in November. She works Monday through Friday. She does the treatments Monday through Friday. She does pressure ulcer and wound measurements on Thursdays. The problems the survey team have discovered are not new. Basically, since the time she became the wound nurse, she has had problems getting staff to complete residents' treatments on Saturdays and Sundays. She has even placed each resident's treatment in plastic bags with their names and times the treatments should be done and left them in the medication rooms so the nurses would not forget to do the treatments over the weekends. That did not work out well, as she continued to have the same problems. She does not think staff are turning and repositioning the residents timely and that is a problem. She is aware skin assessments and bath/shower sheets are not being completed per facility policy. It is really frustrating trying to get everyone to do what they are supposed to do. She has discussed all of these problems with the previous director of nursing (DON) as well as the new DON. During an interview on 5/10/21 at 10:46 A.M., the DON said she had been at the facility since late February of this year. She first noticed the nurses had not been completing their weekly skin assessments a few weeks ago. It is a concern because there is no consistency. Over the past two to three weeks, she asked the wound nurse to do the weekly skin assessments and document the findings in the medical records. The same is true for the CNA bath/shower sheets which should be completed two times a week. They are not being completed consistently. The CNAs are supposed to notify the charge nurses immediately if there is any bruising or wounds and the charge nurse should sign off on the shower sheet before his/her shift is over. If a new area or concern is identified, the nurse is responsible to assess the area and notify the physician. Both the nurse's weekly skin assessment and the CNA bath/shower sheets are meant to identify skin problems before they get worse. She expected treatments to be completed as ordered. If a dressing is soiled or has come off, she expected the CNAs to notify the nurses, and the nurses to replace the dressing as soon as possible. During an interview on 5/11/21 at 11:43 A.M., the facility Medical Director answered the survey team's questions regarding the problems that had been identified with pressure ulcers. The Medical Director said she attends the QAPI meetings and she had not been informed of the problems identified by the survey team. During an interview on 5/14/21 at 6:40 A.M., the DON said the QAPI team meets the third Thursday of every month. As far as she can recall, they had not addressed the issues they were having regarding pressure ulcers at the QAPI meetings. The facility Medical Director, along with the facility management team, attend the QAPI meetings. During an interview on 5/21/21 at 10:50 A.M., the administrator said the DON worked with the wound nurse on a process to implement improvements. At the April QAPI meeting, the wound nurse reviewed the existing wounds, the wound company and the progress notes with wounds in the past couple of weeks. It was briefly mentioned that the assessments and treatments on the weekends needed to be done more consistently and the DON and wound nurse were working on an action plan. The action plan developed in the two weeks following the QAPI meeting included turning over skin assessments to the wound nurse and for the weekend nurses, including nurse management, to follow-up.

Based on interview and record review, the facility failed to ensure residents and/or responsible parties were notified in a timely manner when a resident's account was within the $200 social security (SSI) limit. This affected seven of eight residents who were either over the SSI limit or within $200 of the SSI limit (Residents #500, #501, #502, #503, #504, #505 and #506). The census was 75. Review of the facility's policy regarding resident funds (RFMS), revised on 5/1/20, showed when the resident's account reaches within the $200 limit set by the state of Missouri, the business office manager (BOM) or designee will utilize the RFMS letter and send to appropriate party. The policy did not have a time of when the BOM should send the notification. 1. Review of Resident #500's trust account (a Medicaid recipient), showed the following: -In February 2021, his/her account had $5,108.79 in it; -In April 2021, his/her account had $6,214.82 in it. Review of the letter notification to the resident, dated 4/14/21, showed he/she was within $200 or exceeding what is allowable under medical assistance. The letter asked for the responsible party to respond within 7 days. The letter was signed by the responsible party. Further review of the resident's ledger, showed as of 5/6/21, he/she had $6265.45 in his/her account. 2. Review of Resident #501's trust account (a Medicaid recipient), showed the following; -On 4/30/21, his/her account had $5686.26 in it. Review of the letter notification to the resident, dated 5/6/21 (the date of the survey), showed he/she was within $200 or exceeding what is allowable under medical assistance. The letter asked for the responsible party to respond within 7 days. The letter was not signed by the resident, responsible party or the facility representative. Further review of the resident's ledger, showed on 5/6/21, he/she had $5686.30 in his/her account. 3. Review of Resident #502's trust account (a Medicaid recipient), showed the following; -On 1/31/21, his/her account had $5148.07 in it; -On 2/28/21, his/her account had $5198.19 in it; -On 3/31/21, his/her account had $5248.31 in it; -On 4/30/21, his/her account had $5298.31 in it. Review of the letter notification to the resident, dated 5/6/21 (the date of the survey), showed he/she was within $200 or exceeding what is allowable under medical assistance. The letter asked for the responsible party to respond within 7 days. The letter was not signed by the resident, responsible party or the facility representative. Further review of the resident's ledger, showed on 5/6/21, he/she had $5298.42 in his/her account. 4. Review of Resident #503's trust account (a Medicaid recipient), showed the following; -On 1/31/21, his/her account had $6947.56 in it; -On 2/28/21, his/her account had $6997.31 in it; -On 4/30/21, his/her account had $5466.73 in it. Review of the letter notification to the resident, dated 5/6/21 (the date of the survey), showed he/she was within $200 or exceeding what is allowable under medical assistance. The letter asked for the responsible party to respond within 7 days. The letter was not signed by the resident, responsible party or the facility representative. Further review of the resident's ledger, showed on 5/6/21, he/she had $5466.77 in his/her account. 5. Review of Resident #504's trust account (a Medicaid recipient), showed the following; -On 3/31/21, his/her account had $6141.36 in it; -On 4/30/21, his/her account had $6136.15 in it. Review of the letter notification to the resident, dated 5/6/21 (the date of the survey), showed he/she was within $200 or exceeding what is allowable under medical assistance. The letter asked for the responsible party to respond within 7 days. The letter was not signed by the resident, responsible party or the facility representative. Further review of the resident's ledger, showed on 5/6/21, he/she had $6186.21 in his/her account. 6. Review of Resident #505's trust account (a Medicaid recipient), showed the following; -On 3/31/21, his/her account had $6644.34 in it; -On 4/30/21, his/her account had $7479.38 in it. Review of the letter notification to the resident, dated 5/6/21 (the date of the survey), showed he/she was within $200 or exceeding what is allowable under medical assistance. The letter asked for the responsible party to respond within 7 days. The letter was not signed by the resident, responsible party or the facility representative. Further review of the resident's ledger, showed on 5/6/21, he/she had $7529.97 in his/her account. 7. Review of Resident #506's trust account (a Medicaid recipient), showed the following: -On 4/30/21, his/her account had $6217.12 in it. Review of the letter notification to the resident, dated 5/6/21 (the date of the survey), showed he/she was within $200 or exceeding what is allowable under medical assistance. The letter asked for the responsible party to respond within 7 days. The letter was not signed by the resident, responsible party or the facility representative. Further review of the resident's ledger, showed on 5/6/21, he/she had $6399.17 in his/her account. 8. During an interview on 5/6/21 at 1:10 P.M., the BOM said she was behind with sending out the letters. There are some residents who don't want to spend their money. She was not sure why some of the letters were not sent out on time. The company RFMS will send her a list of who is getting close to the SSI limit.

Based on interview and record review, the facility failed to ensure they maintained a surety bond for the resident trust fund account in the amount of one and one half times the average monthly balance for the past 12 months. The census was 75. Review of the facility's policy regarding resident funds (RFMS), revised on 5/1/20, showed no instructions on how to monitor the facility's surety bond to ensure it was sufficient. Review of the resident trust account for the past 12 months, from April 2020 to March 2021, showed an average monthly balance of $147,000. (This would yield a required bond in the amount of $220,500 (one and one half times the average monthly balance)). Review of the bond report for approved facility bonds by Department of Health and Senior Services (DHSS), showed an approved bond of $120,000, dated 1/30/15. Review of the ending balance for April 2021, showed an amount of $167,072.65. Review of the Surety Rider provided by the facility, showed an increase on 1/13/21 for $200,000. The Rider did not show it had been submitted to DHSS for approval. During an interview on 5/06/21 at 2:11 P.M., the business office manager said the corporate office is responsible for the oversight of the Rider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and implement a grievance policy to ensure the prompt resolution of all grievances, that included the grievance official receiving and tracking grievances through to their conclusion. The facility census was 75. Review of the facility's Resident/Patient/Family grievance policy, dated 1/14/19, showed the following: -Protocol: A resident/patient and/or family member has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished; -The facility will provide residents/patients and their family members with prompt efforts to resolve grievances, including those with respect to the behavior of other residents/patient and/or staff; -Procedure: The facility has a grievance officer that is central to managing the grievance process and is the key contact for residents that wish to file a grievance. The grievance officer is the director of social services; -Residents will be notified of the grievance process and the grievance officer in person or by posting. They will be notified of their right to file the grievance orally or in written format, that they may file anonymously, the contact information of the grievance officer, the right to obtain a written decision regarding the grievance and the contact information of the pertinent state agencies such as state survey agency and Ombudsman office; -Encourage the resident to first notify the nurse manager, DON or administrator if they feel a need to express, file or otherwise communicate a concern and if the issue can be addressed immediately; -Any complaints that involve abuse, neglect, misappropriation and financial exploitation will be reported to the administrator and state authorities in accordance with federal and state guidelines; -Residents have the right to express grievances in a confidential manner, anonymously if desired, and have the grievance overseen by the director of social services who is also the resident advocate. If the resident requests, the local ombudsman may be also involved; -Grievances can be submitted to any nurse, manager, or directly to the director of social services and may be communicated in writing or verbally; -Grievance forms are available at each nursing station. Staff are also able to help provide a grievance form; -The forms may be submitted directly to the director of social services. If unavailable, the grievance can be submitted to the administrator, DON and manager on duty; -The facility will follow up on the grievance with the resident or family member in a reasonable timeframe, within three days and no later than five days; -The facility will keep grievances and the grievance log on file for three years; -The facility will maintain a log to track the grievance process, types of grievances and the process. Appropriate action will be taken to resolve the grievance; -Provide direction and information on how to contact other outside sources for assistance in filing complaints and/or grievances. This information will be provided in admissions, social services, and will be posted throughout the facility regarding how and where to contact such sources. 1. During an interview on 5/4/21 at 10:00 A.M., four of five residents who attended the resident council meeting said they received no responses to grievances they filled out or they did not know how to file one. Staff will take their grievances, and then no one gets back with them and they do not know what happens to the grievance. They do not like having to go to the nurse's station to get a grievance form because then staff know they are filling one out. Sometimes the social services director will come talk to them, but often they do not hear anything. They do not worry about retaliation because staff know no one is going to do anything about the grievance. 2. Review of Resident #525's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/26/21, showed: -admitted on [DATE]; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -Brief Interview for Mental Status score of 14 out of a possible 15 (a score of 13 - 15 indicates cognitively intact); -No behavioral symptoms. During an interview on 5/12/21 at 9:25 A.M., resident #525 said he/she did not know how to fill out a formal grievance. He/she complained to a nurse a couple of weeks prior about staff rudeness, and the nurse told him/her he/she would file a grievance for the resident, but the resident never heard anything back. He/she did not know where to get a grievance to fill out or who to talk to about filling out one. 3. Review of Resident #64's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -Brief Interview for Mental Status score of 15 (a score of 13 - 15 indicates cognitively intact); -No behavioral symptoms. During an interview on 5/12/21 at 11:15 A.M., resident #64 said he/she did not know how to fill out a grievance form or where they were kept. If if he/she had an issue, he/she would just have to report it to the nurse on duty. 4. During an interview on 5/12/21 at 8:15 A.M., the social services director said grievances are kept at the front desk and at the nurses stations. The residents would fill it out and bring it to her. Who responded to the grievance depended on the residents' concerns. She would give it to nursing if it was a nursing complaint, dietary if it was a food complaint and housekeeping if it was a housekeeping complaint. She would expect that person to get back with the resident and address the complaint. He/she did not check back with the staff or resident to see if the complaint was addressed. The problem was that staff did not always communicate well, so she might not be aware of how the grievance was handled. She did not always get a copy of the completed grievance. The grievances would be filled out by the person who addressed it, and then a copy would be kept in a book in the medical records office. Review of the grievances filed in the medical records office on 5/12/21 at 8:25 A.M., showed two completed grievances since 1/1/21. During an interview on 5/12/21 at 10:15 A.M., Certified Nurse's Aide F said he/she did not know where grievances were kept. He/she thought residents had to get them from the social services director. During an interview on 5/12/21 at 10:20 A.M., Licensed Practical Nurse (LPN) B said the grievances were kept at the nurse's station in a binder. If a resident filled one out, he/she would give it to the Assistant Director of Nursing, the Director of Nursing or the social services director. Once LPN B gave the form to the residents, he/she would not be expected to follow through with the residents to see if their concerns had been addressed. He/she had never been given a grievance to investigate. During an interview on 5/12/21 at 10:55 A.M., LPN A said he/she thought the grievances were kept at the nurse's station and the front desk. He/she would turn them in to the administrator or the social services director after residents filled them out. He/she had never been asked to investigate a grievance or talk to a resident about the results of one. During an interview on 5/17/21 at 1:30 P.M., the administrator said someone should get back with the resident with a response to all grievances filed. Grievances get turned into social services or him. They might assign someone to handle it but social services is supposed to get back with them to make sure it is resolved. The form would then go back to social services and be filed. He did not realize that residents did not feel comfortable getting grievance forms from the staff at the nursing stations. Residents should be informed at admission about the grievance procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy by failing to thoroughly investigate concerns made by family members on behalf of two residents regarding alleged mistreatment by staff members (Residents #15 and #379). In addition, the facility failed to ensure new employees did not have potential contact with residents prior to conducting criminal background and the employee disqualification check for three of nine sampled staff. The census was 75. Review of the facility's abuse prevention policy dated 2/19, showed: -Prevention and reporting: The administrator has primary responsibility in the facility for implementation of the abuse/neglect program; -The facility will follow all state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse, sexual abuse or involuntary seclusion; -The facility encourages and supports all residents, staff and families in feeling free to report any suspected acts of abuse, neglect, misappropriation or injury of unknown origin. The facility takes all measures possible to ensure that residents, staff and families are free from fear of retribution if reports or incidents are filed with the facility; -Reports of abuse will be promptly reported and thoroughly investigated. Additionally the facility should immediately report all such allegations to administrator/designee and to the Department of Health and Senior Services. In cases where a crime is suspected staff should also report the same to local law enforcement; -The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc.; -The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property; -The facility has implemented the following processes in an effort to provide residents/patients and staff a safe and comfortable environment; -The shift supervisor (charge nurse, nurse manager or administrator) is identified as responsible for immediate initiation of the reporting process; -The administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect and/or misappropriation of property standards and procedures: *Implementation; *Ongoing monitoring; *Reporting; *Investigation; *Tracking and trending; -Implementation and ongoing monitoring consist of the following: *Screening; *Training; *Prevention; *Identification; *Protection; *Investigation; *Reporting; -Investigation: When an incident or suspected incident of abuse or neglect is reported, the administrator or designee investigates the incident with the assistance of appropriate personnel; -Initiate the investigation, the investigation should be thorough with witness statements from staff, residents, family members who may be interviewable and have information regarding the allegation; -The investigation may consist of an interview with the person reporting the incident and witnesses, and interview with the resident if possible, a review of the residents medical record, an interview with staff members having contact with the resident during the period of the alleged event, interviews with resident's roommate, family members and visitors, a review of all circumstances surrounding the incident; -Conclusion must include whether the allegation was substantiated or not and what information supported the decision. The conclusion/summary must take into account an objective overview of the facts and a reason or basis for the decision to substantiate or not substantiate the allegation; -Reporting: Any person witnessing or having knowledge of alleged violation of involving abuse, neglect, misappropriation or injury of unknown origin are to notify the administrator or Director of Nursing immediately; -The administrator or Director of Nursing or designee to report to the regional clinical manager; -Notify the appropriate state agency(s) immediately of allegations or suspicious of abuse, neglect or injury of unknown injury by fax or telephone after identification of alleged/suspected incident. Allegations or suspicion of mistreatment of resident property or exploitation are to be reported to the state agency immediately and no later than 24 hours upon discovery; -Reports of abuse, neglect and injury of unknown origin are to be made to the state agency immediately, but no later than two hours from the allegation being made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hour if the event that cause the allegation do not involve abuse or result in bodily injury; -Follow reporting requirements as outlined by the state agency. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/18/21, showed: -admission date of 10/14/20; -Adequate hearing/vision; -Clear speech - distinct intelligible words; -Ability to express ideas and wants: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to understand others: Usually understands - misses some part/intent of message but comprehends most conversation; -Brief interview for Mental Status (an assessment used to determine cognitive status) score of 07 (a score of 0 -07 indicates severely impaired cognition); -No hallucinations or delusions; -No physical, verbal or other behaviors noted; -Wandering: Behavior not exhibited; -Rejection of care: Behavior not exhibited; -Limited assistance of one person required for bed mobility; -Extensive assistance on one person required for transfers, dressing, toilet use, personal hygiene and bathing; -Supervision - oversight, encouragement or cueing required for eating; -Independent for locomotion on/off the unit; -Functional limitation of both lower extremities; -Mobility device: Wheelchair; -Diagnoses of renal (kidney) insufficiency, diabetes mellitus, stroke, hemiplegia (the complete loss or paralysis on one half of the body) or hemiparesis (minor to severe weakness of one half of the body) and manic depression (alternating moods of abnormal highs (mania) and lows (depression)). Review of a facility self-report to the DHSS, dated 5/12/21 at 10:22 P.M., showed: -Resident's family contacted the admission Coordinator on 5/12/21 and stated the night shift staff (Night shift hours for Certified Nursing Assistants (CNAs) is 6:00 P.M. until 6:00 A.M.) had been rude to the resident. Administrator arrived on the night shift on 5/12/21 at approximately 7:30 P.M. and interviewed resident. Resident claimed that a staff member had been verbally rude, insulting him/her and had been physical with him/her. He/she claimed a Certified Nursing Assistant had pushed him/her on the night shift of 5/7/21. During an interview on 5/13/21 at 8:45 A.M., the admission Coordinator (AC) said yesterday, 5/12/21 around 3:00 P.M., the resident's family contacted her by phone about sending the resident to another facility. During the conversation, the family member told her the resident was having problems with two Certified Nursing Assistants (CNAs) on the night shift. They threatened to throw the resident out of his/her wheelchair. The resident had fallen once and those same CNAs left him/her on the floor longer than he/she should have been. The AC said she was surprised as she speaks to the resident most every day and he/she had not mentioned that to her. She did not go and speak to the resident after the phone conversation because she went to the daily management meeting and told the Administrator what the family had said. During an interview on 5/13/21 at 9:13 A.M., the resident said an agency staff member, he/she was not sure if they were a CNA or a Nurse, but on the night shift was mean to him/her. The staff member hit him/her on his/her head around the mouth. This happened last Friday when he/she wanted to go into Resident #12's room to speak to him/her. Resident #12 was asleep in his/her recliner. The staff member came down the hall and would not allow him/her to go into the room. The staff member called him/her an ignorant bastard. The staff member hit him/her with his/her fist, then pulled Resident #12's door shut. Both he/she and the staff member left Resident #12's room at that time. The resident had no facial bruising noted during the interview. During an interview on 5/13/21 at 10:10 A.M., the administrator said the AC told him yesterday in their meeting around 3 o'clock. All he heard the AC say was Resident #15 said someone had been rude to him/her so he did not think it had anything to do with abuse at that time. He ended up leaving the facility and going home before returning between 6:00 P.M. and 6:30 P.M. to speak to the resident. He did not designate anyone to speak to the resident before he left to go home. It was not until he returned and spoke to the resident that he learned the resident claimed verbal abuse. He did not know what the facility policy showed in regards to initiating an abuse/neglect investigation although he did help write the policy. He said the resident did not tell him anything about being struck or threatened to be pushed out of his/her wheelchair. All the resident said was staff had verbally abused him/her. He reviewed the video of the resident and the CNA from 5/7/21, Friday evening. At that time the Administrator played the video that had no audio, and showed a CNA walking with Resident #15 towards Resident #12's room. Resident #15 was in his/her wheelchair. At the doorway of Resident #12's room, the CNA blocked the resident from entering by standing in the doorway. The CNA was not observed striking the resident. The CNA eventually stepped behind the resident, grabbed the handle bars on the back of the resident's wheelchair and pull the resident backwards a minimum of 4 or 5 feet away from Resident #12's door to the other side of the hall before letting go. The resident appeared to be upset by this and left the area at that time. The entire encounter lasted approximately two minutes. The administrator said the CNA should not have dragged Resident #15 backwards away from the door. The CNA should have asked Resident #12 if Resident #15 could come in. The CNA was suspended pending an investigation. During an interview on 5/13/21 at 10:40 A.M., Resident #12 said he/she liked Resident #15 and thought of Resident #15 like a son/daughter. Resident #15 is welcome to come in his/her room any time. Had the staff member woke him/her and asked if Resident #15 could come in he/she would have said yes. He/she had not heard what the staff member said to the resident and had not seen the resident hit by anyone. During a telephone interview on 5/13/21 at 10:48 A.M., the resident's family member confirmed what he/she had told the AC on 5/12/21. He/She added it was not the first time he/she had reported the resident had problems with two night shift staff. Approximately six months ago, he/she spoke to someone at the facility, but was not sure if it was the AC or the Social Service Director regarding the resident alleging two staff members threatened to throw him/her out of his/her bed or wheelchair. The family member said he/she never heard back from the facility after alerting them to his/her concerns. Review of DHSS complaints, showed no other complaint listed for Resident #15. Review of the resident's progress notes, including social service notes on 5/13/21, showed no documentation regarding a family member complaining about the resident's treatment by staff. During an interview on 5/13/21 at 1:49 P.M., the Social Service Director said she did not recall having any previous conversations with that family member, but did recall another family member telling her the resident was having trouble with the night shift staff. It was how they were approaching him/her. The way they were speaking to him/her. The family member did not know the names or titles of the staff. She could not recall how long ago that conversation took place and she did not document it. She did tell the Administrator and Director of Nurses (DON). She did not know if anyone followed up or not. During an interview on 5/13/21 at 2:15 P.M., the DON said she attended the meeting yesterday at 3:00 P.M. Everyone was talking at once and there was a lot of conversations going on. The AC was at the other end of the table from where she and the Administrator were sitting so she did not hear what the AC said. She did not recall the SSD telling her that the resident had a problem with two night staff a few months ago. She started at the facility in late February of this year. During an interview on 5/14/21 at 8:09 A.M., the Business Office Manager said she attended the management meeting on 5/13/21 at 3:00 P.M. She was sitting close to where the AC sat. She recalled the AC saying to everyone that the resident's family had called and said the resident was having problems with the night shift staff. She did not hear any specific details. The Administrator did not respond to AC after she announced it. She was not even sure the Administrator heard what AC had said as everyone was talking. During an interview on 5/14/21 at 8:59 A.M., the resident confirmed he/she had told his/her family that two night shift staff threatened to push him/her out of his/her wheelchair a few months ago. During an interview on 5/14/21 at 10:30 A.M. the Administrator denied being told by the SSD the resident had problems a few months ago with two night shift staff threatening to throw the resident out of his/her wheelchair. He was only aware of the problem the resident told him about on 5/12/21. 2. Review of Resident #379's admission MDS dated [DATE], showed: -Date of admission 8/15/19; -Diagnoses included cerebral palsy, malignant neoplasm of colon, sleep apnea and history of falling; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -Brief Interview for Mental Status score of 14 (a score of 13-15 indicates cognitively intact); -Extensive assistance of one person needed for bed mobility, transfers and dressing; -Total dependence needed for toilet use; -One person assistance needed for showers. Review of the resident's progress notes dated 9/23/19 at 9:56 A.M., showed staff had a small care plan meeting with the resident's family member/power of attorney because of allegations at recent emergency room visit. The family member said he/she received calls from the hospital that residents were snotty and aides were too rough for showers. The family member wanted staff to be aware the resident could be manipulative and worried the resident acted like this because he/she wanted to return to a group home. The staff member assured the family member the transition was very difficult but they would work through it. The staff member explained the resident had been different since a visit from group home staff. He/she was more withdrawn and argumentative with residents but would apologize and move on when talked to by staff. The staff member assured the family member would educate staff on being extra gentle as the resident's diagnosis might make him/her perceive care differently. The staff member spoke to the resident and explained anytime he/she feels like residents are rude or staff are rough that he/she could talk to the staff member or social services so it could be addressed immediately. The family member was thankful for the meeting. Review of an investigative summary provided by the facility on 5/13/21, showed staff was informed of the allegation after the hospital called the family member on or about 9/22/19. The allegation was vague, the resident did not name any staff and simply claimed staff were rough in the shower. The resident had a diagnosis of cerebral palsy. He/she yelled during showers and when being transferred or walked. The resident was argumentative with behaviors after admission such as frequently arguing with other residents in the hallway. Staff who were interviewed had no issues with other staff, only concerns about the resident's behavior. The staff member who investigated supervised showers with the resident and noted the resident did not like water hitting his/her face. Staff would hold a washcloth at top of his/her head to avoid water striking his/her face. During an interview on 5/13/21 at 12:15 P.M., the administrator said he could not find documentation of an investigation. He called the former staff member who entered the information in the progress note and he/she provided the information in the investigative summary. The allegation should have been thoroughly investigated and documented. 3. Review of the new facility policy dated 2/2019 regarding new hire/employee screening showed: -The hiring process will include screening of all potential employees for criminal background history and history of abuse, neglect or mistreatment residents; -The following will be processed for new employees: -Criminal background checks must be completed; -Criminal background checks (CBC's) and decisions to hire must be done in accordance with state regulation as stated below; -Each facility shall, not later than two working days of the date an applicant for a position to have contact with residents hired, request a criminal background check; -Facility will not hire any person listed on the employee disqualification list (EDL); -The policy did not show that the facility would upon hire check the CBC's or EDL's on potential new employees. 4. Review of Housekeeping EE's hire information, showed: -Date of hire 2/1/21; -Check of the Family Care Safety Registry (FCSR), a state registry which checks criminal history and the EDL) dated 3/2/21. 5. Review of Receptionist FF's hire information, showed: -Date of hire 7/17/20; -Check of the FCSR dated 7/21/20 . 6. Review of Occupational Therapy Assistant (OTA) GG's hire information, showed: -Date of hire 2/1/21; -Check of the FCSR dated 7/4/20. 7. During an interview on 5/6/21 at 1:10 P.M. human resource director HH said OTA GG was rehired on 1/29/21. He/she is a part time employee. She should have rechecked him/her. The date of hire is not necessarily when they are assigned to work the floor. However orientation, which is the date of hire, involves new employees going through the building at least three times going onto resident floors, observing residents, fire safety features and the layout of the building. She did not think about the potential of having resident contact. 8. Review of state statute 192.2495, for showed: - Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: - Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose of conducting an employee criminal records background check shall be deemed to fulfill the provider's duty to conduct employee criminal background checks pursuant to this section; except that, completing the inquiries pursuant to this subsection shall not be construed to exempt a provider from further inquiry pursuant to common law requirements governing due diligence. If an applicant has not resided in this state for five consecutive years prior to the date of his or her application for employment, the provider shall request a nationwide check for the purpose of determining if the applicant has a prior criminal history in other states. The fingerprint cards and any required fees shall be sent to the highway patrol's central repository. The fingerprints shall be used for searching the state repository of criminal history information. If no identification is made, fingerprints shall be forwarded to the Federal Bureau of Investigation for the searching of the federal criminal history files. The patrol shall notify the submitting state agency of any criminal history information or lack of criminal history information discovered on the individual. The provisions relating to applicants for employment who have not resided in this state for five consecutive years shall apply only to persons who have no employment history with a licensed Missouri facility during that five-year period. Notwithstanding the provisions of section 610.120, all records related to any criminal history information discovered shall be accessible and available to the provider making the record request; and - (2) Make an inquiry to the department of health and senior services whether the person is listed on the employee disqualification list as provided in section 192.2490. MO00185248 MO00182036

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who are unable to carry out activities of daily living (ADLs) received services to maintain good personal hygiene and grooming. The facility failed to provide thorough perineal care (peri-care, cleansing from the front of the hips, between the legs and buttock and back of the hips) to one resident (Resident #55), the facility also failed to ensure one resident (Resident #22) maintained trimmed toenails, the facility also failed to ensure resident showers had been completed for two residents (Resident # 224 and Resident #69). The sample size was 18. The census was 75. 1. Review of the facility care of incontinent resident policy and procedure, reviewed 1/2020, showed: -Purpose: To keep residents clean and dry; -Policy: All residents who are identified as being incontinent will have incontinence care provided every two hours; -Procedure: -Explain procedure to the resident and bring the equipment to the bedside; -Remove excess feces and urine with diaper, pad or tissue as indicated; -Spray periwash (used for peri-care) on a wet washcloth and cleanse with the wet washcloth or cleanse with a wet, soapy washcloth; -Rinse washcloth (or turn washcloth to the clean side) and wipe the area clean. If cleaning feces, use a second washcloth; -For male residents: Cleanse moving from the tip of the penis to the base of the penis; -Dry the area well; -Apply protective ointment, lotion or cream and observe the skin closely for reddened or unusual areas. 2. Review of Resident #55's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 3/12/21, showed: -Severe cognitive impairment, unable to make needs and wants clearly known; -Extensive staff assistance needed with toileting, dressing, transfers and daily hygiene; -Frequently incontinent of bowel and bladder; -Diagnoses of Downs Syndrome (a genetic disorder causing developmental and intellectual delays), heart failure and depression. Review of the undated care plan, in use during the survey, showed: -Focus: The resident has self care deficit; -Goal: The resident will maintain current level of function in ADLs; -Interventions: The resident requires assistance with bathing, dressing, eating, transfers and personal hygiene. Staff provide incontinence care. Observation and interview on 5/10/21 at 6:48 A.M., showed Certified Nurse's Aide (CNA) R entered the resident's room, washed his/her hands and applied gloves. The resident slept in his/her recliner. CNA R said he/she last provided care to the resident at 4:30 A.M. CNA R obtained several wet wipes and placed the resident's wheel chair up next to the resident. He/She explained care to the resident and assisted the resident to stand with use of the wheel chair handles. CNA R lowered the resident's brief. A moderate amount of brown fecal material noted to the resident's buttocks and testes. CNA R used one wipe and wiped from the front of the groin to the buttocks. He/She repeated the motion with a second wipe. CNA R applied a clean brief and secured the brief into place. Multiple areas of brown stool remained on the resident's skin. The resident's buttocks appeared red, and CNA R did not apply cream to the buttocks. CNA R said the resident is incontinent of bowel and bladder. He/She had run out of wipes and had been scheduled to end the shift soon. He/She forgot to apply barrier ointment and would pass onto the next day shift aide about the resident needing ointment on his/her buttocks and more wipes in the room. During an interview on 5/10/21 at 11:05 A.M., the Director of Nursing (DON) said staff should always complete thorough perineal care. All areas should be cleaned and dried. There should be no visible stool on the resident before applying clean briefs or clothing. It is the aides' responsibility to ensure enough supplies are brought into the resident's room before providing care. Supplies are available for staff to use. 3. Review of Resident #22's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Extensive staff assistance for toileting, bathing and hygiene; -Diagnoses of stroke, Parkinson's (neurological disease causing uncontrollable tremors) and schizophrenia (mental disorder affecting reality, often causing delusions). Review of the undated care plan, in use during the survey, showed: -Focus: The resident has a self care deficit; -Goal: The resident will maintain current level of function in ADLs; -Interventions: The resident requires total staff assistance with bathing and dressing. During an observation and interview on 5/10/21 at 10:09 A.M., the wound care nurse examined the resident's toe nails and said Those are very long. Those toe nails need to be trimmed badly or they may start cutting into the skin. The toenails appeared approximately 1/2 inch to 3/4 inch long and jagged. The toenails had begun to curl and the jagged edges pressed into the sides of the opposing toes. The resident is not able to dress or bathe himself/herself and the aides are expected to tell the nurse when toe nails need to be trimmed. The facility has a podiatrist that comes to see residents. The resident's toe nails are long enough that he/she should be seen by podiatry. During an interview on 5/10/21 at 11:05 A.M., the DON said toe nails and finger nails should be trimmed during the shower or bath. Long nails can cause discomfort or get caught on socks and tear. There should be no long toe nails on residents. Resident #22 will need to be seen by podiatry due to the length of the toe nails. As aides assist a resident to dress or bathe, the aide can also notify the nurse for nail trimming. 4. Review of Resident #224's medical record, showed: -admitted [DATE]; -Diagnoses included depression; -Moderate cognitive impairment. Review of the resident's care plan, undated and in use at the time of survey, showed no documentation of the resident's preferences for bathing or grooming. Review of the facility's 200 hall shower schedule, undated and posted at the 200 hall nurse's station, showed the resident scheduled for showers on Tuesday and Friday nights. Review of the resident's shower sheets from April and May 2021, showed one bed bath documented as completed on 4/13/21. Observations of the resident, showed: -On 5/3/21 at 8:42 A.M., 9:09 A.M., 10:47 A.M., 11:45 A.M., 12:27 P.M. and 1:06 P.M., the resident lay in bed, dressed in a hospital gown; -On 5/4/21 at 7:02 A.M., 7:48 A.M., 9:11 A.M., 10:10 A.M. and 1:02 P.M., the resident lay in bed, dressed in a hospital gown; -On 5/5/21 at 7:35 A.M., 9:47 A.M., 11:27 A.M. and 1:01 P.M., the resident lay in bed, dressed in a hospital gown. His/her shoulder-length hair disheveled and stringy; -On 5/6/21 at 7:53 A.M. and 11:14 A.M., the resident lay in bed, dressed in a hospital gown. His/her shoulder-length hair stringy; -On 5/12/21 at 8:44 A.M., the resident lay in bed, dressed in a hospital gown. His/her face greasy and hair stringy; -On 5/13/21 at 8:49 A.M. and 12:38 P.M., the resident lay in bed, dressed in a hospital gown. His/her hair combed back and stringy. During an interview on 5/10/21 at 9:33 A.M., Certified Nurse Aide (CNA) BB said Resident #224 spends all day in bed and never really gets up. He/She seems like he/she is tired, worn out, but doesn't refuse care. The resident gets bed baths and the CNA has provided one to the resident before. When CNAs provide bed baths or assist residents with bathing, they should document completion of a bed bath or shower on a shower sheet, and turn it in at the nurse's station. During an interview on 5/12/21 at 8:05 A.M., CNA P said Resident #224 has been in bed since admitted to the facility a month ago. He/she never comes out of his/her room and sleeps all day, but does allow staff to provide care and does not refuse it. Residents should be bathed or showered at least twice a week or more if needed, but residents are probably not getting bathed that often. The facility used to have a shower aide, but they do not anymore. Ensuring residents are clean is important because being soiled all day leads to skin breakdown. 4. Review of Resident #69's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Severe cognitive impairment; -Rejection of care not exhibited; -Total dependence of one staff physical assist required for personal hygiene and bathing; -Upper and lower extremity impaired on one side; -Diagnoses included stroke, dysphagia (swallowing disorder), unsteadiness on feet and depression. Review of the resident's care plan, undated and in use at the time of survey, showed: -Focus: The resident has a behavior problem, tends to place his/her hand in soiled undergarment before and during changing. Refuses medication, showers and care at times; -Interventions included: Explain all procedures to resident before starting and allow resident to adjust to changes, come back and approach later if necessary; -Focus: Resident requires assistance with all ADLs related to stroke with right sided weakness. The resident has limited mobility and refuses care at times; -Interventions included the resident is totally dependent on one staff to provide bath/shower two times weekly and as necessary, and the resident requires total care by one staff with personal hygiene and oral care. Review of the facility's 200 hall shower schedule, undated and posted at the 200 hall nurse's station, showed the resident scheduled for showers on Wednesday and Saturday nights. Review of the resident's shower sheets from March through May 2021, showed one shower sheet, dated 4/27/21, with bed bath or shower not specified. Observations of the resident, showed: -On 5/3/21 at 11:04 A.M. and 5/4/21 at 7:43 A.M., the resident lay in bed with stringy hair and greasy face; -On 5/10/21 at 12:25 P.M. and 5/13/21 at 8:54 A.M. and 1:02 P.M., the resident lay in bed, dressed in a hospital gown, with stringy hair and greasy face. 6. During an interview on 5/11/21 at 7:43 A.M., Nurse I said all residents should receive bed baths or showers at least twice a week. Residents have the right to refuse care and if this occurs, staff should ask them again later. Any resident refusals should be documented in the resident's medical record. The intervention is to ask the resident again later, and if they continue to refuse, they should document it in the medical record. During an interview on 5/14/21 at 1:06 P.M., the Director of Nursing said showers or baths should be done twice a week and as needed. Bed baths and showers should be documented on shower sheets when offered. She was not aware they had not been done as often as expected. MO00182036 MO00182550

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff implemented interventions consistent with a resident's individual needs in accordance with their care plan to eliminate the risk and/or reduce the risk of an accident, and to ensure staff performed neurological assessments and fall investigations in accordance with the facility's policy, for five residents (Residents #37, #69, #15, #20 and #384). The sample was 18. The census was 75. Review of the facility's Falls Programs Policy and Procedure, reviewed January 2020, showed: -Purpose: To identify all residents who have a high risk for falls and to ensure adequate interventions are in place to prevent a major injury; -Policy: All residents will be evaluated to assess for fall risk on admission/readmission. An investigation of all falls will be completed by the DON/designee and submitted to the interdisciplinary team (IDT) committee for review; -Procedure: -The Fall Risk Evaluation will be completed on every resident upon admission/readmission by the nurse on the shift that the resident is admitted on ; -When a resident is identified as being at a high risk for falls, an Initial Plan of Care must be implemented upon admission and the fall risk interventions noted on the [NAME]; -When a resident within the facility falls, the nurse will assess/evaluate the resident and document in the electronic medical record (EMR). Neuro checks (neurological assessments) will be initiated for all unwitnessed falls, residents on anticoagulant or antiplatelet medication or hit their head and as ordered by the physician/practitioner; -The nurse will complete a new Fall Risk Evaluation in the EMR; -The nurses document post fall for 72 hours completing the Fall Follow Up 72 Hour in the EMR; -The DON/designee will complete the Post Fall Evaluation within 24 hours and/or the next business day in the EMR; -Fall tracking/incident reports are completed in the electronic Risk Management Program; -Fall tracking is reviewed during monthly Quality Assurance Performance Improvement (QAPI) for patterns and trends. 1. Review of Resident #37's medical record, showed: -admitted on [DATE]; -Diagnoses included heart failure, high blood pressure, dementia, history of falling and history of healed traumatic fracture; -A Fall Risk Evaluation, dated 6/25/20 identified the resident as At Risk for falls with a score of 14. Review of the resident's progress notes and assessments, showed: -An incident note, dated 6/25/20 at 1:55 A.M., in which staff documented the resident found laying on the floor in the doorway of his/her room. Resident stated he/she was trying to get dressed. Resident assessed and vitals taken; blood pressure was 196/81. Resident had some complaint of pain on right side hip and leg. Resident stayed up in chair next to certified nurse's aide (CNA) and did not want to go to bed at this time. Resident was able to communicate needs; -No documentation regarding Neurological checks (neuro checks, assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength, including assessment of range of motion); -A situation-background-assessment-recommendation (SBAR), dated 6/25/20 at 2:25 A.M., in which staff documented the resident's vitals obtained at 2:29 A.M. Neurological Status Evaluation: Resident was laying on the floor in the doorway, stated he/she was getting dressed for work. Primary Care Provider feedback; no recommendations; -No documentation regarding assessment of range of motion; -A transfer to hospital note, dated 6/25/20 at 4:57 A.M., in which staff documented the resident complained of pain on the right side hip and leg. Nurse assessed resident and called physician. Resident is being sent out to the hospital. -No Post Fall evaluation or fall investigation documented. Review of the resident's hospital record, showed the resident admitted to the hospital on [DATE] and diagnosed with right femur fracture. Resident underwent surgery and returned to the facility on 6/29/20. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/26/21, showed: -Severe cognitive impairment; -Required limited assistance of one person for transfers; -Balance not steady when moving from seated to standing position, or surface-to-surface transfer; -One fall without injury since last assessment. Review of the resident's [NAME], printed on 5/11/21, showed guidance for safety included ensuring resident wears a seat belt and the bed is to remain in the lowest position with fall mat next to bed. Review of the resident's undated care plan, showed: -Focus: Resident at risk for falls related to gait/balance problems. Unaware of safety needs. Diagnoses of dementia and femur fracture in May (year not specified). 6/29/20 readmitted after fall on 6/25/20 and sustained hip fracture; -Interventions included ensure nonskid footwear and bed in lowest position with fall mat next to bed; -Focus: The resident has had an actual fall related to poor balance, and unsteady gait; -11/8/20 removed seat belt and attempted to stand in dining room, sustained hematoma to right temple and laceration to right wrist and hand; -3/3/21 resident slid out of wheelchair; -3/11/21 resident slid from wheelchair and sustained abrasion to right elbow; -4/6/21 resident stood from wheelchair in courtyard and fell; -4/7/21 fall transferring himself/herself to a recliner; -Interventions included ensure resident wears seat belt and keep bed in lowest position. Observations on 5/3/21, showed: -At 8:39 A.M., the resident lay in bed with head of bed elevated 45 degrees. Bed positioned at regular height. No fall mats on floor next to bed; -At 1:10 P.M., the resident seated in his/her wheelchair in the dining room. He/she unbuckled his/her seat belt, pulled off his/her nonskid socks, and stood up. Two staff seated in the dining room did not acknowledge or redirect the resident. He/she sat back in his/her wheelchair and socks remained off; -At 3:14 P.M., the resident lay in the bed, positioned at regular height. No fall mats on floor next to bed. Observation on 5/5/21 at 9:45 A.M., showed the resident lay in bed with eyes closed. Bed positioned at regular height. No fall mats on floor next to bed. Observation on 5/12/21 at 8:04 A.M., showed the resident seated at the foot of his/her bed, facing the left side of the bed and visible from the doorway to the room. The resident was alert and confused, talking nonsensically. He/she wore a brief and long-sleeved shirt without footwear. The bed was in the low position. No fall mats were on the floor next to the bed. 2. Review of Resident #69's medical record, showed: -admitted on [DATE]; -Diagnoses included heart failure, unsteadiness on feet, stroke, traumatic brain bleed with loss of consciousness for unspecified duration, dysphagia following stroke (difficulty swallowing), attention and concentration deficit following stroke and depression; -A physician's order, dated 1/31/20, for floor mats down while resident is in bed. Review of the facility's incident/accident report, dated 2/3/21 through 5/3/21, showed the resident had one unwitnessed fall, which occurred 3/31/21 at 9:20 A.M. Review of the resident's Fall Risk Evaluation, dated 3/1/21, showed the resident identified as At Risk for falls with a score of 11. Review of the resident's medical record, showed: -A nurse's note, dated 3/25/21 at 11:00 A.M., the resident fell forward out of his/her wheelchair and had a large hematoma to left side of the forehead, complaints of head pain. Physician notified, received order to send to hospital; -A Neurological Focused Evaluation, dated 3/25/21 at 11:46 A.M., in which staff documented vital signs obtained at 11:22 A.M. and within normal limits. Resident complains of generalized pain, rated as a 5 and constant. Cool compress applied. Neurologic: Pupils with sluggish response. Mood/Behavior: Resident is disoriented, confused. Oriented to person. Current disorientation is baseline for resident. As needed (PRN) medication administered. Pain/discomfort: Yes. Additional vital signs obtained at 12:18 P.M.; -A nurse's note, dated 3/25/21 at 6:52 P.M., resident returned from emergency room with no new orders. Continue with neuro checks; -No documentation of additional neuro checks or Fall Follow Up 72 Hour completed on 3/26/21 or 3/27/21; -No new Fall Risk Evaluation completed; -A nurse's note, dated 3/31/21, showed a loud thud heard from the resident's room. Upon entering the room, the resident found on the floor next to his/her bed, in front of his/her wheelchair. No injuries noted and range of motion performed without difficulty. Vitals documented. Physician notified; -A Fall Risk Evaluation, dated 3/31/21, the resident identified as At Risk for falls with a score of 18; -A Neurologic Focused Evaluation, dated 3/31/21 at 11:46 A.M., resident complained of head pain at a 10 and PRN medication administered. Vitals within normal limits; -Neuro check evaluations completed 3/31/21 and 4/1/21; -No neuro checks documentation of neuro checks or Fall Follow Up 72 Hour completed on 4/2/21. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence of one person physical assist for bed mobility; -Total dependence of two (+) person physical assist for transfers; -Upper and lower extremity impaired on one side; -One fall with injury and one fall without injury since prior assessment. Review of the resident's [NAME], printed 5/11/21, showed guidance for safety included keep bed in low position and blue mat on floor next to bed. Review of the resident's undated care plan, showed: -Focus: The resident is at risk for falls related to stroke with hemiplegia (paralysis to one side of the body). Resident is in new surroundings with overall decline in functioning ability. Falls on 3/25/21 and 3/31/21 documented; -Interventions included keep bed in low position and blue mat on floor next to bed. Observations of the resident, showed: -On 5/3/21 at 11:47 A.M., the resident lay in bed with eyes closed. Bed at regular height, not in low position. No fall mats on floor; -On 5/3/21 at 1:03 P.M., the resident seated in bed with eyes open, alert. Bed at regular height, not in low position. No fall mats on floor next to bed; -On 5/4/21 at 9:04 and 10:10 A.M., the resident lay in bed with eyes closed. Bed at regular height, not in low position. No fall mats on floor; -On 5/4/21 at 1:02 P.M., the resident seated in bed, with head of bed elevated 45 degrees. The resident slouched down so his/her lower back lay on the flat part of the bed, while he/she ate lunch. Bed at regular height, not in low position. No fall mat on floor; -On 5/5/21 at 12:58 P.M., the resident lay in bed with eyes closed. Bed in low position. No fall mat on floor; -On 5/6/21 at 7:53 A.M. and 11:14 A.M., the resident seated in bed with head of bed elevated 45 degrees. Bed at regular height, not in low position. No fall mat on floor; -On 5/10/21 at 8:47 A.M., the resident lay in bed. Bed in low position. No fall mat on floor; -On 5/13/21 at 8:54 A.M. and 12:35 P.M., the resident seated in bed with eyes open, alert. Head of bed elevated. Bed at regular height, not in low position. No fall mat on floor. 3. Review of Resident #15's quarterly MDS, dated [DATE], showed: -admission date of 10/14/20; -Adequate hearing/vision; -Ability to express ideas and wants: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to understand others: Usually understands - misses some part/intent of message but comprehends most conversation; -Brief interview for Mental Status (an assessment used to determine cognitive status) score of 7 out of a possible 15 (severely impaired cognition); -Required limited assistance of one person for bed mobility; -Required extensive assistance on one person for transfers, dressing, toilet use, personal hygiene and bathing; -Independent for locomotion on/off the unit; -Functional limitation of both lower extremities; -Mobility device: Wheelchair; -Diagnoses of renal (kidney) insufficiency, diabetes mellitus, stroke, hemiplegia (the complete loss or paralysis on one half of the body) or hemiparesis (minor to severe weakness of one half of the body) and manic depression (alternating moods of abnormal highs (mania) and lows (depression)); -No falls since admission or prior assessment. Review of the resident's care plan, showed: -At risk for falls related to bilateral lower extremity amputation and new surroundings; -The resident had actual falls on: -10/18/20: Found on floor next to bed; -10/25/20: Fall, slid out of wheelchair attempting to transfer unassisted; -10/31/20: Resident found on floor next to bed; -1/26/21: Fall transferring self from bed; -1/26/21: Another fall attempting to transfer, complained of right wrist pain; -1/27/21: Observed on floor next to bed; -2/10/21: Fall attempting to transfer from bed to wheelchair; -2/13/21: Fall attempting to transfer self without assistance; -2/23/21: Found on floor between wall and bed; -2/26/21: Fall transferring self to wheelchair unassisted; -3/4/21: Found on floor next to bed on fall mat; -4/8/21: Found on floor in front of toilet in his/her bathroom; -4/29/21: Fall transferring self from bed to wheelchair; Further review of the care plan, showed interventions included: -10/18/20: Remind resident to use call light to transfer safely; -10/31/20: Continue education. Bed in low position and fall mat next to bed' -1/27/21: Resident states understanding that it is unsafe to transfer self, will wait for assistance; -No date: Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed; -No date: The resident needs a safe environment, even floors, free from spills and/or clutter, reachable call light, the bed in lowest position at night with fall mat; -2/22/21: Ensure bed in lowest position and fall mat next to bed; -3/4/21: Continue to keep bed in lowest position with fall mat next to bed. Observations of the resident on 5/4/21 at 6:59 A.M. and 11:34 A.M., 5/5/21 at 7:07 A.M. and 7:37 A.M., 5/6/21 at 5:13 A.M., 7:50 A.M. and 8:17 A.M. and on 5/10/21 at 6:45 A.M., showed the resident lay in bed, his/her bed against the wall and the fall mat underneath the bed. Review of the 100 Hall Key Interventions form, kept in the [NAME] report book (used by CNAs), showed: -Remind resident to use call light to transfer for safety, wait for staff assist, stand by assistance for transfers. Fall risk, check on resident's needs such as toileting. Review of the resident's [NAME] report, showed the same interventions as listed on the resident's care plan. During an interview on 5/14/21 at 12:00 P.M., the Director of Nursing (DON) said the resident's fall mat is an intervention used to prevent or limit injuries to the resident from falls. When the resident is in bed, the fall mat should be positioned on the floor next to the bed and not underneath it. 4. Review of Resident #20's annual MDS, dated [DATE], showed: -admitted on [DATE]; -Severe cognitive impairment; -Required extensive assistance of one person physical assist for transfers; -Balance not steady when moving from seated to standing position, or surface-to-surface transfer; -Diagnoses included heart disease, dementia, non-traumatic brain dysfunction, and peripheral vertigo (problem with inner ear affecting balance); -Two or more falls since last assessment. Review of the resident's Fall Risk Evaluation, dated 3/17/21, showed: -Disoriented at all times; -Three or more falls in past three months; -Chair bound; -Balance problem while standing and walking; -Decreased muscular coordination; -At Risk of falls with a score of 20. Review of the resident's undated care plan, showed: -Focus: The resident is at risk for falls. Resident has history of falls. Resident can be impulsive and stands from wheelchair. Resident has dementia and decreased safety awareness. -2/5/21: fall to floor attempting to transfer self from bed; -3/17/21: fall from wheelchair in room; -3/21/21: fall transferring self from couch in lobby; -4/13/21: fall transferring self from wheelchair to couch; -5/4/21: removed seat belt and slid to floor from wheelchair; -Interventions included properly fitting footwear, and ensure bed is in lowest position and blue mat next to bed. Review of the resident's [NAME], printed on 5/11/21, showed guidance for safety included ensure bed is in lowest position and blue mat is next to bed, and properly fitting footwear. Observations on 5/3/21, showed: -At 8:35 A.M. and 10:39 A.M., the resident lay on his/her right side in bed, positioned low. A thin, gray fall mat on the floor, half underneath the bed with approximately 6 inches of the mat exposed on the left side of the bed. No fall mat on the right side of the bed; -At 10:59 A.M., the Assistant Director of Nurses (ADON) entered the room and exited within a few minutes; -At 11:07 A.M. and 12:19 P.M., the resident lay on his/her right side in bed with the fall mat unchanged in position, half underneath the bed; -At 12:28 P.M., CNA N entered the resident's room and left a lunch tray on his/her bedside table; -At 12:42 P.M., 1:12 P.M., and 3:11 P.M., the resident lay on his/her right side in bed, with the fall mat unchanged in position, half underneath the bed with approximately 6 inches of the mat exposed on the left side of the bed. Observations on 5/4/21, showed: -At 7:23 A.M., the resident seated in his/her wheelchair in the dining room, wearing regular socks and no shoes. No pedals on the wheelchair; -At 10:10 A.M., the resident lay on his/her right side in bed, positioned low. A thin, gray fall mat on the floor, mostly underneath the bed with several inches of the mat exposed on the left side of the bed. No fall mat on the right side of the bed. Observation on 5/11/21 at 4:51 P.M., showed the resident lay on his/her back in bed, positioned low. A thin, gray fall mat on the floor, completely underneath the bed. Observation on 5/13/21 at 8:34 A.M., showed the resident lay on his/her back in bed, positioned low. A thin, gray fall mat on the floor, completely underneath the bed. Observation on 5/14/21 at 9:26 A.m., showed the resident lay in bed with a cover over his/her head. Bed positioned low and a thin, gray fall mat on the floor, half underneath the bed with approximately 6 inches of the mat exposed on the left side of the bed. No fall mat on the right side of the bed. During an interview on 5/11/21 at 7:43 A.M., Nurse I said the resident has frequent falls and tries to transfer himself/herself all the time. The resident can unlock his/her wheelchair brake, unfasten his/her seat belt, and transfers himself/herself without assistance. His/Her bed should be in the low position, but ideally, his/her bed would be directly on the floor because more often, the resident falls when transferring to and from the bed. He/She has a fall mat that should be next to his/her bed, not underneath it; however, this might not be an effective intervention because he/she falls during transfers. 5. During an interview on 5/10/21 at 9:33 A.M., CNA BB said residents who have histories of falls should be wearing shoes and/or nonskid socks, and should be positioned correctly in their wheelchairs or if in bed, the bed should be low to the ground. He/She did not know how to identify which residents were a fall risk or which resident required specific fall interventions. Sometimes the back of a resident's wheelchair will show if they are a fall risk. To his/her knowledge, Residents #37, 69, and #20 have not had any recent falls. None of them have fall mats. If an aide comes across a resident who has fallen, they have to notify the nurse as soon as possible and the nurse will assess the resident. During an interview on 5/11/21 at 6:03 A.M., Nurse Q said if an aide comes across a resident who has fallen, they should notify the nurse right away. A resident should not be moved until the nurse completes a full assessment. The nurse should assess the resident's vitals, pain level, and range of motion. Neuro check protocol is initiated for all unwitnessed falls and any fall with a head injury. Neuro checks are performed to assess for head injury and should be completed every 15 minutes for an hour, then every 30 minutes, every hour, and every shift until 72 hours has passed. Neuro checks should be documented in the resident's EMR. During an interview on 5/11/21 at 7:58 A.M., Nurse I said neuro checks are initiated for all unwitnessed falls and falls with head injury. Neuro checks must be performed by the nurse, who assess a resident's cognition and range of motion. Neuro checks are done every 15 minutes, every 30 minutes, every hour, and every shift for 72 hours following a fall. They are documented in the resident's electronic medical record. It is not acceptable to stop neuro checks a day or so after the fall because they must be completed until 72 hours have passed in order to ensure there is no brain bleed or delayed injury. During an interview on 5/11/21 at 11:24 A.M. and 4:58 P.M., the DON said neuro checks should be initiated for unwitnessed falls and any fall with head injury, suspected head injury, or altered level of consciousness. If a fall is unwitnessed and the resident can tell staff what happened, then there is no need for neuro checks. Neuro checks should be performed by the nurse every 15 minutes, every hour, and every shift for the 72 hours following a resident's fall. They are performed to see if there are any neurological issues or injury, and should be documented in the resident's EMR. The circumstances of a fall should be investigated and documented in the resident's record. Falls are discussed in the daily clinical meetings, at which time staff discusses what interventions should be put in place. Falls are also discussed in the monthly Quality Assurance/Performance Improvement (QAPI) meetings. Fall interventions are added to the resident's care plan and [NAME]. The [NAME] is used by CNAs to determine what interventions they should implement. Fall mats should not be positioned under a resident's bed. They need to be on each side of the bed to be effective. Residents who are at risk of falls should be wearing nonskid socks or footwear, and when in bed, their bed should be positioned low. All staff, including housekeeping, are responsible for ensuring beds in the low position. 6. Review of Resident #384's face sheet, showed the following: -admission date of 5/5/21; -Diagnoses of abscess of the buttock, diabetes, high blood pressure and chronic kidney disease. Review of the resident's initial care plan, dated 5/6/21, showed the following: -Focus: Resident has an ADL deficit; -Intervention: Required moderate assistance of staff for bathing/showering two times per week. Required minimal assistance with bed mobility, dressing, personal hygiene and transfers. Review of the resident's progress note dated 5/21/21, showed the following: -9:55 A.M.: Resident complained of being tired and doesn't feel like him/herself. Resident's physician assessed him/her. New order received for urinalysis, Complete Blood Count (CBC, Laboratory test used to evaluate the cells that circulate in the blood), Basic Metabolic Profile (BMP, blood test used to check kidney function); -10:03 A.M.: Notified resident's significant family member of the physician's orders; -10:51 A.M.: Resident had a change of condition. New order received to send to the hospital for evaluation and treatment; -11:00 A.M.: Resident had a change of condition, very loose stools, change in mental status. During an interview on 5/21/21 at 6:15 P.M., Nurse TT, agency nurse, said he/she worked 5/20/21 from 6:00 P.M. until 6:30 A.M., on the 200 hall. During report, he/she asked how the resident was because when he/she last worked the floor, the resident had a cough. The nurse reported the resident slept most of the day but nothing unusual. When he/she made rounds on the hall, he/she saw the resident lay in the bed sleeping. During rounds, CNA UU reported the resident had diarrhea and was fussing about getting cleaned. He/She went into the room and spoke to the resident. He/She told the resident his/her bed was soiled and for him/her to allow CNA UU to clean him/her. He/She instructed CNA UU to clean the stool off the floor in the bathroom and clean the resident. He/She left the room. Not more than five minutes later, CNA UU reported the resident was on the floor. He/She reentered the room, observed the resident was on the floor and a skin tear to his/her hand close to the wrist. He/She asked CNA how the skin tear occurred. CNA UU reported the resident pulled away from him/her and lay on the floor when he/she tried to get him/her up so he/she could change the bed. He/She and CNA UU assisted the resident off the floor. He/she applied triple antibiotic ointment and a dressing. After CNA UU cleaned the resident's bed, the resident slept the rest of the night without further complaints. When asked why she failed to document the skin tear in the process note, Nurse TT said he/she became busy and forgot to document. He/she did not notify the oncoming shift regarding the skin tear or the incident. During an interview on 5/21/21 at 4:40 P.M., Nurse I said he/she was one of the nurses who worked the day shift on the 200 hall. He/she started the shift at 6:00 A.M., this morning, 5/21/21. During rounds, he/she noticed a change in the resident's mental status and he/she was having diarrhea. This was not his/her normal behavior. They notified the physician and received an order to send him/her to the hospital for evaluation. He/she did see the dressing on the resident's right wrist. He/She didn't remove the dressing. The was nothing documented in the report regarding the resident's dressing, diarrhea or a fall. During an interview on 5/21/21 at 5:00 P.M., Nurse VV said he/she arrived to start the shift at 6:00 A.M. He/she received report from Nurse TT. Nurse TT did not report any concerns regarding the resident. Nothing was reported about a fall or a skin tear. The resident did not report anything unusual to him/her. During an interview on 5/24/21 at 1:10 P.M., the ADON said he was unaware the resident fell or had a skin tear until this surveyor asked about it on 5/21/21. He would have expected Nurse TT to complete the Risk Management/Incident Report in the electronic record, notify the DON/ADON regarding the incident, notify the physician, obtain a treatment order and document it in the resident's progress note. MO00171991

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent urinary tract infections (UTIs) by failing to adequately assess and report changes regarding an indwelling urinary catheter (a tube inserted into the bladder for the purpose of continual urine drainage) for one resident (Resident #224), and by failing to provide appropriate indwelling urinary catheter positioning for three residents (Residents #51, #19 and #59). The facility identified four residents as having indwelling urinary catheters. All four residents were chosen for the sample and problems were found with all four. The sample was 18. The census was 75. Review of the facility's indwelling urinary catheter care policy, dated January 2020, showed: -Procedure: -Provide perineal care (peri-care) first prior to catheter care; -Check catheter to make sure positioning promotes proper flow of urine, no pulling present, and catheter bag is below level of bladder; -Notify physician of any concerns; -Document all changes. 1. Review of Resident #224's face sheet, showed: -admitted on [DATE]; -Diagnoses included degenerative disease of nervous system, heart disease, heart attack, diabetes, and major depressive disorder. Review of the resident's discharge orders from his/her previous facility, printed 4/9/21, showed a physician's order, dated 4/6/21 through 4/11/21, for ciprofloxacin (Cipro, an antibiotic) 500 milligrams (mg) one tab every 12 hours for five days for a UTI. Review of the resident's primary care physician's (PCP) progress note, dated 4/9/21, showed: -Medication list included Cipro 500 mg every 12 hours for 5 days; -Assessment/Plan: UTI, treatment Cipro for 5 days, Enterobacter (a gram-negative bacteria). Review of the resident's physician order sheet (POS) and medication administration record (MAR) for April 2021, showed no orders for ciprofloxacin, or documentation of the medication as administered. Review of the resident's clinical admission evaluation, dated 4/9/21, showed: -Body System Baselines: Resident continent of bladder. Urine clear yellow. Denies urinary complaints; -Mental status: Alert and oriented x 3. -General note: Resident came from another facility. He/she has a urinary catheter size 18 French (fr) with 30 cubic centimeter (cc) balloon draining amber urine. Further review of the resident's POS, showed: -An order, dated 4/22/21, to change urinary catheter with 18 fr with a 30 cc balloon every morning on the 15th for UTI, starting on 5/15/21; -No physician's orders for catheter care or catheter changes as needed (PRN). Review of the resident's care plan, undated and in use at the time of survey, showed no documentation regarding the resident's indwelling urinary catheter. Review of the resident's progress notes, from 4/22/21 through 5/3/21, showed no documentation of the resident experiencing a decline in his/her health status. No documentation of the resident experiencing hallucinations or increased lethargy, or issues with his/her catheter. Observations on 5/3/21, showed: -At 8:42 A.M., 9:21 A.M., 10:47 A.M., 11:45 A.M., and 12:01 P.M., the resident lay on his/her back in bed with eyes closed, dressed in a hospital gown with his/her lower legs uncovered. A catheter bag hung on the right side of the resident's bed, visible from the doorway to the room, with pink-tinged urine and thick strings of mucus in the catheter tubing; -At 12:13 P.M., Certified Nurse Aide (CNA) N entered the resident's room and shut the door; -At 12:25 P.M., CNA N exited the resident's room. The resident remained on his/her back in bed with eyes closed and his/her catheter tubing remained full of pink-tinged urine and thick strings of mucus, visible from the doorway to the resident's room; -At 12:34 P.M., Certified Medication Technician (CMT) C delivered a lunch tray to the resident's room. He/She uncovered the resident's lunch plate and opened his/her cup of fruit, then left the resident's room. The resident remained in bed with his/her eyes closed and food untouched. His/Her catheter tubing remained full of pink-tinged urine and thick strings of mucus, visible from the doorway to his/her room; -At 1:06 P.M., CNA N entered the resident's room and called the resident's name. The resident opened his/her eyes and took several bites of potato salad and watermelon. His/her catheter bag remained hanging on the right side of the bed, and the catheter tubing remained full of pink-tinged urine and thick strings of mucus, visible from the doorway to the resident's room. Observations on 5/4/21, showed; -At 7:02 A.M., the resident lay on his/her back in bed. A catheter bag hung on the right side of the resident's bed, visible from the doorway to the room, with pink-tinged urine and thick strings of mucus in the catheter tubing; -At 7:32 A.M., staff delivered a breakfast tray to the resident's room and the resident pushed food around on his/her plate; -At 9:12 A.M., the resident lay on his/her back in bed with eyes closed. CNA P entered the resident's room and exited a minute later. The resident remained on his/her back in bed. His/her catheter bag remained hanging on the right side of the bed, and the catheter tubing was full of pink-tinged urine and thick strings of mucus, visible from the doorway to the resident's room; -At 10:10 A.M. and 1:02 P.M., the resident lay on his/her back in bed with eyes closed. His/her catheter bag remained hanging on the right side of the bed, and the catheter tubing was full of pink-tinged urine and thick strings of mucus, visible from the doorway to the resident's room. Observations on 5/5/21, showed: -At 7:35 A.M., the resident lay on his/her right side in bed. A catheter bag hung on the right side of the bed, and the catheter tubing was full of pink-tinged urine and thick strings of mucus, visible from the doorway to the resident's room; -At 7:47 A.M., the resident remained on his/her back in bed with his/her catheter bag hanging on the right side of the bed. CNA O sat in a chair next to the resident's catheter tubing, while he/she fed the resident breakfast; -At 9:47 A. M, 11:27 A.M., and 1:01 P.M., the resident lay in bed with eyes closed. His/Her catheter bag remained hanging on the right side of the bed, visible from the doorway to the room, with pink-tinged urine and think strings of mucus in the catheter tubing. Observations on 5/6/21, showed: -At 7:53 A.M., the resident lay on his/her back in bed. His/er catheter bag hung on the right side of the bed with pink-tinged urine and thick strings of mucus in the catheter tubing. A staff member sat in a chair next to the resident's catheter tubing, while he/she fed the resident breakfast; -At 11:14 A.M., the resident remained on his/her back in bed. His/Her catheter bag remained hanging on the right side of the bed, visible from the doorway to the room, with pink-tinged urine and think strings of mucus in the catheter tubing. Review of the resident's progress notes, from 5/3/21 through 5/6/21, showed no documentation of the resident experiencing a decline in his/her health status. No documentation of the resident experiencing hallucinations, increased lethargy, or issues with his/her catheter. Review of the resident's psychiatrist's note, dated 5/7/21, showed: -History: Patient seen, chart reviewed, obtained verbal update from staff. Nursing notes reviewed, no report regarding mood since last visit. Verbally, nursing reported patient has been declining, has not been eating. Primary physician started antidepressant medication trial on 4/22/21. Staff also reported patient has been hallucinating, appears to be talking to people and calling them by name. Further reported to be intermittently sleeping more and not eating very well; -Assessment and Plan: Given presence of active hallucinations, recommend decreasing sedating medications. Discontinue one antidepressant medication and decrease anticonvulsant medication for five days, then discontinue. Requesting to rule out UTI. Review of the resident's handwritten physician orders, showed on 5/7/21, the psychiatrist documented his/her recommendation to discontinue medications as indicated in his/her progress note, and to obtain a urinalysis with culture and sensitivity (a test to determine if there is infection and if so to identify what the organism is and what medication will treat it) if necessary for diagnoses of acute hallucinations. No documentation staff communicated the psychiatrist's recommendation to the PCP. Review of the resident's progress note, dated 5/10/21 at 8:30 A.M., showed staff documented the resident was lethargic, responds to verbal and physical stimuli. Urinary catheter intact with some mucus in tubing. Unable to make needs known. Will continue to monitor. No documentation staff notified the PCP of the resident's condition. Observations on 5/10/21 at 8:46 A.M. and 12:25 P.M., showed the resident lay on his/her back in bed with eyes closed. His/Her catheter bag hung on the right side of the bed, visible from the doorway to the room, with pink tinged urine and thick strings of mucus in the catheter tubing. Observation on 5/11/21 at 6:03 A.M., showed the resident lay on his/her back in bed with eyes closed. His/her catheter bag hung on the right side of the bed, with pink-tinged urine and thick strings of mucus in the catheter tubing. Nurse Q entered the resident's room and observed the catheter tubing. During an interview, Nurse Q, said he/she was the nurse assigned to the resident's hall that night. He/she had not noticed the pink-tinged urine and mucus in the catheter tubing until now. The catheter tubing appeared to contain blood-tinged sediment. The resident might have hematuria (blood in the urine). If one of the CNAs noticed this before, they should have reported it to the nurse right away. The nurse would have to assess the resident, obtain his/her vitals, and see if the resident had a fever. This should be reported to the physician. The resident could have a UTI or the hematuria could be from his/her catheter getting yanked. During an interview, on 5/11/21 at 7:58 A.M., Nurse I said he/she saw the resident's catheter tubing earlier that morning and it looked full of sediment, but he/she has not made his/her way to the resident to pass medication yet, and has not checked the resident's catheter bag. The resident might be on a medication that causes his/her urine to have a pink tinge. He/she reviewed the resident's POS in the electronic medical record (EMR) and noted the resident was not prescribed medication that would cause his/her urine to have a pink tinge. The POS showed orders to change the resident's catheter on 5/15/21, but there were no orders to change the catheter on an as needed (PRN) basis. Nurse I said the resident's urine might have a pink tinge because he/she drinks cranberry juice. Observation showed, Nurse I entered the resident's room, donned gloves, and pulled the resident's catheter bag out of the protective covering. He/she said there is sediment in the bottom of the bag, and pink-tinged sediment in the catheter tubing. The pink-tinged sediment does not appear to be hematuria (blood in the urine). The catheter might need to be irrigated and the bag should be changed. He/she will have to assess the resident and notify the physician. The resident should have physician's orders for PRN catheter changes and flushes. CNAs should be looking at catheter tubing when they provide care, and if they notice a pink tinge, they should notify the nurse right away. The resident does not usually complain of pain. He/she sleeps all the time. During an interview on 5/11/21 at 11:24 A.M., the Director of Nurses (DON) said no one told her about issues with the resident's catheter. If the nurse notices a resident's catheter tubing is filled with pink-tinged sediment or mucus, they should notify the physician and change the catheter. The nurse should assess the resident for signs and symptoms of a UTI, get a current temperature on him/her, and document any increased confusion, lethargy, or changes to level of consciousness. The resident has been tired since admitted to the facility. Staff need to follow up about his/her catheter. If there are only orders to change his/her catheter once a month, the nurse should notify the physician to get orders for PRN catheter changes. Review of the residents' medical record, showed: -A nurse's note entered on 5/11/21 at 11:53 A.M., in which staff documented the resident is experiencing altered mental status. PCP notified and an order was given to obtain a urinalysis with culture if indicated; -No temperature documented on 5/11/21. Observation on 5/11/21 at 12:39 P.M., showed the resident on his/her back in bed. His/her catheter bag hung on the right side of the bed with clear catheter tubing, draining yellow urine. During an interview, Nurse I said the physician was notified of the resident's pink-tinged urine and orders were received to obtain labs to check for a UTI. At 12:44 P.M., CNA K began feeding the resident lunch. The resident laughed to him/herself, and talked nonsensically. During an interview on 5/12/21 at 8:05 A.M., CNA P said the resident never comes out of his/her room and sleeps all day. He/She does not refuse care from staff, and allows them to provide peri-care as needed. CNAs are supposed to clean catheters when they provide peri-care. The resident is still incontinent of bowel, so it is important to make sure and clean his/her catheter after a bowel movement. If CNAs notice issues with catheter tubing, such as it looking clogged, they must report it to the nurse. CNA P noticed mucus and sediment in the resident's catheter tubing last week and discussed it with the other nursing staff, but they didn't know what the cause was. Observations on 5/12/21, showed: -At 8:44 A.M., the resident sat upright in bed, eating breakfast. His/her catheter bag hung on the right side of the bed, with yellow urine in the catheter tubing; -At 10:01 A.M., the resident sat upright in bed, talking and laughing to him/herself. His/her catheter bag hung on the right side of the bed, with yellow urine in the catheter tubing. Observation on 5/13/21 at 8:49 A.M., showed Nurse I sat in a chair next to the right side of the resident's bed, next to the resident's catheter bag. Pink-tinged urine and thick strings of mucus were in the catheter tubing. The resident talked nonsensically and laughed to him/herself. During an interview, Nurse I said the resident had red in his/her urine again. His/her urine was collected and sent to the lab, and the results were pending. Review of the resident's partial lab results, collected on 5/11/21 and reported to the facility on 5/14/21, showed: -Blood: 3+, abnormal (normal range: negative); -Leukocytes: 2+, abnormal (normal range: negative); -White blood count: 21-50, abnormal (normal range: less than 6); -Bacteria: Many, abnormal (normal range: negative); -Mucous: Present, abnormal (normal range: absent); -Results met criteria to perform urine culture. During an interview on 5/14/21 at 12:01 P.M., the DON said CNAs are the front line staff and should be keeping their eyes on resident catheters. If they notice any issues, they need to report it to the nurse right away. All residents with catheters should have orders for nurses to be able to change catheters and tubing PRN. The resident's labs were received, and showed abnormal values with culture indicated. Staff should have notified the nurse about the resident's catheter issues sooner than they did. Review of the resident's medical record, showed the urinalysis with culture and sensitivity, collected on 5/11/21 and reported on 5/15/21, was reported to the physician. The physician said the counts were low, likely due to colonization (there is bacteria in the urine, but there are no signs or symptom and it is not causing illness), and no new orders were received. During an interview on 5/17/21 at 2:25 P.M., the DON said the resident's urinalysis culture was reviewed by the PCP, who determined the culture was colonized. No new orders were received. Prior to the resident's admission to the facility, he/she was prescribed Cipro for a UTI. The medication was ordered on 4/6/21 and should have been administered through 4/11/21. When admitted to the facility, it doesn't look like his/her orders for Cipro carried over and she does not see documentation of the medication as administered by the facility in April 2021. The physician should have been notified to obtain approval for transferring physician's orders and the resident should have received his/her full course of the antibiotic. During the survey from 5/3/21 though 5/13/21, 31 licensed nursing staff worked on the resident's hall. 2. Review of Resident #51's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/21, showed: -admission date of 3/1/21; -Total dependence of one person for bed mobility, toilet use and bathing; -Total dependence of two (+) persons for transfers; -Extensive assistance of one person for dressing and personal hygiene; -Indwelling urinary catheter; -Diagnoses of septicemia (body wide bacterial infection), UTI in the past 30 days, paraplegia (paralysis of the legs and lower body) and anxiety; -Special treatments and programs: IV (intravenous) medications while not a resident. Review of the resident's care plan, undated, showed: -admitted with indwelling catheter; -Resident will show no signs and symptoms of urinary infection through next review; -Position catheter bag and tubing below the level of the bladder and away from entrance room door; -4/17/21: readmitted with UTI and sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues); -4/17/21: Continue to administer antibiotic therapy as ordered. Observation on 5/4/21 from 6:50 A.M. until 9:14 A.M., showed the resident lay in bed sleeping. His/her catheter bag was full of urine and laying on the floor between the bed and the window. At 9:30 A.M., the resident lay in bed sleeping, his/her catheter bag remained on the floor full of urine. At 11:46 A.M., the resident's catheter bag had been emptied and was off the floor hanging from the bed frame. During an interview on 5/10/21 at 7:10 A.M., Nurse I said the resident had a fever of 101.7 and was being sent to the hospital. Review of the resident's hospital emergency room notes, dated 5/10/21 at 9:27 A.M., showed he/she was admitted with diagnoses that included severe sepsis with septic shock and UTI associated with indwelling urinary catheter. During an interview on 5/14/21 at 12:00 P.M., the DON said catheter bags should not be on the floor for infection control reasons. The resident was readmitted to the facility that day with a new urinary catheter. 3. Review of Resident #19's annual MDS, dated [DATE], showed: -Diagnoses of quadriplegia, diabetes and depression; -Short/long term memory loss; -Required total assistance of staff for all activities of daily living; -Urinary catheter into the bladder. Review of the resident's care plan, updated 4/21/21, showed: -Focus: Indwelling catheter; -Goal: Will be/remain free from catheter-related trauma; -Intervention: Check tubing for kinks routinely. Change catheter as ordered. Provide privacy bag. Ensure catheter bag is below the bladder. Provide catheter care each shift. Review of the resident's POS, dated 5/21, showed an order to change the catheter every month on the 24th. Observation on 5/3/21 showed: -At 9:03 A.M., the resident lay in bed on a low air loss mattress with the catheter drainage bag on the floor on the right side of the bed, without a cover over the bag; -At 12:32 P.M., the resident lay on his/her back. The catheter bag remained on the floor without a cover over the bag. 4. Review of Resident #59's quarterly MDS, dated [DATE], showed: -Diagnosis of Multiple Sclerosis; -No short/long term memory loss; -Required total staff assistance for all activities of daily living; -Suprapubic catheter (a tube placed surgically through the abdomen into the bladder, used to drain urine). Review of the resident's care plan, undated, showed: -Focus: Resident has a Suprapubic Catheter. Resident has a diagnosis of Neurogenic Bladder (lack of bladder control due to brain, spinal cord or nerve problem); -Resident will remain free from catheter-related trauma; -Intervention: Position catheter bag below the the level of the bladder and away from the entry room door. Monitor and document output as ordered. Monitor/record/report to physician for signs and symptoms of UTI, pain, burning, blood tinged urine, cloudiness, no out put, increased temperature, foul smelling urine, fever, chills, altered mental status and change in behavior. Observation on 5/12/21 at 9:43 A.M., during a transfer, showed the resident lay in bed with a full bulging catheter drainage bag. CNA F and CNA K positioned the lift pad under the resident and attached the drainage bag to the Hoyer Lift (a machine used to lift and transfer dependent residents). The resident asked CNA F whether he/she would empty his/her catheter drainage bag prior to transfer. CNA F replied CNA K would empty it. During the transfer, urine flowed backward (up toward the bladder) in the tubing. CNA K emptied the drainage bag of 1000 cc of urine. 5. During an interview on 5/14/21 at 11:47 A.M., the DON said she would expect staff to empty the drainage bag prior to transferring the resident to the wheelchair. Draining the urine from the bag will prevent a backflow of urine in the tubing. Urinary catheters tubing and bags should be kept off the floor for infection control. In addition, catheter bags should be place in a privacy bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy for hemodialysis (dialysis, the mechanical treatment of blood to clean it of impurities and excess fluids when the body's kidneys are not working properly) by failing to consistently assess residents' shunts (the connection from a hemodialysis access point to a major artery) and/or fistulas (a surgical connection made between an artery and a vein used for hemodialysis), failing to consistently communicate with the dialysis units and failing to ensure residents wore an identification bracelet showing in which arm the shunt/fistula was located. The facility identified two residents as receiving dialysis. One resident (Resident #15) was sampled, one resident was selected as an expanded sample (Resident #382) and problems were identified with both residents' care. The sample was 18. The census was 75. Review of the facility Clinical Management Hemodialysis policy, last revised on 5/1/2018, showed: Protocol: -The facility has designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of hemodialysis residents; Procedure: -Contractual agreement will include, but may not be limited to, the following: Medical and non-medical emergencies, development and implementation of resident's care plan, and interchange of information useful/necessary for the care of the resident; -Obtain a clear understanding of roles and responsibilities between the facility and the dialysis center and define in writing. This will include: Responsibility of monitoring lab values, how physician's orders will be validated and how physician's orders will be communicated between the nursing staff; -Assure assessment and documentation of fistula or graft (type of access used for hemodialysis and usually placed in the arm) site; -Manage special dietary regime and dietary restrictions as ordered. Review of the facility's Dialysis Policy for facility staff, undated, showed: -Dialysis patients must not have their blood pressure taken in the arm where the shunt/fistula is located; -An alert bracelet will be placed on the arm with the fistula/shunt to assist with identifying the arm with the fistula/shunt; -Dialysis patients must have a pre/post assessment on dialysis days; -The facility will maintain ongoing communication with the dialysis centers. Review of the facility's Dialysis Communication Form, showed the following information to be communicated to, and received from, the dialysis centers: Information to be completed by the facility: -Attending physician; -Facility nurse or contact person; -Care plan meeting and update information; -Medications administered; -Meal provision; -Condition alert; Information to be completed by the dialysis center: -Pre-weight; -Post-weight; -Dialysis completed without incident?; -Problem with access graft/catheter?; -Lab work completed?; -Medications given at dialysis; -Recommendations. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/18/21, showed: -admission date of 10/14/20; -Ability to express ideas and wants: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to understand others: Usually understands - misses some part/intent of message but comprehends most conversation; -Brief interview for Mental Status ((BIMS), an assessment used to determine cognitive status) score of 7 out of a possible 15 (severely impaired cognition); -Required limited assistance of one person for bed mobility; -Required extensive assistance of one person for transfers, dressing, toilet use, personal hygiene and bathing; -Independent for locomotion on/off the unit; -Functional limitation of both lower extremities; -Mobility device: Wheelchair; -Diagnoses of renal (kidney) insufficiency, diabetes mellitus, stroke, hemiplegia (the complete loss or paralysis on one half of the body) or hemiparesis (minor to severe weakness of one half of the body) and manic depression (alternating moods of abnormal highs (mania) and lows (depression)); -Dialysis. Review of the resident's undated care plan, in use during the survey, showed: -Receives dialysis on Tuesday, Thursday and Saturday.; -Assist with transfer needs when going to dialysis; -Shunt in left forearm; -Check for bruit (a rumbling sound that you can hear) and thrill (a rumbling sensation that you can feel) and notify the dialysis center if not present;; -Check for new orders upon return from dialysis; -Maintain communication with dialysis center staff; -No blood pressures or blood draws in left arm. Review of the resident's medical record for Dialysis Communication Forms, showed the forms were completed and sent to the resident's dialysis unit on the following dates: -10/26/20, 10/29/20, 11/3/20, 11/23/20, 11/28/20, 12/1/20, 4/20/21 and 4/29/21; -The facility could not provide any other dialysis communication forms. Review of the resident's physician's order sheet (POS), showed an order, dated 11/12/21, for staff to check fistula on left arm for bruit and thrill each shift. Review of the resident's treatment administration record (TAR) for 3/2021, 4/2021 and 5/1/21 through 5/10/21, showed the following: -11/12/20: An order dated 11/12/20 for staff to check fistula site left arm for bruit and thrill each shift (there are two shifts a day for nurses); -Staff did not initial the bruit and thrill was checked two of 62 times for March, seven out of 60 times for April and six out of 20 times from 5/1/21 through 5/10/21. Review of the resident's [NAME] report book (kept at the nurse's station for certified nurses aides (CNAs) to refer to regarding residents' care) on 5/5/21 at 10:00 A.M., showed the same interventions as those on the care plan. Observations of the resident on the following dates and times, showed the resident had no identification bracelet on his/her left arm: -5/3/21 at 10:15 A.M.; -5/4/21 at 6:59 A.M., 7:48 A.M. and 11:34 A.M.; -5/5/21 at 7:07 A.M., 8:42 A.M. and 10:59 A.M.; -5/6/21 at 5:13 A.M., 7:50 A.M. and 9:06 A.M.; -5/12/21 at 7:58 A.M. During an interview on 5/13/21 at 7:52 A.M.,, the Assistant Director of Nurses (ADON) said he was not aware their policy showed a dialysis resident would wear an identification bracelet on the arm with a shunt or fistula. He was not aware the resident did not have an identification bracelet. 2. Review of Resident #382's admission face sheet, showed: -An admission date of 4/30/21; -Diagnoses of end stage renal disease, anemia (low red blood cells) and diabetes mellitus. Review of the resident's undated care plan, in use during the survey, showed: -Receives dialysis on Monday, Wednesday and Friday at 8:30 A.M.; -Assist with transfers as needed when going to dialysis; -Check for new orders upon return from dialysis; -Maintain communication with dialysis center staff; -Dialysis pre/post assessment to include vitals and description of site and bruit and thrill; -Limb alert bracelet placed on arm where new fistula is placed; -No blood pressure or lab draw in arm with fistula. Review of the resident's current POS, in use during the survey, showed no order for staff to check the fistula on the right forearm. Review of the resident's TAR, dated 5/1/21 through 5/11/21, showed: -From 5/1/21 through 5/10/21, no order for staff to check the fistula on the right forearm; -5/11/21: An order for staff to check the fistula on the right forearm for bruit and thrill each shift. Observation of the resident on 5/13/21 at 7:52 A.M., showed the resident sitting on the side of his/her bed, eating breakfast. The fistula and dressing on his/her right forearm were visible. The ADON was in the room. The resident was not wearing an identification bracelet on his/her right wrist. During an interview on 5/13/21 at 7:52 A.M.,, the resident showed his/her fistula, which was located on his/her right forearm. The ADON, who was present during the interview, said he was not aware their policy showed a dialysis resident would wear an identification bracelet on the arm with a shunt or fistula. Review of the resident's medical record, showed facility staff had not sent any Dialysis Communication Forms with the resident to dialysis. 3. During an interview on 5/11/21 at 6:55 A.M., Agency Nurses Q and OO said they thought there was a dialysis book kept at the nurse's station, but neither one knew what was in them. They had not been inserviced to document on dialysis patients' fistula/shunt sites or bruit and thrill. Neither nurse knew dialysis residents should wear an identification bracelet on the fistula/shunt arm and neither were aware of the Dialysis Communication Forms. During an interview on 5/11/21 at 7:35 A.M., the Director of Nurses said she expected staff to document an assessment of the fistula/shunt site every shift. Staff should document bruit and thrill and what the fistula/shunt site looked like (bleeding, infections, etc.). It has been difficult for the facility to get information from the dialysis units. She had been at the facility since February, 2021 and did not know the facility had communication forms to send with residents on their dialysis days. During an interview on 5/11/21 at 10:16 A.M., the ADON stated he could not find any more dialysis communication forms for Resident #15 and Resident #382 and said the nurses are not good about sending the dialysis communication forms like they should.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents using bed/side rails, had adequate assessments to determine the side rails were appropriate and safe to be used and/or had physician's orders. The facility identified 17 residents that utilize side rails. Four residents were sampled for the use of side rails (Residents #13, #19, #69, and #224), two identified by the facility as using side rails (Residents #19 and #224) and two who had side rails but not identified by the facility as having side rails (Residents #13 and #69). The sample was 18. The census was 75. Review of the facility's Bed Rails policy, dated 11/27/19, showed: -The facility will attempt to use appropriate alternatives prior to installing a side rail or bed rail. If a bed/side rail is used the facility will verify correct installation, use, and maintenance of bedrails; -Protocols: -Assess the resident for risk of entrapment from bed rails prior to installation; -Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation; -Ensure that the bed's dimensions are appropriate for resident's size and weight; -Follow the manufacturer's recommendations and specifications for installing and maintaining bed rails; -Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars, and assist bars; -In the event that bedrails are necessary the facility will adhere to the following policies: -A physician's order must be present which clarifies the exact type of bed rail to be utilized, duration, and medical symptoms present secondary to diagnosis; -Bed rails are to be checked every shift and as needed (PRN). This is to be documented on the treatment administration record (TAR); -If a resident has an order for bed rails the nurse will complete the Bed rail Evaluation/Assessment; -The Bed rail Evaluation/Assessment will be completed initially, quarterly, significant change, annually, and PRN; -Bed rails will be checked by Maintenance monthly to verify they are secured/installed properly to the resident's bed frame. 1. Review of Resident #13's medical record, showed: -admitted to facility on 10/6/20; -Diagnoses included stroke, dementia, and dysphagia (swallowing disorder) following stroke; -A physician's order, dated 10/6/20, for side rail assessment to be done on admission and quarterly every three months, starting on the 7th; -No active physician's orders for use of side rails. Review of the resident's Bed Rail Evaluation, dated 10/6/20, showed: -Cognition: Current cognitive status includes poor short term memory, poor long term memory, safety impairment, fall risk. Dementia may affect resident's safety awareness. Can resident communicate needs: No; -Medical: Diagnoses include stroke, dysphagia, dementia. Total dependence with two (+) person physical assist needed for bed mobility; -History/alternatives attempted: Previous intervention of high-low bed. Describe why these alternatives did not work, prompting need for bed rails: Resident can't follow direction; -Type of mattress used: Low air loss; -Bed rail information: Half-length rail requested. Power of Attorney requested bed rail for safety. Physician order obtained 10/6/20; -Risks of bed rail use discussed with resident/legal representative: Immobility, increased confusion, and incontinence. Staff did not indicate discussing risk of entrapment, temporary/permanent bodily injury, increased falls, strangulation/asphyxiation, or death; -Reason for recommendation/use: Safety; -Determination: The bed rail use impedes the resident's freedom of movement. Review of the resident's incident notes, showed: -On 11/24/20 at 5:57 A.M., staff documented certified nurse aide (CNA) reported that he/she just finished rounds around 1:30 A.M., on the resident. When the CNA checked on resident, he/she was found with his/her neck between the side rails and the bed. Nurse assessed resident and no injuries observed, no signs of pain. Vitals obtained. Physician was notified of the incident; -On 11/24/20 at 2:53 P.M., staff documented as per the employee's statement, the resident's head was between the bed rail and mattress. Side rails have been taken off. Review of the facility's investigation, submitted to the Department of Health and Senior Services within the required timeframe, showed statements regarding the incident were obtained from staff. The CNA demonstrated how the resident was found during rounds, with his/her head between the mattress and bed rail. The IDT (interdisciplinary team) decided that residents with dementia and poor mobility should be assessed to have bed rails removed. Review of the resident's Bed Rail Evaluation, dated 11/24/20, showed: -Cognition: Current cognitive status includes able to retain safety information and safety impairment. Resident totally dependent for bed mobility and transfers, also unable to communicate needs; -History/alternatives attempted: High-low bed, and anticipating hunger, pain, heat, and cold. Describe why these alternatives did not work, prompting need for bed rails: Resident cannot follow direction or communicate needs; -Reason for recommendation/use: Not recommended; -Determination: The bedrail use impendes the resident's freedom of movement. Resident does not use side rails. Review of the resident's incomplete Bed Rail Evaluation, dated 12/4/20, showed: -Cognition: Current cognitive status includes able to retain safety information. How this may affect the resident's safety awareness: Getting his/her head stuck; -Type of bedrail requested: None; -Reason for recommendation/use: None; -Determination: blank. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/21, showed: -Severe cognitive impairment; -Extensive assistance of one person physical assist required for bed mobility; -Total dependence of two (+) person physical assist required for transfers; -Upper and lower extremities impaired on both sides; -Bed rails not used. Review of the resident's care plan, undated and in use at the time of survey, showed: -Focus: The resident has an activities of daily living (ADL) self-care performance deficit related to overall decline in functioning ability related to stroke. Resident totally dependent with bed mobility. At risk for entrapment; -Interventions included the resident is totally dependent on one staff for repositioning and turning in bed; -No documentation regarding the use of side rails. Further review of the resident's medical record, showed no Bed Rail Evaluations completed after 12/4/20. Observations on 5/3/21 at 8:45 A.M. and 10:51 A.M., 5/4/21 at 7:17 A.M. and 9:04 A.M., 5/5/21 at 7:40 A.M. and 9:45 A.M., and 5/6/21 at 7:53 A.M. and 11:14 A.M., showed the resident lay in bed, on a pressure reducing mattress, with U-shaped side rails raised on both sides, at the head of the bed. During an interview on 5/13/21 at 9:59 A.M., the Assistant Director of Nurses (ADON) said in November 2020, the resident was able to hold onto side rails for repositioning. Certified medication technician (CMT) C said when the CNA did rounds one night that month, he/she found the resident on the side of his/her bed with his/her knee on the floor and head against the quarter-length rail on the side of his/her bed. CMT C was called to the room, observed the resident, and notified the nurse. The nurse assessed the resident, who did not have any injuries or complaints of pain. After this incident, the quarter-length rails were removed from his/her bed. The ADON said the resident was given U-shaped side rails he/she could hold onto to maintain positioning when receiving care. He/she has since declined and can no longer use the side rails. The side rails should have been removed a while ago. 2. Review of Resident #19's annual MDS, dated [DATE], showed: -admitted to facility on 11/21/13; -Moderate cognitive impairment; -Total dependence of one person physical assist required for bed mobility, and two (+) person physical assist required for transfers; -Upper and lower extremities impaired on both sides; -Diagnoses included quadriplegia (paralysis of all four limbs), muscle spasms, and depression; -Bed rails not used. Review of the resident's physician's order sheet (POS), showed: -An order, dated 5/8/19, for may have side rails per resident request. Type of side rail not specified; -An order, dated 3/9/21, for side rail assessment to be done on admission and quarterly every three months, starting on the 15th. Review of the resident's Bed Rail Evaluation, dated 4/6/21, showed: -Cognition: Current cognitive status includes alert and able to follow instructions; -Medical: Diagnoses include quadriplegia. Total dependence with two (+) person physical assist needed for bed mobility; -History/alternatives attempted: Previous intervention of high-low bed. Describe why these alternatives did not work, prompting need for bedrails: Resident has fear and requests bed rails. Family representative agrees; -Type of mattress: Standard; -Bed rail information: Quarter-length rail requested. Physician requested bed rail. Physician order for four quarter-length bed rails obtained 3/28/17; -Risks of bed rail use discussed with resident/legal representative: Loss of independence. Staff did not indicate discussing risk of entrapment, temporary/permanent bodily injury, increased falls, strangulation/asphyxiation, or death; -Reason for recommendation/use: Resident requested. Review of the resident's care plan, undated and in use at the time of survey, showed: -Focus: The resident has an ADL self-care performance deficit related to quadriplegia with spinal cord injury, contracture right elbow and hand. Resident requires total care from staff. On 7/15/20, resident found with head resting against bed rail causing abrasion; -Interventions included: -The resident is totally dependent on one staff for repositioning and turning in bed as necessary. Resident may have four side rails for bed mobility and positioning as needed. On 7/15/20, resident must be positioned using wedges and pillows to keep body away from bed rails. 8/25/20, bed rails requested to remain and padded with pillows (discontinued 5/11/21). Observation on 5/3/21 at 9:03 A.M. and 5/4/21 at 9:26 A.M., showed the resident lay in bed, on a low air loss mattress, with one quarter-length side rail raised on both sides, at the head of the bed. 3. Review of Resident #69's medical record, showed: -admitted to facility on 1/30/20; -Diagnoses included unsteadiness on feet, stroke, traumatic brain bleed with loss of consciousness for unspecified duration, dysphagia following stroke, attention and concentration deficit following stroke, and depression; -A physician's order, dated 1/31/20, for side rail assessment to be done on admission and quarterly every three months, starting on the 1st; -No active physician orders for use of side rails. Review of the resident's Bed Rail Evaluation, dated 2/1/21, showed: -Cognition: Current cognitive status includes poor short term memory, poor long term memory, delirium. How above areas may affect resident's safety awareness: Difficult to follow instructions; -Medical: Diagnoses not listed. Extensive assistance of two (+) person physical assist needed for bed mobility; -History/alternatives attempted: Previous intervention of family companion. Describe why these alternatives did not work, prompting need for bedrails: not applicable; -Resident's height and weight not documented; -Bed rail information: Quarter-length rail requested. Doctor requested bed rail for repositioning/transfers. Physician order obtained 1/31/20; -Risks of bed rail use discussed with resident/legal representative: Immobility. Staff did not indicate discussing risk of entrapment, temporary/permanent bodily injury, increased falls, increased confusion/agitation, loss of independence, strangulation/asphyxiation, or death; -Reason for recommendation/use: Transfers/repositioning. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence of one staff physical assist for bed mobility; -Extensive assistance of two person physical assist required for transfers; -Upper and lower extremities impaired on one side; -One fall without injury and one fall with injury occurred during review period; -Bed rails not used. Review of the resident's care plan, undated and in use at the time of survey, showed: -Focus: Requires assist with all ADLs related to stroke and right sided weakness. Resident has limited mobility; -Interventions included the resident requires total assist by one staff to turn and reposition in bed; -No documentation regarding the use of side rails. Observations on 5/3/21 at 11:04 A.M. and 1:03 P.M., 5/4/21 at 9:04 A.M. and 1:02 P.M., 5/5/21 at 12:58 P.M., 5/6/21 at 7:53 A.M. and 11:14 A.M., 5/10/21 at 8:47 A.M. and 12:25 P.M., and 5/13/21 at 8:54 A.M., showed the resident lay in bed, with the bed's left side next to the wall. A quarter-length rail raised on the left side, at the head of the bed, with a gap of approximately 4 inches in between the rail and the wall. 4. Review of Resident #224's medical record, showed: -admitted to facility on 4/9/21; -Diagnoses included degenerative disease of nervous system and depression; -A physician's order, dated 4/9/21, for side rail assessment to be done on admission and quarterly every three months, starting on the 9th; -No active physician's orders for use of side rails. Review of the resident's assessments, showed no documentation of a Bed Rail Evaluation completed. Review of the resident's care plan, undated and in use at the time for survey, showed no documentation regarding the use of side rails. Observations on 5/3/21 at 8:42 A.M. and 12:27 P.M., 5/4/21 at 7:02 A.M. and 1:02 P.M., 5/5/21 at 7:35 A.M. and 11:27 A.M., 5/6/21 at 7:53 A.M. and 11:14 A.M., 5/10/21 at 8:46 A.M. and 12:25 P.M., 5/11/21 at 6:03 A.M., and 5/13/21 at 8:49 A.M. and 12:38 P.M., showed the resident lay in bed with quarter-length side rails raised on both sides, at the head of the bed. 5. During an interview on 5/10/21 at 11:37 A.M., the Maintenance Director said therapy assesses residents for the use of side rails and they let him know which type of side rail should be installed on the bed. Some of the beds have side rails with controls built into them; the ADON inspects these and measures the space in between the rails and the bed. The Maintenance Director is responsible for inspecting all side rails in the building to make sure they are secure, but he does not have a routine schedule of inspections or documentation of any inspections completed within the past year. During interviews on 5/10/21 at 11:40 A.M. and 5/11/21 at 4:58 P.M., the ADON said the facility is transitioning to the use of U-bars, which are the U-shaped rails on some of the residents' beds, instead of the bed rails they have used in the past. Bed/side rail assessments are completed upon admission and quarterly. All fields of the side rail assessments should be accurate and completed. He is responsible for completing the side rail assessments, but there is also a spot on the resident's administration record to notify other nurses if the assessment is due. Side rails are installed by him or the Maintenance Director. He has not been assessing the gaps in between the rail and the bed, but understands the gap should be measured to assess for entrapment. Any resident who should have side rails is included on the list of residents with side rails, and if a resident is not listed, they should not have side rails on their beds. Residents #19 and #69 do not have a need for side rails and should not have them. During an interview on 5/11/21 at 11:24 A.M., the Director of Nurses said assessments for the use of side rails should be completed upon admission and quarterly. The ADON assesses residents for the use of side rails, and the assessment is listed on the resident administration records for all nurses. All fields of the side rail assessment should be completed and staff should assess the risk of entrapment. If side rails are used, physician's orders for them should be obtained and it should be documented on the resident's care plan. MO00178524

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nursing staff with the appropriate competencies and skill sets were used to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility failed to ensure that nursing staff are able to demonstrate competency in skills and techniques necessary to care for residents, by failing to conduct weekly skin assessments, report discovery of new wounds in a timely manner, and provide appropriate wound care. In addition, the facility failed to ensure all staff, including contracted agency staff, were adequately trained and informed of facility policies and expectations per acceptable nursing standards. The census was 75. 1. Review of the facility assessment tool, reviewed [DATE], showed: -Staff: -Registered Nurse (RN); -Licensed Practical Nurse (LPN); -Direct Care Staff: utilize Certified Nurse Aides (CNA) agency staff on day and night shift; -Nurse Consultant; -Staff training/education and competencies: -Describe the staff members training/education and competencies that are necessary to provide the level and types of support and care needed for the resident population. Include staff member certification requirements. Potential data sources include hiring, education, training, competency, instruction and testing policies: Agency staff are provided orientation using agency staff orientation packet. This education packet to include education provided to regular staff as need arises such as cardiopulmonary resuscitation (CPR) education, elopement education and other regulatory needs. The assessment did not expand on staff or agency competencies, testing or inservicing. The assessment did did not address frequency of inservicing, training or testing; -Consider the following training topics: communication for direct staff members, behavior management, resident rights, abuse, neglect and exploitation training and infection control; -Required in-servicing training for nurse aides must be sufficient to ensure the continuing competence of nurse aides, but no less than 12 hours per year. No further documentation in the assessment for the training used; -Consider the following competencies: Activities of daily living, resident assessments and examinations such as skin assessment, pressure injury assessment, wound care/dressings, dialysis care, tube feedings. No further documentation in the assessment for the competencies were addressed. 2. Review of the undated agency orientation packet showed: -Wound Care education for all new nursing hires: -CNAs: Upon finding any area/skin issue, report the finding to the charge nurse immediately. If a dressing is saturated or has fallen off, report it to the nurse immediately. When bathing/showering a resident, never wash a wound with a wash cloth, and only pat the area dry if uncovered. Shower sheets must be completed noting any area found; -Nurses: When a skin issue is found or reported to you, immediately obtain an order from the physician. Notify the Director of Nurses (DON)/designee for the resident to be added to the weekly wound rounds. Skin assessments must be completed weekly when scheduled and entered into the system. 3. During an interview during the entrance conference on [DATE] at 8:23 A.M., the administrator said the facility used nursing agency staff to fill staffing needs. The facility did not have many hired staff and had been working on continuing to hire more staff in nursing. 4. Observations during the survey, showed: -The facility failed to ensure residents received care to prevent pressure ulcers (injury to the skin and/or underlying tissues, as a result of pressure or friction) and ensure residents with pressure ulcers received necessary treatments and services to promote healing. The facility identified 13 residents with pressure ulcers. Of those, eight were included in the sample (Residents #19, #224, #46, #45, #51, #55, #3 and #22). and issues were discovered with all eight of these sampled residents regarding pressure ulcers. The facility failed to assess wounds and skin per facility policy and standards of practice and provide treatments as ordered: -Resident #19: The staff failed to apply wound treatment as ordered daily. This failure resulted in the wound becoming foul smelling. Interviewed agency staff had been unsure on the procedure when a wound is discovered and untreated. The facility staff aide applied a treatment, and practiced outside of the scope of practice; -Resident #224: The staff failed to maintain the functionality of an ordered wound vacuum (used to promote wound healing) for extended hours. Interviews with staff, showed in-servicing regarding wounds had recently been conducted prior to the observation. Staff also failed to ensure dressings were changed as ordered. Also, soiled dressings remained in place for several days; -Resident #46: The facility staff failed to report unstageable pressure areas to the feet upon discovery for several days. Interviewed staff said if aides observe a soiled dressing, the aides remove the dressing and report the finding to the nurse. Staff added that agency nurses do not apply dressings to wounds; -Resident #45: The staff failed to ensure ordered dressing treatments were changed as the physician ordered; -Resident #51: The staff failed to report and identify unstageable wounds timely to the nurse for several days. -Resident #55: The staff failed to ensure an ordered wound treatment remained in place, and when the dressing had been identified as missing and in conjunction with the observation of a new bleeding pressure injury, the staff failed to report the wound; -Resident #3: The staff failed to ensure ordered wound treatments remained in place. When discovered while dressing the resident, staff did not report the uncovered wound to the nurse; -Resident #22: The staff failed to report an identified unstageable outer foot wound to the nurse upon discovery. The agency staff also said they had been unsure if the area had already been reported to the nurse. The staff did not report the findings. 5. Staff interviews on [DATE], showed: -At 2:14 P.M., Nurse S said that nurses are supposed to perform skin assessments weekly. The facility had recently started to discuss the facility wound care nurse to conduct all the skin assessments, Nurse S added he/she had been uncertain if that had begun. There had been no clear direction from management whether the charge nurses or the wound care nurse conducted weekly skin assessments. The facility used several different nursing agency staff aides and nurses. The agency staff do not seem to get an orientation and do not report concerns or issues to the facility nurses. He/She had not received in-servicing or return demonstration practices in a long time. Staffing has been an issue, and he/she felt there was no time from management to train staff right now. The facility is attempting to hire more staff, but the facility used many agency staff; -At 2:15 P.M., CNA T said he/she had not worked at the facility before. He/She was an agency staff member. He/She reported to the facility staffing coordinator office and received a very fast orientation and a paper packet had been handed to him/her. He/She had been shown to the floor of scheduled assignment. He/She did not get to review the agency packet forms, and did not have time to ask questions. No facility staff educated him/her on what to do if he/she discovered a wound, and no policies or procedures had been reviewed in person with him/her. Facility staff did not provide him/her with a resident report. He/She did not review the agency packet with the staffing coordinator; -At 2:29 P.M., Nurse U said he/she had been unsure of the facility's policy and procedure regarding wounds. He/She had not received in-servicing for several months and there had been a lot of staff turnover. The facility used agency nurses and CNAs. The agency staff seemed confused as what is expected. The facility CNAs should give report to the agency CNAs. If no facility CNA is on shift, the agency CNA should get report from the charge nurse. If a wound had been reported to him/her, he/she would notify the wound nurse so he/she could treat the wound. If the wound nurse was not available, he/she may have attempted to apply the ordered dressing. Nurse U said Wound care is a speciality, and that is the wound care nurse's speciality. 6. During an interview on [DATE] at 2:01 P.M., the DON and Certified Medication Technician (CMT) C said that CMT C had been asked to take over the staff training from the former DON in February 2021. He/She assisted with training the aides. The DON trains the nurses. The current DON started at the facility 2/21 and had not been able to conduct many trainings. CMT C said staffing at the facility has been difficult, and he/she worked the floor many times. It is hard to get the training program organized. The facility had not offered any training with return demonstration. Staff training has been difficult to get done and a lot of agency staff are working at the facility as well. MO00182036

Based on interview and record review, the facility failed to ensure eight out of nine randomly selected certified nurse aides (CNA), who worked at the facility for more than one year, had the total required annual 12 hours of resident care training. The census was 75. Review of the facility assessment, last reviewed 8/27/20, showed: -Staff education/training and competencies: -Required in-service training for nurse aides training must: -Be sufficient to ensure the continuing competence of nurse aides, but be no less than 12 hours per year; -Include dementia management training and resident abuse prevention training; -Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff members; -Care for cognitively impaired residents; -Identification of resident change in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of interventions; -Consider the following competencies: -Person centered care; -Activities of daily living (ADLs); -Infection control; -Resident assessment and examinations, skin assessments, pressure ulcer assessments. Review of the annual CNA training sheets, showed: -CNA JJ: hired on 11/9/17, total hours listed for the past year: 6.25 hours; -Certified medication technician (CMT)/CNA E: hired on 9/18/19, total hours listed for the past year: 6.5 hours; -CNA KK: hired on 2/7/20, total hours listed for the past year: 8 hours; -CNA MM: hired on 3/19/01, total hours listed for the past year: 8.5 hours; -CNA N: hired on 11/21/17, total hours listed for the past year: 8.5 hours; -CNA II: hired on 10/1/04, total hours listed for the past year: 8.75 hours; -CNA/CMT AA: hired on 1/7/20, total hours listed for the past year: 9.5 hours; -CNA LL: hired on 3/1/2018, total hours listed for the past year: 11 hours. Interviews on 5/13/21, showed the following: -At 1:46 P.M., the Assistant Director of Nursing (ADON) said CMT C had been asked to oversee the CNA annual training from the former Director of Nursing (DON). The former DON left around 2/2021. CMT C can train the aides and other CMTs, but not the nurses. CMT C is often assigned to work on the floor as an aide or CMT. The facility has been short staffed and had been using agency staff as well. Training has been forgotten about many times; -At 2:01 P.M., CMT C said he/she was asked to take over the training from the former DON as she was leaving in February 2021. The old education binder did not have dates or accurate staff names. Staffing at the facility has been difficult and he/she worked the floor many times. It had been difficult to get the CNA/CMT training organized. CMT C had been unaware the annual training had specific training the aides needed, involving resident care. No one had explained to him/her what needed to be in the training. He/She said the program needed to be improved and no training had occurred with return demonstration; Training has been difficult to get done, and there are a lot of agency there as well; -At 2:19 P.M., the DON said CMT C took over the CNA/CMT training from the former DON before he/she left 2/21. CMT C worked the floor several times and it had been difficult for him/her to train staff as well. The nurses are trained by the DON. The training/in-servicing program needed improvement. The DON is responsible to ensure all CNAs have the required annual 12 hour training. If needed for staffing, CMTs are used as CNAs on the floor and are expected to participate in the annual CNA training requirements. Staff in-servicing is attempted at shift change at the nurse station, or at times on paydays the facility attempted additional trainings. Training and in-servicing had not been done on a routine basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The controlled substance shift change count check sheets were missing documentation for four of the four facility medication carts. The facility also failed to secure narcotics in two out of two medication rooms. The census was 75. Review of the facility's controlled substances policy, dated May 2019, showed the following: -Policy: Medications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping; -Only authorized nursing personnel and pharmacy personnel have access to medication. The Director of Nursing is responsible for the control of these medications; -All controlled substances will be dispensed in tamper resistant containers designed for easy counting of contents; -All control substances will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: -Inspect both the drug package and the corresponding count sheet to verify the accuracy of the amount remaining; -Both nurses will count the number of packages of controlled substances that are being reconciled during the shift/shift count and document on the Shift Controlled Substance Count sheet; -Both the nurses will count the controlled substances count sheets and verify the accuracy of the number of remaining count sheets; -Both nurses will sign the Shift Controlled Substance Count sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented; -Any discrepancy in the count of controlled substances shall be reported in writing to the responsible supervisor and a signed entry shall be recorded on the page where the discrepancy is found; -The supervisor shall institute an investigation to determine the reason for the discrepancy. The record shall then be updated; -The consultant pharmacist shall be notified if any discrepancy in the count is detected for any controlled substances regardless of the classification. The pharmacist shall make regular checks of the handling, storage, and recording of controlled substances. 1. Review on 5/3/21 at 8:27 A.M., of the facility's Controlled Substance Shift Change Check Sheet for the rooms 101 through 112 hall medication cart, dated March 2021, showed the following: -31 out of 127 shifts with one nurse documented; -34 out of 127 shifts without count of narcotics or nurse documentation. 2. Review on 5/3/21 at 8:28 A.M., of the facility's Controlled Substance Shift Change Check Sheet for the rooms 113 through 126 medication cart, dated April 20, 2021, showed the following: -Four out of 25 shifts with one nurse documented; -Four out of 25 shifts without count of narcotics or nurse documentation. 3. Review on 5/3/21 at 8:29 A.M., of the facility's Controlled Substance Shift Change Check Sheet for the rooms 201 through 213 medication cart, dated March 30, 2021, showed the following: -30 out of 69 shifts with one nurse documented; -17 out of 69 shifts without count of narcotics; -13 out of 69 shifts without count of narcotics or nurse documentation. 4. Review on 5/3/21 at 8:30 A.M., of the facility's Controlled Substance Shift Change Check Sheet for the room [ROOM NUMBER] through 226 medication cart, dated April 15, 2021, showed the following: -18 out of 35 shifts with one nurse documented; -12 out of 35 shifts without count of narcotics; -Seven out of 35 shifts without count of narcotics or nurse documentation. 5. Observation on 5/3/21 at 9:10 A.M., of the 100 hall medication room, showed the following: -Unlocked refrigerator containing three bottles of Ativan (a controlled substance used to treat symptoms of anxiety disorders). Two were opened. During an interview on 5/3/21 at 9:30 A.M., the Infection Preventionist/Wound Nurse said narcotics should be locked in the refrigerator to deter theft. 6. Observation on 5/3/21 at 10:29 A.M., of the 200 hall medication room, showed the following: -Unlocked medication refrigerator containing one opened bottle of Lorazepam (a sedative used to treat anxiety and seizures) and one bottle of Vimpat (controlled substance used to treat seizures). During an interview on 5/3/21 at 10:29 A.M., Nurse D said the narcotics should be under a secondary lock in the refrigerator to deter theft. 7. Observation on 5/3/21 at 10:41 A.M., of the medication cart for room [ROOM NUMBER] through 226 hall, showed the following: -One packet of Alprazolam (sedative used to treat anxiety and panic disorder) 0.25 milligrams (mg) containing three pills, loose in the bottom of locked narcotic medication box, without name and dosing instructions for a resident; -One packet of Zolpidem (sedative used to treat insomnia) 5 mg containing four pills, loose in the bottom of locked narcotic medication box, without pharmacy label, without resident name and without dosing instructions for resident; -The room [ROOM NUMBER] through 226 hall narcotic book did not contain a narcotic report sheet for the Alprazolam 0.25 mg, three pills. During an interview on 5/3/21 at 11:06 A.M., certified medication technician (CMT) E said the following: -He/she pulled the packet of Alprazolam 0.25 mg containing three pills, from the facility's automatic pill dispenser this morning and put them in the locked medication drawer on the cart; -He/she did not create a new narcotic sheet to for the packet of Alprazolam 0.25 mg containing three pills from the facility's automatic pill dispenser. 8. During an interview on 5/3/21 at 11:25 A.M., the Director of Nursing (DON) said the following: -Staff were expected to follow the facility's policies; -Refrigerated narcotics were expected to be in a locked refrigerator to deter theft; -Staff were expected to create a new narcotic report sheet when they pulled out multiple doses of narcotics which showed the resident's name, physician order, and how many pills were in the locked narcotic box; -Staff were expected to put loose pills from the automatic pill dispenser in an envelope or baggy labeled with resident's name, the name and dose of the medication, and the physician's order for administration; -Nursing staff were expected to count narcotics with every shift change; -Both the offgoing and oncoming nursing staff were expected to count narcotics together and completely fill out the Controlled Substance Shift Change Check Sheet -The facility would know if narcotics were missing from shift to shift if the count was wrong on the controlled substance shift change count check sheets; -Given the examples of missing documentation on the controlled substance shift change count check sheet, they were not sufficient to obtain accurate reconciliation of narcotics.

Based on observation, interview and record review, the facility failed to administer medications with a less than five percent medication error rate. Out of 26 opportunities for error, three errors occurred, resulting in an 8.66% medication error rate for two of six sampled residents (Residents #12 and #59). The facility census was 75. Review of facility's medication administration policy, last revised on 5/1/11, showed the following: -Purpose: To administer the following: Right medication; Right dose; Right dosage form; Right route; Right resident; Right time; -Read the Medication Administration Record (MAR) for the ordered medication, dose, dosage form, route, and time; -Verify the correct medication, dose, dosage form, route, and time again by comparing to MAR before administering; -Document the following as applicable: -Administration of medication on the MAR as soon as medications are given; -Omitted dose by circling your initials in the appropriate block on the MAR; -Reason for omission in the Nursing Progress Notes or on the back of the MAR; -As needed (PRN) medication, reason for administration, and effectiveness in the nursing progress notes or on the back of the MAR; -When medication has been discontinued by writing D/C (discontinued) next to the last dose of the medication on the MAR; block out the rest of the days that month; -Notify physician of changes in resident or with refusal of medication. 1. Review of Resident #12's physician order sheet (POS), dated 5/4/21, showed the following: -An order dated 5/18/20, for Fluticasone Propionate Suspension (a nasal spray used to relieve allergy symptoms) 50 micrograms (mcg/act) per spray, two sprays in each nostril one time a day for allergies; -An order dated 10/21/20, for Pazeo Solution 0.7% (antihistamine used to treat eye itching caused by allergic conjunctivitis (pink eye, inflammation of the white area of the eye), instill one drop in both eyes one time a day for allergic conjunctivitis; -Diagnoses included Guillain-Barre syndrome (a condition in which the immune system attacks the nerves), human immunodeficiency virus/acquired immunodeficiency syndrome (virus that interferes with the body's ability to fight infections). Observation on 5/4/21 at 8:16 A.M., showed Nurse A gathered the resident's medications and entered the resident's room. The resident lay on his/her bed. The nurse took his/her gloved finger and lowered the resident's left eyelid. Nurse A then administered one drop of Pazeo 0.7% eye drops into the pocket of the resident's eyelid. The nurse did not hold the resident's left inner eye for two to three minutes while instructing the resident to keep his/her eye closed. Nurse A then took his/her gloved finger and lowered the resident's right eyelid. The nurse administered one drop of the Pazeo eye drops into the pocket of the resident's left eyelid. Nurse A did not hold the resident's right inner eye for two to three minutes while instructing the resident to keep his/her eye closed. Nurse A asked the resident to sit up. Further observation on 5/4/21 at 8:18 A.M., showed the resident sat on the edge of his/her bed. Nurse A gave the resident his/her bottle of Flonase. The resident put the tip of the Flonase bottle into his/her right nostril and administered one spray. The resident then took the tip of the Flonase bottle, inserted it into his/her left nostril and administered one spray. The nurse did not educate the resident to administer two sprays into each nostril. Review of the Pazeo manufacturer's directions for use, showed the following: -Remove cap. Hold bottle upside down between thumb and index finger; -Tilt the head back slightly and pull the lower eyelid down with the index finger of the opposite hand to create a pocket between the eye and the lower eyelid; -With the bottle positioned above the eye, gently squeeze the side of the bottle to dispense one drop; -Keep head tilted backwards and close eyes for two to three minutes while gently pressing index finger on the inside corner of the eye. 2. Review of Resident #59's POS, dated 5/4/21, showed the following: -An order, dated 11/10/19, for Flonase Suspension 50 mcg/act, give two spray in both nostrils one time a day for sinus allergies; -Diagnosis included nasal congestion. Observation on 5/4/21 at 7:45 A.M., showed Nurse A gathered all of the resident's medications and brought them into the resident's room. The resident lay on his/her bed. Nurse A raised the resident's head of bed to 90 degrees, and straightened the resident into an upright position. Nurse A washed his/her hands, donned gloves and removed the cap from a new, unused bottle of Flonase. The nurse primed the bottle of Flonase by spraying two sprays into the air and then placed the tip of the Flonase bottle into the resident's right nostril, counted out loud to three and then sprayed one dose. The resident inhaled the medication through his/her nose. Nurse A repeated the process spraying one dose of the medication into the resident's left nostril. The nurse did not give an additional spray of Flonase into the resident's right or left nares. 3. During an interview on 5/4/21 at 12:53 P.M., Nurse A said the following: -Each medication must have a physician's order in the resident's medical record before nursing staff could administer medications to residents; -Nursing staff were expected to administer medications exactly as the physician ordered; -If he/she had any questions regarding the medication, he/she would clarify the order with the physician before administering the medication; -He/she did not know if there were any special instructions when administering Pazeo eye drops. During an interview on 5/6/21, at 9:00 A.M., the Director of Nursing (DON) said the following: -She expected staff to follow manufacturer's instructions and physician orders when administering medications to residents; -She expected staff to report a medication error to the physician, the DON, the resident or the resident's responsible party; -She expected staff to document medication errors in resident progress notes, detailing what occurred, who was notified and when, if there were new orders, and what follow up occurred; -Staff were expected to follow all policies.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards in two out of two medication rooms, two out of two treatment carts, one out of one insulin cart and four out of four medication carts. The census was 75. Review of the facility's medication storage in the facility policy, dated May 2019, showed the following: -Policy: Medications and biologicals are stored safely, securely, and properly, following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Medications are not to be transferred medications in containers in which they were received; -Drugs used for internal use are kept separate from externally used medications; -Eye drops, ointments, drops, and inhalers are kept separate from externally used medications; -Medication rooms, carts, and medication supplies are locked or attended by person with authorized access; -All drugs classified as Schedule H of the Controlled Substances Act will be stored under double locks. Schedule ll-V medications must be maintained in separately locked, permanently affixed compartments and cannot be stored with other nonscheduled medications; -Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closure will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists; -Medication storage areas are kept clean, well lit, and free of clutter -Facility staff will assure that the multiple dose vial is stored following manufacturer's suggested storage conditions and that aseptic technique is used by staff accessing the drug product. 1. Observation on 5/3/21 at 8:31 A.M., of the insulin cart on 200 hall, showed the following: -Two vials of Novolog insulin (a rapid acting insulin used to treat diabetes mellitus (DM)) opened used and undated. 2. Observation on 5/3/21 at 8:42 A.M., of the medication cart for 201 through 213 hall, showed the following: -One vial of Novolin insulin (a short acting insulin used to treat DM) used, undated, without a pharmacy label rolling around loose in the top drawer of the cart. 3. Observation on 5/3/21 at 8:48 A.M., of the medication cart for 101 through 112 hall, showed the following: -One Tresiba insulin pen (a long acting insulin used to treat DM), used and undated; -One Basaglar insulin pen (a long acting insulin used to treat DM) new and undated; -Dirty fork with dried food on it mixed in with over the counter medications (OTC); -One vial of ipratropium bromide (used to treat and symptoms (wheezing and shortness of breath) caused by lung disease) loose in top drawer without pharmacy label; -Two open bags of ipratropium bromide, open without pharmacy label; -One bottle of fluconazole propionate nose spray (Flonase, used to treat symptoms caused by allergies) loose in drawer, without pharmacy label, without name. 4. During an interview on 5/3/21 at 8:50 A.M., the Infection Preventionist/Wound Nurse said the following: -Insulin should have a date on it as soon as it comes to room temperature; -Insulin was only stable for 30 days after it comes to room temperature; -Dirty forks should not be in a medication cart next to OTC medications due to infection control; -Medications should be in pharmacy bag or have pharmacy label on them so nursing staff could correctly administer the correct medication to the resident; -Each medication was specific to a resident and if medication was unlabeled or not in pharmacy packaging, staff should throw it away. 5. Observation on 5/3/21 at 8:59 A.M., of treatment cart for the 100 hall, showed the following: -Three used, opened tubes of Santyl (a prescription medication used to remove dead tissue from wounds so they can start to heal) without pharmacy labels, loose in drawer; -One tube of Nystatin (antifungal medicine used to treat or prevent infections), without pharmacy label, loose in drawer; -One used tube of Medihoney (an ointment used to remove dead tissue and aid in wound healing), without a pharmacy label located in a small box with alcohol pads, tubes of lotion, packets of plastic cutlery, leaking its contents into the box; -Two pharmacy cards of unidentifiable pills, without pharmacy label; -One opened package of alginate wound dressing (used to cover wounds to absorb exudate), with a piece cut out of it, without a label. During an interview on 5/3/21 at 9:05 A.M., the Infection Preventionist/Wound Nurse, said the following: -Medications should be in pharmacy box or have pharmacy label so staff uses the medication as prescribed on the correct resident; -It was not appropriate to use medications on more than one resident due to infection control; -It was important to keep treatment carts clean and free of debris for infection control and to ensure residents are receiving the correct medications; -Once packets for wound dressings were opened, and left open to air, they were no longer sterile and could introduce new bacteria into a wound if used. 6. Observation on 5/3/21 at 9:10 A.M., of the 100 hall medication room, showed the following: -Unlocked refrigerator containing three bottles of Ativan (a controlled substance used to treat symptoms of anxiety disorders) two opened; -A bag of staff's personal belongings on counter located next two four bags of Vancomycin (antibiotic used intravenously (in the veins); -Four thermal cups, two filled with fluid on the countertop; -One packet of Albuterol Sulfate vials (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing and chest tightness caused by lung diseases) without pharmacy label, not in pharmacy bag, loose in upper cabinet; -A cosmetic bag full of toothpaste, toothbrush, mints, mouthwash, lotions, located in upper cabinet with a box of hot chocolate, dirty blue nightgown, used hairbrush full of hair; -One box of Narcan (used to treat narcotic overdose in an emergency situation) located in upper cabinet, shoved behind a wound vacuum, with rolls of bandages, and one tube of used nystatin cream; -A grocery bag with an open bag of sunflower seeds and a bottle of water located on the countertop next to the sink; -One packet of trazadone (an antidepressant and sedative used to treat depression, anxiety and insomnia), unlabeled, loose in a drawer with a can of tea and several packets of foam border bandages. During an interview on 5/3/21 at 9:30 A.M., the Infection Preventionist/Wound Nurse said the following: -He/she did not know there was Narcan located in the upper cabinet and it would have been difficult to find in an emergency situation; -Narcotics should be locked in the refrigerate to deter theft; -Food and personal belongings should not be kept in medication rooms due to infection control; -Medication rooms should be neat and clean so staff can quickly find what they need and for infection control; -All medications should be in pharmacy packaging or labeled for infection control and to ensure medications were used on the correct resident as the physician ordered. 7. Observation on 5/3/21 at 9:34 A.M., of the medication cart for 113-126, showed the following: -An open, uncapped bottle of Omeprazole (used to treat heart burn and acid reflux) with four unidentifiable capsules inside; -An open packet of Restasis (used to reduce inflammation in the tear ducts) eye drops, not in pharmacy package, not labeled. During an interview on 5/3/21 at 9:34 A.M., Certified Medication Technician (CMT) C, said the following: -It was not appropriate to have opened bottles of medications due to infection control and staff would not know if the correct medication was in the bottle; -The Restasis eye drops should be in the pharmacy package to prevent any medication errors; -Without medication properly labeled, nursing staff would not know if they were administering the correct medication to the right resident per physician orders. 8. Observation on 5/3/21 at 10:29 A.M., of the 200 hall medication room, showed the following: -Unlocked medication refrigerator containing one opened bottle of Lorazepam (a sedative used to treat anxiety and seizures) and one bottle of Vimpat (controlled substance used to treat seizures). During an interview on 5/3/21 at 10:29 A.M., Nurse D said the following: -The narcotics should be under a secondary lock in the refrigerator to deter theft. 9. Observation on 5/3/21 at 10:36 A.M., of the 200 hall treatment cart, showed the following: -An opened bag filled with a roll of material coated in a white substance, open to air, without a label; -Two opened packages of Xeroform gauze dressings (used to cover and protect low to non-fluid producing wounds), loose in a drawer, without labels; -Three open packets of dermal collagen powder (a wound filler dressing applied to wounds to aid in wound healing) each leaking powder into the bottom of the drawer, without labels. 10. Observation on 5/3/21 at 10:41 A.M., of the medication cart for 214 through 226 hall, showed the following: -One packet of Alprazolam (sedative used to treat anxiety and panic disorder) 0.25 milligrams (mg) containing three pills, loose in bottom of locked narcotic medication box, without name and dosing instructions for a resident; -One packet of Zolpidem (sedative used to treat insomnia) 5 mg containing four pills, loose in bottom of locked narcotic medication box, without pharmacy label without resident name and dosing instructions for resident; -The 214 through 226 hall narcotic book did not contain a narcotic report sheet for the Alprazolam 0.25 mg, three pills. During an interview on 5/3/21 at 11:06 A.M., CMT E said the following: -He/she pulled the packet of Alprazolam 0.25 mg containing three pills, from the facility's automatic pill dispenser this morning and put them in the locked medication drawer on the cart; -He/she did not create a new narcotic sheet to for the packet of Alprazolam 0.25 mg containing three pills from the facility's automatic pill dispenser. 11. During an interview on 5/3/21 at 11:25 A.M., the Director of Nursing (DON) said the following: -Staff were expected to follow the facility's policies; -Refrigerated narcotics were expected to be in a locked refrigerator to deter theft; -Staff were expected to create a new narcotic report sheet when they pulled out multiple doses of narcotics which showed the resident's name, physician order, and how many pills were in the locked narcotic box; -Staff were expected to put loose pills from the automatic pill dispenser in an envelope or baggy labeled with resident's name, the name and dose of the medication, and the physician's order for administration; -Nursing staff were expected to count narcotics with every shift change; -Both the off going and oncoming nursing staff were expected to count narcotics together and completely fill out the Controlled Substance Shift Change Check Sheet; -The facility would know if narcotics were missing from shift to shift if the count was wrong on the controlled substance shift change count check sheets; -Given the examples of missing documentation on the controlled substance shift change count check sheet they were not sufficient to obtain accurate reconciliation of narcotics. During an interview on 5/5/21 at 11:28 A.M., the DON said the following: -Charge nurses were ultimately responsible for maintaining medication storage rooms and medication/treatment carts; -It was important to maintain cleanliness and order in storage rooms and carts for infection control, to prevent cross contamination, and so staff could find items when needed; -Staff should store their personal belongings and food in lockers or in the break room; -It was not appropriate for staff to store personal belongings or food in medication storage rooms or medication/treatment carts due to infection control. It brought in filth, food borne illness, and could contaminate sterile supplies and medications; -Medications were stored in their pharmacy packaging. It was not appropriate to store medications in a plastic cup, without a label; if not labeled or in pharmacy package, staff would not know who they belong to or what the order was specifically; -Insulin should be dated when up to room temperature per manufacture's recommendation and according to standard procedure; -Staff should discard expired, used medications or medical supplies according to procedure; -Medication carts, treatment carts and refrigerators with narcotics are to be locked when not in use; -Expected nursing staff to date insulin pens and vials when they were first used, or when brought up to room temperature; -She expected staff to follow all policies.

Based on interview, and record review, the facility failed to ensure all meals met the needs of residents in accordance with established national guidelines, by providing an alternative menu not reviewed or approved by the registered dietician (RD). The census was 75. Review of the menus and recipes, prepared by the Registered Dietician (RD), dated 5/3/21 through 5/13/21, showed the meals met recommended dietary requirements. No alternative menu options were documented by the dietician. Review of the facility's menus, prepared by the Dietary Director (DD), dated 5/3/21 through 5/13/21, showed the RD's prepared menu available for lunch and dinner. An alternative meal option available for lunch and dinner, not approved by the RD. Review of the dinner menus for 5/5/21, showed: -RD menu: cup of soup, egg salad on croissant, pickled beets, and chilled peaches; -DD menu: chicken and cheese wrap, pasta chips, chilled peaches, and tomato, pickles, and lettuce. Alternate option of beef gravy over noodles, whipped potatoes/gravy, and corn. Observation of dinner on 5/5/21 at 5:45 P.M., showed residents served a burrito, cheese puffs, and side salad, or a sandwich with chips. During an interview on 5/4/21 at approximately 10:30 A.M., the DD said the menu provided by the RD does not list alternatives, so she designed her own alternative menu options based on nutritional guidelines. The menus posted in the kitchen and provided to residents, include the RD's recommended menu and the DD's alternative menu. During an interview on 5/14/21 at 9:51 A.M., the DD said she created the alternate menu based on information she had from the previous DD. She did not consult with the dietician before providing the alternative menu, but should have. Alternative menus need to be reviewed by the dietician to make sure they are nutritionally sound. During an interview on 5/13/21 at 2:27 P.M., the RD said she creates a menu for the facility twice a year. Menus are given to the DD and come with production sheets, which tell dietary staff exactly what should be served at each meal. If something on the menu cannot be served for whatever reason, an appropriate substitution should be made. The RD was unaware that the DD created her own alternative menu. An alternative menu should meet nutritional guidelines, and should be reviewed and approved by the dietician before implemented.

Based on observation, interview, and record review, the facility failed to ensure one resident's medical records were accurate, kept confidential and secure in accordance with accepted professional standards and practices for one out of six sampled residents (Resident #19). This had the potential to affect all residents. The census was 75. Review of the facility's Confidentiality and Non-disclose Agreement, undated, showed the following: -The facility's information systems contained confidential records pertaining to the business operations, the residents, business associates, health care professionals and employees; -Employees were expected to protect data in accordance with current Health Insurances Portability and Accountability Act (HIPPA) regulations and facility policies governing the access, use and disclosure of protected health or facility information; -Employees were expected to respect the privacy and confidentiality of any information they have access through the computer system or network and would only access or use that information necessary to perform their job; -Employees would safeguard and not disclose their password or user identification (ID) code that allowed access to protected information; -Employees accepted responsibility for all entries and actions recorder using their password and user ID code; -Employees would immediately report to the HIPPA Compliance Officer any suspicions that their password and user ID code had been compromised; -Employees would not permit others to access the facility's computer system or network using their password or ID code. 1. Review of Resident #19's medical record, showed the following: -An order dated 11/12/19, for Baclofen (a muscle relaxant) suspension, give 1 milliliter (ml), 6 milligrams (mg) per 1 ml, via gastrostomy tube (g-tube, surgically placed device used to give direct access to the stomach) three times a day related to muscle spasm; -An order dated 11/13/19, for Acetaminophen (treats mild to moderate pain) liquid, give 20 ml via g-tube for pain; -Diagnoses included chronic pain and muscle spasms. During an interview on 5/5/21 at 8:14 A.M., Certified Medication Technician (CMT) C, said the following: -He/she was responsible for administering medications to the residents on the 101 through 112 hall; -He/she could not administer medications to residents with g-tubes because it was out of his/her scope of practice; -Nurse B would administer medications to Resident #19 using the 101 through 112 medication cart. Observation on 5/5/21 at 8:28 A.M., showed Nurse B administered medications, including Baclofen and Acetaminophen, to Resident #19 via his/her g-tube. Before preparing the resident's medications, the nurse pulled up the resident's current physician orders in the electronic medical record and verified the medications against the physician orders before dispensing medications to administer to the resident. As the nurse prepared each medication, he/she signed the Medication Administration Record (MAR) signifying he/she administered the medication. While preparing the medications, Nurse B said he/she accidentally logged in as CMT C when accessing the resident's medical record. Nurse B logged out and then logged back in to the resident's medical record and completed the medication pass. Review of the resident's MAR, dated 5/1/21 through 5/31/21, showed the following: -On 5/3/21 at 8:00 A.M., CMT C's initials indicating he/she administered Acetaminophen 20 ml via g-tube; -On 5/3/21 at 8:00 A.M., CMT C's initials indicating he/she administered Baclofen Suspension 1 ml via g-tube. During an interview 5/5/21 at 10:19 A.M., CMT C said the following: -He/she would not sign off on a resident's MAR if he/she did not administer the medication because it was falsification of information on a legal document; -The facility's electronic medical record program did not erase log in names and passwords after staff logs out of the program, so anyone could open up a resident's medical record under someone else's electronic signature; -He/she did not administer medications to Resident #19; -Nurse B used CMT C's tablet when he/she was administering medications to the resident and accidentally logged in under CMT C's name. During an interview on 5/5/21 at 10:33 A.M., the Director of Nursing (DON) said the following: -Anyone could sign into a resident's medical record because the system did not erase staff members' log in information; -The facility's medical records could easily contain falsified information regarding notes, administration of medication, and possible theft of controlled substances because they were not secure; -All agency staff were given the same log in user names and passwords; -There was no way to verify which agency staff documented in the medical records, even with staffing records. During an interview on 5/5/21 at 10:53 A.M., the Administrator said the following: -He noticed that the facility's electronic medical record program saved his sign-in information after he logged out of the system; -All agency staff were given the same user name and passwords to access electronic medical records. Although staffing sheets showed what assignments agency staff were responsible for during their shift, the facility would not be able to prove no one else signed in a resident's medical record because they all had the same electronic signature. During an interview on 5/6/21 at 10:00 A.M., the DON said the following: -The facility used the document named Confidentiality and Non-disclosure Agreement as a policy regarding compliance to HIPPA regulations for medical records; -Employees were trained on HIPPA confidentiality requirements for resident medical records using the Confidentiality and Non-Disclosure Agreement in the orientation packet and requiring signature of receipt; -The facility did not have an additional policy outlining their expectations of how electronic records were maintained, secured, or how staff were assigned individualized electronic signatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff completed routine inspection of bed frames, mattresses and bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #13, #19, #69, and #224) with side rails to reduce the risks of accidents. The facility identified 17 residents with side rails in use. Residents #13 and #69 were not identified by the facility as having side rails. The sample was 18. The census was 75. Review of the FDA (Federal Drug Administration) documents, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/06, showed bed rails, also called side rails, may be used as a restraint, reminder, or assistive device. Evaluating the gaps in hospital beds is one component of a mitigation strategy to reduce entrapment. Hospital beds have seven potential entrapment zones. The neck, head, and chest are the key body parts at risk for life-threatening entrapment. Elderly residents are among the most vulnerable for entrapment, particularly those who are frail, confused, restless, or who have uncontrolled body movement. Review of the facility's Bed Rails policy, dated 11/27/19, showed: -The facility will attempt to use appropriate alternatives prior to installing a side rail or bed rail. If a bed/side rail is used the facility will verify correct installation, use, and maintenance of bed rails; -Protocols: -Assess the resident for risk of entrapment from bed rails prior to installation -Ensure that the bed's dimensions are appropriate for resident's size and weight; -Follow the manufacturer's recommendations and specifications for installing and maintaining bed rails; -Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars, and assist bars; -In the event that bed rails are necessary the facility will adhere to the following policies: -A physician's order must be present which clarifies the exact type of bed rail to be utilized, duration, and medical symptoms present secondary to diagnosis; -Bed rails are to be checked every shift and as needed (PRN). This is to be documented on the treatment administration record (TAR); -If a resident has an order for bed rails the nurse will complete the Bed rail Evaluation/Assessment; -Bed rails will be checked by Maintenance monthly to verify they are secured/installed properly to the resident's bed frame. 1. Review of Resident #13's medical record, showed: -admitted to facility on 10/6/20; -Diagnoses included stroke, dementia, and dysphagia (swallowing disorder) following stroke; -A physician's order, dated 10/6/20, for side rail assessment to be done on admission and quarterly every three months, starting on the 7th; -No active physician orders for use of side rails; -No documentation of a maintenance inspection to include an entrapment assessment for the use of side rails. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/21, showed: -Severe cognitive impairment; -Extensive assistance of one person physical assist required for bed mobility; -Total dependence of two (+) person physical assist required for transfers; -Upper and lower extremities impaired on both sides; -Bed rails not used. Review of the resident's care plan, undated and in use at the time of survey, showed: -No documentation regarding the use of side rails. Observations on 5/3/21 at 8:45 A.M. and 10:51 A.M., 5/4/21 at 7:17 A.M. and 9:04 A.M., 5/5/21 at 7:40 A.M. and 9:45 A.M., and 5/6/21 at 7:53 A.M. and 11:14 A.M., showed the resident lay in bed with U-shaped side rails raised on both sides, at the head of the bed. 2. Review of Resident #19's annual MDS, dated [DATE], showed: -admitted to facility on 11/21/13; -Moderate cognitive impairment; -Total dependence of one person physical assist required for bed mobility, and two (+) person physical assist required for transfers; -Upper and lower extremities impaired on both sides; -Diagnoses included quadriplegia (paralysis of all four limbs), muscle spasms, and depression; -Bed rails not used. Review of the resident's physician order sheet (POS), showed: -An order, dated 5/8/19, for may have side rails per resident request. Type of side rail not specified; -An order, dated 3/9/21, for side rail assessment to be done on admission and quarterly every three months, starting on the 15th. Review of the resident's Bed Rail Evaluation, dated 4/6/21, showed: -Type of mattress used: Standard; -Bed rail information: Quarter-length rail requested. Physician requested bed rail. Physician order for four quarter-length bed rails obtained 3/28/17. Review of the resident's care plan, undated and in use at the time of survey, showed: -The resident is totally dependent on 1 staff for repositioning and turning in bed as necessary. Resident may have 4 side rails for bed mobility and positioning as needed. 7/15/20 - Resident must be positioned using wedges and pillows to keep body away from bed rails. 8/25/20 - Bedrails requested to remain and padded with pillows (discontinued 5/11/21). Observation on 5/3/21 at 9:03 A.M. and 5/4/21 at 9:26 A.M., showed the resident lay in bed with quarter-length side rails raised on both sides, at the head of the bed. Review of the resident's medical record, showed no documentation of a maintenance inspection to include an entrapment assessment for the use of side rails. 3. Review of Resident #69's medical record, showed: -admitted to facility on 1/30/20; -Diagnoses included unsteadiness on feet, stroke, traumatic brain bleed with loss of consciousness for unspecified duration, dysphagia following stroke, attention and concentration deficit following stroke, and depression; -A physician's order, dated 1/31/20, for side rail assessment to be done on admission and quarterly every three months, starting on the 1st. Review of the resident's Bed Rail Evaluation, dated 2/1/21, showed: -Resident's height and weight not documented; -Bed rail information: Quarter-length rail requested. Doctor requested bed rail for repositioning/transfers. Physician order obtained 1/31/20. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Total dependence of one staff physical assist for bed mobility; -Extensive assistance of two person physical assist required for transfers; -Upper and lower extremities impaired on one side; -One fall without injury and one fall with injury occurred during review period; -Bed rails not used. Further review of the resident's medical record, showed: -No active physician orders for the use of side rails. -No documentation of a maintenance inspection to include an entrapment assessment for the use of side rails. Review of the resident's care plan, undated and in use at the time of survey, showed: -No documentation regarding the use of side rails. Observations on 5/3/21 at 11:04 A.M. and 1:03 P.M., 5/4/21 at 9:04 A.M. and 1:02 P.M., 5/5/21 at 12:58 P.M., 5/6/21 at 7:53 A.M. and 11:14 A.M., 5/10/21 at 8:47 A.M. and 12:25 P.M., and 5/13/21 at 8:54 A.M., showed the resident lay in bed, with the bed's left side next to the wall. A quarter-length rail raised on the left side, at the head of the bed. 4. Review of Resident #224's medical record, showed: -admitted to facility on 4/9/21; -Diagnoses included degenerative disease of nervous system and depression; -A physician's order, dated 4/9/21, for side rail assessment to be done on admission and quarterly every three months, starting on the 9th; -No active physician orders for use of side rails; -No documentation of a maintenance inspection to include an entrapment assessment for the use of side rails. Review of the resident's care plan, undated and in use at the time for survey, showed no documentation regarding the use of side rails. Observations on 5/3/21 at 8:42 A.M. and 12:27 P.M., 5/4/21 at 7:02 A.M. and 1:02 P.M., 5/5/21 at 7:35 A.M. and 11:27 A.M., 5/6/21 at 7:53 A.M. and 11:14 A.M., 5/10/21 at 8:46 A.M. and 12:25 P.M., 5/11/21 at 6:03 A.M., and 5/13/21 at 8:49 A.M. and 12:38 P.M., showed the resident lay in bed with quarter-length side rails raised on both sides, at the head of the bed. During an interview on 5/10/21 at 11:37 A.M., the Maintenance Director said therapy assesses residents for the use of side rails and they let him know which type of side rail should be installed on the bed. Some of the beds have side rails with controls built into them; the ADON inspects these and measures the space in between the rails and the bed. The Maintenance Director is responsible for inspecting all side rails in the building to make sure they are secure, but he does not have a routine schedule of inspections or documentation of any inspections completed within the past year. During interviews on 5/10/21 at 11:40 A.M. and 5/11/21 at 4:58 P.M., the ADON said side rails are installed by him or the Maintenance Director. He has not been assessing the gaps in between the rail and the bed, but understands the gap should be measured to assess for entrapment. Any resident who should have side rails is included on the list of residents with side rails, and if a resident is not listed, they should not have side rails on their beds. Residents #19 and #69 do not have a need for side rails and should not have them. During an interview on 5/14/21 at 12:01 P.M., the administrator said he used to perform routine inspections of side rails in the past, and turned this task over to Maintenance over a year ago. They have discussed assessing side rails for the risk of entrapment and obtaining gap measurements. He will try to locate documentation of side rail inspections completed over the past year. (As of the exit date, no additional information was provided.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff answered one resident's call light timely. The resident was observed with their call light on as several staff stood by the nurse's station or walked by the resident's room without answering the call light and/or assisting the resident (Resident #51). Five additional residents complained that it sometimes took staff one to three hours to answer their call lights. (Residents #14, #22, #64, #60 and #16). The census was 75. 1. Review of Resident #51's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/21, showed: -admission date of 3/1/21; -Adequate hearing/vision; -Clear speech, distinct intelligible words; -Ability to express ideas and wants: Understood; -Ability to understand others: Understands; -Brief Interview for Mental Status (BIMS, a brief screener of cognition) score of 15 (cognitively intact); -Total dependence of one person required for bed mobility, toilet use and bathing; -Total dependence of two (+) persons required for transfers; -Required extensive assistance of one person for dressing and personal hygiene; -Functional limitation of both lower extremities (hip, knee, ankle, foot); -Mobility device: Wheelchair; -Indwelling urinary catheter (inserted through the urethra into the bladder to drain the bladder of urine); -Diagnoses of anemia (low number of red blood cells), septicemia (systemic (body wide) illness with toxicity due to invasion of the bloodstream by virulent bacteria coming from a local site of infection), urinary tract infection (last 30 days), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), anxiety and depression. Review of the resident's current care plan, showed: -Activities of daily living performance deficit: -Encourage resident to use call light for assistance; -Chronic pain; -The resident is able to call for assistance when in pain, reposition self, ask for medication, tell how much pain he/she is experiencing. Observation on 5/3/21 at 12:50 P.M., showed the resident turned on his/her call light. Staff were in the hall, passing his/her room and at the nurse's station. At 1:15 P.M., a staff member answered the resident's call light. During an interview on 5/4/21 at 6:50 A.M., the resident said his/her back hurt the previous day when he/she had his/her call light on. He/she needed pain medication. Sometimes it took up to three hours for staff to answer his/her call light. 2. Review of Resident #14's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -BIMS score of 15; -No behavioral symptoms. During the group interview on 5/4/21 at 10:00 A.M., five of five residents said it took a long time for staff to answer call lights. Resident #14 said it could take over an hour for staff to respond to a light. 3. Review of Resident #22's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Required extensive staff assistance for dressing, toileting and hygiene; -Diagnoses of dementia, Parkinson's (a neurological disease affecting nerve signals to the brain, often cause tremors), disease, stroke history and schizophrenia (affects the perception of reality often symptoms include hallucinations). Review of the undated care plan, in use during the survey, showed: -Focus: The resident has a self-care performance deficit related to dementia; -Goal: The resident will improve current level of function; -Interventions: Staff encourage the resident to participate in care as much as possible to increase his/her strength and mobility, assist with bathing, dressing, and toileting. The resident requires maximum assistance with daily care. During an observation and interview on 5/3/21: -At 10:14 A.M., the call light for room [ROOM NUMBER] noted to be sounding and lit above the doorway. The resident's roommate said Resident #22 wanted to get out of bed, but had some difficulty activating the call light. The roommate activated his/her own. He/she added the call light had been activated for 30 minutes and no staff had responded. He/she saw multiple staff walk past the open doorway. From the hallway, a nurse sat at the nurses station. The call light was noted to be audible and the room lit on the call light board at the nurses station; -At 10:30 A.M., two additional staff walked past the resident's room as the call light sounded and did not enter the resident's room; -At 10:45 A.M., the room call light was answered by staff. During a group interview on 5/4/21 at 10:00 A.M., five of five residents said it took a long time for staff to answer call lights. Resident #22 said the night staff were the worst. It regularly took over an hour for staff to respond and when they did they were rude about it. 4. Review of Resident #64's quarterly MDS, dated [DATE], showed: -admitted on [DATE]; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -BIMS score of 15; -No behavioral symptoms. During an interview on 5/4/21 at 12:25 P.M., the resident said it would take up to an hour for staff to answer his/her call light. 5. Review of Resident #60's admission MDS, dated [DATE], showed: -admitted on [DATE]; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -BIMS score of 12 (severely cognitively intact); -No behavioral symptoms. During an interview on 5/10/21 at 1:00 P.M., the resident said it could take up to three hours for staff to answer call lights. Sometimes staff would come into their rooms, turn off the light, say they would be right back and would not come back. It was worse in the evenings and at night. 6. Review of Resident #16's admission MDS, dated [DATE], showed: -admitted on [DATE]; -Adequate hearing and vision; -Clear speech; -Ability to express ideas and wants: Understood; -Ability to understand others: Understood; -BIMS score of 15; -No behavioral symptoms. During an interview on 5/13/21 at 9:15 A.M., the resident said he/she has had to wait up to an hour for staff to answer his/her call light. It happened a lot. The longest was four hours when they left him/her in his/her wheelchair when he/she wanted to go back to bed, so he/she would not get up in his/her wheelchair anymore. 7. During an interview on 5/14/21 at 12:00 P.M., the Director of Nurses (DON) said she expected staff to answer resident call lights within five minutes and no longer than 15 minutes. Any staff member can answer a call light, it does not have to be a nursing staff member. There are times when a resident's need does not require a nurse such as pushing a bed table closer to the bed or turning on a light on/off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement person-centered comprehensive care plans to meet preferences and goals and address residents' medical, physical, mental and psychosocial needs, by not including pain, contractures and dietary preferences on the care plans for three of 20 sampled residents (Residents #296, #6 and #88). The census was 96. 1. Review of Resident #296's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/31/19, showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Extensive assistance required for mobility; -Diagnoses included end stage kidney disease, renal dialysis (an artificial invasive procedure to eliminate waste and unwanted water from the blood), heart disease, chronic lung disease and bilateral below the knee amputations. Review of the physician's order sheet (POS), dated 5/30/19, showed an order, dated 5/25/19, to administer Hydrocodone (narcotic analgesic) 5/325 milligrams (mg) one tablet twice a day for relief of leg pain. Review of the resident's care plan, dated 5/30/19, showed no documentation regarding pain or the medication prescribed to relieve the pain. Observation and interview on 5/31/19 at 10:19 A.M., showed the resident sat on the bed and said he/she has a chronic pain issue in his/her back. The pain level was usually a level four (out of 10). He/she said the scheduled medication was usually effective but on occasion he/she required more medication. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Functional limitation in range of motion: Impairment to both sides; -Required total care from staff for all activities of daily living (ADLs, self care activities); -Diagnoses included diabetes, quadriplegia (total or partial paralysis of all four limbs) and depression. Review of the resident's May 2019 POS, showed the following: -An order, dated 7/13/18, for staff to clean between the elbow and upper arm crest, then perform passive range of motion (PROM) to passively stretch before putting roll of towel in between right elbow every day; -An order, dated 9/20/17, for staff to clean the resident's right palm once per shift and place dry washcloth in right hand every day and night shift to prevent skin breakdown. Review of the resident's care plan, last revised on 5/29/19, showed the following: -Focus: The resident has an ADL self-care performance deficit related to quadriplegia with spinal cord injury and contracture of the right elbow and hand. Resident requires total care from staff; -Goals: The resident will maintain current level of function in (staff did not specify) through the review date; -Interventions included: The resident requires staff assistance for bathing, personal hygiene, bed mobility, dressing and eating; -Staff failed to include the orders for PROM and application of the towel and washcloth to prevent further contracting of the resident's right elbow and hand. 3. Review of Resident #88's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required limited assistance with dressing, toileting and person hygiene; -Independent with eating; -Diagnoses included heart failure, high blood pressure, diabetes, seizure disorder and schizophrenia. During an interview on 5/30/19 at 11:16 A.M., the resident said he/she did not eat pork for religious reasons. Review of the resident's meal ticket showed, Dislikes: Pork. Review of the resident's care plan, last revised on 5/14/19 and in use during the survey, showed staff did not address the resident's food preferences. 4. During an interview on 6/4/19 at 10:00 A.M., the DON said the care plans should reflect the residents' current needs and goals. She reviewed resident care plans with the MDS coordinator on a weekly basis. The care plan should include the resident's food preferences.

Based on observation, interview and record review, the facility failed to provide adequate perineal care (peri-care, cleaning the front of the body from hips, between legs and the buttocks) to one resident out of four residents observed who required total staff assistance for personal hygiene care (Resident #30). The sample size was 20. The census was 96. Review of Resident #30's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/25/19, showed the following: -Severe cognitive impairment; -Extensive assistance to total dependence on staff for all personal care; -Unable to ambulate; -Incontinent of bowel and bladder; -Diagnoses included stroke, dementia, chronic lung disease and heart disease; -Life expectancy of less than six months. Observation on 6/3/19 at 12:40 P.M., showed Certified Nurse Aide (CNA) K entered the resident's room and donned gloves. He/she uncovered the resident and found the bed, brief and resident's lower shirt saturated with urine. He/she removed the resident's shirt and brief and turned him/her to his/her left side, which revealed a small amount of feces. Wiping from front to back, CNA K cleansed the feces from the inner buttocks, removed the saturated with urine bottom sheet and dressed the resident in a clean brief and shirt. CNA K did not cleanse the front peri area, did not cleanse the buttocks and did not cleanse the resident's thighs or lower back. During an interview on 6/3/19 at approximately 1:00 P.M., CNA K said Oh I didn't realize the mattress was wet. I just thought it was the sheet. CNA K said he/she should have cleansed the mattress. With prodding, he/she said he/she should have washed the front peri area and any part of the body wet with urine. Review of the facility's Perineal Care Policy, dated 5/1/11 and last revised on 1/7/19, showed the following: -Purpose: -To promote cleanliness and prevent infection; -To remove irritating and odorous secretions; -To prevent extended skin exposure to incontinence of urine and feces. -Frequency: -Perineal care will be routinely provided in the morning and with bedtime care; -Perineal care will be provided after each incontinent episode; -The resident will be checked at minimum of thirty minutes to two hours depending on each resident's needs/patterns. More frequent checking (i.e. hourly) may be required if the resident is having acute frequent episodes of urine or bowel incontinence related to acute change in condition. -Procedure: -Wash hands and don gloves; -Cover resident exposing only the genital area; -Wash from the front to the back, rinse and dry thoroughly; -Turn the resident on his/her side and wash the inner and outer buttocks from the front to the back; -Remove soiled linen and place in soiled utilities; -Remove gloves and wash hands. During an interview on 6/4/19 at 10:00 A.M., the Director of Nursing said any time peri care is provided, the staff member should wash any area on the body that has been touched with urine or feces. Staff should also make sure the mattress has not been soiled with urine or feces, and if it has, the mattress should be washed as well.

Based on observation, interview and record review, the facility failed to provide meaningful activities or one-on-one activities to one resident who was dependent on staff for his/her needs (Resident #92). The sample size was 20. The census was 96. Review of Resident #92's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/15/19, showed the following: -Severe cognitive impairment; -Required total assistance from staff for all self care activities such as mobility, dressing and personal hygiene; -Nutritional approach: gastrostomy tube (G-tube, a tube surgically inserted into the stomach to provide hydration, nutrition and medications); -Should activity interview be conducted with the resident? Yes; -Resident's activity preferences: -Having books, newspapers, magazines to read: Very important; -Keeping up with the news, doing thing with groups of people, doing favorite activities: Very Important; -Observing religious services or practices: Very important; -Diagnoses included aphasia (loss of ability to understand or express speech, caused by brain damage), seizure disorder, nontraumatic chronic subdural hemorrhage (a collection of blood on the brain's surface, under the outer covering of the brain) and dysphagia (difficulty or discomfort in swallowing). Review of the resident's care plan, dated 5/14/19 and in use during the survey, showed the following: -Focus: The resident has little or no activity involvement related to physical limitations. The resident wishes not to participate. Resident needs encouragement to participate; -Goal: The resident will participate in activities of choice three times per week by review date; -Interventions included: Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain to the resident the importance of social interaction and leisure activity time. Encourage the resident's participation by inviting resident to participate. Remind the resident that the resident may leave activities at any time, and is not required to stay for the entire activity. Resident will be encouraged to participate in activities by staff. Resident will be included in all snack carts and pet visits as resident allows. Resident will receive monthly calendar of activities. Observations of the resident on 5/29/19 at 2:05 P.M., 5/30/19 at 10:00 A.M., 5/31/19 at 7:58 A.M. and at 10:08 A.M., 6/3/19 at 9:11 A.M. and 1:00 P.M. and 6/4/19 at 9:10 A.M., showed the resident up in a geri-chair (specialized reclining chair), alert with eyes open, facing either the doorway to the hall or a wall with only a clock on it. Staff were not observed engaging or interacting with the resident other than to provide care. Review of the facility 1:1 Activity binder, showed the resident did not receive 1:1 engagement from activity staff. During an interview on 6/04/19 at 9:38 A.M., the Activity Director (AD) said when the resident first moved in, he/she was very combative and stayed in bed. He/she would try to get out of bed or slide out, so he/she did not get up in the geri-chair. The AD was not aware the resident had been getting up in his/her chair. She had gone in a few times to check on the resident and planned to add specific activities to the care plan. She was not aware the resident faced either the wall or the hallway for a majority of the day. If the resident gets up, then he/she could come to activities for socialization. During an interview on 6/4/19 at 10:00 A.M., the Director of Nursing said when the resident first moved in, he/she was appropriate for 1:1 activities. Now the resident could be involved in more activities. The administrator said the AD assesses residents for activity preferences as needed, but at least quarterly. Assessing the resident's preferences more often would be ideal.

Based on observation, interview and record review, the facility failed to ensure resident behavior triggers, which may have predisposed the resident's aggression, were adequately monitored and addressed. Staff did not develop interventions to address the resident's behavior and prevent him/her from responding aggressively toward other residents for one of 20 sampled residents (Resident #53). The facility census was 96. Review of Resident #53's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/18/19, showed the following: -Clear comprehension; -Behavior symptoms such as hitting or pushing not exhibited; -Verbal behavior symptoms such as yelling, cursing or threatening not exhibited; -No behavioral symptoms that interfere with participation in activities and social interactions; -No behaviors that impact others or pose a significant risk for injury; -No rejection of care; -No change in behaviors; -Diagnoses included high blood pressure, dementia, anxiety and depression. Review of the resident's nurse's notes dated 4/21/19 at 3:17 P.M., showed the resident in the dining room when he/she noticed his/her chair missing. He/she started to search for it and found a visitor seated in it. A verbal altercation occurred with another resident where Resident #53 slapped the other resident with an open hand. At 3:57 P.M., staff spoke to the resident about the incident and educated him/her to stay clear of the other resident. Review of the resident's care plan, dated 4/21/19, showed the following: -Focus: The resident has potential to be physically aggressive, hitting or yelling at other resident and staff related to poor impulse control. The resident has dementia; -Goal: The resident will verbalize understanding of need to control physically aggressive behavior; -Interventions: Administration educated resident to stay clear from the area of the other resident. Staff educated to monitor resident in the dining room to prevent further altercations. Staff would remove the resident from the area if he/she became agitated. Further review of the nurse's notes, showed the following: -On 5/12/19 at 9:50 P.M., the resident used his/her furniture to barricade his/her door; -On 5/29/19 at 2:09 A.M., the resident refused to leave his/her room door open so staff could make sure his/her roommate, who received a tube feeding, could be checked to make sure he/she did not aspirate or need to be changed. The room was extremely hot and stuffy and had a bad smell. The resident barricaded the room after cursing at staff and attempted to hit staff who entered the room until he/she realized it was staff. His/her roommate constantly took off his/her clothes and removed his/her covers due to the heat. This was an ongoing problem with Resident #53, who claimed it was his/her room and no one should be in there. The roommate could not speak for him/herself and relied on staff to help him/her. The staff recommended a different roommate who would do better in there than the current resident who could not defend him/herself against the tirades of Resident #53; -On 5/31/19 at 7:59 A.M., the resident became aggressive with another resident when the other resident approached the table to pick up paper off the floor. Staff observed Resident #53 grab the other resident's left wrist. Staff were directed to place themselves to keep the resident in their direct line of sight. At 2:11 P.M., the resident was aggressive towards staff and residents. He/she preferred his/her own personal space and became agitated if someone came by him/her. Administration, social services and the Director of Nursing (DON) would intervene in situations when the resident was agitated to provide safety for residents and all staff. Further review of the resident's updated care plan, dated 5/31/19, showed the following: -Focus: New behavior. Resident became physically aggressive and hit at other residents; -Goal: The resident would verbalize understanding of need to control physically aggressive behavior; -Interventions: Dining room staff to monitor resident in dining room to monitor behavior. Staff to conduct more activities in dining room where resident usually sits during the day. Psychiatric consultation ordered. Observations of the resident in the dining room during breakfast time, showed the following: -On 5/29/19 between 7:00 A.M. and 8:00 A.M., the resident sat alone at a table, behind a pillar, out of sight of staff at the preparation table; -On 5/30/19 between 7:00 A.M. and 8:00 A.M., the resident sat at the same table, out of sight of staff at the preparation table; -On 6/3/19 between 7:55 A.M. and 8:10 A.M., the resident sat at the same table, out of sight of staff at the preparation table; -Many other residents were present in the dining room during these above times. Further review of the resident's nurse's notes dated 6/3/19 at 9:18 A.M. showed the resident's physician was aware of the 5/31/19 incident. He told staff since the resident refused medication and refused going out for a psychiatric evaluation, staff needed to keep the resident in sight in the dining room. During an interview on 6/3/19 at 8:22 A.M. certified nurse's aide (CNA) N said the resident was very possessive and would run you out of his/her room. He/she would yell at residents and staff. He/she did not know about any precautions put in place but would try to redirect other residents away from his/her room. During an interview on 6/3/19 at 8:26 A.M., Licensed Practical Nurse (LPN) O said the resident would yell at staff and residents. He/she heard the resident grabbed a couple of residents in the dining room. The other staff kept his/her door closed, but the LPN needed it opened so he/she could hear if there was a problem with the resident's roommate. The resident could possibly be a danger to another resident if they wandered into his/her room because he/she did not like people in his/her space. He/she did not know about any interventions to keep the other residents safe. During an interview on 6/4/19 at 8:15 A.M., the resident who was hit in the 4/21/19 incident, said no one interviewed him/her about the incident. He/she was not doing anything when Resident #53 hit him/her a number of times. It was a slap not a push. It left a reddened area. Staff did not do anything after the incident. He/she felt scared in the dining room now. He/she saw Resident #53 push people in wheelchairs who were in his/her way and would yell at other residents in the television area. Resident #53 thought he/she owned the place. During an interview on 6/4/19 at 8:35 A.M., the resident threw his/her hands in the air and yelled, Don't bother me! During an interview on 6/3/19 at 11:25 A.M., the MDS coordinator said the resident had two problems. He/she was resistive to staff care and could be verbally or physically aggressive. Staff were supposed to monitor him/her in the dining room. He/she had not not addressed behavior in the resident's room on the care plan because nothing had happened in there. During an interview on 6/3/19 at 11:30 A.M., the social services director said she did monthly assessments on the resident due to his/her behavior. His/her behavior could change depending on the day. He/she could be very controlling. There was a possibility he/she could be a danger if someone walked into his/her room. During an interview on 6/3/19 at 11:45 A.M., the administrator said he did not believe there needed to be interventions in the resident's room because he/she only had problems in the dining room. The resident's roommate was non verbal and was not mobile so could not get in Resident #53's space. He was not aware the resident would not allow staff to care for his/her roommate or kept the room too hot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have adequate indications for residents' medications to support their use for two out of 20 sampled residents (Residents #48 and 92). The census was 96. 1. Review of Resident #48's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/19, showed the following: -No cognitive impairment; -Extensive assistance required for personal hygiene; -Unable to ambulate; -Diagnoses included diabetes, anxiety, peripheral vascular disease (PVD, poor circulation in the extremities) and insomnia; -Received an antianxiety, antipsychotic and an antidepressant seven out of seven days. Further review of the MDS section of the medical record, showed an original admission date of 12/23/18 and a readmission on [DATE]. Review of the physician's order sheet (POS), dated 3/17/19, showed an order, dated 3/21/19, to administer Seroquel (antipsychotic) 25 milligrams (mg) at bedtime related to insomnia. Review of the May 2019 POS, showed an order, dated 5/14/19, to administer Seroquel 25 mg one tablet every morning and at bedtime related to insomnia and anxiety. Review of the pharmacy reviews for March 2019, April 2019 and May 2019, showed no documentation regarding the use of Seroquel. During a phone interview on 6/6/19 at 8:25 A.M., the pharmacist from the facility's participating pharmacy said Seroquel was sometimes used as an off-label for anxiety but was not used for insomnia. During an interview on 6/4/19 at 10:00 A.M., the Director of Nursing (DON) said she believed Seroquel was used for depression and anxiety but believed insomnia to be an inappropriate diagnosis. She said as far as nursing staff cueing in on the diagnosis for any particular drug, it depends on the physician or the situation. She said she would expect the pharmacist to notice these types of things when they complete monthly reviews. 2. Review of Resident #92's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required total assistance from staff for all self care activities such as mobility, dressing and personal hygiene; -Nutritional approach: Feeding tube (Gastrostomy (G-tube) a tube surgically inserted into the stomach to provide hydration, nutrition and medications); -Diagnoses included aphasia (loss of ability to understand or express speech, caused by brain damage), seizure disorder, non-traumatic chronic subdural hemorrhage (a collection of blood on the brain's surface, under the outer covering of the brain) and dysphagia (difficulty or discomfort in swallowing). Review of the resident's May 2019 POS, showed an order, dated 5/26/19 for Seroquel 25 mg tablet. Give 0.5 mg by mouth two times a day related to epilepsy. Review of the resident's May 2019 medication administration record (MAR) showed staff provided the medication to the resident six times from 5/26 through 5/30/19. During an interview on 6/4/19, the DON said epilepsy was not an appropriate diagnosis for the use of Seroquel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs by failing to obtain a time frame for use of as needed psychotropic mediations and failed to thoroughly assess, monitor and document the use of non-pharmacological approaches prior to administration of a psychotropic drug for two of five residents investigated for unnecessary medications (Residents #48 and #72). The sample was 20. The facility census was 96. 1. Review of Resident #48's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/19, showed the following: -No cognitive impairment; -Extensive assistance required for personal hygiene; -Unable to ambulate; -Diagnoses included diabetes, anxiety, peripheral vascular disease (PVD, poor circulation in the extremities) and insomnia; -Received an antianxiety, antipsychotic and an antidepressant seven out of seven days. Continued review of the MDS section of the medical record, showed he/she discharged to the hospital on 5/8 and returned to the facility on 5/14/19. Review of the physician's order sheet (POS), dated 3/17/19, showed an order to administer alprazolam (antianxiety) 0.5 milligrams (mg) every eight hours as needed (PRN) for anxiety. Further review of the POS, dated 3/17/19, showed an order, dated 3/20/19, to change alprazolam 0.5 mg to every six hours PRN. Review of the medication administration record (MAR), dated 3/17 through 3/31/19, showed he/she received alprazolam a total of 19 times. Review of the pharmacy review form, dated 4/15/19, showed the following: -Resident is currently receiving alprazolam 0.5 mg every six hours PRN, started on 3/20/19; -For all psychotropic medication, Center for Medicare/Medicaid Services (CMS) has placed 14 day limits on their duration of use when prescribed with PRN orders. Extension of use beyond 14 days can occur provided the following documentation is complete: 1. Documents clinical rationale for the extension; 2. Include a specific duration of use. Further review of the pharmacy review form, dated 4/15/19, showed the attending physician signed the form on 4/17/19 to continue the medication for general anxiety disorder. He/she did not include a specific duration for use. Review of the MAR, dated 4/1 through 4/30/19, showed he/she received alprazolam a total of 17 times. Review of the POS, dated 5/30/19, showed an order, dated 5/14/19, to administer alprazolam 0.5 mg every six hours PRN for anxiety. Review of the MAR, dated 5/1 through 5/31/19, showed he/she received alprazolam four times between 5/1 and 5/8/19 and a total of five times between 5/14 and 5/29/19. Review of the MAR, dated 6/1 through 6/30/19, showed he/she received alprazolam four times. Review of the nurse's notes, dated 3/17 through 6/4/19, showed no documentation of any non-pharmacological approaches prior to administration of PRN alprazolam. 2. Review of Resident #72's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -Set up help only from staff for transfers, dressing, eating, toileting, hygiene and bathing; -Unable to ambulate; -Diagnoses included diabetes, heart failure, CVA (cerebrovascular accident or stroke), COPD (chronic obstructive pulmonary disease) and respiratory failure; -Received an antidepressant seven out of seven days. Review of the pharmacy review form, dated 5/8/19, showed the following: -Resident is currently receiving alprazolam 0.5 mg every six hours PRN started on 12/27/18; -For all psychotropic medication, CMS has placed 14-day limits on their duration of use when prescribed with PRN orders. Extension of use beyond 14 days can occur provided the following documentation is complete: 1. Documents clinical rationale for the extension; 2. Include a specific duration of use. Further review of the pharmacy review form, dated 5/8/19, showed the attending physician signed the form on 5/16/19 to continue the medication for general anxiety disorder. He/she did not include a specific duration for use. Review of the POS, dated 5/31/19, showed an order, dated 5/13/19 to discontinue alprazolam 0.5 mg, 1 tablet every six hours PRN and to restart alprazolam 0.5 mg, 1 tablet every six hours PRN. Review of the MAR, dated 4/1 through 4/30/19, showed he/she received alprazolam a total of 9 times. Review of the MAR, dated 5/1/19 through 5/31/19, showed he/she received alprazolam three times between 5/1/19 and 5/13/19 and a total of two times between 5/23/19 and 5/29/19. Review of the MAR, dated 6/1 through 6/30/19, showed he/she received alprazolam two times. 4. During an interview on 6/4/19 at 10:00 A.M., the Director of Nursing said she was aware that PRN psychotropic medications were good for 14 days and the physician then needed to re-order them and give a rationale for the order. She would also expect staff to try other alternatives before administering medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff treat each resident with respect and dignity and provide care in a manner and in an environment that promotes his/her quality of life by failing to ensure residents were spoken to in a respectful and dignified manner (Resident's #40 and #43) and ensure residents maintained a dignified appearance in the hallway and dining room (Residents #45 and #32). The sample was 20. The census was 96. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/4/19, showed the following: -Intact cognition; -No behaviors; -Required assistance from one staff person for dressing and personal hygiene; -Wheelchair for mobility; -Diagnoses included diabetes, anxiety and depression. During an interview on 6/3/19 at 2:45 P.M., the resident said the prior evening, he/she put on his/her call light to alert staff he/she was ready for bed. A staff member entered the resident's room and dropped something. When the resident looked at him/her, he/she asked the resident, What are you looking at? in a harsh voice. The resident assured the staff member he/she was not staring. He/she told the resident he/she needed to change his/her attitude and left. Later the resident put on his/her call light and the same staff member came to the room. The resident told the staff member he/she was ready for bed and needed assistance. The staff member told him/her to get up from his/her wheelchair and get into bed. The resident told him/her he/she needed assistance to move from the wheelchair to the bed. The staff member helped the resident stand up and asked him/her to take off his/her shirt. The resident had to ask for assistance to remove his/her oxygen nasal cannula (Device used to deliver oxygen with two small tubes that fit into the nostrils) to remove the shirt. The staff member removed the cannula and set it to the side. Then the resident told the staff member he/she needed a dry brief for the night. The staff member asked him/her why since he/she was not wet. The resident explained he/she always wore a brief to bed. The staff member said he/she did not have a brief and would have to go get one. He/she left the room with the resident on the bed with no pants. The staff member was gone from the room over 20 minutes. When the staff member returned, he/she was on his/her cell phone and stood in the room talking on the phone for over ten minutes. When he/she finished the phone call, he/she looked at the resident and asked him/her what he/she was supposed to be doing. The resident reminded him/her about the brief and he/she had to leave the room again to go get the brief. The staff member helped the resident into his/her brief and told him/her to get in bed. The staff member started to leave the room and the resident asked for his/her call light and he/she threw it at him/her. The resident reminded the staff member he/she needed his/her nasal cannula placed put back on and was told to Hold on (grandma/pa). The resident was very upset about this and did not want the staff member working with him/her. He/she reported this to his/her hospice nurse who was going to notify administration. During an interview on 6/4/18 at 2:55 P.M., the resident's roommate said he/she was there when the interactions occurred. The staff member was very rude and disrespectful. He/she refused to get off his/her phone to provide care to Resident #40. His/her roommate was very upset after the interaction. During an interview on 6/4/19 at 2:30 P.M., the administrator said no one told him about the incident and it was totally unacceptable for a staff member to treat a resident that way. 2. During an interview on 5/31/19 at 8:51 A.M., Resident #43 said he/she was told recently by agency staff that they were only here to get paid. He/she said agency staff don't make any effort to engage in conversation or interact with them on a personal level. It made him/her feel worthless and bad. The resident said agency staff told him/her to do his/her own shower because agency staff didn't want to get their shoes wet. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Unable to ambulate; -Required extensive assistance to total dependence on staff for personal hygiene and mobility; -Diagnoses included dementia, anxiety, personality disorder and chronic lung disease. Observations showed the following: -On 5/29/19 at 12:40 P.M., the resident sat in a wheelchair in his room with his cheeks and neck covered with 1/4 inch whiskers around a pronounced mustache and goatee; -On 5/30/19 at 10:33 A.M., the resident sat at a table in the dining room. Food remnants trailed from the top middle of his shirt down to his waist. The resident's slacks showed an open zipper. He remained unshaved. Three staff members passed by the resident but did not acknowledge him; -On 5/31/19 at 6:38 A.M., the resident sat at the dining room table. The resident's cheeks and neck remained covered with 1/4 inch whiskers. The resident said, I need to be shaved; -On 5/31/19 at 9:41 A.M., the resident remained at the dining room table and food particles trailed down the front of his shirt. Approximately three staff passed by the resident but did not acknowledge him; -On 6/3/19 at 9:23 A.M. and 1:14 P.M., the resident sat at the dining room table, alert, unshaven and food particles trailed down the front of his shirt; -On 6/4/19 at 6:45 A.M., the resident sat at the dining room table and 1/4 inch whiskers remained on his cheeks and neck around his goatee and mustache. During an interview on 6/4/19 at 10:00 A.M., the Director of Nursing (DON) said all men are shaved on their shower days which is twice a week. She said it is not uncommon for this resident to refuse to be shaved; however she does expect staff to continue to try and to document refusals. She expects staff to change the resident's shirt whenever it is dirty. 4. Review of Resident #32's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behaviors; -Occasionally incontinent of bowel and bladder; -Independent with bed mobility and transfers; -Required set up help only from staff for dressing, eating and toileting; -Required one-person physical assist from staff for hygiene and bathing; -Diagnoses included atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), dementia, arthritis and depression. Observations of the resident on 6/3/19, showed the following; -At 6:52 A.M., a very strong urine smell in the hallway emitted from the resident's room. The resident was not in the room and the resident's bed was observed to be unmade, with a brownish substance on the mattress, mattress pad and sheets, and a gown soaked in urine and brownish substance on it. A pair of brown pants lay on the floor beside the bed. A staff member walked past the room and said whew but did not stop to maintain the room; -At 6:59 A.M., the resident came into the room and identified his/her side of the room. There was a pair of soiled pants on the floor and the resident said he/she did not want them. The resident had on clean clothes, socks and tennis shoes; -At 7:12 A.M., the resident propelled him/herself out of the room with the gown soaked with urine and brownish substance on his/her lap. He/She propelled him/herself down the hallway past nine staff members into the dining room with the gown soaked with urine and brownish substance still on his/her lap. The resident said he/she brought the gown to laundry. -At 7:40 A.M., staff had still not cleaned the resident's bed. A plastic bag lay on the floor. The pants were gone. The brownish substance remained on the mattress and mattress pad. The room still smelled of strong urine and feces; -At 7:50 A.M., observation showed staff had wiped off the resident's bed. The mattress appeared wet. There was a plastic bag of soiled linen on the bed. The mattress pad lay on top of the soiled linen bag. During an interview on 6/4/19 at 10:00 A.M., the DON said staff should clean a resident or his/her room as soon as they identify a problem. The resident refused staff assistance sometimes. How soon the resident or the room would be cleaned would depend on the timing of the rounds. In this situation, she expected the aides to act more quickly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain signed code status forms and annually update code status forms to identify residents' directives of do not resuscitate (DNR, no life prolonging methods are performed) or full code (Cardiopulmonary resuscitation (CPR), all lifesaving methods are performed) for seven of 20 sampled residents (Residents #296, #30, #45, #36, #73, #28 and #6). The census was 96. 1. Review of Resident #296's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Diagnoses included end stage kidney disease, heart disease and chronic lung disease. Review of the resident's medical record, showed the following: -No order on the POS regarding code status; -No information on the resident's profile page related to code status; -A blank facility code status form not signed by the resident. 2. Review of Resident #30's significant change MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Severe cognitive impairment; -Diagnoses included dementia, stroke and chronic lung disease; -Life expectancy of less than six months. Review of the resident's medical record, showed the following: -A facility code status form, signed and dated [DATE], showed DNR; -An order, dated [DATE], for DNR; -No further updates documented in the chart. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Moderate cognitive impairment; -Diagnoses included dementia, anxiety, personality disorder and chronic lung disease. Review of the resident's medical record, showed the following: -A facility code status form, signed and dated [DATE], showed full code; -An order, dated [DATE], for full code; -No further updates documented in the chart. 4. Review of Resident #36's medical record, showed the following: -admitted to the facility on [DATE]; -An electronic physician order sheet (POS), dated [DATE] through [DATE], showed DNR; -A facility code status form signed and dated [DATE], showed no CPR; -No further updates documented in the chart. 5. Review of Resident #73's quarterly MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Diagnoses included high blood pressure, hip fracture, anxiety, depression and bipolar. Review of the resident's medical record, showed the following: -An order, dated [DATE], for full code; -The facility code status form, signed [DATE], showed full code; -No further updates documented in the chart. 6. Review of Resident #28's medical record showed the following: -admitted to the facility on [DATE]; -An electronic POS, dated [DATE] through [DATE], showed CPR. -A facility code status form signed and dated [DATE], showed CPR; -No further updates documented in the chart. 7. Review of Resident #6's quarterly MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Diagnoses included diabetes, quadriplegia (paralysis of all four limbs) and depression. Review of the resident's medical record, showed the following: -The facility code status form, signed [DATE], showed DNR; -An order, dated [DATE], for DNR; -No further updates documented in the chart. 8. During an interview on [DATE] at 10:00 A.M., the Director of Nursing said the residents' code status should be documented on the facility code status form and on the residents' profile page in the medical record. She said the facility code status form should be reviewed annually and for any change in the resident's condition. The code status should be addressed within 24 to 48 hours after admission and the social worker was responsible for the annual follow up.

Based on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry. This affected seven of 10 sampled employees hired since the last survey. The facility hired at least 41 new employees since the last survey. The census was 96. According to Missouri Department of Health and Senior Services (DHSS): Section for Long-term Care LTC Bulletin, Volume 3 Issue 1, Fall 2004, if a CNA had or currently has had their name on the Employee Disqualification List (EDL), they receive a federal marker. Those CNAs who have a federal marker may not be employed at any time in a facility that receives Medicaid or Medicare benefits. According to Missouri Department of Health and Senior Services (DHSS): Section for Long-term Care LTC Bulletin, Volume 6 Issue 1, Winter 2008, providers are required to check the registry before hiring any individual and may not continue to employ a person whose name appears on the registry with a federal indicator. Providers must seek registry verification from all states believed to have information on an individual. Review of the facility's Abuse Prevention policy, dated February 2019, showed the following: Screening: Screen all potential employees for a history of abuse, neglect, or mistreating residents during the hiring process. Screening will consist of, but not limited to: Inquiries into state nurse aide registry, and check into nurse aide registries that the facility has reason to believe contain information on an individual, prior to using the individual as a nurse assistant. 1. Review of Speech Therapist C's employee file, showed the following: -Hire date: 10/26/18; -CNA registry check performed on 5/30/19. 2. Review of CNA D's employee file, showed the following: -Hire date: 10/19/18; -CNA registry check performed on 5/30/19. 3. Review of [NAME] E's employee file, showed the following: -Hire date: 12/14/18; -CNA registry check performed on 5/30/19. 4. Review of Dietary Aide F's employee file, showed the following: -Hire date: 10/2/18; -CNA registry check performed on 5/22/19. 5. Review of Licensed Practical Nurse G's employee file, showed the following: -Hire date: 11/26/18; -CNA registry check performed on 5/30/19. 6. Review of Physical Therapy Aide H's employee file, showed the following: -Hire date: 10/19/18; -CNA registry check performed on 5/30/19. 7. Review of the social services director's employee file, showed the following: -Hire date: 11/26/18; -CNA registry check performed on 5/30/19. During an interview on 6/3/19 at 7:20 P.M., the human resource manager said she started on 1/18/19. She checked the nurse registry for direct care staff before they were hired. She did not do a check on housekeeping or dietary staff because she did not know it was required. She did not know why the former human resources manager did not do the checks when staff were hired. They should have been done. During an interview on 6/4/19 at 2:15 P.M., the administrator said he was aware all staff needed to be checked for a federal indicator. He did not know the prior human resources manager did not do checks when staff were hired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff followed physician orders by not applying one resident's (Resident #19) abdominal binder (a wide compression belt that encircles the abdomen) and orthotic brace (Thoracolumbosacral robotic (TLSO), a brace used to correct the lateral (sideways) curve of the spine in scoliosis), failed to record one resident's (Resident #28) gastrostomy (G-tube, a tube surgically inserted into the stomach to provide hydration, nutrition and medications) feedings or care and failed to obtain and or record one resident's (Resident #45) ordered daily weights. The facility also failed to honor a resident's request to go to the hospital for mental health treatment in a timely manner (Resident #73) and failed to follow-up on a resident with documented blood sugars over 500 (Resident #18). The sample size was 20. The census was 96. 1. Review of Resident #73's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/12/19, showed the following: -readmission date of 3/26/19; -No cognitive impairment; -Required extensive assistance with transfers, dressing toileting and personal hygiene; -Diagnoses included high blood pressure, hip fracture, anxiety, depression and bipolar; -Use of an antianxiety or antidepressant medication in past seven days: seven out of seven days. Review of the resident's care plan, last reviewed on 5/29/19 and in use during the survey, showed the following: -Focus: The resident has history of diagnosis bipolar disorder. Resident has been feeling down since readmission. Facility psychiatrist continues to follow. Resident expresses sadness with winter time, misses living in California. Resident continues feeling down and anxious and negative; -Goal: The resident will have stable mood by review date. Support and validate feelings by encouraging resident to present with positive affect when interacting and continue counseling through next review; -Interventions included: If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Excessive talking, sexual inappropriateness, disorganized thinking, New medication ordered by psychiatrist, Invega (antipsychotic, can treat schizophrenia and schizoaffective disorder) injections monthly. Counseling for supportive and validation therapy. Review of the resident's medical record, showed the following: -On 4/5/19, an order to monitor for irritability, intrusiveness ,talkativeness and disorganized behavior. Notify the resident's psychiatrist immediately if these are noted two times a day; -No documentation in April or May 2019 regarding any changes in the resident's mood or behavior; -On 5/30/19, an order from the resident's primary physician to please inform the resident's psychiatrist of patient's request to go to the hospital medication adjustment to get stabilized and belligerent behavior; -Staff noted the order; -Staff failed to document contacting the resident's psychiatrist. During observation and interview on 5/31/19 at 9:23 A.M., the resident lay in bed. When asked how he/she was doing, the resident said everything was wrong. He/she had bipolar and was constantly up and down and wanted to go to the psychiatric ward at the hospital to get his/her medications stabilized. He/She said the doctor wouldn't approve it because he/she wasn't in crisis and would just be sent right back. He/she appeared tearful, very anxious and his/her hands shook as he/she spoke. Observation on 5/31/19 from 9:28 A.M. to 9:33 A.M., showed the resident lay in bed. The resident could be heard from the hall repeating over and over I want to go to the hospital. During an interview on 5/31/19 at 9:34 A.M. the facility social worker (SW) said she was aware the resident wanted to go to the hospital. She had a degree in social work and provided one-on-one support to the resident. The resident also participated in therapy. The SW agreed the resident had the right to go to the hospital if he/she wanted, but the physician needed to be notified. A resident had the right to go to the hospital if they requested to do so. A physician order was not needed. During an interview on 5/31/19 at 9:58 A.M., the SW said the nurse on the resident's hall was calling the physician and relative to make them aware the resident was going out to the hospital. The SW was unaware if the resident was his/her own responsible party (RP). Further review of the medical record, showed a progress note by the SW, dated 5/31/19 at 11:06 A.M., which showed: As of today, resident communicated that he/she wanted to go to the hospital. The resident's nurse notified the doctor and was working on contacting an ambulance to come get him/her from the facility. Further observation of the resident on 5/31/19 at 12:12 P.M., showed the resident continued to lay in bed. Further review of the medical record on 6/3/19, showed the following: -The resident left the faciity on 5/31/19 at 2:43 P.M. to go to the hospital; -No further documentation regarding the resident's status. During an interview on 6/4/19 at 7:39 A.M., the SW said she could tell the resident needed to go to the hospital because he/she was getting very anxious and stating he/she wanted to go to the hospital. The resident said his/her bipolar was getting worse for about the past week. It didn't just happen over night. Nursing or anyone that notices a resident acting unusual should document new behaviors. The SW wrote weekly behavior notes. The SW was aware of the order by the resident's primary doctor to inform the resident's psychiatrist of the resident's request to go to the hospital. The resident was his/her own responsible party. The SW talked to the Director of Nursing (DON) and then decided to send the resident out. The SW was the one responsible to ensure all residents' psycho-social well-being. The SW did not know why the resident went to the hospital on 5/31/19 instead of earlier. If a resident said he/she wanted to go to the hospital, everyone should immediately take action. During an interview on 6/4/19 at 8:20 A.M., Certified Nurse Assistant (CNA) J said he/she cared for the resident on a regular basis. He/she had noticed the resident's mood starting to escalate. The resident seemed more anxious and paranoid. It began last week and continued to get worse. He/she told the charge nurse every time he/she noticed a change. During an interview on 6/4/19 at 10:00 A.M., the DON and administrator said they were not aware of the resident's escalating mood. The DON was made aware of it on 5/31/19, when the SW told her. She would expect staff to follow orders. There should have been documentation of staff notifying the resident's psychiatrist. About two weeks ago, the resident was very upset due to medication changes and wanted to change doctors. He/she then wanted to change doctors again. The resident was very upset on 5/30/19, regarding a change in his/her medications. The resident's mood spiraled and his/her cycles have gotten worse. Residents have the right to go to the hospital if they request it. 2. Review of Resident #18's medical record, showed the following; -admission date of 11/3/16 and readmission date of 10/25/18; -Diagnosis of diabetes. Review of the resident's comprehensive care plan, in use during the survey, showed the following: -Problem: Resident has diabetes and receives insulin daily; -Interventions: Dietary consultation for nutritional regimen, administer insulin as ordered, notify physician if blood sugar level is above 400 or below 60, monitor/document/report signs of hyperglycemia (elevated blood sugar) for increased thirst, appetite, frequent urination, weight loss and/or fatigue and monitor/document/report compliance with diet; -Goal: Resident will have no complications related to diabetes through next review date. Review of the resident's physician's orders sheet (POS), dated 5/1/19 through 5/31/19, showed the following; -An order, dated 5/2/19, to administer Humalog (fast acting) insulin per sliding scale regimen for blood sugar result 150-200= 2 units, 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400= 10 units, 401-450= 12 and notify physician for blood sugar result greater than 450 (discontinued 5/16/19); -An order dated 5/17/19, to notify physician for blood sugar result above 400 and below 60. Review of the resident's medication administration record (MAR), dated 5/1 through 5/31/19, showed the following: -An order dated 5/2/19, to administer Humalog (fast acting) insulin per sliding scale regimen for blood sugar result 150-200= 2 units, 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400= 10 units, 401-450= 12 and notify physician for blood sugar result greater than 450; -On 5/3/19 at 4:00 P.M., staff documented blood sugar result of 500 and documented a number 4 (number 4 means vitals outside of parameters for administration) for no insulin administered -On 5/3/19 at 9:00 P.M., staff documented blood sugar result 512 and documented a number 4 for no insulin administered; -On 5/29/19 (undated time on MAR) for morning medication administration, staff documented blood sugar result 50 and documented a number 4 for no insulin administered. Review of the resident's blood sugar levels in the electronic medical record, showed the following: -On 5/3/19 at 4:00 P.M., staff documented blood sugar level of 500; -On 5/3/19 at 9:00 P.M., staff documented blood sugar level of 512; -On 5/29/19 at 12:12 P.M., staff documented blood sugar level 50 and at 12:23 P.M., staff documented a blood sugar level of 210; -On 5/29/19 at 5:00 P.M., staff documented blood sugar level of 210. Review of the resident's progress notes, dated 5/1/19 through 6/2/19, showed the following: - 5/3/19 at 9:43 P.M., resident's blood sugar level at 515, outside parameters for sliding scale insulin and telephone call out to resident's physician for orders; - 5/3/19 at 11:51 P.M., no return telephone call from physician, so per nursing judgement, nurse administered 12 units of Humalog insulin; -No documentation of nursing staff rechecking the resident's blood sugar level after 12 units of Humalog insulin administered for blood sugar level of 515; -No documentation of nursing staff contacting the physician regarding the resident's blood sugar level of 500 on 5/3/19 and/or blood sugar level of 50 on 5/29/19. During an interview on 6/4/19 at 12:12 P.M., the DON said she expected nursing staff to have attempted to contact the resident's physician when he/she did not return their telephone call on 5/3/19, regarding the resident's blood sugar level of 500 and 512. She expected nursing staff to have obtained the resident's blood sugar level after they administered 12 units of Humalog insulin on 5/3/19. The nursing staff should have contacted the physician on 5/29/19 regarding the resident's blood sugar level of 50 as ordered. She said this was unacceptable nursing practice. 3. Review of Resident #92's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required total assistance from staff for all self care activities such as mobility, dressing and personal hygiene; -Nutritional approach: G-tube; -Diagnoses included aphasia (loss of ability to understand or express speech, caused by brain damage), seizure disorder, nontraumatic chronic subdural hemorrhage (a collection of blood on the brain's surface, under the outer covering of the brain), and dysphagia (difficulty or discomfort in swallowing). Review of the resident's May 2019 POS, showed the following: -An order, dated 5/7/19, for abdominal binder to be worn at all times; -An order, dated 5/22/19, for resident to be up with assist only. Must wear TLSO if out of bed. Review of the resident's May 2019 treatment administration record (TAR), showed the following: -Staff documented application of the abdominal binder every day; -No order for the TLSO brace or documentation of it being applied. Observations of the resident on 5/29/19 at 2:05 P.M., 5/30/19 at 12:56 P.M., 5/31/19 at 7:58 A.M., 6/3/19 at 9:11 A.M. and 6/4/19 at 8:30 A.M., showed the resident sitting up in a geri chair (reclining wheeled chair). Staff failed to apply the TLSO brace. The brace was observed in a basket on a nightstand in the corner of the resident's room. During an interview on 5/30/19 at 12:56 A.M., CNA J said the therapy department was supposed to put on the resident's brace. CNA J had not seen the resident wear the brace since he/she was admitted . CNA J tried to put the brace on the resident, but it did not fit. CNA J was told there was not an order for the resident to wear a brace. During an interview on 6/3/19 at 9:36 A.M. Physical Therapy Aide H said the order for the brace was active and nursing staff should apply it when the resident is up. Observation of the resident during a skin assessment on 6/3/19 at 11:05 A.M., showed the resident did not have the abdominal binder on. Review of the resident's May and June 2019 TAR, showed staff documented the application of the abdominal binder on day and evening shifts. During an interview on 6/4/19 at 10:00 A.M., the DON said she expected staff to follow physician orders. If there was an order for the brace and binder, they should be applied. 4. Review of Resident #28's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -G-tube; -Required one-person physical assist from the staff for bed mobility, dressing, toileting, hygiene and bathing; -Required two-person physical assist from staff for transfers; -Diagnosis of stroke. Review of the care plan, dated 3/29/19 and in use during the survey, showed the following: -Focus: The resident requires continuous tube feeding relating to dysphagia and history of malnutrition; -Goal: The resident will maintain adequate nutritional and hydration status, and weight stable, no signs or symptoms of malnutrition or dehydration through review date, the resident will remain free of side effects or complications related to tube feeding through review date; -Intervention: Elevate head of bed 30 to 45 degrees at all times and 30 to 45 degrees after feeding is stopped or during care, check for tube placement and residual before meds and every day and night shift, provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection,the resident is dependent with tube feeding and water flushes, see physician orders for current feeding orders, Jevity (tube feeding nutritional formula) 1.5 55 milliliters (ml)/hr continuous, 200 ml water flushes every six hours, document enteral input and weekly weights. Review of the POS, dated 5/31/19, showed the following: -An order, dated 5/12/18, for enteral feeding every day and night shift, document enteral input every shift; -An order, dated 5/12/18, to elevate the head of the bed to 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped every day and night shift; -An order, dated 5/12/18, to check g-tube placement and residual before medications and every shift, every day and night shift; -An order, dated 5/12/18, for g-tube care every day and night shift; -An order, dated 6/8/18, for Jevity 1.5 55 ml/hour continuously. Review of the resident's medication administration record (MAR), dated 4/1/19 through 4/30/19, showed no documentation the enteral input was documented on day shifts on 4/13/19 and 4/28/19. Review of the resident's TAR, dated 4/1/19 through 4/30/19, showed no documentation that g-tube care was documented on day and evening shifts on 4/13/19, evening shift on 4/19/19, and day shift on 4/28/19. Review of the resident's TAR, dated 5/1/19 through 5/31/19, showed no documentation that g-tube care was documented on evening shifts on 5/3/19 and 5/16/19. During an interview on 1/29/18 at 2:02 P.M., the DON said she would expect the resident's g-tube care and enteral input to be documented as ordered. If the MAR and TAR indicate g-tube care, she would expect this to be done. The nurse was responsible for documentation. Only a nurse would document on the TAR. 5. Review of Resident #45's quarterly MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Moderate cognitive impairment; -Diagnoses included dementia, anxiety, personality disorder and chronic lung disease. Review of the POS, dated 5/30/19, showed an order, dated 5/22/19, to obtain daily weights. Review of the TARs, dated 5/22 through 5/31/19 and 6/1 through 6/4/19 showed the weight obtained and recorded on 5/23, 5/25, 5/26 and 5/30/19. During an interview on 6/4/19 at 10:00 A.M., the DON said she would expect staff to obtain the weights as ordered or to document the reason why it was not done. She said if it was not documented, she could only assume that it was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide thorough assessments, monitoring and ongoing communication with the dialysis (process for removing toxins from the blood for individuals with kidney failure) center for residents on dialysis. The facility identified six residents who received dialysis. Of those six, three were selected for the sample and issues were found with all three (Residents #22, #296 and #93). The census was 96. 1. Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/29/19, showed the following: -Intact cognition; -Required total assistance of one to two staff with bed mobility, transfers, toilet use, dressing, hygiene and bathing; -Diagnoses included end stage renal disease (ESRD, chronic irreversible kidney failure), disorder of kidney and ureter (tube that carries urine from the kidney to the bladder) and heart failure; -Treatment: Dialysis. Review of the resident's comprehensive care plan, dated 5/13/19, showed the following: -Focus: Dialysis treatment five times per week on Monday, Tuesday, Thursday, Friday and Saturday; -Goal: Would receive treatments as scheduled with monitoring of disease process; -Intervention: Replace or reinforce dressing if it came off while not at dialysis, monitor for signs and symptoms of bleeding and check for new orders on return from dialysis and maintain communication with dialysis center staff. Review of the resident's physician's order sheet (POS), dated 5/19/19 through 5/31/19 and in use during the survey, showed the following: -An order, dated 3/7/19, to check the left forearm dialysis fistula (connection of an artery and vein under the skin), check the bruit/thrill (Bruit, the normal sensation heard with stethoscope, a swishing sound at site of anastomosis (cross-connection of blood vessels) for grafts and fistulas. Thrill, the normal sensation felt at site of anastomosis for grafts and fistulas); every day and night shift and notify the dialysis center if dressing over the fistula comes off; -An order, dated 3/11/19, for dialysis treatments five times a week (Monday, Tuesday, Thursday, Friday and Saturday) with location of the dialysis center. Review of the resident's nurse's notes, showed the following: -On 5/14/19 at 11:47 A.M., the resident went to dialysis, his/her arm clotted and was going out for a temporary dialysis port to be placed due to the clotting; -On 5/24/19 at 2:04 P.M. the physician sent an order to send the resident to the hospital due to unable to gain access for dialysis; -On 5/25/19 at 5:35 P.M., staff received a report that resident had a STAT (immediate) basic metabolic panel (BMP) lab. When staff called the lab, it was discovered no one performed the lab. Staff contacted the physician who wanted the resident sent to the emergency room to check his/her potassium level to avoid a cardiac arrest; -On 5/27/19 at 6:07 P.M., the resident returned from the hospital with a dialysis port revision. -On 5/29/19 through 6/4/19, there were no continual thorough assessments of the resident's condition before/after dialysis, assessment of the resident's dialysis port/catheter for signs of infection, bleeding, redness or swelling and no on-going communication between the dialysis center and facility. Review of the resident's pre/post dialysis communication forms, showed the following: -5/14/19, completed post dialysis assessment; -5/23/19, completed post dialysis assessment. Problem with access port, clotted (obstructed); -No other pre/post dialysis assessments for the month of May. During an interview on 6/3/19 at 2:30 P.M., the resident said staff never assessed him/her after dialysis. He/she had several issues with the port and it caused him/her a lot of pain. He/she was wearing a temporary port now, and the dialysis center told him/her it was beginning to fail. He/she was supposed to get a communication form filled out at the dialysis center but they usually forget to send it back with him/her. The facility staff did not ask him/her about the form. Observation on 6/3/19 at 2:30 P.M., showed the resident's dialysis port/catheter with dry dressing intact to his/her left upper chest. During an interview on 6/3/19 at 9:41 A.M., Licensed Practical Nurse (LPN) B said staff were supposed to get the dialysis communication sheet from residents every time they went. They were supposed to put the sheet in a binder kept at the nurse's station. He/she did not know why the resident only had two sheets in the book. It was the nurse's responsibility to check and make sure it was put in the binder. The resident would not always come to the desk after returning from dialysis and would not turn in the sheets. Staff should find the resident to get the sheets. The dialysis center usually called them if there was an issue. During an interview on 6/4/19 at 7:26 A.M. , LPN A. said residents should be assessed whenever they returned from dialysis. The assessment should include vitals, pain management and checking the port sites. They should review paperwork from the dialysis center. 2. Review of Resident #296's admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Extensive assistance required for mobility; -Diagnoses included end stage kidney disease, renal dialysis, heart disease, chronic lung disease and bilateral below the knee amputations. Review of the POS, dated 5/30/19, showed the following: -An order, dated 5/24/19, for a no added salt diet, no orange juice, bananas or tomatoes and limit milk to one serving a day; -An order, dated 5/28/19, for dialysis on Monday, Tuesday, Thursday and Saturday. Transportation to pick up resident at 5:00 A.M. on Tuesday, Thursday and Saturday and 1:00 P.M. on Monday; -An order, dated 5/24/19, to check right arm fistula for bruit and thrill every day; Review of the care plan, dated 5/30/19, showed the following: -Focus: Resident receives dialysis treatment four times a week on Monday, Tuesday, Thursday and Saturday. Pick up at 10:00 A.M. on Monday and 5:00 A.M. on Tuesday, Thursday and Saturday to transport to the participating dialysis center. Fistula to right arm to administer dialysis treatment; -Goal: Resident will receive treatments as scheduled with monitoring of disease process through next review; -Interventions: Assist with transfer needs when going to dialysis, have resident ready for dialysis on scheduled day and times, do not send medication to dialysis, fistula to right arm, check bruit and thrill, if dressing over the fistula should come off, replace with a new one, monitor and report labs as ordered, maintain communication with dialysis, no blood pressure or lab draws in the right arm. Review of the facility dialysis communication book, showed no information regarding the resident. 3. Review of Resident #93's admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -No cognitive impairment; -Required one-person physical assistance from the staff for bed mobility, dressing, toileting, hygiene and bathing; -Required two-person physical assistance from staff for transfers. -Set up help only, from staff for eating; -Dialysis; -Diagnoses included ESRD, renal dialysis, anemia, diabetes, and seizure disorder or epilepsy. Review of the POS, dated 5/31/19, showed the following: -An order, dated 4/5/19, for a consistent carbohydrate diet (CCHO) diet, regular texture, no added salt diet, no orange juice, or tomatoes and limit milk to one serving a day; -An order, dated 2/25/19, for dialysis on Monday, Tuesday, Thursday and Saturday at 9:30 A.M., transportation to dialysis via facility van, -An order, dated 5/3/19, to check right arm fistula for bruit and thrill every day shift. Review of the resident's care plan, dated 5/18/19 and in use during the survey, showed the following: -Focus: Resident receives dialysis treatment three times a week on Thursday, Friday, and Saturday at 9:30 A.M., transported to the participating dialysis center via the facility van, fistula to right arm to administer dialysis treatment; -Goal: Will receive treatments as scheduled with monitoring of disease process thru next review; -Intervention: Assist with transfer needs when going to dialysis. Ensure resident is ready for transport on dialysis days. Check for new orders on return from dialysis. Maintain communication with dialysis center and monitor labs and report to physician as ordered. Resident has fistula right upper arm. Nurse to check for bruit and thrill as ordered. If no bruit or thrill noted, notify dialysis center. If dressing to fistula site comes off while not at dialysis, reinforce or replace with a new one. May not send medications to dialysis center unless specified by physician. No blood pressure or blood draws in the right arm; -The care plan did not address refusal of dialysis. Review of the medical record showed the following: -Physician note, dated 5/6/19, showed the resident had been refusing to attend dialysis; -Staff took the resident's blood pressure on the right arm (the same arm as the fistula site) on the following days: 2/7/19, 2/8/19, 2/12/19, 2/16/19, 2/17/19, 3/1/19-3/3/19, 3/7/19, 3/10/19, 3/11/19, 3/15/19, 3/16/19, 3/19/19, 3/10/19, 3/24/19, 3/25/19, 3/31/19, 4/1/19, 4/7/19, 4/12/19, 4/15/19, 4/17/19, 4/19/19, 4/21/19, 4/28/19, 5/13/19 and 5/21/19. Review of the facility dialysis communication book, showed communication sheets completed on two days (5/4/19 and 5/7/19) regarding resident #93. 4. During interviews on 6/4/19 at 10:00 A.M. and at 12:00 P.M., the Director of Nursing said there should be a thorough assessment done on dialysis patients. The nurses are responsible for conducting the assessments. They should check for bleeding and reinforcement. They should make a note that they are checking for bleeding. She would expect for the blood pressure to not be taken on the same side as the fistula for bleeding purposes and because they may not get an accurate report. Also, it could interfere with the fistula. When a resident goes to dialysis, a form is sent with him/her to foster communication with the dialysis company. Ideally, the resident would return to the facility with the communication form, but if it was not in the binder, then there was no communication. She would expect the nurse to contact the dialysis company with any problems or issues. The resident had days where he/she refused to attend dialysis. She would expect for his/her refusals to be addressed on the care plan. Diets should also be noted on the care plan along with the dialysis section.

Based on observation, interview and record review, the facility failed to ensure all staff, including agency staff, were adequately trained and informed of facility policies, expectations and provided person-centered care by not providing appropriate personal care (Resident #43 and #30) per acceptable nursing standards. This had the potential to affect all residents. The census was 96. 1. During the resident council interview on 5/30/19 at 10:00 A.M., seven out of seven residents, whom the facility identified as alert and oriented, said the agency certified nurse aides (CNA) have bad attitudes and do not seem to be interested in their jobs. They either don't know how to do their job or they won't do their job. Some of them talk down to the residents like children. The residents said this was their home and they should not be treated like children. 2. During an interview on 5/31/19 at 8:51 A.M., Resident #43 said the worst time in the facility is from Saturday evening until Monday morning. That is when it is mostly agency staff and they seem like they don't know what they are doing or that they don't want to work. An agency staff member recently told the resident that they were only there to get paid. They don't make any effort to engage in conversation or interact with them on a personal level. It made him/her feel worthless and bad. His/Her bed was frequently unmade. When agency staff gave him/her a shower, they didn't seem to know what to do and asked the resident What do I do? Agency staff told the resident to do his/her own shower because they didn't want to get their shoes wet. 3. During an interview on 5/31/19 at approximately 1:00 P.M., the administrator said they did not provide the same orientation to agency staff as was given to permanent staff. He expected the agency to provide in-depth orientation. The facility provided the following orientation information to agency staff: -How to clock-in; -How to utilize the plan of care and cardex; -Policy on taking breaks; -How to make a maintenance request; -Proper handwashing related for wound care; -The facility is drug free; -Proper glove application; -The facility did not provide information in their agency packet regarding facility policy and procedures related to providing resident care, person-centered care or reporting abuse and neglect. 4. Review of Resident #30's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/25/19, showed the following: -Severe cognitive impairment; -Extensive assistance to total dependence on staff for all personal care; -Unable to ambulate; -Incontinent of bowel and bladder; -Diagnoses included stroke, dementia, chronic lung disease and heart disease; -Life expectancy of less than six months. Observation on 6/3/19 at 12:40 P.M., showed CNA K entered the resident's room and donned gloves without washing his/her hands. He/she uncovered the resident and found the bed, brief and resident's lower shirt saturated with urine. He/she removed the resident's shirt and brief and turned him/her to his/her left side, which revealed a small amount of feces. He/she cleansed the feces and did not clean the buttocks, the front perineal area, the thighs or the lower back. He/she changed gloves without washing his/her hands, removed the saturated with urine bottom bed sheet and dressed the resident in a clean shirt and brief. He/she then removed the bottom sheet which exposed a wet area on the mattress that measured approximately three feet long by two feet wide. Without cleaning or drying the area, he/she placed a clean sheet on the mattress. After placing all of the soiled linens in a bag, he she washed his/her hands. During an interview on 6/3/19 at approximately 1:00 P.M.,CNA K said he/she worked through an agency and this was his/her first day at this particular facility. He/she had not received any orientation and was not being shadowed by any of the regular facility staff. 5. On 6/3/19 at 8:00 A.M., the administrator provided two additional forms that will be added to the agency orientation packet covering important codes and reporting abuse/neglect. 6. During an interview on 6/4/19 at 6:49 A.M., CNA I, agency staff, said he/she did not receive any type of orientation prior to coming to work at the facility. The CNA said the only paperwork he/she received from the facility to sign was for customer service. The CNA said when he/she started to work at the facility, he/she received information from the residents' cardex/care plan regarding the type of care needed for each resident on his/her assignment. 7. During an interview on 6/4/19 at 8:00 A.M., CNA J said he/she knew agency staff would refuse to do their jobs. He/she has witnessed agency staff refuse to answer call lights or give showers. He/she did his/her best to train them, but there was one agency CNA who would go sit in the car and not do anything. The Director of Nursing (DON) had been made aware. 8. During an interview on 6/4/19 at 10:00 A.M., the administrator said the original intent of the agency orientation packet was to follow facility specific guidelines. He recently added other key things to serve as reminders, such as codes, handwashing and reporting abuse/neglect. It was a joint responsibility to train staff. He believed the agency contract included a provision for orientation, but he was not aware of what the agency covered during their orientation. They provided classroom and floor orientation for permanent employees. He was not responsible for floor orientation. The DON said they did not address facility policies or procedures with agency staff. They relied heavily on standard care practices, which everyone should know how to do. She expected permanent staff to provide guidance as well. It was not okay for agency staff to say they were only here for a check. Residents should never feel like an agency staff member was incompetent. Residents should be equally comfortable with agency staff or permanent staff. If there was a complaint about an agency staff member, the facility has the option to tell them to not return. Permanent staff had not informed the DON or administrator about agency staff having bad attitudes. -

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly date and label insulin flexpens (prefilled injectable insulin) and insulin vials with a resident's name once opened and dated when opened. The facility also failed to destroy one expired insulin vial. This deficiency affected four of eleven flex-pens and vials on one of one medication carts checked. The census was 96. Observation on [DATE] at 7:17 A.M., of the medication cart on the 100 hall, showed the following: -One Novolog (fast acting insulin) flexpen opened and in use with no resident name or date opened; -One Humulin N (fast acting insulin) vial opened and in use with no date opened; -One Humulin N vial opened and in use with no resident name or date opened; -One Humulin N vial opened and dated [DATE] (31 days after opened). During an interview on [DATE] at 7:20 A.M. Licensed Practical Nurse L said all insulin vials and pens were good for 30 days, and if the pen/vial did not have a name or date or was outdated, it should be destroyed. Review of the facility's Insulin Labeling and Storage Policy, dated [DATE], showed the following: -All insulins will be stored in the refrigerator on delivery until opened for usage; -New insulins need to be dated when opened and include the resident's name; -Insulins are only good for 28 days after opening. During an interview on [DATE] at 10:00 A.M., the Director of Nursing said all insulin flex pens and vials were good for 28 days, and should be destroyed after the 28 days. She said upon opening insulin, staff should label the flex pen or vial with the date opened and the resident's name.

Based on observation and interview, the facility failed to maintain food under sanitary conditions by not ensuring food was properly closed and sealed from air. In addition, the facility failed to ensure dishes were properly cleaned and stored during five of five days of observation. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 96. 1. Observations on 5/29/19 at 10:52 A.M., 5/30/19 at 7:08 A.M., 5/31/19 at 6:51 A.M., 6/3/19 at 11:20 A.M. and 6/4/19 at 8:30 A.M., of the kitchen, showed the following: -In the storage room on the metal shelf, three opened bags of biscuit mix, each rolled up inside of a zip lock bag together, not dated; -Two trays of bowls stacked on top of each other with two bowls on top of the trays. Inside the bowls were two big spoons and two measuring cups. The big green spoon had a dried, brown substance on it. Approximately three of the bowls had a brown substance on them and there were food particles on the bowls and on the rack where the bowls were stacked. Observations on 5/29/19 at 10:52 A.M., 5/30/19 at 7:08 A.M. and 5/31/19 at 6:35 A.M., of the kitchen, showed one package of hotdog buns sat on a shelf and were open to air. Observations on 5/30/19 at 6:56 A.M., 5/31/19 at 7:09 A.M. and 6/3/19 at 11:05 A.M., of the kitchen, showed a zip lock bag with frozen pork, dated 5/7/19, sat on the top shelf in the freezer and was open to air. Observations on 5/30/19 at 6:56 A.M. and on 5/31/19 at 7:09 A.M., of the kitchen, showed one package of individual frozen cookies, opened and twisted on the end, on a shelf in the freezer with no date. 2. During an interview on 6/3/19 at 8:30 A.M., the dietary manager said once items were opened, they should be put in a bag, sealed and labeled with the date opened. She tells the staff about this all of the time. The trays of dishes were partially dirty and partially clean. The dishes had been clean at one time, but they rarely use them. If they use them in the future, they will run them through the dishwasher again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to follow acceptable infection control practices to prevent the spread of infection by not washing hands before or after providing personal care, not cleaning off a mattress soaked with urine, failed to provide a barrier for a glucometer (device used to measure blood sugar), failed to sanitize the glucometer between use and touched residents' food with bare hands (Residents #30, #90 and #17). The sample was 20. The census was 96. 1. Review of Resident #30's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/25/19, showed the following: -Severe cognitive impairment; -Extensive assistance to total dependence on staff for all personal care; -Unable to ambulate; -Incontinent of bowel and bladder; -Diagnoses included stroke, dementia, chronic lung disease and heart disease; -Life expectancy of less than six months Observation on 6/3/19 at 12:40 P.M., showed Certified Nurse Aide (CNA) K entered the resident's room and donned gloves without washing his/her hands. He/she uncovered the resident and found the bed, brief and resident's lower shirt saturated with urine. He/she removed the resident's shirt and brief and turned him/her to his/her left side which revealed a small amount of feces. CNA K cleansed the feces, removed his/her gloves, did not wash his/her hands, reached in his/her pocket, removed a pair of gloves and donned the gloves. He/she removed the saturated with urine bottom sheet, dressed the resident in a brief and clean shirt and placed a clean sheet on the mattress. Without washing his/her hands or changing gloves, he/she covered the resident in a clean sheet, gathered all the soiled linen that lay on the floor and placed them in a trash bag, He/she then removed his/her gloves and washed his/her hands. During an interview on 6/3/19 at approximately 1:00 P.M., CNA K said to always wash hands when finished providing care. He/she said you should change gloves after cleaning bodily fluids but it is not necessary to wash your hands. He/she said Oh, I didn't realize the mattress was wet, I just thought it was the sheet. CNA K agreed he/she should have washed the mattress. During an interview on 6/4/19 at 10:00 A.M., the Director of Nursing (DON) said hands should always be cleansed before providing care to any resident and always after touching bodily fluids. She said the rule of thumb is to wash hands when going from dirty to clean. She also said the soiled mattress should have been cleansed with either soap and water or a disinfectant to aid in infection control and to prevent any odors. 2. Review of Resident #90's annual MDS, dated [DATE], showed a diagnosis of diabetes. During observation on 5/30/19 at 7:06 A.M., Licensed Practical Nurse (LPN) L lay the glucometer on top of the medication cart, donned gloves after washing his/her hands, gathered the needed supplies, entered the room and lay the glucometer on the sheet on the resident's abdomen. He/she completed the test, returned to the medication cart, discarded the used supplies and lay the glucometer on top of the cart without placing it on a barrier. He/she then placed the glucometer in the drawer without cleaning it. 3. Review of Resident #17's quarterly MDS, dated [DATE], showed a diagnosis of diabetes. Observation on 5/30/19 at 7:12 A.M., showed LPN L washed his/her hands, donned gloves, removed the glucometer from the drawer of the medication cart, gathered the needed supplies, entered the resident's room and lay the glucometer on the sheet on the resident's abdomen. He/she completed the test, returned to the medication cart, discarded the used supplies and placed the glucometer in the drawer of the cart. During an interview on 5/30/19 at approximately 7:20 A.M., LPN L said At my other job, we cleansed the glucometer with a sani wipe but I haven't seen any here and I haven't seen anyone clean the glucometer. During an interview on 6/4/19 at 10:00 A.M., the DON said the glucometer should always be cleansed before and after each use with a bleach wipe and there should always be a barrier between the glucometer and the surface that it sits on. The glucometer should not be placed on the resident's bed. 5. Observation on 5/29/19 at 12:39 P.M., showed Certified Medication Technician (CMT) P sat in the dining room with two residents who required assistance with eating. The CMT used his/her bare hands and picked up a corn bread muffin and tore it in half. He/she then buttered half of the corn bread muffin and used his/her bare hands to tear the other half into small pieces and dropped them into the resident's bowl of stew. The resident began eating the stew. At 12:43 P.M., without washing his/her hands or donning gloves, CMT P took the cornbread muffin off of the plate of the other resident at the table and tore it into pieces and placed in the resident's stew. CMT P then began to spoon the stew mixture into the resident's mouth. During an interview on 6/4/19 at 10:00 A.M., the DON said staff should never use their bare hands to touch resident's food because of infection control.

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. In addition, the facility failed to properly document narcotic counts for the controlled substances on four of four medication carts. The facility census was 96. 1. Review of the narcotic count sheet, dated 4/9 through 5/31/19, for resident rooms 101-110 on the 100 Hall, showed the following: -No signature by the on-coming nurse, a total of three days; -No signature by the off-going nurse, a total of seven days; -Narcotic cards counted on only one shift, a total of five days; -Narcotic count not recorded as completed on either shift (12-hour shifts), for one day; -Narcotic card count incorrect on three different shifts. 2. Review of the narcotic count sheet, dated 5/14 through 6/3/19, for resident rooms 111-126 on the 100 Hall, showed the following: -No documentation of the total number of narcotic cards on 5/19/19; -No signature by the off-going nurse on 5/21/19; -Incorrect count recorded on 5/28, 5/30 and 5/31/19. 3. Review of the narcotic count sheet, dated 4/1 through 5/31/19, for resident rooms 201-210 on the 200 Hall, showed the following: -Illegible narcotic counts, a total of nine days at the beginning and end of each nursing shift; -No signature by the off-going nurse, a total of 10 days; -No signature by the on-coming nurse, a total of seven days; -Incorrect count recorded a total of 26 days; -No resident's name for the narcotics added and/or deducted from the narcotic count on 25 days. 4. Review of the narcotic count sheet, dated 4/1 through 5/31/19, for resident rooms 214-226 on the 200 Hall, showed the following: -Illegible narcotic count, a total of 15 days at the beginning and end of each nursing shift; -No signature by the off-going nurse, a total of 14 days; -No signature by the on-coming nurse, a total of 12 days; -Incorrect count recorded a total of 20 days; -No resident's name for the narcotics added and/or deducted from the narcotic count on 21 days. 5. During an interview on 5/30/19 at 1:44 P.M., Licensed Practical Nurse (LPN) M said the nurse going off and the nurse coming on duty count the cards and the pills per card, and any discrepancies need to be called to the Director of Nursing (DON) and the issue resolved before anyone leaves the building. 6. During an interview on 5/30/19 at 1:10 P.M., Nurse B said nursing staff did the narcotic count at the beginning and end of each nursing shift with the off-going and on-coming licensed nursing staff. He/she said the off going and on coming nursing staff should sign the narcotic sheet when the narcotics were counted. If there was a discrepancy with the narcotic count, nursing staff were not allowed to leave. The DON should be notified immediately and narcotic keys should not be given to the on-coming licensed nursing staff. 7. Review of the facility's Policy and Procedure for Controlled Drug Administration, dated 1/1/19, showed the following: -Policy: -The Controlled Substances Act was designed to control the rapidly increasing problem of drug abuse and misuse. Controlled drugs are placed in different schedules to which different regulations apply; -Procedure: 1.) A strict accounting system shall be maintained when administering controlled drugs. The controlled drug record shall contain the resident's name, prescribing physician's name, medication time, date, time of administration, name of the nurse who administers the medication and the number remaining in the package; 2.) Controlled substances shall be counted every shift by two licensed personnel to ensure adequate control. When there is a discrepancy in the records, nursing administration shall be notified as soon as possible. 8. During an interview on 6/4/19 at 10:00 A.M., the DON said she expected nursing staff to correctly count and reconcile the narcotic count at the beginning and end of each nursing shift. The narcotic count sheets should contain the off-going and on-coming licensed nursing staff signature, name of narcotics added or deducted and amount of narcotics counted between the off going and on coming nursing staff. The nursing staff signatures and amount of narcotics counted should be legible. She expected nursing staff to follow the facility's policy/procedure regarding receipt, disposition and reconciliation of controlled drugs. The DON verified the 100 and 200 Hall narcotic count sheets were not an accurate reconciliation of controlled substances.