Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #2), who staff identified as incontinent and required staff assistance with toileting and incontinence care, in a review of nine residents, was provided incontinence care timely and maintained good personal hygiene. The facility census was 54. Review of the facility policy, Urinary Continence and Incontinence, Assessment and Management, dated 8/2022 showed the following: -As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence; -Staff will check the resident for incontinence and change the resident at regular intervals using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. 1. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 9/27/24 showed the following: -Severely impaired cognition; -Frequently incontinent of urine; -Always incontinent of bowel; -Required substantial/maximum staff assistance (helper does more than half the effort) with toileting, dressing lower body and personal hygiene; -Dependent on staff for transfers to and from the toilet. Review of the resident's Care Plan dated 10/20/24 showed the following: -Diagnoses of dementia, urinary incontinence, abnormal gait and mobility, unsteadiness on feet, kidney disease, stroke and urinary tract infection; -Impaired physical mobility and risk for self-care deficit. Staff should determine the level of assistance needed, provide assistance with Activities of Daily Living (ADL) as needed; -ADL self-care performance deficit related to stroke. Staff should provide assistance with ADLs, transfers, dressing and personal hygiene and total assistance with toileting. Observation of the resident on 1/22/25 showed the following: -At 10:05 A.M. the resident sat in a wheelchair in his/her room, facing the television. A strong urine odor was noted in the room; -At 11:00 A.M. the resident remained in the wheelchair with no change in position. A strong urine odor was noted coming from the resident; -At 11:45 A.M. Certified Nurse Assistant (CNA) B pushed the resident's wheelchair to the dining room for lunch. During an interview on 1/22/25 at 11:46 A.M. CNA B said he/she toileted the resident and changed the resident's clothing before lunch. The resident was soiled and wet. Observation on 1/23/25 showed the following: -At 8:30 A.M. the resident sat in a wheelchair in his/her room facing the television, dressed in black pants and a gray shirt; -At 9:50 A.M. the resident sat in a wheelchair in his/her room facing the television, dressed in the same black pants and gray shirt, in the same position; -From 11:30 A.M. through 12:45 P.M. the resident sat in a wheelchair in the dining room eating lunch, dressed in the same black pants and gray shirt. A strong urine odor was noted coming from the resident. CNA G said the resident was last toileted at about 9:00 A.M.; -At 12:45 P.M. staff pushed the resident in his/her wheelchair from the dining room to his/her room and positioned the resident's wheelchair facing the television and did not offer to assist the resident with toileting or check the resident for incontinence. The resident had a strong urine and feces odor. During an interview on 1/23/25 at 12:48 P.M. the resident said staff got him/her up about 9:00 A.M. Staff had not taken him/her to the toilet or changed his/her incontinence brief since 9:00 A.M. The resident needed to go to the bathroom and needed his/her soiled incontinence brief changed. Observation of the resident 1/23/25 at 1:00 P.M. showed the following: -CNA H and Nurse Assistant (NA) E transferred the resident to the toilet and removed the resident's urine and feces saturated incontinence brief. Feces was noted on the inside of the resident's pants; -CNA H repeatedly wiped the resident's buttocks and perineal area removing firm feces stuck to the resident's skin from the resident's buttock and perineal areas. CNA H said the feces had been there awhile as it was dried and was hard to clean. During an interview on 1/23/25 at 1:15 P.M. Nurse Aide (NA) E said he/she worked the resident's hall and last toileted and changed the resident at 9:00 A.M. that day. During an interview on 1/23/25 at 1:20 P.M. CNA H said staff should check the resident at least every two hours change the resident if the resident was incontinent. Staff should not let the resident sit in feces and urine. During an interview on 1/24/25 at 11:45 A.M. the Director of Nursing said staff should keep residents clean and dry, check and change residents every two hours and should not leave residents wet and soiled for extended periods of time. During an interview on 1/24/25 at 11:15 A.M. the Administrator said staff should check incontinent residents every one hour and provide incontinence care as needed. Staff should make sure residents were clean and dry and not left soiled. MO242963 MO245840 MO246518

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #2) in a review of nine residents, was provided treatment and care in accordance with professional standards of practice when staff failed to assess the resident's clinical condition, failed to ensure a heart monitor was in place and functioning as ordered by the physician, failed to ensure the resident received therapy services following a hospitalization, and failed to ensure the resident's Care Plan was up to date and reflected the resident's current condition and care needs. The facility census was 54. Review of the facility policy admission Notes, dated 9/2012, showed the following: -Preliminary resident information shall be documented upon a resident's admission to the facility; -When a resident is admitted to the nursing unit, the admitting nurse must document the following information in the nurses' notes, admission form, or other appropriate place, as designated by facility protocol; -The date and time of admission, from where the resident was admitted , reason for the admission and admitting diagnoses, the general condition of the resident upon admission, the presence of a urinary catheter (a sterile tube inserted into the bladder), dressings and any other medical equipment, a brief description of any disabilities, a statement indicating the nursing history and preliminary assessment is completed or has been started, notation of any signs or symptoms of an infectious or communicable disease; -This initial information-gathering precedes the complete history and physical assessment that also accompanies the resident admission process; -Should a resident be discharged from and readmitted to the facility, new admission data must be recorded. Review of the facility admission Chart Audit, dated 2/7/24, showed the following: -The audit was to be completed every admission and re-admission; -The audit included the admission nurses note completed by the charge nurse; -admission vital signs. 1. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 9/27/24, showed the following: -Severely impaired cognition; -Required substantial/maximum staff assistance (helper does more than half the effort) with toileting, dressing lower body and personal hygiene; -Dependent on staff for transfers to and from the toilet, to and from the chair. Review of the resident's Care Plan, dated 10/20/24, showed the following: -Diagnoses of dementia, anxiety, urinary incontinence, abnormal gait and mobility, unsteadiness on feet, kidney disease, and stroke; -Impaired physical mobility and risk for self-care deficit. Staff should determine the level of assistance needed, provide assistance with Activities of Daily Living (ADL) as needed, determine residents ability to transfer, educate resident on exercise and safe transfer techniques, encourage resident to increase activity as indicated, evaluate skin for areas of redness, evaluate functional abilities; -Risk for disturbed sensory perception. Staff should consult occupational and physical therapy per orders; -ADL self-care performance deficit related to stroke. Staff should provide assistance with ADLs, transfers, dressing and personal hygiene and total assistance with toileting. Review of the resident's Nurses Note, dated 12/29/24, showed staff documented the following: -At 12:48 P.M. the resident was not acting right. The resident sat in the wheelchair with head tilted back, no response to verbal stimuli and slight response to sternal rub (act of forcefully rubbing the sternum) Blood pressure 186/116 (normal 120/80), heart rate 128 (normal 60-80) beats per minute and bounding, respirations 16 (normal 12-18) breaths per minute and slow. COVID-19 (an infectious disease caused by severe acute respiratory syndrome Coronavirus 2(SARS-CoV-2) test was positive. Staff called the ambulance and transferred resident to the emergency room for evaluation and treatment; -At 4:20 P.M. the resident was admitted to the hospital with acute CVA (cardiovascular accident or stroke). Review of the resident's Hospital Discharge Physician Orders dated 12/31/24 showed the following: -Hospital admission diagnosis of acute stroke; -Physical therapy, occupational therapy and speech therapy evaluation and treat; -Check weights and record; -Check vital signs and record; -COVID-19 precautions; -Follow up with cardiology physician in 30 days related to Zio heart monitor (a heart monitor patch applied to the skin that records the heart rhythm for up to two weeks). Review of the resident's Physician Order Sheet (POS), dated 12/31/24, showed speech therapy evaluate and treat. Review of the resident's POS showed no physician orders for readmission, physical therapy, occupational therapy, check weights and vital signs and record or the Zio heart monitor. Review of the resident's Nurses Note, dated 12/31/24 at 6:33 P.M., showed staff documented the resident returned to the facility by medical transport. The resident was on isolation precautions due to positive COVID-19 status. Review of the resident's medical record showed no documentation staff completed an admission clinical assessment or assessed the resident's vital signs (blood pressure, heart rate, respirations, temperature and oxygen saturation level) upon readmission on [DATE]. Review of the resident's Speech Therapy Evaluation and Plan of Treatment, dated 1/1/25, showed the following: -Diagnoses of stroke, dysphagia (difficulty swallowing), cognitive communication deficit; -Evaluation of speech sound production and language assessment; -Treatment of swallowing dysfunction and/or oral function for feeding; -Evaluation of oral and pharyngeal (pharynx, commonly referred to as the throat) swallow function; -Frequency 14 times/period for 30 days; -Resident referred to Speech Therapy due to recent hospitalization following acute stroke indicating the need for Speech Therapy to analyze oral/pharyngeal function and analyze speech, language and cognitive skills; -Recommendations for any/all solid intake and any liquid intake with supervision for oral intake. To facilitate safety and efficiency, alternate liquid and solids, decrease environmental distractions, be seated at a table with assist for verbal cues as needed. Review of the resident's Vital Signs Record, dated 1/1/25, showed staff documented the resident's heart rate was 91 beats per minute. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs, other than heart rate, (blood pressure, respirations, temperature, oxygen saturation level) on 1/1/25. Review of the resident's POS dated 1/2/25 showed the following: -Admit to the facility, the resident needed continuous care due to inability to live independently and the need for 24 hour assistance, observation and planning; -Physical Therapy and Occupational Therapy evaluate and treat; -Check vital signs and weigh monthly. Review of the resident's Vital Signs Record, dated 1/2/25, showed staff documented the resident's heart rate was 83 beats per minute. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs, other than heart rate, (blood pressure, respirations, temperature, oxygen saturation level) on 1/2/25 and no documentation staff updated the resident's Care Plan regarding the recent hospitalization for stroke and the presence of a heart monitor. Review of the resident's Nurses' Note, dated 1/3/25, showed staff documented the following: -At 1:21 A.M. the resident was re-admitted and was positive for COVID-19. The resident was isolated in his/her room and monitored for any worsening of symptoms; -At 12:05 P.M. the resident remained COVID-19 positive and in isolation. The resident was up in the wheelchair in room for meals, no complaints noted. Vital signs within normal limits, medications administered. Review of the resident's Vital Signs Record, dated 1/3/25, showed staff documented the resident's heart rate was 77 beats per minute and oxygen saturation level was 94 percent (normal greater than 92 percent). Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's blood pressure, respirations or temperature) on 1/3/25. Review of the resident's Nurses' Note, dated 1/4/25, showed staff documented the following: -At 1:47 A.M. the resident continued isolation due to positive COVID-19. No cough noted and no adverse reactions; -At 5:18 P.M. the resident continued isolation due to positive COVID-19. No cough noted. The resident ate well for meals while staff set up food and offered limited assistance. Review of the resident's Vital Signs Record, dated 1/4/25, showed staff documented the resident's blood pressure was 144/86, heart rate was 79 beats per minute, respirations 20 breaths per minute, and temperature was 98.7 degrees (normal 98.6 degrees). Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's oxygen saturation on 1/4/25. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs on 1/5/25, 1/6/25 or 1/7/25. Review of the resident's Nurses Note, dated 1/7/25 at 2:16 P.M., showed staff documented hospital staff called and said cardiology did not receive any recording of the resident's heart monitor that was on the resident when he/she returned from the hospital on [DATE]. The hospital staff member said the transmitter should be within ten feet of the resident to allow recording. Facility staff were not aware of any transmitter, but the resident had a heart monitor still in place. Staff searched the resident's room but were unable to locate the transmitter. The hospital will send another heart monitor and transmitter to be placed on the resident 1/14/25 for 14 days and then remove the monitor and send back to the hospital. Review of the resident's Occupational Therapy Evaluation and Plan of Treatment, dated 1/8/25, showed the following: -Diagnoses of stroke, need for assistance with personal care, muscle weakness, unsteadiness on feet and lack of coordination; -Therapeutic exercises; -Neuromuscular reeducation; -Self-care management training, -Wheelchair management training; -Three times per week for 30 days; -Referred to Occupational therapy after hospitalization, dementia and repeated falls; -Resident presented with impaired cognition, right sided weakness, decreased participation in self-care and functional mobility; -Required skilled Occupational Therapy to assess safety and independence with self-care and functional tasks of choice in order to enhance the resident's quality of life by improving ability to facilitate increased participation with functional daily activities; -Due to documented physical impairment and associated functional deficits, the resident was at risk for further decline in function and increased dependency upon caregivers. Review of the resident's Physical Therapy Evaluation and Plan of Treatment, dated 1/8/25, showed the following: -Diagnoses of stroke and muscle weakness; -Therapeutic exercises; -Neuromuscular re-education; -Gait training therapy; -Referred to Physical Therapy due to new onset of decrease in transfers and decrease in strength; -Will benefit from skilled therapy to progress with strength and mobility to return to prior level of function and reduce need for assistance; -Increase range of motion and strength, increase functional activity tolerance and evaluate need for assistive device in order to enhance the resident's quality of life by improving ability to facilitate increased functional mobility throughout the facility; -At Risk for falls and further decline in function and immobility. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs on 1/8/25, 1/9/25 or 1/10/25. Review of the resident's Nurses Note, dated 1/10/25 at 4:26 P.M., showed staff documented the heart monitor box was found with the transmitter at the nurses desk behind some papers. Staff attached the transmitter to the resident's wheelchair. Review of the resident's POS, dated 1/10/25, showed check for the heart monitor on the resident and check transmitter attached to the wheelchair. Change the heart monitor and transmitter to a new one on 1/14/25. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs on 1/11/25, 1/12/25, 1/13/25 or 1/14/25. Review of the resident's POS, dated 1/14/25, showed place Zio heart monitor, keep transmitter within ten feet of the resident. Take the heart monitor off on 1/28/25. Review of the resident's Nurses Note, dated 1/14/25 at 12:25 P.M., showed staff documented the new heart monitor did not arrive to replace the original heart monitor. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs on 1/15/25 or 1/16/25. Review of the resident's Nurses Note, dated 1/16/25 at 8:10 A.M., showed staff documented the cardiology hospital nurse was notified the new heart monitor was not received. Cardiology hospital staff said the new monitor was sent to the resident's home address. Family notified and will bring in the hew heart monitor. Review of the resident's POS, dated 1/17/25, showed check heart monitor daily, remove on 1/28/25. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs on 1/17/25 or 1/18/25. Review of the resident's Nurses Note, dated 1/19/25, showed the following: -At 12:41 P.M. staff documented around breakfast time the cardiology physician's staff requested the nurse press on the heart monitor to obtain a reading. At 11:00 A.M. the cardiology physician's staff instructed the facility to send the resident to the emergency room due to abnormal readings obtained from the heart monitor. Staff transferred the resident to the emergency room by ambulance. Vital signs at the time of transfer were blood pressure 102/64, heart rate 62 beats per minute, respirations 18 breaths per minute, temperature 98.2 degrees, oxygen saturation 98 percent; -At 8:46 P.M. the resident was admitted to the hospital with bradycardia (abnormal slow heart rate). Review of the resident's Hospital Discharge Physician Orders, dated 1/20/25, showed the following: -Diagnoses of heart pause lasting seven seconds per cardiac monitor, recent stroke, bradycardia; -Zio heart monitor patch remained in place; -Check and record weights; -Check and record vital signs. Review of the resident's Nurses Note, dated 1/20/25 at 5:29 P.M., showed the resident returned to the facility. Alert and responded verbally to questions. Blood pressure 130/90, heart rate 96 beats per minute, respirations 18 breaths per minute, temperature 98.7 degrees, oxygen saturation 98 percent. Review of the resident's medical record showed no documentation staff completed a clinical assessment on 1/20/25 or updated the resident's care plan regarding the recent hospitalization for bradycardia and heart pause or the presence of a heart monitor. Observation of the resident on 1/22/25 showed the following: -At 10:05 A.M. the resident sat in a wheelchair, a heart monitor was noted attached to the resident's left chest wall just below the collar bone. Four, square foam dressings, dated 1/19/25, covered both the resident's inside and outside ankle areas; -At 4:45 P.M. the resident sat in a wheelchair, the square foam dressings dated 1/19/25 remained covering the resident's inside and outside ankle areas. Observation on 1/23/25 at 10:00 A.M. showed RN A removed the foam dressings from both of the resident's ankle areas. The skin was intact. During an interview on 1/22/25 at 2:40 P.M. Certified Occupational Therapy Assistant (COTA) J said the resident had an acute stroke and returned from the hospital on [DATE]. Physician orders for therapy services was received with evaluation and treatment provided until discharge back to the hospital on 1/19/25. The resident should continue therapy following discharge from the hospital on 1/20/25. He/She was not aware of any continuation of the therapy services. The resident would benefit from continued therapy services. The charge nurse or nursing administration obtained the discharge physician orders and communicated with therapy either by a written form or verbal notification. Therapy had no documentation to indicate when therapy services should resume for the resident. Therapy services discharged the resident on 1/19/25 due to the hospitalization. The last occupational therapy session was 1/15/25, the last physical therapy session was 1/17/25 and the last speech therapy session was 1/17/25. Observation on 1/23/25 at 8:30 A.M. showed the resident sat in a wheelchair, the square foam dressing dated 1/19/25 remained covering the resident's inside and outside ankle areas. During an interview on 1/23/25 at 9:50 A.M. Registered Nurse (RN) A said the following: -The charge nurse was responsible to complete a head-to-toe assessment and document the findings in the medical record on admission and readmission. Staff did not assess the resident following the two hospitalizations and readmissions on 12/31/24 and 1/20/25. The electronic medical record system triggered the assessments required at the time of admission and readmission. Staff had not completed the nursing admission assessment and had not documented a head-to-toe assessment, including skin condition following either re-admission as required; -The resident's heart monitor was not implemented as ordered on 12/31/24. Staff lost the heart monitor transmitter and had to get a new transmitter. After the new transmitter was obtained and put into place, the resident ended up in the hospital with bradycardia; -Staff should have assessed the resident's skin and removed the 1/19/25 foam dressings from the resident's ankles. Staff did not know if the resident had a wound under the dressings or not. There was no documented skin assessments in the resident's medical record since the resident's re-admission on [DATE]. During an interview on 1/23/25 at 1:45 P.M. the MDS coordinator said the following: -The charge nurse was responsible for obtaining orders and completing admission assessments at the time of a resident's admission or readmission; -He/She was responsible for updating the resident's Care Plan. The resident's care plans should be up to date and reflect the resident 's current status; -He/She was not aware therapy services were not resumed following the 1/20/25 hospital discharge. Therapy services should have resumed. The physician should be notified of the resident's return to the facility and orders reviewed including therapy services; -Staff did not place the resident's heart monitor on correctly and the resident went two weeks without the monitor working correctly; -Charge nurses should utilize the admission check list to make sure all assessments, orders and procedures were implemented following admission or readmission. Currently, the charge nurses were not completing the check list as intended and there was no process to ensure the admission process was completed accurately. During an interview on 1/23/25 at 2:30 P.M. Licensed Practical Nurse (LPN) C said the charge nurse was responsible for completing a resident's admission or readmission. Currently there was no check or balance to ensure accuracy. During an interview on 1/23/25 at 9:00 P.M. LPN I said he/she was the charge nurse on 12/31/24 evening/night shift. He/She did not know the resident had a heart monitor and did not see the heart monitor attached to the resident's chest. The resident was COVID-19 positive and in isolation. He/She did not complete an admission assessment. He/She should have completed a head-to-toe assessment on his/her shift and documented the assessment in the resident's medical record. During an interview on 1/24/25 at 11:45 A.M. the Director of Nursing (DON) said the following: -The charge nurse should complete the admission or readmission process and assess the resident on admission. The admission check list should be completed to ensure accuracy of the admission and all assessments were completed timely. The assessments and check list were not done 99 percent of the time and admission assessments were not completed. Staff were not completing a head-to-toe assessment on admission or readmission; -The resident did not currently have therapy following the 1/20/25 readmission. The charge nurse should have contacted the physician and reviewed the hospital discharge orders and obtained orders for continued therapy following the resident's stroke; -Staff did not implement the resident's heart monitor correctly. The DON was not working at the facility on 12/31/24 and she did not know the circumstances. Staff should review the hospital admission orders and implement the orders on facility admission. The charge nurse should contact the primary care physician and review the hospital discharge orders; -The care plan should be updated with any new changes to the resident's care following hospitalization or a change in condition. During an interview on 1/24/25 at 11:15 A.M. the Administrator said the following: -On admission or readmission, the electronic medical record triggered all the assessments staff should complete and all the assessments should be completed timely. The charge nurse should complete a head-to-toe assessment and document the findings in the medical record including skin condition; -Staff should follow the physician orders and ensure medical devices were attached and functioning. Staff should have assessed the resident's cardiac status and should have monitored the resident's vital signs. Staff should have ensured the resident's therapy services resumed and contacted the primary care physician regarding continuation of the therapy and any new orders or changes following hospitalization; -Care Plans should be up to date and reflect the residents' current status. MO242963 MO244306

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control measures were followed when staff failed to utilize proper handwashing and gloving techniques while providing wound care and failed to utilize Enhanced Barrier Precautions (EBP, an infection control intervention that utilizes personal protective equipment to reduce the spread of multi drug-resistant organisms) during wound care for two residents (Resident #3 and #7) in a review of nine residents. The facility census was 54. Review of the facility policy, Handwashing/Hand hygiene, dated 8/2019, showed the following: -The facility considered hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol based hand rub or alternatively soap and water before and after direct contact with resident, before performing any non-surgical invasive procedure, before donning gloves, before handling used dressings, contaminated equipment, after contact with objects such as medical equipment in the immediate vicinity of the resident, after removing gloves; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of glove does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections; -Single use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids and when in contact with a resident or the equipment or environment of a resident who is on contact precautions; -Perform hand hygiene before applying non-sterile gloves. Review of the facility policy, Personal Protective Equipment - gloves, dated 7/2009, showed the following: -Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin; -Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed; -Wash your hands after removing gloves. Review of the facility policy, Enhanced Barrier Precautions, dated 8/2022, showed the following: -Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents; -EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs; -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; -Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); -Personal protective equipment (PPE) is changed before caring for another resident; -Face protection may be sued if there is also a risk of splash or spray; -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care (any skin opening requiring a dressing); -EBPs are indicated when contact precautions do not otherwise apply for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; -EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; -Staff are trained prior to caring for residents on EBP; -Signs are posted in the door or wall outside the resident room indicating the type of precautions and personal protective equipment (PPE) required; -PPE is available outside of the resident rooms. 1. Review of Resident #3's Care Plan, dated 10/12/24, showed the following: -Diagnoses of mild cognitive impairment, chronic pain, stroke, muscle weakness, unsteadiness on feet, difficulty in walking; -Impaired mobility. Staff should assist the resident in performing movements, ensure proper positioning and evaluate skin for areas of redness; -Risk for impaired skin integrity. Staff should monitor for moisture, provide skin care as needed; -Activities of Daily Living (ADLs) self-care performance deficit related to activity intolerance and chronic pain. Staff should provide total assistance with ADLs. Review of the resident's annual Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 10/16/24, showed the following: -Severe cognitive impairment; -Dependent on staff for toileting, showers, transfers, bed mobility, wheelchair mobility; -Always incontinent of bladder; -Frequently incontinent of bowel; -No pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction). Review of the resident's Physician Order Sheet (POS) showed the following: -On 1/13/25 cleanse back of left foot/ankle Stage II pressure ulcer (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister) pressure ulcer with wound cleanser (spray solution used to cleanse an open wound) and apply Medihoney (ointment applied to wound base to promote healing) daily and as needed, apply non-adherent pad and wrap with gauze until healed; -On 1/22/25 cleanse skin tears to left wrist/lower thumb area with wound cleanser, apply steri-strips (thin strips of tape used to secure torn skin), monitor every shift until healed; -On 1/22/25 cleanse skin tears to right forearm with wound cleanser, apply steri-strips, monitor every shift until healed. Apply gauze and wrap if needed. Observation on 1/22/25 at 1:10 P.M. showed the following: -No EBP signage on the resident's room door and no PPE stocked on the resident's room door; -Licensed Practical Nurse (LPN) C cleaned his/her hands with hand sanitizer, applied gloves and without applying EBP, removed the soiled wound dressings from the back of the resident's left lower leg below the knee. LPN C, without washing hands or changing gloves, removed a soiled wound dressing from the resident's left heel area; -LPN C, without washing hands or changing gloves, cleansed both open wounds with wound cleanser and the same gauze pad using the exact same surface of the gauze pad on both wounds; -LPN C, without washing hands or changing gloves, applied Medi-honey on a clean gauze pad and placed the new dressing on the resident's left heel open wound and secured with gauze wrap; -LPN C said the left posterior upper calf wound had no wound care orders and left the moist open wound uncovered. LPN C applied the resident's pressure relieving boot directly over the left posterior upper calf open wound; -LPN C changed gloves and washed hands, obtained a stack of gauze pads and sprayed two skin tears on the resident's left arm with wound cleanser and wiped the open skin tears with the same surface of the same gauze pad; -LPN C did not apply a dressing over the skin tears. 2. Review of Resident #7's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Impaired mobility of both upper extremities and one lower extremity; -Dependent on staff for toileting, bathing, dressing upper and lower body, personal hygiene; -Dependent on staff for bed mobility, transfers, wheelchair mobility; -At risk for pressure ulcers and had one, unhealed stage II pressure ulcer. Review of the resident's Care Plan, dated 10/20/24, showed the following: -Diagnoses of stroke, contractures (immobility and stiffness of the joints preventing movement), paralysis of the left side, muscle weakness, open wound of the foot; -ADL self-care performance deficit related to impaired balance and paralysis of the left side. Staff should apply a brace to the resident's left leg when out of bed and elevate legs when in bed, assist and provide all ADLs as needed. The resident had contractures of the left arm and leg, provide skin care every shift to keep clean and prevent skin breakdown; -Impaired skin integrity. Staff should administer treatments as ordered, follow facility protocol for treatment of injury, keep skin clean and dry, monitor skin for changes, monitor and document location, size and treatment of skin injury; Review of the resident's POS, dated 1/15/25, showed cleanse left ball of foot wound and right heel wound with wound cleanser daily. Apply calcium alginate (wound dressing used to promote healing) cut to fit inside the wound. Cover with foam dressing daily until healed. Observation on 1/22/24 at 1:45 P.M. showed the following: -EBP signage hung on the resident's room door and PPE was stocked on the resident's room door; -LPN C washed his/her hands, applied a gown and gloves; -LPN C removed a soiled wound dressing from the bottom of the resident's left foot. A quarter size amount of brownish drainage was noted on the soiled dressing. LPN C, without changing gloves or washing hands, touched the resident's bed controller and elevated the bed. LPN C changed gloves without washing his/her hands; -LPN C cut a quarter size piece of calcium alginate wound dressing and with the same soiled hands placed the calcium alginate on the base of the resident's left foot wound and covered with a foam dressing. LPN C removed the gloves and gown and washed his/her hands; -LPN C obtained additional dressing supplies from the wound cart in the hallway and without applying EBP and without washing hands, applied gloves and removed a wound dressing from the resident's right foot. LPN C with the same soiled gloves, cleansed the open wound with wound cleanser and a gauze pad. LPN C changed gloves and without washing his/her hands applied a calcium alginate wound dressing in the base of the right foot wound and covered it with a foam dressing. 3. During an interview on 1/22/24 at 2:00 P.M. LPN C said he/she should have washed his/her hands and apply gloves before providing wound care and should use EBP for all wound care. He/She should change gloves and wash hands every time his/her hands were soiled, after removing soiled wound dressings and before cleansing the resident's wounds. He/She should use a clean gauze pad with each wound and not use the same soiled gauze pad on more than one wound. PPE was available on multiple resident doors, he/she should have followed the facility infection control procedures and EBP procedures. During an interview on 1/23/25 at 9:50 A.M. Registered Nurse (RN) A said he/she was the facility Infection Preventionist. Staff should utilize EBP when providing wound care and follow the facility infection control policy regarding handwashing and gloving. Staff should use clean technique during wound care for each wound individually and not use the same gauze pad to clean more than one wound. Staff should wash their hands before putting on gloves and wash hands between each glove change. During an interview on 1/23/25 at 4:00 P.M. the Director of Nursing said staff should follow the facility EBP policy and the instructions posted on the doors of resident rooms. All residents with an invasive device or wound care required EBP during care. Staff should provide wound care utilizing clean technique and prevent cross contamination. Staff should not use the same gauze pad to clean more than one wound and should not wear the same soiled gloves and provide wound care to more than one wound. During an interview on 1/24/25 at 11:15 A.M. the Administrator said staff should always follow the EBP when providing care, including wound care. Staff should follow the facility handwashing and gloving policy while providing wound care and personal care. MO244306

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of two residents (Resident #2 and #8) in a review of nine residents when staff failed to provide incontinence care timely and maintain good personal hygiene and failed to ensure resident clinical assessments were completed and documented for Resident #2. The facility failed to provide sufficient staff on the memory care unit to ensure supervision of Resident #8. The facility also and failed to consistently have Certified Nurse Assistant (CNA) staff as identified in the facility assessment. The facility census was 54. Review of the facility policy Staffing, Sufficient and Competent Nursing, dated 8/2022 showed the following: -The facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment; -Licensed nurses and certified nurse assistants are available 24 hours a day, seven days a week to provide competent resident care services including assuring resident safety, attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident, assessing, evaluating, planning and implementing resident care plans, and responding to resident needs; -Licensed nurses are required to supervise nurse assistants and are scheduled in such a way that permits adequate time to do so; -Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment; -Factors considered in determining appropriate staffing ratios and skills include an evaluation of the disease, conditions, physical or cognitive limitations of the resident population and acuity. 1 Review of the facility Assessment Tool, revised 8/5/24, showed the following: -Use of the facility assessment will demonstrate a good faith effort by the facility to evaluate necessary resources to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies; -Based on our resident population and their needs for care and support, the facility had made a good faith effort and approach to ensure sufficient staff to meet the needs of the resident at any given time; -Average daily census was 55 residents; -Average 20 residents with behavioral health needs; -Nursing services hours per day listed by shift (day and night); -Registered Nurse eight hours per day; -Licensed Practical Nurse (LPN) 24 hours per day shift and 24 hours per night shift; -Certified Nurse Assistant (CNA) 72 hours per day shift and 60 hours per night shift; -Certified Medication Technician (CMT) 24 hours per day shift. Review of the facility December 2024 daily nursing assignment sheets showed the following CNA hours documented as worked per day shift (6:00 A.M. to 6:00 P.M.) and night shift (6:00 P.M. to 6:00 A.M.): -On 12/1/24 day shift 52 hours and night shift 36 hours, 20 CNA hours less on day shift and 24 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/3/24 day shift 37 hours, 23 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/4/24 day shift 39 hours, 33 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/5/24 day shift 35 hours, 37 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/6/24 day shift 67 hours and night shift 42 hours, five CNA hours less on day shift and 18 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/7/24 day shift 48 hours, 24 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/9/24 day shift 64 hours and night shift 32 hours, eight CNA hours less on day shift and 28 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/10/24 day shift 47 hours and night shift 51 hours, 25 CNA hours less on day shift and six CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/11/24 day shift 52 hours, 20 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/13/24 night shift 44 hours, 16 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/14/24 day shift 55 hours and night shift 51 hours, 17 CNA hours less on day shift and nine CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/15/24 day shift 64 hours, 18 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/16/24 day shift 60 hours, 12 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/17/24 night shift 39 hours, 21 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/18/24 day shift 29 hours, 43 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/19/24 day shift 32 hours, 40 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/20/24 day shift 52 hours and night shift 34 hours, 20 CNA hours less on day shift and 26 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/21/24 day shift 58 hours, 24 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/23/24 day shift 48 hours and night shift 32 hours, 24 CNA hours less on day shift and 28 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/24/24 day shift 63 hours, nine CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/25/24 day shift 43 hours, 29 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/26/24 day shift 66 hours and night shift 48 hours, 16 CNA hours less on day shift and 12 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/27/24 day shift 52 hours and night shift 48 hours, 20 CNA hours less on day shift and 12 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/28/24 day shift 36 hours, 35 CNA hours less on day shift than indicated as needed on the facility assessment; -On 12/29/24 day shift 60 hours and night shift 48 hours, 12 CNA hours less on day shift and 12 CNA hours less on night shift than indicated as needed on the facility assessment; -On 12/31/24 day shift 44 hours and night shift 44 hours, 28 CNA hours less on day shift and 16 CNA hours less on night shift than indicated as needed on the facility assessment. Review of the facility January 2025 daily nursing assignment sheets showed the following CNA hours scheduled per day shift and night shift: -On 1/1/25 day shift 58 hours, 14 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/2/25 day shift 56 hours and night shift 36 hours, 16 CNA hours less on day shift and 24 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/3/25 day shift 60 hours, 12 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/5/25 day shift 48 hours and night shift 24 hours, 24 CNA hours less on day shift and 36 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/6/25 day shift 40 hours and night shift 36 hours, 32 CNA hours less on day shift and 24 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/7/25 day shift 42 hours, 30 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/10/25 day shift 45 hours, 27 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/11/25 day shift 60 hours and night shift 42 hours, 12 CNA hours less on day shift and 18 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/12/25 day shift 60 hours and night shift 36 hours, 12 CNA hours less on day shift and 24 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/13/25 day shift 60 hours, 12 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/14/25 day shift 60 hours, 12 CNA hours less on day shift than indicated as needed on the facility assessment; -On 1/16/25 day shift 48 hours and night shift 42 hours, 24 CNA hours less on day shift and 18 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/17/25 night shift 24 hours, 36 CNA hours less on night shift than indicated as needed on the facility assessment; -On 1/18/25 night shift 48 hours, 12 CNA hours less on night shift than indicated as needed on the facility assessment. 2. Review of Resident #2's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 9/27/24, showed the following: -Severely impaired cognition; -Frequently incontinent of urine; -Always incontinent of bowel; -Required substantial/maximum staff assistance (helper does more than half the effort) with toileting, dressing lower body and personal hygiene; -Dependent on staff for transfers to and from the toilet. Review of the resident's Care Plan, dated 10/20/24, showed the following: -Diagnoses of dementia, anxiety, urinary incontinence, abnormal gait and mobility, unsteadiness on feet, kidney disease, stroke and urinary tract infection; -Impaired physical mobility and risk for self-care deficit. Staff should determine the level of assistance needed, provide assistance with Activities of Daily Living (ADL) as needed, determine residents ability to transfer, educate resident on exercise and safe transfer techniques, encourage resident to increase activity as indicated, evaluate skin for areas of redness, evaluate functional abilities; -ADL self-care performance deficit related to stroke. Staff should provide assistance with ADLs, transfers, dressing and personal hygiene and total assistance with toileting. Review of the resident's Nurses Note, dated 12/29/24, showed staff documented the following: -At 12:48 P.M. the resident was not acting right. The resident sat in the wheelchair with head tilted back, no response to verbal stimuli and slight response to sternal rub (act of forcefully rubbing the sternum) Blood pressure 186/116 (normal 120/80), heart rate 128 (normal 60-80) beats per minute and bounding, respirations 16 (normal 12-18) breaths per minute and slow. Covid-19 (an infectious disease caused by severe acute respiratory syndrome Coronavirus 2(SARS-CoV-2) test was positive. Staff called the ambulance and transferred the resident to the emergency room for evaluation and treatment; -At 4:20 P.M. the resident was admitted to the hospital with acute CVA (cardiovascular accident or stroke). Review of the resident's Hospital Discharge Physician Orders, dated 12/31/24, showed the following: -Hospital admission diagnosis of acute stroke; -Physical therapy, occupational therapy and speech therapy evaluation and treat; -Check weights and record; -Check vital signs and record; -COVID-19 precautions; -Follow up with cardiology physician in 30 days related to Zio heart monitor (a heart monitor patch applied to the skin that records the heart rhythm for up to two weeks). Review of the resident's Nurses Note, dated 12/31/24 at 6:33 P.M., showed staff documented the resident returned to the facility by medical transport. The resident was on isolation precautions due to positive COVID-19 status. Review of the resident's medical record showed no documentation staff completed an admission clinical assessment or assessed the resident's vital signs (blood pressure, heart rate, respirations, temperature and oxygen saturation level) on 12/31/24. Review of the resident's medical record showed no updated and current MDS assessment since the admission MDS assessment completed on 9/27/24. Review of the resident's vital signs record dated 1/1/25 showed staff documented the resident's heart rate was 91 beats per minute. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs other than heart rate (blood pressure, respirations, temperature, oxygen saturation level) on 1/1/25. Review of the resident's Physician Order Sheet (POS), dated 1/2/25, showed the following: -Admit to the facility, the resident needed continuous care due to inability to live independently and the need for 24-hour assistance, observation and planning; -Vital signs and weigh monthly. Review of the resident's medical record dated 1/2/25 showed staff documented heart rate 83 beats per minute. No documentation staff completed a clinical assessment or updated the resident's care plan regarding recent hospitalization for stroke and presence of a heart monitor or assessed the resident vital signs other than heart rate. Review of the resident's Nurses' Note, dated 1/3/25, showed staff documented the following: -At 1:21 A.M. the resident was re-admitted and was positive for COVID-19. The resident was isolated in his/her room and monitored for any worsening of symptoms; -At 12:05 P.M. the resident remained COVID-19 positive and in isolation. The resident was up in the wheelchair in room for meals, no complaints noted. Vital signs within normal limits, medications administered. Review of the resident's medical record dated 1/3/25 showed staff documented heart rate 77 beats per minute and oxygen saturation level of 94 percent (normal greater than 92 percent). No documentation staff completed a clinical assessment or assessed the resident vital signs other than heart rate and oxygen saturation level. Review of the resident's Nurses' Note, dated 1/4/25, showed staff documented the following: -At 1:47 A.M. the resident continued isolation due to positive COVID-19. No cough noted and no adverse reactions; -At 5:18 P.M. the resident continued isolation due to positive COVID-19. No cough noted. The resident ate well for meals while staff set up food and offered limited assistance. Review of the resident's medical record dated 1/4/25 showed staff documented blood pressure was 144/86, heart rate was 79 beats per minute, respirations 20 breaths per minute, and temperature was 98.7 degrees (normal 98.6 degrees).and oxygen saturation level of 94 percent (normal greater than 92 percent). No documentation staff completed a clinical assessment or assessed the resident's oxygen saturation level. Review of the resident's medical record showed no documentation staff completed a clinical assessment or assessed the resident's vital signs from 1/5/25 through 1/18/25. Review of the resident's Nurses Note, dated 1/19/25, showed the following: -At 12:41 P.M. staff documented around breakfast time the cardiology physician's staff requested the nurse press on the heart monitor to obtain a reading. At 11:00 A.M. the cardiology physician's staff instructed the facility to send the resident to the emergency room due to abnormal readings obtained from the heart monitor. Staff transferred the resident to the emergency room by ambulance. Vital signs at the time of transfer were blood pressure 102/64, heart rate 62 beats per minute, respirations 18 breaths per minute, temperature 98.2 degrees, oxygen saturation 98 percent; -At 8:46 P.M. the resident was admitted to the hospital with bradycardia (abnormal slow heart rate). Review of the resident's Hospital Discharge Physician Orders, dated 1/20/25, showed the following: -Diagnoses of heart pause lasting seven seconds per cardiac monitor, recent stroke, bradycardia; -Zio heart monitor patch remained in place; -Check and record weights; -Check and record vital signs. Review of the resident's Nurses' Note, dated 1/20/25 at 5:29 P.M., showed the resident returned to the facility, alert and responded verbally to questions. Blood pressure 130/90, heart rate 96 beats per minute, respirations 18 breaths per minute, temperature 98.7 degrees, oxygen saturation 98 percent. Review of the resident's medical record dated 1/20/25 showed no documentation staff completed a clinical assessment or updated the resident's care plan regarding the recent hospitalization for bradycardia and heart pause or the present of the a heart monitor and no updated MDS assessment since the admission MDS assessment completed on 9/27/24. Observation on 1/22/25 showed the following: -At 10:05 A.M. the resident sat in a wheelchair, a heart monitor was noted attached to the resident's left chest wall just below the collar bone. Four square foam dressings dated 1/19/25 covered the resident's inside and outside ankle areas. A strong urine odor was noted coming from the resident; -At 11:00 A.M. the resident remained in the wheelchair with no change in position. A strong urine odor was noted coming from the resident; -At 11:45 A.M. Certified Nurse Assistant (CNA) B pushed the resident's wheelchair to the dining room for lunch. During an interview on 1/22/25 at 11:15 A.M. Licensed Practical Nurse (LPN) K said he/she was a charge nurse. The facility needed additional CNA staff especially for the East side (200 hall) and memory care unit. Two CNA staff were not enough for the East Hall, the residents required a lot of assistance with care, and many required mechanical lift transfers. During an interview on 1/22/25 at 11:46 A.M. CNA B said he/she toileted the resident and changed the resident's clothing before lunch. The resident was soiled and wet. The East Hall (200 hall) had many two person transfers and the residents required staff assistance to meet care needs. The East Hall needed additional CNA staff. Observation on 1/23/25 showed the following: -At 8:30 A.M. the resident sat in a wheelchair in his/her room, dressed in black pants and gray shirt. The square foam dressing dated 1/19/25 remained covering the resident's inside and outside ankle areas; -At 9:50 A.M. the resident sat in a wheelchair in his/her room, dressed in the same black pants and gray shirt; -From 11:30 A.M. through 12:45 P.M. the resident sat in a wheelchair in the dining room eating lunch, dressed in the same black pants and gray shirt. A strong urine odor was noted coming from the resident. CNA G said the resident was last toileted at about 9:00 A.M.; -At 12:45 P.M. staff pushed the resident in his/her wheelchair from the dining room to his/her room and parked the resident's wheelchair facing the television and did not offer to assist the resident with toileting or check the resident for incontinence. The resident had a strong urine and feces odor. During an interview on 1/23/25 at 12:48 A.M. the resident said staff got him/her up about 9:00 A.M. Staff had not taken him/her to the toilet or changed his/her incontinence brief since 9:00 A.M. The resident needed to go to the bathroom and change his/her soiled incontinence brief. Observation 1/23/25 at 1:00 P.M. showed the following: -CNA H and Nurse Assistant (NA) E transferred the resident to the toilet and removed the resident's urine and feces saturated incontinence brief. Feces was noted on the inside of the resident's pants; -CNA H repeatedly wiped the resident's buttocks and perineal area removing feces stuck to the resident's skin from the resident's buttock and perineal areas. CNA H said the feces had been there awhile as it was dried and was hard to clean. During an interview on 1/23/25 at 1:15 P.M. NA E said he/she worked the resident's hall and last toileted and changed the resident at 9:00 A.M. The East Hall needed three CNA staff to provide adequate care for the residents. The East Hall had multiple residents who required two-person total assistance with mechanical lift transfers and total care including showers and incontinence care. Staff was not able to keep the residents clean and dry. During an interview on 1/23/25 at 1:20 P.M. CNA H said staff should check the resident every two hours at least and change the resident if the resident was incontinent. Staff should not let the resident sit in feces and urine. The East Hall (Resident #2's hall) needed additional staff. The East Hall was usually staffed with two CNAs on the day shift, and they were not able to provide the resident cares, showers and two person transfers to meet the resident needs. Residents were left soiled and wet for extended periods of time and were not toileted as frequently as they should be. Review of the East Hall resident roster on 1/23/25 at 1:30 P.M., with LPN C and CNA H, showed 12 of the 19 residents who lived on the East Hall required a two-person mechanical lift transfer. During an interview on 1/23/25 at 1:45 P.M. the MDS Coordinator said the following: -He/She was responsible for completing the resident's MDS assessments. He/She should have completed a significant change MDS assessment for Resident #2 following the 12/31/24 hospital discharge and updated the resident's Care Plan at that time. He/She should also have updated the resident's care plan following the 1/20/25 hospital discharge. The resident's assessments and Care Plan updates were behind. He/She was currently working on December MDS assessments and was about three weeks behind. He/She was usually pulled to the floor to work as a charge nurse two days per week and could not keep up with the MDSs and Care Plan updates. 3. Review of the resident roster provided 1/22/25 showed eight residents resided on the memory care unit. Observation of the Memory Care Unit (a locked unit located adjacent to the 200 hall and the 200 hall nurses' desk) on 1/22/25 at 11:05 A.M. showed eight residents and one staff member. Multiple residents sat in wheelchairs at the core area table with the television on, drink cups sat on the table. CNA D came out of a resident's room. During an interview on 1/22/25 at 11:10 A.M. CNA D said he/she was the only staff assigned to the memory care unit. The memory care unit was usually staffed with one CNA. The CNA provided the residents' meals, incontinence care and toileting needs, showers, safety monitoring and activities. While the CNA provided resident cares and showers there was no staff to monitor the other residents. If behaviors occurred while he/she was providing a resident's care there was no other staff to ensure safety. Observation of the Memory Care Unit on 1/22/25 at 2:30 P.M., showed Resident #8 yelled for help multiple times from the bathroom. No staff was in the resident's room or bathroom. The resident shuffled out of the bathroom with pants down to his/her ankles, a shirt on and no shoes or socks. The resident shuffled towards his/her bed yelling for help. CNA B rushed into the resident's room, pulled up the resident's pants and sat the resident in a chair. CNA B returned to the core dining area where three residents sat in wheelchairs. Resident #9 hollered and attempted to stand. Two other residents' wheelchair wheels were tangled and the residents attempted to reach for the table and each other. CNA B attempted to redirect the residents. During an interview on 1/22/25 at 2:40 P.M. CNA B said he/she did not know what was wrong with Resident #9, the resident was new to the memory care unit. One staff member on the memory care unit was not enough to meet the residents' needs and provide supervision. During an interview on 1/23/25 at 8:55 A.M. Certified Medication Technician (CMT) F said the memory care unit staff provided all the residents care needs and supervision. One staff member was not enough to provide cares, showers and supervision. 4. During an interview on 1/23/25 at 9:50 A.M. Registered Nurse (RN) A said the following: -The charge nurse was responsible to complete a head-to-toe clinical assessment and document the findings in the medical record on admission and readmission. Staff did not assess Resident #2 following the two hospitalizations and readmissions and did not complete and document clinical assessments and assess vital signs as clinically indicated. The electronic medical record system triggered the assessments required at the time of admission and readmission. Staff had not completed the nursing admission assessment and had not documented a head-to-toe assessment including skin condition following either re-admission as required. The charge nurses filled in the CNA staff and floated to the memory care unit to meet the resident care needs. Additional CNA staff on the East Hall and memory care unit would allow the charge nurses additional time for clinical assessments and follow ups; -The charge nurse should have assessed the resident's skin and removed the 1/19/25 foam dressings from the resident's ankles. Staff did not know if the resident had a wound under the dressings or not. There was no documented skin assessments in the resident's medical record since the resident's re-admission on [DATE]. The charge nurse should complete a weekly skin assessment for every resident and document the findings. -The facility did not have enough staff to meet the resident's needs. Additional CNA staff was needed on the East Hall and the memory care unit. One CNA staff was not enough on the memory care unit to meet the resident's needs and provide supervision. Staff from the East Hall had to float over to the memory care unit and left the East Hall understaffed. The East Hall had heavy care and many residents required two person transfer assistance with mechanical lifts. During an interview on 1/23/25 at 10:30 A.M. the Human Resources Director said he/she made the nursing schedule. The facility did not have enough staff currently to meet the residents' needs. The facility was trying to hire additional staff. During an interview on 1/24/25 at 11:45 A.M. the Director of Nursing said the following: -Staff should keep residents clean and dry, check and change residents every two hours and should not leave residents wet and soiled for extended periods of time; -The charge nurse should complete the admission or readmission process and assess the resident on admission. The admission check list should be completed to ensure accuracy of the admission and all assessments were completed timely. The assessments and check list were not done 99 percent of the time and admission assessments were not completed. Staff were not completing a head-to-toe assessment on admission or readmission and not completing and documenting daily clinical assessments as should be done. The charge nurses were helping the CNA staff complete cares and floating to the memory care unit when needed preventing the charge nurses from completing the assessments and clinical care; -The Care Plan should be updated with any new changes to the resident's care following hospitalization or a change in condition. -It was difficult to get all things done as they should be. The facility needed additional staff. The memory care unit needed two CNA staff on each shift to provide the residents' needs and safety, currently one CNA staff was generally scheduled for the memory care unit and a staff member from the East Hall floated to the memory care unit at times. The CMT or chare nurse should not be pulled to the memory care unit unless it was emergent. The East Hall needed an additional CNA staff on the day shift to meet the residents' needs. The MDS coordinator was pulled to work the floor and was three weeks behind on MDS assessments and Care Plan updates. The MDS coordinator should not be pulled to the floor to work as a charge nurse. During an interview on 1/24/25 at 11:15 A.M. the Administrator said the following: -On admission or readmission, the electronic medical record triggered all the assessments staff should complete and all the assessments should be completed timely. The charge nurse should complete a head-to-toe assessment and document the findings in the medical record including skin condition. He did not know why charge nurses were not completing the assessments; -Staff should follow the physician orders and ensure medical devices were attached and functioning. Staff should have assessed Resident #2's cardiac status and should have monitored the resident's vital signs. -Care Plans should be up to date and reflect the residents' current status; -Staff should check incontinent residents every one hour and provide incontinence care as needed. Staff should make sure residents were clean and dry and not left soiled; -The facility assessment reflected the current staffing needs of the facility. The facility was not meeting the staffing needs; -The MDS coordinator was pulled to fill in as a charge nurse and MDSs and Care Plans were not up to date; -Currently the staff was pulled from one area to help another. Two CNA staff assigned to the memory care unit would help. MO244306 MO246518

Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for four residents (Resident #35, #39, #100 and #101). The facility census was 47. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 02/08/24, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #35 $1,455.70 #39 $2,540.75 #100 $92.40 #101 $57.60 Total $4,146.45 During email correspondence on 02/09/24 at 9:59 A.M., the Business Office Manager said he/she did not realize there could be no resident credits in the operating account.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by facility staff, after two residents (Resident #1 and #39), in a review of 12 sampled residents, were admitted to hospice. The census was 47. Review of the facility's Change in a Resident's Condition or Status Operational Policy, revised February 2021, showed a significant change in condition is a major decline or improvement in the resident's status that: -a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); -limpets more than one area of the resident's health status; -creatures interdisciplinary review and/or revision to the care plan; and -d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0, showed the following: -A significant change in status assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The ARD (assessment reference date) must be within 14 days from the effective date of the hospice election; -A SCSA must be performed regardless of whether an assessment was recently conducted on the resident; 1. Review of Resident #1's hospice binder showed the resident admitted to hospice on 8/29/23 with a diagnosis of heart failure. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/11/23, showed no evidence the resident received hospice services. Review of the resident's Physician Order Sheet (POS), dated January 2024, showed admit to hospice on 10/17/23. Review of the resident's quarterly MDS, dated [DATE], showed the resident received hospice services. Review of the resident's medical record showed no documentation the facility completed a significant change MDS after the resident admitted to hospice. 2. Review of Resident #39's progress notes, dated 1/19/24, showed the resident admitted to hospice that day. Review of the resident's Physician Order Sheet (POS), dated February 2024, showed the resident was currently on hospice care. Review of the resident's medical record showed no documentation the facility completed a significant change MDS after the resident admitted to hospice. During interview on 2/8/24 at 9:30 A.M., the MDS Coordinator said the following: -He/She followed the RAI manual when completing the MDS; -A SCSA would be required when a resident admitted to hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs, and risks for two residents (Residents #39 and #40), in a review of 12 sampled residents. The facility census was 47. Review of the facility's Care Plans, Comprehensive Person-Centered Policy, revised [DATE], showed the following: -The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The interdisciplinary team reviews and updates the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) Users Manual, Version 3.0, Chapter 4, dated [DATE], showed the following: -The care plan should be revised on an ongoing basis to reflect changes in the resident and the care the resident is receiving; -The effectiveness of the care plan must be evaluated from its initiation and modified as necessary; -Changes to the care plan should occur as needed in accordance with professional standards of practice and documentation. The interdisciplinary tem members should communicate as needed about care plan changes; -MDS are not required for minor or temporary variations in resident status- in these cases, the resident's condition is expected to return to baseline within two weeks. However, staff must note thee transient changes in the resident's status in the resident's record and implement necessary assessment, care planning, and clinical interventions, even though an MDS assessment is not required. 1. Review of Resident #40's face sheet showed his/her diagnoses included acute (sudden) kidney failure, chronic kidney disease,pleural effusion (the buildup of too much fluid between the layers of the pleura around your lungs), respiratory failure with hypoxia (not enough oxygen in the tissues in the body). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the resident was cognitively intact. Review of the resident's outside of the hospital do not resuscitate (DNR) order, dated [DATE], showed the following: -The resident signed the document on [DATE] (indicating cardiopulmonary resuscitation should not be attempted); -The physician signed the document on [DATE]. Review of the resident's discharge from hospital instructions, dated [DATE], showed the resident had an hemodialysis catheter (a tunneled catheter placed under the skin and into a vein) placed on [DATE] and started hemodialysis (a process of filtering the blood of a person whose kidneys are not working normally) and had been scheduled to continue outpatient hemodialysis treatments on every Tuesday, Thursday, and Saturday. Review of the resident's progress notes, dated [DATE], showed the resident had a double lumen port (a thin, flexible tube placed in a large vein, connected to a double chamber or 'port' implanted under the skin) on the right chest and had received dialysis. Review of the resident's care plan, dated [DATE], showed the resident was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of the resident's Physician Order Sheet, dated February 2024, showed the following: -Document mental status in a progress note upon arrival from dialysis in the afternoon every Tuesday, Thursday and Saturday; -Ensure dialysis port to right chest is clean, dry, and intact one time a day. -Progress note with arrival time from dialysis in the afternoon every Tuesday, Thursday and Saturday; -DNR (order dated [DATE]); -Oxygen 2 LPM (liters per minute) for oxygen saturation under 90% every four hours as needed for pleural effusion and diminished lung sounds dyspnea for oxygen saturation under 90% start date [DATE]. Review of the resident's current care plan, dated [DATE], showed the following: -No documentation the resident was a DNR; -No documentation showing the care the resident was receiving hemodialysis for end stage renal disease; -No documentation showing oxygen use. Observation on [DATE] at 2:00 P.M. showed the resident pulled his/her shirt collar down to show his/her port. There was an oxygen concentrator sitting by the resident's chair in his/her room. During an interview on [DATE] at 2:00 P.M., the resident said he/she had a port for dialysis and he/she sometimes used oxygen at night. During an interview on [DATE] at 9:30 A.M., the interim Director of Nursing (DON) said the following: -He/She had been the MDS/care plan coordinator and was responsible for completing the care plan updates until [DATE]; -From [DATE] until [DATE], he/she was responsible for performing the duties of MDS/care plan coordinator and as well as duties as the interim DON; -He/She did not update the resident's care plan to reflect oxygen use or dialysis treatment when the resident returned from the hospital; -He/She would expect the care plan to have been updated when the resident returned from the hospital. 2. Review of the Resident #39's significant change quarterly MDS, dated [DATE], showed the following: -The resident's diagnoses included Alzheimer's disease; - No documentation showing the resident received hospice services. Review of the resident's progress notes, dated [DATE], showed the resident was admitted to hospice today. Review of the resident's Physician Order Sheet (POS), dated February 2024, showed the resident was currently on hospice care and was a do not resuscitate (DNR) (a person has decided not to have cardiopulmonary resuscitation (CPR) attempted if their heart or breathing stops). Review the resident's current care plan, dated [DATE], showed the following: -The resident was a full code. (Staff did not update the care plan to show the resident was a DNR). -No documentation to show the resident received hospice services. 3. During an interview on [DATE], at 9:30 A.M. and [DATE] at 9:30 A.M., the MDS Coordinator said the following: -She had been completing the MDS/care plans since [DATE]; -She was responsible for updating the care plan; -She would expect the care plan to be updated when a resident was admitted to hospice, when a resident had any significant care changes, and when a resident was on dialysis. During an interview on [DATE], at 9:42 A.M., the interim administrator said she expected staff to update the care plan with any significant change and also when a resident was admitted to hospice.

Based on observation, interview, and record review, the facility failed to administer medications through a gastrostomy tube (g-tube; a tube placed through the abdomen directly into the stomach for nutrition and medications) in accordance with facility policy for one resident (Resident #3), in a review of 12 sampled residents. The census was 47. Review of the facility policy, A Stepwise Approach: Selecting Medications for Feeding Tube Administration, dated 2020, showed giving medications through an enteral feeding tube can be complicated. Clogging can be a major complication with feeding tubes. Inappropriate medication administration and inadequate flushing can lead to clogging. Generally, do NOT mix medications with tube feedings, mix medications together, or give multiple medications at the same time. Always flush tube before and after the administration of a medication with at least 15 to 30 milliliters (ml) of water. 1. Review of Resident #3's care plan, dated 11/23/23, showed the following: -Nothing by mouth (NPO), g-tube use; -Give fluids as ordered via tube; -Administer medications as ordered. Review of the resident's Physician Order Sheet (POS), dated February 2024, showed the following: -NPO; -16 French (sizing of the tube) g-tube; -Acetaminophen (an analgesic used to treat minor pain) 325 milligrams (mg) via g-tube (tube) daily; -Hydrocortisone (a type of steroid medication) 10 mg via tube in the morning; -Hydroxazine hydrochloride (antihistamine) 25 mg via tube daily; -Vitamin D3 (a vitamin supplement) 25 micrograms, one tablet via tube daily; -Benztropine (an anti-tremor medication) 2 mg, one tablet via tube two times daily. Observation on 02/07/24 7:10 A.M. showed the following: -Licensed Practical Nurse (LPN) J crushed the acetaminophen, hydrocortisone, hydroxazine, vitamin D and the benztropine and combined them in a cup of water; -He/She administered the medications all together. He/She did not administer the medications separately and flush with water in between each medication (as directed by facility policy). During an interview on 2/7/24 at 11:54 A.M., LPN J said he/she did not know to administer each medication via g-tube separately. He/She had always mixed all the medications together and administered. He/She was not aware of facility's policy or standard of practice. During interview on 2/8/24 at 12:14 P.M., the Director of Nursing said the facility's policy was to give each medication separately with a 10-15 ml water flush after each medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders and ensure one resident (Resident #11), in a review of 12 sampled residents, was free from a significant medication error, when staff failed to discontinue a medication for 34 days after the resident's physician ordered to discontinue the medication. The facility also failed to properly transcribe the physician's orders received upon the resident's readmission to the facility from the hospital to show the previously discontinued medication was to be given as needed (PRN). Staff administered the medication as scheduled and not PRN. The facility census was 47. Review of the facility policy for administering medications, last revised April 2019, showed the following: -Medications were administered in a safe and timely manner, and as prescribed; -The director of nursing services supervised and directed all personnel who administered medications and/or have related functions; -Medications were administered in accordance with prescriber's orders, including any required time frames. 1. Review of Resident #11's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, dated 10/29/23, showed his/her cognition was moderately impaired. Review of the resident's Physician's Orders Sheet (POS), dated 11/1/23, showed an order for tizanidine (muscle relaxer) two milligrams (mg); one tablet by mouth every evening. Review of the resident's Pharmacist/Physician Communication documentation, dated December 2023, showed the following: -The pharmacist reviewed the resident's medications after the resident fell and recommended to discontinue tizanidine 2 mg; -On 12/28/23, the physician agreed to discontinue tizanidine 2 mg. Review of the resident's POS, dated December 2023, showed an order for tizanidine 2 mg, give one tablet by mouth every evening. (Review showed no evidence the medication was discontinued on 12/28/23.) Review of the resident's Medication Administration Record (MAR), dated 12/28/23-12/31/23, showed the following: -No evidence the tizanidine 2 mg was discontinued on 12/28/23; -Staff documented the resident received tizanidine 2 mg, one tablet every evening on 12/28/23, 12/29/23, 12/30/23, and 12/31/23. Review of the resident's POS, dated January 2024, showed an order for tizanidine 2 mg, give one tablet by mouth every evening. (Review showed no evidence the medication was discontinued on 12/28/23.) Review of the resident's MAR, dated January 2024, showed staff documented the resident received tizanidine 2 mg, one tablet every evening on 1/1/24 and 1/3/24 through 1/29/24. Review of the resident's progress notes showed the resident was hospitalized for an illness from 1/30/24 through 2/5/24. Review of the resident's hospital discharge records, dated 2/5/24, showed medications on discharge included tizanidine 2 mg tablet, give one tablet by mouth once daily (in the evening) as needed (PRN) for muscle spasms. Review of the resident's MAR, dated 2/5/24 (the resident's readmission date following hospitalization), showed the following: -Tizanidine 2 mg, give one tablet by mouth every evening. (Staff failed to transcribe the medication to PRN as directed in the hospital discharge orders); -Staff documented the resident received tizanidine 2 mg on 2/5/24. Review of the resident's progress notes, dated 2/5/24, showed no documentation the resident complained of muscle spasms or pain which would indicate administration of the PRN tizanidine. During an interview on 2/6/24 at 5:15 P.M., Licensed Practical Nurse (LPN) J said the resident's tizanidine should have been removed from the resident's MAR's and not been administered if it was discontinued on 12/28/23. The faxed pharmacist/physician communication documentation with the discontinued medication order should have been given to the charge nurse on the unit so he/she could transcribe the order. The medication was not discontinued on the physician's orders and staff administered the medication. The resident went to the hospital on [DATE]. The resident returned on 2/5/24 with an order for tizanidine 2 mg every 24 hours as needed, but the order was transcribed as daily. Staff administered the medication on 2/5/24. He/She did not know why the tizanidine was not discontinued on 12/28/23 (on the physician's orders) and/or transcribed correctly on 2/5/24. During an interview on 2/6/24 at 5:35 P.M., the Director of Nursing (DON) said it appeared that on 12/28/23, tizanidine was discontinued by the resident's physician per pharmacy recommendations after an evaluation of the resident's falls. Staff administered tizanidine on 12/28-12/31/23, 1/1/24, and 1/3/24 through 1/30/24. The resident went to the hospital on 1/30/24. The resident returned on 2/5/24 with a PRN order for tizanidine. Staff failed to transcribe the order as PRN and it was administered on 2/5/24. She considered this to be a medication error as it was not discontinued when an order was received on 12/28/23. The medication should not have been administered after 12/28/23. She was not sure why the order was not given to the charge nurse on the resident's unit on 12/28/23.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 41 residents. The facility census was 47. 1. Record review of the facility maintained bank statements for months 01/2023 through 12/2023 showed no documentation of reconciliations. Record review of the facility maintained reconciliation forms, dated 01/2023 through 12/2023, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation. During an interview on 02/07/24 at 9:50 A.M., the Business Office Manager said there was no Business Office Manager in the beginning of 2023 and he/she was only told to reconcile to the bank statement. He/She was not told to reconcile to the residents' current balance.

Based on interview and record review, the facility failed to complete required pre-employment screenings for three of seven sampled employees hired since the previous survey. The facility failed to request a criminal background check for three employees and complete an Employee Disqualification List (EDL) check for one employee, prior to hire. The facility census was 47. Review of the facility policy, Background Screening Investigations, revised March 2019, showed the following: - For purposes of this policy ''direct access employee'' means any individual who has access to a resident or patient of a long term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. -The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment. 1. Review of Office Receptionist E's employee file showed the following: -Date of hire 10/11/23; -No documentation staff requested a criminal background check prior to his/her date of hire; -Family Care Safety Registry (FCSR, a registry maintained by the state agency for facilities to utilize for completion of the criminal background check and EDL check) check requested 1/4/24 (85 days after hire date). 2. Review of Housekeeper I's employee file showed the following: -Date of hire 11/2/23; -EDL check completed on 11/8/23 (six days after hire date); -FCSR check requested 1/6/24 (65 days after hire date); -No documentation staff requested a criminal background check prior to his/her date of hire. 3. Review of Maintenance Staff F's employee file showed the following: -Date of hire 11/13/23; -No documentation staff requested a criminal background check prior to hire date; -FCSR check requested 1/5/24 (53 days after hire date). 4. During an interview on 2/6/24 at 3:09 P.M., the Office Manager/Human Resources staff said he/she was responsible to complete all background checks, including FCSR (CBC and EDL), prior to hire. There was a recent policy change for completing their criminal background checks, which included completing the checks through the FCSR, which caused some delays. Prior to an individual starting employment, he/she checked to see if the individual was registered with the FCSR. If the individual was not registered, he/she submitted the registration so he/she could make a request for the background screening. At times, there was a lag time to process the registration, so he/she had to remember to check if the individual was now registered with the FCSR. Some times he/she forgot to follow up and check if the individuals were registered and this was the reason the background screenings were not requested. During an interview on 2/6/24 at 4:15 P.M., the Administrator said the facility changed their procedure for completing background checks and were to use the FCSR to obtain the CBC and EDL checks. The Office Manager/Human Recourses staff was responsible for completing the background checks prior to hire. Currently, the facility did not have a system for monitoring to ensure the checks were completed as required.

Based on observation, interview, and record review, the facility failed to ensure residents on a pureed diet and residents on a dental soft (mechanical soft) diet received food in the proper form in accordance with their physician's orders. The facility census was 47. Review of the facility policy, Pureed Diet, dated 2022, showed the following: -The pureed diet is designed for individuals who cannot chew foods of the dental soft (mechanical soft) consistency and/or difficulty swallowing; -All foods are prepared in a food processor or blender, with the exception of those foods which are normally in a soft, moist and smooth state; -Additional liquid is added in the form of broth, gravy, vegetable or fruit juices, or milk to achieve the appropriate consistency (puddings, smooth mashed potatoes); -Process hot or cold items until they are smooth and homogenous in texture; -Add measured amounts of hot liquid for cooked foods and cold liquid (if required) for cold foods and process until a smooth consistency is achieved; -Scrape down sides and reprocess until very smooth like pudding; -Top pureed foods with appropriate sauces to ensure adequate moisture for consumption as needed. Review of the facility policy, Dental Soft (Mechanical Soft) Diet, dated 2022, showed the following: -The dental soft (mechanical soft) diet is for individuals with limited or difficulty in chewing regular consistency foods; -This diet may also be used for those experiencing mouth irritation and dentition problems including lack of teeth or poor fitting dentures; -Meat is ground or chopped into bite size pieces (1/2 inch or smaller) and should be mixed or served with gravy, broth or another type of moistening agent; -Ground meats generally would fit through the tongs of a fork; -Vegetables are cooked soft, moist and fork tender with no large chunks or pieces. 1. Review of the facility's Diet Type report, dated 2/5/24, showed six residents had a physician-ordered pureed diet. Review of the Diet Spreadsheet menu for the lunch meal on 2/5/24 showed staff were to serve residents on a pureed diet pureed glazed ham, pureed zucchini and tomatoes, and mashed potatoes and brown gravy. Observation on 2/5/24 between 11:10 A.M. and 11:36 A.M., during the lunch meal service, showed the dietary manager served pureed ham with visible chunks, pureed zucchini and tomatoes with visible chunks and mashed potatoes without gravy to all residents on a pureed diet. Observation on 2/5/24 at 11:41 A.M. of the pureed diet test tray showed the following: -The pureed ham had large visible chunks of ham and the mixture was chunky and not smooth; -The pureed zucchini and tomatoes was chunky and not smooth; -The mashed potatoes were not served with gravy and were plain. During interviews on 2/5/24 at 12:10 P.M. and on 2/6/24 at 10:30 A.M., the Dietary Manager said the following: -Staff should prepare all pureed food items to a pudding consistency; -She prepared the pureed items for the lunch meal; -She used the spreadsheet to know what food items to prepare. She just missed that she needed to prepare more gravy to put on the mashed potatoes. -She let the blender grind/blend for a while, but it must not have done it for long enough; -She doesn't taste test pureed items for texture or quality. She didn't realize the pureed items were chunky. She also didn't realize the mashed potatoes should have been served with gravy for residents on pureed diets. She was still getting used to the new menus. 2. Review of the facility's Diet Type report, dated 2/5/24, showed four residents had a physician-ordered dental soft (mechanical soft) diet. Review of the Diet Spreadsheet menu for the lunch meal on 2/5/24 showed staff were to serve residents on a dental soft (mechanical soft) diet ground glazed ham with gravy and zucchini and tomatoes. Observation on 2/5/24 between 11:10 A.M. and 11:36 A.M. during the lunch meal service showed the dietary manager served ground glazed ham with visible large chunks and served zucchini and tomatoes that had large slices/pieces of zucchini and large round thick slices of tomato to all residents on a (dental soft) mechanical soft diet. Observation on 2/5/24 at 11:41 A.M. of the requested dental soft (mechanical soft) diet test tray showed the following: -The mechanical soft ham had large visible chunks that were not ground; -The zucchini and tomatoes had large slices/pieces of soft zucchini and large round thick slices of soft tomatoes. The zucchini and tomatoes were not cut into small chucks or pieces (as directed in the facility policy). During interview on 2/5/24 at 12:10 P.M. and on 2/6/24 at 10:30 A.M., the Dietary Manager said mechanical soft items should be of a fine texture and crushed up well. She prepared the mechanical soft food items. She let the blender grind/blend for a while, but it must not have done it for long enough. She doesn't taste test the mechanical soft food items for texture or quality. She didn't realize the mechanical soft meat was chunky. She was still getting used to the new menus.

Based on interview and record review, the facility failed to ensure procedures were implemented to address prevention of Tuberculosis (TB) for four staff members in a review of seven sampled employees reviewed, when the facility failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for TB testing for long-term care employees. The facility census was 47. Review of the facility's policy, Employee Screening for Tuberculosis, revised March 2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment; -Screening includes a baseline test for LTBI using either a TST or IGRA, individual risk assessment and symptom evaluation; -The employee health coordinator (or designee) will accept documented verification of TST or IGRA results within the preceding 12 months. Review of the Department of Health and Senior Services Tuberculosis Screening for Long-Term Care Facility Employees Flowchart, updated 03/11/14, (based on the requirements identified in the state regulation for administering TB testing) showed the following: -Administer TST first step prior to employment. (Can coincide reading the results with the employee start date by administering TST two to three days prior to the employee start date); -Read results of first step TST within 48-72 hours of administration (results must be read and documented in millimeters (mm) induration prior to or on the employee start date); -If first TST is negative, administer second step within 1-3 weeks; -Read results within 48-72 hours of administration; -The employee cannot start work for compensation until the first step TST is administered and read; -Do a one step TST by anniversary date of last TST and then annually. 1. Review of Office Receptionist E's employee file and Initial Employment and annual Tuberculosis Testing showed the following: -Start date 10/23/23; -First step TST administered on 10/14/23. Staff documented the results were 0 mm, however, staff did not document the date the test was read; -Second step TST administered on 12/13/23, nine weeks after the first step TST was administered. 2. Review of Maintenance Staff F's employee file and Initial Employment and Annual Tuberculosis Testing showing the following: -Start date 11/13/2; -First step TST administered on 11/3/23, with results read 11/5/23; -Second step TST administered on 12/3/23, four weeks after the first step TST was administered. Staff documented the results were 0 mm, however, staff did not document the date the test was read. 3. Review of Housekeeper G's employee file and Initial Employment and Annual Tuberculosis Testing showed the following: -Start date 11/28/23; -First step TST administered on 11/20/23. No evidence staff read the results. 4. Review of Certified Nurse Assistant (CNA)/Certified Medication Technician (CMT) H's employee file and Initial Employment and Annual Tuberculosis Testing showed the following: -Start date 12/27/23; -First step TST administered on 12/27/23. Staff read the results on 12/29/23; -No evidence a second step TST was administered within three weeks after the first step TST to complete the two-step TST, and no evidence of a two-step TST prior to employment. 5. During an interview on 2/6/24 at 3:09 P.M., the Office Manager/Human Resources staff said he/she scheduled the new employee to come in for their first step TST, but after that he/she did not know who was responsible for following up to ensure the full TB testing was completed. The nurses have a binder to document the TB tests as new employees come in for administration or reading. It is the responsibility of the employee to come in and have a licensed nursing staff administer and read the first step and second step TST. During an interview on 2/6/24 at 4:00 P.M., the interim Director of Nursing (DON) said new employees received their first step TST at orientation and their second step TST one week after. She was aware of a binder kept at the nurse station for tracking TSTs currently in progress. It is the new employee's responsibility, not the nurses' responsibility, to ensure new employees are completing the two-step TB testing. She was not sure who was responsible for tracking the testing and telling the new employees the timeframes to return (for testing and reading results). She did not provide any in-service or training for licensed nurses who were administering or reading TSTs. During an interview on 2/6/23 at 4:15 P.M., the Administrator said new employees should receive the first step TST before hire. Staff should check the results within 72 hours, and then schedule the second step TST. Staff should tell new employees when to come back to have the results read. Staff should monitor and ensure the TSTs are given as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three residents (Residents #32, #33 and #15), in a review of 12 sampled residents, and for one additional resident (Resident #5). The facility census was 47. Review of the undated facility policy, Bed Safety and Bed Rails, showed the following: -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the Food and Drug Administration (FDA). -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. -The maintenance department provides a copy of inspections to the administrator and report results to the Quality Assurance and Performance Improvement (QAPI) committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and or safety committee. -Bed rails are properly installed and used according to the manufacturer's instructions, specifications, and other pertinent safety guidance to ensure proper fit. ( avoid bowing, ensure proper distance from the headboard and footboard). 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/15/23, showed the following: -He/She was independent when rolling from left to right in bed; -He/She was independent with sitting to lying in bed and lying to sitting on the side of the bed;. Review of the resident's care plan, edited on 03/15/23, showed he/she had a mechanical bed with transfer handles on each side of bed to assist with bed mobility and transfers into and out of bed. Review of the resident's evaluation for use of bed rail assessment, dated 01/25/24, showed side rails/assist bars are indicated and serve as an enabler to promote independence. Observation on 2/5/24 at 10:00 A.M. showed 1/8 assist bars in the raised position on both sides of the resident's bed. Observation on 2/6/24 at 9:10 A.M. showed the resident had 1/8 assist bars in the raised position on both sides of his/her bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and assist bars (bed rails) to identify areas of possible entrapment. 2. Review of Resident #32's admission MDS, dated [DATE], showed he/she required assistance of staff with sitting to lying, lying to sitting, sitting on the side of the bed, sit to standing, and chair/bed-to-chair transfers. Review of the resident's evaluation for use of bed rail assessment, dated 01/11/24, showed side rails/assist bars are indicated and serve as an enabler to promote independence. Observation on 2/5/24 at 10:55 A.M. showed assist bars in the raised position on both sides of the resident's bed. During an interview on 2/5/24 at 10:55 A.M., the resident said he/she used the assist bars for bed mobility, due to weakness following a heart attack about eight months ago. Observation on 2/7/24 at 5:55 A.M. showed the resident lay in bed. The resident had assist bars in the raised position on both sides of the bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and assist bars (bed rails) to identify areas of possible entrapment. 3. Review of Resident #33's evaluation for use of bed rail assessment, dated 12/26/23, showed side rails/assist bars are not indicated at this time. Review of the resident's quarterly MDS, dated [DATE], showed he/she was independent with bed mobility. Review of the resident's physician orders for February 2024 showed the following: -Monitor for entrapment while in bed due to transfer handles on bed; -Mechanical bed with transfer handles on both sides to assist with bed mobility and positioning. Observations on 2/5/24 at 10:16 A.M. showed the resident lay in bed. The resident had a 1/8 assist bar attached to the right side of his/her bed. The assist bar was in the raised position. Observation on 2/6/24 at 9:05 A.M., showed the resident lay in bed. The resident had 1/8 assist bar in the raised position on the right side of his/her bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and assist bar (bed rails) to identify areas of possible entrapment. 4. Review of Resident #15's care plan, reviewed 12/22/23, showed the staff should transfer the resident using mechanical lift with two staff members and to monitor the resident for entrapment while in his/her bed. Review of the resident's bed rail assessment, dated 1/31/24, showed the following: -The resident is non-ambulatory; -The resident displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed; -The resident had difficulty with balance or poor trunk control; -Side rails/assist bars are not indicated at this time. Review of the resident's Physician Order Summary, dated February 2024, showed the resident utilized bilateral u-rails (assist bars) for bed mobility. Observation on 2/05/24 through 2/8/24 showed the resident had 1/8 bed rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and assist bars (bed rails) to identify areas of possible entrapment. 5. Review of the maintenance department records showed bed safety audits were completed on 1/1/23, 2/7/23, 2/12/23, and 2/26/23. Staff marked ok on a grid sheet with room numbers. No actual measurements were documented. During interviews on 2/7/24 at 8:15 A.M. and 10:40 A.M., Maintenance Staff D said he/she removed all bed rails six months ago and was now adding assist bars, which did not require the measuring of entrapment zones. He/She was not aware the assist bars were to be measured or monitored. During an interview on 2/8/24 at 10:25 A.M., administrator said she expected the maintenance department to be responsible for measuring and monitoring for entrapment zones.

Based on observation, interview, and record review, the facility failed to ensure sanitation and food storage practices were maintained in the main facility kitchen and the activity kitchen. The facility census was 47. Review of the facility policy, Food Storage (Dry, Refrigerated and Frozen), dated 2020, showed the following: -Food shall be stored on shelves in a clean, dry area free from contaminants; -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Store raw animal products such as eggs, meat, poultry, and fish separately from cooked and ready to eat food; -Raw animal foods such as eggs, meat, poultry and fish should be stored in drip proof containers. Review of the facility policy, Labeling and Dating Foods, dated 2020, showed the following: -All foods stored will be properly labeled according to the following guidelines; -Date marking for refrigerated storage food items: Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date; -Prepared food or opened food items should be discarded when the food item is older than the expiration date. Review of the facility policy, Cleaning Rotation, dated 2020, showed the following: -Items cleaned daily: Kitchen and dining room floors; -Items cleaned monthly: Refrigerators and food containers. 1. Observation on 2/5/24 at 9:51 A.M. of the walk-in cooler located on the service hall near the main kitchen showed the following: -A plastic tray sat on the bottom shelf and contained brown-colored pooled liquid up to the edges of the trays. Three tall cartons of frozen whole eggs sat in the brown liquid on the tray; -Brown pooled liquid and chunky brown-colored debris had accumulated on the walk-in cooler floor below the tray in an area that measured approximately 2 feet by 2 feet in size. The concrete floor was not smooth under the shelving unit and was not easily cleanable. Observation on 2/6/24 at 11:01 A.M. of food items inside the activity kitchen, showed the following: -An opened 16-ounce bottle of salad dressing in the refrigerator had a best by date of 11/20/23; -Two loose eggs rolled around in the refrigerator door shelf. One egg had a stamped letter P to indicate the egg had been pasteurized and the other egg had no labeling Neither egg was dated to show an expiration date; -A milkshake in the freezer was not covered and was open to air. The milkshake was was not dated or labeled with an expiration date; -An open bottle of caramel syrup sat on the countertop next to the refrigerator. The label on the bottle showed refrigerate after opening. During interview on 2/6/24 at 10:30 A.M., the Dietary Manager said the following: -The floor in the walk-in cooler was probably juice/liquid from thawing the tall cartons of frozen whole eggs. The liquid in the tray was also from the thawing process. She changed the tray and emptied the liquid every few weeks or so. If staff discovered spills, they were cleaned up promptly. The actual metal floor for the walk-in had been stolen in 1993 (when the walk-in unit had been installed). The metal floor sat outside the building during the installation and someone stole it before it could be installed. The floor in the walk-in unit was made of concrete instead of metal; -Activity staff was responsible for the refrigerator and freezer in the activity kitchen. Dietary staff did not have any responsibilities in the activity kitchen. -All food items should be labeled and dated and items should be discarded when needed. During interview on 2/6/24 at 11:07 A.M., the Activity Director said the following: -Activity staff was responsible for maintaining the activity area kitchen including cleaning out the refrigerator/freezer, discarding expired items, etc.; -Staff checked and cleaned out the refrigerator on Fridays; -Staff will sometime place personal food items in this refrigerator; -The salad dressing, eggs, and milkshake needed to be discarded; -She had left the caramel syrup out after she had made a cake and forgot to put it in the refrigerator.

Based on interview and record review the facility failed to ensure one resident (Resident #1) in a review of three sampled residents was free from abuse when Registered Nurse (RN) A smacked Resident #1's hand away and cussed at the resident. The facility census was 41. Review of the facility's undated Abuse Prevention Plan Policy showed the following in part: -The facility had a zero tolerance of physical, verbal, sexual and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property by employees, family members, visitors, or other residents; -The goal was to establish as atmosphere encouraging the reporting of any indications of mistreatment, neglect, misappropriation of property or abuse; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Abuse also included the deprivation by an individual of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse irrespective of any mental or physical condition, cause physical harm, pain or mental anguish included verbal abuse, sexual abuse, physical abuse and mental abuse; -Verbal abuse was defined as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend or disability; -Physical abuse included hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment; -Mental abuse included but was not limited to humiliation, harassment, threats of punishment or deprivation. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, completed by facility staff) dated 1/20/23 showed the following: -Severely impaired cognition; -Delusions (mental disorder with altered reality); -Required extensive assistance of one staff member with personal hygiene; -Independent in bed mobility; -Required supervision of one staff member with transfers. Review of the resident's care plan, updated 3/5/23, showed the following: -The resident had dementia with impaired memory and impaired decision making. Staff should provide a consistent daily routine, cue and reorient as needed, not argue with confused statements, use simple words or instructions, promote activities that reduced frustration and support success, offer choices between two items. The resident had behavioral disturbances resulting in combative behaviors of striking, biting, kicking staff, non-compliance with care, taking medications, bathing, eating meals, changing clothes and exit seeking. Allow time for resident to de-escalate and re-focus when agitated or resistant to care from staff; -The resident required total staff assistance with Activities of Daily Living. Staff should anticipate resident needs; -The resident resisted care. Staff should redirect negative behaviors, administer medications as ordered by the physician, assess for discomfort and medicate as needed, use two staff to assist with cares, allow time to de-escalate and re-approach if agitated. Review of the resident's Physician Order Sheet dated 3/21/23 showed the following: -Diagnosis of dementia with behavioral disturbances, bipolar disease (mental illness causing extreme mood swings), anxiety disorder, schizophrenia (mental illness with personality changes, hallucinations); -Haldol (antipsychotic medication) 5 mg (milligrams) per ml (milliliter) injection daily as needed for agitation, anxiety and /or aggression. Review of the resident's Medication Administration Record showed on 3/22/23 at 7:30 P.M. staff documented administration of Haldol 5 mg injection for aggressive behavior. Review of the facility abuse investigation dated 3/23/23 at 7:42 P.M. showed the Director of Nursing (DON) documented Nurse Assistant (NA) B notified the DON, Registered Nurse (RN) A smacked the resident and said fuck this, I will get the shot. Review of NA B's facility acquired written statement dated 3/22/23 at 7:25 P.M., showed Resident #1 was upset while staff assisted the resident in his/her room. The resident grabbed and pinched RN A. RN A slapped the resident's hand and said, fuck this I'm getting the shot. Review of the resident's nurses' notes dated 3/22/23 showed the following: -At 7:37 P.M. RN A documented the resident got up by himself/herself and was walking in the room without aid. The resident attacked staff with fingernails when they attempted to assist her. The resident pinched staff leaving marks but no open areas. The resident yelled at staff to shut up when staff talked to each other and was aggressive and agitated even after bringing the resident to the nurses' desk. Two staff members secured the resident's arms and legs while RN A administered a Haldol injection in the resident's left thigh. Review of the facility abuse investigation dated 3/25/23 at 7:34 A.M. showed the DON documented Licensed Practical Nurse (LPN) C said RN A confessed he/she actually hit Resident #1 on purpose during the incident. During an interview on 4/4/23 at 11:20 A.M. LPN F said he/she was the charge nurse. The resident had a long history of aggression towards others and a tendency to be aggressive towards staff. The resident became aggressive if approached multiple times, refused cares, he/she walked with a walker with an unsteady gait and ate independently. Staff were aware if the resident was aggressive to allow time to settle down and then re-approach. The resident's mood changed frequently. The resident refused his/her medications but LPN F would try again following lunch. During an interview on 4/4/23 at 12:15 P.M. NA B said the following: -On 3/22/23 at about 7:25 P.M. the resident was in his/her room, pinching and hitting at staff while staff attempted to provide care and calm the resident. RN A stood in front of the resident' wheelchair and NA B was behind the wheelchair. RN A smacked the resident's left hand/wrist, said fuck this, I'm getting the shot directly to the resident and walked out of the room. NA B heard a slap when RN A smacked the resident's hand/wrist area and the resident pulled his/her arm away. Staff repositioned the resident in his/her wheelchair, took the resident to the nurses' desk and RN A gave the resident a shot; -RN A should not have smacked the resident or cussed at the resident. RN A was abusive towards the resident. Staff were all well aware of the resident's behaviors. During an interview on 4/4/23 at 1:40 P.M. LPN C said the following: -On 3/22/23 he/she worked the night shift with RN A. About 7:30 P.M. NA B said he/she witnessed RN A hit Resident #1. NA B called the DON and informed her of the allegation; -Later in the shift RN A told LPN C about the incident and said he/she had a Post-Traumatic Stress Disorder (PTSD) moment and smacked the resident. During an interview on 4/4/23 at 1:55 P.M. LPN D said the following: -On 3/22/23 he/she worked the day shift and remained in the facility until approximately 10:00 P.M. that evening. NA B told him/her RN A hit Resident #1. The DON was aware and called asking LPN D what happened. He/She heard RN A speak with the DON on the telephone. During the conversation RN A said he/she hit Resident #1 because RN A's PTSD kicked in when the resident hurt RN A's arm; -Resident #1 took a lot of patience and tolerance, the resident was aggressive towards staff. During an interview on 4/4/23 at 2:15 P.M. the DON said the following: -On 3/22/23 NA B said RN A slapped Resident #1. The DON called the facility, spoke with LPN D and then with RN A; -RN A said he/she hit Resident #1 when the resident pinched RN A's arm; -Hitting, slapping or smacking a resident was abuse, cursing at a resident or toward a resident was abuse, and should be investigated immediately. During interview on 4/4/23 at 3:15 P.M. the administrator said the incident occurred 3/22/23 at about 7:25 P.M. During the investigation he determined it was true RN A smacked Resident #1 and cussed at the resident. That was abuse. MO#215973

Based on interview and record review the facility failed to ensure alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse to the administrator of the facility and to the State Survey Agency (SA) for one resident (Resident #1) in a review of three sampled residents when Registered Nurse (RN) A smacked the resident's hand away and said fuck this I'm getting the shot, directly toward the resident. The facility census was 41. Review of the facility's undated Abuse Prevention Plan Policy showed the following in part: -The facility had a zero tolerance of physical, verbal, sexual and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property by employees, family members, visitors, or other residents; -The goal was to establish as atmosphere encouraging the reporting of any indications of mistreatment, neglect, misappropriation of property or abuse; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Abuse also included the deprivation by an individual of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse irrespective of any mental or physical condition, cause physical harm, pain or mental anguish included verbal abuse, sexual abuse, physical abuse and mental abuse; -Verbal abuse was de fined as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend or disability; -Physical abuse included hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment; -Mental abuse included but was not limited to humiliation, harassment, threats of punishment or deprivation; -If an incident occurred or there was any reason to suspect that an incident might have occurred of abuse the Administrator would investigate; -The person doing the investigation would compete a written investigation report; -Any witnessed incidents, allegations of incidents, suspected incidents were to be immediately reported to a supervisor or the charge nurse who would report the incident to the administrator. Any person may report directly to the Director of Nurses or Administrator or to the elderly abuse and neglect hotline; -If an alleged, suspected, or witnessed incident of abuse occurred the Administrator shall report no later than 2 hours after forming the suspicion, to the State Agency; -The charge nurse was to notify the DON of the report. The DON shall inform the Administrator. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, completed by facility staff), dated 1/20/23, showed the following: -Severely impaired cognition; -Delusions (mental disorder with altered reality); -Required extensive assistance of one staff member with personal hygiene; -Independent in bed mobility; -Required supervision of one staff member with transfers. Review of the resident's care plan, updated 3/5/23, showed the following: -The resident had dementia with impaired memory and impaired decision making. Staff should provide a consistent daily routine, cue and reorient as needed, not argue with confused statements, use simple words or instructions, promote activities that reduced frustration and support success, offer choices between two items. The resident had behavioral disturbances resulting in combative behaviors of striking, biting, kicking staff, non-compliance with care, taking medications, bathing, eating meals, changing clothes and exit seeking. Allow time for resident to de-escalate and re-focus when agitated or resistant to care from staff; -The resident required total staff assistance with Activities of Daily Living. Staff should anticipate resident needs; -The resident resisted care. Staff should redirect negative behaviors, administer medications as physician ordered, assess for discomfort and medicate as needed, use two staff assist with cares, allow time to de-escalate and re-approach if agitated. Review of the resident's Physician Order Sheet dated 3/21/23 showed the following: -Diagnosis of dementia with behavioral disturbances, bipolar disease (mental illness causing extreme mood swings), anxiety disorder, schizophrenia (mental illness with personality changes, hallucinations); -Haldol (antipsychotic medication) 5 mg (milligrams) per ml (milliliter) injection daily as needed for agitation, anxiety and /or aggression. Review of the resident's Medication Administration Record showed on 3/22/23 at 7:30 P.M. staff documented administration of Haldol 5 mg injection for aggressive behavior. Review of the resident's nurses' notes dated 3/22/23 showed the following: -At 7:37 P.M. RN A documented the resident got up by his/herself and was walking in the room without aid. The resident attacked staff with fingernails when attempted to assist him/her. The resident pinched staff leaving marks but no open areas. He/She yelled at staff to shut up when staff talked to each other and was aggressive and agitated even after bringing the resident to the nurses' desk. Two staff members secured the resident's arms and legs while RN A administered a Haldol injection in the resident's left thigh. Review of the facility abuse investigation showed the Director of Nursing (DON) documented the following: -On 3/22/23 at 7:42 P.M. Nurse Assistant (NA) B notified the DON, RN A smacked the resident and said fuck this, I will get the shot, directly toward the resident; -On 3/22/23 at 7:49 P.M. RN A said Resident #1 pinched and hit RN A as he/she and NA B attempted to help the resident sit down. RN A reflexed his/her arms up to protect his/herself and accidentally hit Resident #1's hand. It was not intentional but decided to give the resident an injection for agitation; -On 3/24/23 at 8:25 A.M. the administrator was notified of the abuse allegation and the incomplete investigation; -On 3/25/23 RN A was terminated. During interview on 4/4/23 at 12:15 P.M. NA B said the following: -On 3/22/23 at about 7:25 P.M. the resident was in his/her room, pinching and hitting at staff while staff attempted to provide care and calm the resident. RN A stood in front of the resident's wheelchair and NA B was behind the wheelchair. RN A smacked the resident's left hand/wrist, said fuck this, I'm getting the shot directly to the resident and walked out of the room. NA B heard a slap when RN A smacked the resident's hand/wrist area and the resident pulled his/her arm away. Staff repositioned the resident in his/her wheelchair, took the resident to the nurses' desk and RN A gave the resident a shot; -RN A should not have smacked the resident or cussed at the resident. RN A was abusive towards the resident. Staff were all well aware of the resident's behaviors. RN A continued to work the remainder of the shift; -NA B called the DON immediately and informed her of the abuse. During interview on 4/4/23 at 2:15 P.M. the DON said the following: -On 3/22/23 NA B said RN A slapped Resident #1. The DON called the facility, spoke with LPN D and then with RN A. RN A said he/she hit Resident #1 when the resident pinched RN A's arm; -He/She should have reported the allegation of abuse immediately to the administrator and within 2 hours to the SA. He/She did not report the allegation of abuse to the administrator until 3/24/23 and did not report the abuse allegation to the SA within 2 hours of the incident. During interview on 4/4/23 at 3:15 P.M. the administrator said the incident occurred on 3/22/23 at about 7:25 P.M. The DON should have notified him of the abuse allegation immediately and started an investigation immediately. RN A should have been suspended immediately and sent home pending the investigation. The SA was not notified of the abuse allegation until the morning of 3/25/23. He or the DON was required to notify the SA within 2 hours of the abuse allegation. MO#215973

Based on interview and record review, the facility failed to prevent further potential abuse when Registered Nurse (RN) A continued to work the remainder of the shift and the following scheduled 12 hour shift after staff reported an allegation of abuse by RN A towards one resident (Resident #1) in a review of three residents. RN A smacked Resident #1's hand and cussed at the resident. The facility census was 41. Review of the facility's undated Abuse Prevention Plan Policy showed the following in part: -The facility had a zero tolerance of physical, verbal, sexual and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property by employees, family members, visitors, or other residents; -The goal was to establish as atmosphere encouraging the reporting of any indications of mistreatment, neglect, misappropriation of property or abuse; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Abuse also included the deprivation by an individual of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse irrespective of any mental or physical condition, cause physical harm, pain or mental anguish included verbal abuse, sexual abuse, physical abuse and mental abuse; -Verbal abuse was de fined as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to a resident or their families or within hearing distance, regardless of their age, ability to comprehend or disability; -Physical abuse included hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment; -Mental abuse included but was not limited to humiliation, harassment, threats of punishment or deprivation; -If an incident occurred or there was any reason to suspect that an incident might have occurred of abuse the Administrator would investigate; -The person doing the investigation would compete a written investigation report; -Any witnessed incidents, allegations of incidents, suspected incidents were to be immediately reported to a supervisor or the charge nurse who would report the incident to the administrator; -The charge nurse was to notify the DON of the report. The DON shall inform the Administrator; -While the investigation was ongoing, accused individuals or those suspected of being responsible for the abuse and who were employees of the facility would be place on suspension pending the results of the investigation; -The facility must have evidence that all alleged violations were thoroughly investigated and must prevent further potential abuse while the investigation was in progress. 1. Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 1/20/23 showed the following: -Severely impaired cognition; -Delusions (mental disorder with altered reality); -Required extensive assistance of one staff member with personal hygiene; -Independent in bed mobility; -Required supervision of one staff member with transfers. Review of the resident's care plan updated 3/5/23 showed the following: -The resident had dementia with impaired memory and impaired decision making. Staff should provide a consistent daily routine, cue and reorient as needed, not argue with confused statements, use simple words or instructions, promote activities that reduced frustration and support success, offer choices between two items. The resident had behavioral disturbances resulting in combative behaviors of striking, biting, kicking staff, non-compliance with care, taking medications, bathing, eating meals, changing clothes and exit seeking. Allow time for resident to de-escalate and re-focus when agitated or resistant to care from staff; -The resident required total staff assistance with Activities of Daily Living. Staff should anticipate resident needs; -The resident resisted care. Staff should redirect negative behaviors, administer medications as physician ordered, assess for discomfort and medicate as needed, use two staff assist with cares, allow time to de-escalate and re-approach if agitated. Review of the resident's Physician Order Sheet dated 3/21/23 showed the following: -Diagnosis of dementia with behavioral disturbances, bipolar disease (mental illness causing extreme mood swings), anxiety disorder, schizophrenia (mental illness with personality changes, hallucinations); -Haldol (antipsychotic medication) 5 mg (milligrams) per ml (milliliter) injection daily as needed for agitation, anxiety and /or aggression. Review of the resident's Medication Administration Record showed on 3/22/23 at 7:30 P.M. staff documented administration of Haldol 5 mg injection for aggressive behavior. Review of the facility abuse investigation showed the Director of Nursing (DON) documented the following: -On 3/22/23 at 7:42 P.M. Nurse Assistant (NA) B notified the DON, RN A smacked the resident and said fuck this, I will get the shot directly toward the resident; -On 3/22/23 at 7:49 P.M. RN A said Resident #1 pinched and hit RN A as he/she and NA B attempted to help the resident sit down. RN A reflexed his/her arms up to protect his/herself and accidentally hit Resident #1's hand. It was not intentional but decided to give the resident an injection for agitation; -On 3/24/23 at 8:25 A.M. the administrator was notified of the abuse allegation and the incomplete investigation; -On 3/25/23 RN A was terminated. During an interview on 4/4/23 at 12:15 P.M. NA B said the following: -On 3/22/23 at about 7:25 P.M. the resident was in his/her room, pinching and hitting at staff while staff attempted to provide care and calm the resident. RN A stood in front of the resident' wheelchair and NA B was behind the wheelchair. RN A smacked the resident's left hand/wrist, said fuck this, I'm getting the shot directly to the resident and walked out of the room. NA B heard a slap when RN A smacked the resident's hand/wrist area and the resident pulled his/her arm away. Staff repositioned the resident in his/her wheelchair, took the resident to the nurses' desk and RN A gave the resident a shot; -RN A should not have smacked the resident or cussed at the resident. RN A was abusive towards the resident. Staff were all well aware of the resident's behaviors. RN A continued to work the remainder of the shift; -NA B called the DON immediately and informed her of the abuse. During an interview on 4/4/23 at 2:15 P.M. the DON said the following: -On 3/22/23 NA B said RN A slapped Resident #1. The DON called the facility immediately, spoke with LPN D and then with RN A. RN A said he/she hit Resident #1 when the resident pinched RN A's arm; -The DON asked RN A if he/she wanted to go home at that time, RN A said no; -RN A was allowed to work the remainder of the night shift on 3/22/23 and the following 12 hour night shift on 3/23/23; -She should have suspended RN A immediately and removed RN A from the facility and away from the residents; -She did not follow the facility policy and protect the resident's from potential additional abuse. During an interview on 4/4/23 at 3:15 P.M. the administrator said the incident occurred 3/22/23 at about 7:25 P.M. The DON should have notified him of the abuse allegation immediately and he should have started the investigation immediately. RN A should have been suspended immediately and sent home pending the investigation and not allowed to work the remainder of that shift and work the following 12 hour shift. He and the DON should have followed the abuse policy and protected the residents. MO#215973

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for two residents (Resident #2 and #4), in a review of seven sampled residents. The facility census was 40. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; -The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the IDT a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Reviews and revises the current care plan. 1. Review of Resident #4's care plan, last reviewed 12/15/2022, showed the following: -Activities of daily living (ADL), resident requires assistance with ADL task performance as follows, supervision, set-up at mealtime; one assist for bed mobility, transfer, ambulation, toileting, grooming, bathing and dressing; -Assist as necessary to promote continence, provide assistance with bed mobility, the resident requires limited assistance with bathing, supervision with eating, is independent with bed mobility, transfers with walking in room or corridor, locomotion on and off the unit, dressing, toileting, and personal hygiene; -Falls, potential for injury; -Resident will be free from injuries related to falls; -Cue, orient and supervise as needed, be aware of safety issues, keep bed in the lowest position when not giving care, provide a safe, secure, environment, keep floors clean and clear, assess visual/hearing deficit to determine safety needs, assist with transfers and positioning; -Verbal cues as needed for safety, assess cause, pattern of previous falls and act upon resolvable factors; -The resident was able to be up without assistance with front wheeled walker in room and hallways, the resident was able to go without walker in room to go to and from restroom, effective date 6/3/20. Review of the resident's progress note dated 12/26/22 at 5:35 A.M. showed the resident reported having left hip pain, when asked about the pain he/she reported it was from when he/she fell yesterday about 3:30 P.M. Review of the resident's care plan showed no documentation of the fall on 12/26/22. Review of the resident's progress note dated 1/15/23 at 5:25 P.M. showed the resident was found on the floor, he/she said he/she was coming back from the restroom and went down fast. Review of the resident's care plan showed no documentation of the fall on 1/15/23 or new interventions/review of current interventions put in place to address the resident's falls. Review of the resident's progress note dated 1/18/23 at 1:30 A.M. showed at approximately 12:30 A.M. the resident slid to the floor while trying to get items from his/her drawer, landing on his/her bottom, unable to walk alone due to weakness, tremors and unsteadiness. Review of the resident's care plan showed no documentation of the fall on 1/18/23. Review of the resident's progress note dated 1/18/23 at 12:07 P.M. showed the resident had a non-injury fall in room. Review of the resident's care plan showed no documentation of the second fall on 1/18/23. Review of the resident's progress note dated 1/19/23 at 2:46 P.M. showed the resident was hollering I fell. This nurse and aides approached resident and found the resident sitting on his/her bottom right in front of the bathroom door. Review of the resident's care plan showed no documentation of the fall on 1/19/23. Review of the resident's admission MDS dated [DATE] showed the following: -Severe cognitive impairment; -Limited assistance of one person with bed mobility; -Total dependence of one staff member with transfers, -Extensive assistance of one staff member with walking in room and locomotion on and off unit, dressing and toilet use; -Total dependence of one staff member with personal hygiene; -Not steady with walking, moving on and off of the toilet, with surface to surface transfer, only able to stabilize with human assistance. -The resident had a fall in the last month prior to admission; -The resident had a fall in the last two to six months prior to admission; -Two or more falls since last admission or prior assessment; -One fall with injury except major (skin tears abrasions, lacerations, superficial bruises, hematomas and sprains or any fall related injury that causes the resident to complain of pain). Review of the resident's care plan showed it was not updated with the amount of assistance needed with ADLs and the resident's change in cognition. Review of the resident's progress note dated 1/30/23 at 3:45 P.M. showed resident was transported back to the facility by ambulance, lifted to bed with assistance of three staff, no response to verbal or tactile stimuli, has a urinary catheter (a tube inserted into the bladder to drain urine), the resident was alert to self only and received comfort care, the resident was on a pureed (soft and smooth foods), low potassium diet. Review of the resident's admission MDS dated [DATE] showed the following: -The resident had short term and long-term memory problems; -Severely impaired cognition for daily decision making; -Total dependence of two staff members with bed mobility, transfers and toilet use; -Total dependence of one staff member with dressing, eating and personal hygiene; Surface to surface transfers (between bed and chair or wheelchair) were not safe; -Used a walker and wheelchair; -Diagnoses included heart failure, Alzheimer's disease and diabetes; -The resident had a fall in the last month prior to admission; -The resident has a fall in the last two to six months prior to admission. Review of the resident's physician orders dated 1/30/23 showed an order for a pureed, low potassium diet. Review of the resident's care plan showed it was not updated to address the urinary catheter, pureed low potassium diet, comfort care or the amount of assistance needed with ADLs and change in cognition. 2. Review of Resident #2's admission MDS dated [DATE] showed the following: -Diagnoses included cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure), diabetes and depression -Cognition intact; -The resident was on hospice care. Review of the resident's physician orders showed to admit under the care of hospice on 10/13/22. Review of the resident's care plan, dated 10/16/22, showed no documentation it addressed hospice care. Review of the resident's quarterly MDS dated [DATE] showed the following: -Diagnoses included cirrhosis of the liver, diabetes and depression; -Moderately impaired cognition; -The resident was on hospice care. Review of the resident's care plan last revised 10/18/22 showed no documentation the care plan was updated to address hospice care. 3. During interview on 3/15/23 at 2:00 P.M. the MDS Coordinator said the following: -He/She started in his/her position in October of 2022; -Completing the MDS was the priority, he/she didn't always get the care plans updated; -He/She recently found out he/she needed to update the care plans after falls. During an interview on 3/15/23 at 12:20 P.M. the Director of Nursing said the following: -The facility met daily and would discuss resident falls and specific interventions put in place; -The MDS coordinator ideally should update the care plan within the same day a resident had a fall; -Hospice had a care plan they used, the facility didn't necessarily update the facility care plan with hospice care. During an interview on 3/15/23 at 12:05 P.M. the administrator said the following: -The MDS Coordinator was to update the resident care plans with any changes in care; -Interventions after falls should be updated on the care plan within the same day; -The MDS Coordinator was trying to catch up all the care plans; -The facility was without a MDS Coordinator from February 2022 until October 2022 and care plans were not updated at that time; -There was an order for Hospice care, he was not sure it was necessarily needed on the facility care plan.

Based on interview and record review, the facility failed to notify one resident's (Resident #500's) responsible party after the resident fell and re-opened a skin tear requiring treatment. The resident's responsible party learned of the resident's fall from another resident when he/she visited the facility. The facility census was 56. Review of the undated facility policy titled, Accident/Incident Event Report, showed the following: PROCEDURES: 1. Notify family; 8. The family should be notified immediately. Review of the facility policy titled, Assessing Falls and Their Causes, revised October 2010, showed the following: -Steps in the Procedure: -After a Fall: 4. Nursing staff will notify the resident's family in an appropriate time frame; -Reporting: 1. Notify the following individuals when a resident falls: a. The resident's family. 1. Review of Resident #500's admission Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 4/13/22, showed the following: -Mild cognitive impairment; -Required extensive assistance of two staff for bed mobility; -Required total dependence of two staff for transfers; -Required limited to extensive assistance for locomotion; -Not steady, only able to stabilize with human assistance; -Walker and wheelchair used for mobility. Review of the resident's undated face sheet, showed the resident had a family member listed as a primary contact with a phone number. Review of the resident's facility progress notes, dated 4/27/22 at 2:27 A.M., showed staff documented that at 11:05 P.M., heard a loud noise and someone cussing and saying they wanted to get up and leave this place. Went from room to room to inspect and try and figure out who was talking. Upon entry into the room, noted resident not in bed and lay on the floor with his/her back to the wall and upper back up against bedside table. Resident said he/she rolled out of bed. Noted resident had re-opened an old skin tear to his/her left elbow and dressing applied. Review of a facility Accident Report, dated 4/27/22, showed the following: -Date and time of accident: 4/27/22, 11:05 P.M.; -Description:11:05 P.M., heard a loud noise and someone cussing and saying they wanted to get up and leave this place. Went from room to room to inspect and try and figure out who was talking. Upon entry into the room, noted resident not in bed and on the floor with his/her back to the wall and upper back was up against bedside table. Resident said he/she rolled out of bed. Noted resident had re-opened an old skin tear to his/her left elbow and dressing applied; -Notifications: none. Review of the resident's care plan, last updated 4/28/22, showed the following: -Falls, potential for injury; -Potential for injury related to falls due to noted balance problems. During an interview with the resident's family member on 6/7/22 at 7:45 P.M., he/she said the following: -He/She was the resident's emergency contact; -He/She had learned the resident fell on 4/27/22, the day after the resident fell, when he/she had gone to the facility to visit the resident. He/She was surprised to hear this information from another resident that resided across the hall from the resident; -He/She did not like hearing this information that way and did not understand why the facility had not contacted him/her. He/She made the facility aware on admission that the resident's family was very involved in his/her care. During an interview on 6/8/22 at 3:00 P.M., Registered Nurse (RN) C said he/she was the nurse on duty when the resident had a fall and was found on the floor the night of 4/26/22. He/She had not contacted the resident's family, because he/she thought it was too late in the night to be calling families. The resident had re-opened an old skin tear and he/she had to re-dress it after that fall. During an interview on 6/8/22 at 2:15 P.M., the Social Services Director said the family was very particular and had expressed several times they were, and wanted to be, very involved with the resident's care. During an interview on 6/10/22 at 9:00 A.M., the Director of Nursing said responsible parties, emergency contacts, and/or families should be notified after any resident incident; this would include a fall. If the fall was during the night and there was no injury, it would be okay to make the contact the next day. During an interview on 6/10/22 at 9:06 A.M., the administrator said the following: -If a resident has a non-injury fall through the night, it would be okay to contact the family first thing in the morning; -Typically the next shift, the day shift nurse, would notify the responsible party about the fall; -She had not specified a time frame for the notification, if it was a minor issue, then within 24 hours, if serious and had to send to the hospital then immediately; -Families should not learn of their resident's fall or incidents from another resident. MO 202239

Based on interview and record review, the facility failed to ensure all staff who worked in the facility did not have a finding (Federal indicator) entered into the State certified nurse aide (CNA) registry concerning abuse, neglect, or misappropriation of property. Licensed Practical Nurse (LPN) PP, began work in the facility on 12/22/19 and had a Federal indicator preventing him/her from working in the facility. The facility failed to identify the LPN had a federal indicator. The facility census was 56. Review of the facility's undated Abuse Prevention Plan, showed the facility will not hire or maintain employment with a person with a history of abuse and will report any employee known to be abusive to the appropriate authorities. This facility will not employ or otherwise engage individuals who: -Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by court of law; -Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property;or -Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property; -Background checks will be done at the time of hire in accordance with the facility background screen policy. Staff will not be hired who have been found guilty or pleaded nolo contendere (accepts conviction but does not admit guilt), of abuse, neglect, mistreatment of residents, or misappropriation of resident property by a court of law. Such determination will not be limited to residents but shall include any known abusive acts against others; -The nurse aide registry will be checked prior to employment for each state where a nurse aide has shown to have worked, or has listed certification. Nurse aides will not be hired whose name is on any state abusive registry; -Verification of background checks, nurse wide registry checks and reference checks will be maintained in the personnel file of each employee. A notation by facility staff member of telephone contacts and/or printed verification for online contacts for registry check and previous employer checks will constitute verification. Record review of LPN PP's employee information obtained from the facility showed the following: -The facility completed a CNA Registry check on 12/9/19; -The CNA Registry check showed LPN PP had a federal indicator for abuse, neglect or misappropriation of property; -LPN PP's date of hire was 12/22/19. During interview with the Office Manager/Human Resources staff on 6/8/22 at 9:22 A.M. and 12:14 P.M. and on 6/27/22 at 9:29 A.M., he/she said the following: -He/She had been the Office Manager/Human Resources staff since July 2021; -He/She checked new hire background information including the CNA registry checks prior to employment and does not do any periodic checking after that; -He/She would not have known to look for a federal indicator; -LPN PP's pre-hire checks were completed prior to him/her starting this position; -The facility had changed systems and he/she could not go back past 2021 to see when the first date of work was for LPN PP. During interview on 6/8/22 at 9:28 A.M. and 12:20 P.M., the administrator said she started as temporary administrator in December 2019 with the previous administrator. She said all background checks are emailed to her. The first background check she received was on 12/11/19 and it was not LPN PP's information. She was not aware that LPN PP had a federal indicator preventing him/her from working in a certified facility. Anyone with a federal indicator would not be eligible for hire. LPN PP would be taken off the schedule and would no longer be employed at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs and risks to provide effective person centered care within 21 days of admission to the facility for one resident (Resident #207) in a review of 19 sampled residents and three additional residents (Resident #306, #355, and #208). The facility census was 55. Review of the facility policy, Care Planning - Interdisciplinary Team, revised September 2013, showed the following: -The facility's Care Planning/Interdisciplinary Team (IDT) is responsible for the development of an individualized comprehensive care plan for each resident; -A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff. Review of the Center for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the IDT a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Reviews and revises the current care plan, as needed; 11. Communicates with the resident or his/her family or representative regarding the resident, care plans, and their wishes; -If the RAI (MDS and CAAs) is not completed until the last possible date (the end of calendar day 14 of the stay), a complete care plan is required no later than seven days after the RAI is completed. (day 21) 1. Review of Resident #306's electronic medical record on 2/14/22 showed the following: -The resident was admitted to the facility on [DATE]; -No evidence the facility completed a comprehensive care plan for the resident (26 days since the resident's admission); -The facility failed to complete the resident's comprehensive care plan by the 21st day after admission. 2. Review of Resident #355's electronic medical record, on 2/15/22, showed the following: -The resident was admitted to the facility on [DATE]; -No evidence the facility completed a comprehensive care plan for the resident (22 days since the resident's admission); -The facility failed to complete the resident's comprehensive care plan by the 21st day after admission. 3. Review of Resident #207's face sheet showed the following: -The resident was admitted to the facility on [DATE]; -Diagnoses included: fracture of lumbosacral spine and pelvis (a broken bone in the lower spine and pelvic region), chronic congestive heart failure (a progressive condition that affects the pumping power of the heart muscle), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), anemia (low iron in the blood), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No delirium, behavior issues or rejection of care; -Mild depression; -Limited assistance of one staff for feeding and bathing; -Extensive assistance of one staff for personal hygiene; -Extensive assistance of two staff for bed mobility, transfers, dressing, and toileting; -Total dependence of one staff member for locomotion on and off the unit; -Frequently incontinent of bladder and bowel. Review of the resident's care plan status on 2/23/22 showed no evidence facility staff completed a comprehensive care plan. 4. Review of Resident #208's face sheet showed the following: -The resident was admitted to the facility on [DATE]; -Diagnoses include: diabetes mellitus (too much sugar in the blood), anxiety disorder, orthostatic hypotension (dropping of blood pressure with position changes), Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), and anxiety disorder (disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Independent decision making; -Mild depression; -No behavior symptoms or rejection of care; -Supervision by one staff member for eating and personal hygiene; -Limited assistance of one staff member for bed mobility, transfers, walking, and dressing; -Extensive assistance of one staff member for locomotion on and off the unit, toileting and bathing; -Occasionally incontinent of urine; -Continent of bowel; -Uses a walker and wheelchair for mobility with limited range of motion one upper extremity; -Has a history of falls. Review of the resident's care plan status on 2/23/22 showed no evidence facility staff completed a comprehensive care plan. 5. During an interview on 2/24/22 and 3/10/22, at 10:28 A.M. and 11:48 A.M., the MDS Coordinator said the following: -A comprehensive care plan should be completed one week after the admission MDS was completed; -She was the only person that completes the comprehensive care plans; -She did not complete a comprehensive care plan for Residents #207, #208, #306, and #355 within the required 21 days; -While the facility was without a Director of Nursing (DON), she was pulled away from her job duties to complete other duties. During an interview on 2/25/22 at 8:30 A.M., the DON said she was not sure when a comprehensive care plan should be completed, but she thought it was within 5-7 days of the admission MDS. During an interview on 2/25/22 at 8:30 A.M., the administrator said there are a lot of new staff in the last six months, staff are still learning how to do the care plans.

Based on interview and record review, the facility failed to follow physician orders for one resident (Resident #500), who had orders for lab work (blood and urine testing), out of seven sampled residents. The facility census was 56. 1. Review of Resident #500's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/13/22, showed the following: -Date of admission 4/6/22; -Brief Interview for Mental Status (BIMS) (brief screener that aids in detecting cognitive impairment) of 14 (BIMS scores range from 0-15, the higher the score, the lower the impairment to the cognitive response); -No problems recalling three words; -Could recall the year; -Could recall the week; -Missed the month by six days to one month; -Resident was usually understood; -Resident understands others; -Always continent of bowel and bladder; -Rejection of cares one to three days out of the last seven. Review of the resident's discharge MDS, completed by facility staff, dated 6/1/22, showed the following: -Date of discharge 6/1/22; -BIMS score decreased to 13; -Responding to the month was accurate within five days; -Required cueing to remember two of the three words he/she was asked to remember; -No rejection of cares; -Always continent of bowel and bladder. Review of the resident's facility face sheet showed the resident had diagnoses that included severed chronic kidney disease. Review of the resident's facility progress notes showed staff documented the following: -4/10/22, 4:20 A.M., resident refused multiple times to be put to bed or to be changed; had not allowed staff to put him/her to bed or to help change. Review of the resident's care plan, dated 4/18/22 and updated 4/21/22, showed the following: -Communication: Impaired ability to understand; -Requires assistance with activities of daily living (ADLs) including toileting; -Focus area: immobility and incontinence; potential for skin break down due to immobility and incontinence; will have no skin breakdown from pressure or incontinence; monitor for incontinence care; wash with soap and warm water; -Behavior symptoms: resists care; resident is resistive to care as evidenced by one episode of multiple times refusing to go to bed or help changing. Review of the resident's May 2022 POS showed the resident had a diagnosis of chronic kidney disease. Review of the resident's neurology appointment notes, dated 5/24/22, showed the following -Appointment date 5/24/22; -Family member reported concern that resident is not back to baseline and has fluctuating episodes of confusion and vivid recall of things; -Will check for any underlying/secondary causes for his/her confusional state; -Orders for urinalysis with microscopic exam (test of urine to detect infection) and culture if indicated, comprehensive metabolic profile (CMP) (a blood test that provides information about the body's fluid balance, level of electrolytes and how well the kidneys and liver work), complete blood count (CBC) with platelet differential (identifies seven types to cells in the blood), prothrombin time (blood test that determines coagulation time), CBC, and platelets. Review of the resident's medical record on 6/7/22 and 6/8/22, showed no documentation the facility had obtained the CMP, CBC with platelet differential, prothrombin time, CBC, and platelets. Review of text messages on 6/9/22 at 10:00 A.M. between the resident's family member and the Social Services Director on 5/28/22 at 7:13 A.M., showed the Social Services Director responded to the family member that she was aware bloodwork had been ordered. Review of the resident's resulted urinalysis showed the following: -Collected on 6/1/22 at 1:43 P.M.; -Reviewed on 6/8/22; -Leukocytes resulted 3+ (normal is negative) (indicates a urinary tract infection); -Blood resulted 1+ (normal is negative) (could indicate urinary tract infection). During an interview on 6/7/22 at 7:45 P.M., the resident's family member said the following: -On 5/24/22 he/she took the resident to a neurology appointment; the resident had been having problems with increased confusion and struggled to make sense of anything; the facility provided him/her with a list of the resident's current medications and other care notes from the facility to give to the physician; the physician told him/her he/she was going to send the facility an order for bloodwork and a urinalysis; -On 5/28/22, the administrator had confirmed with a family member that bloodwork had been ordered for the resident; -On 5/28/22, the Social Services Director had texted with a family member and confirmed she knew the resident had orders for bloodwork; -On 5/30/22, the charge nurse told the family member the resident's lab work would be obtained on 5/31/22; -On 6/1/22, when the family picked the resident up to return him/her to the hospital for in-patient therapy, it was discovered the bloodwork and urinalysis had not been completed, so the hospital obtained the ordered lab work. During an interview on 6/8/22 at 10:22 A.M., the Social Services Director said she did not know anything about ordered lab work from the neurologist for the resident. During an interview on 6/8/22 at 1:18 P.M., the Director of Nursing and the Administrator said they did not know anything about the resident having orders for lab work from a neurologist. During a phone interview on 6/9/22 at 1:10 P.M., the neurologists's office staff said the office sent the orders for the labwork to the facility on 5/24/22 to the facility fax number and confirmation showed the fax went through; the office had not drawn the lab work or collected the urinalysis and the physician wanted the collection as soon as possible to evaluate for the resident's confusion. The physician said waiting one week to obtain the labwork delayed the resident's care and he/she required an antibiotic for a urinary tract infection that could have been the cause for his/her increased confusion. During an interview on 6/10/22 at 9:00 A.M., the Director of Nursing said she expected physician orders to be followed. During an interview on 6/10/22 at 9:06 A.M., the administrator said the following: -She expected staff to follow physician orders; -If family members take a resident to a doctor's appointment, staff are to provide paperwork for the family to take with them to the doctor's appointment and families should be bringing that paperwork back to the nurse so it can be checked for new orders; -During the day the Social Services Director monitors the fax machine in the office; the office is open 24/7 so licensed nurses can check the fax machine for any orders that might come through; licensed nurses and supervisors should check the fax machine any time they walk by it; -If the facility gets a faxed order for a resident, it should be given to the charge nurse to enter in the electronic system, facility nurses can draw labs (bloodwork) and obtain urine samples that are not stat (right now) orders and transport picks up the next day and takes to the lab; -She was aware the resident had orders for lab work and a urinalysis, but the orders/paperwork were confusing and thought the nurse did not understand if they were to be obtained that day, or that they had been obtained that day, or if they were to be obtained before the resident's next appointment; (when this documentation was presented for review, the date of this communication was from 4/12/22 and from another physician and not from the 5/24/22 office visit); -The nurse should have called and clarified what needed to be done, if it was not clear; -The facility had not obtained the labwork or urinalysis; -The resident had had some falls and increased confusion; a urinary tract infection could cause confusion. MO202239

Based on interview and record review, the facility failed to develop a policy and procedure based on current standards of practice, to address the care of residents receiving dialysis services. The facility failed to consistently monitor the dialysis access site (fistula) according to the resident's physician's orders, and failed to complete post dialysis assessments to ensure no significant changes in the resident's condition following dialysis treatments for one resident (Resident #4), in a review of 19 sampled residents. The facility census was 55. Review of Nursing Management: The Journal of Excellence in Nursing Leadership, October 2010, Volume 41, Issue 10, Caring for a Patient's Vascular Access for Hemodialysis showed the following: -A patient in end-stage kidney disease relies on dialysis to mechanically remove fluid, electrolytes, and waste products from the blood. For the most effective hemodialysis, the patient needs good vascular access with an arteriovenous (AV) fistula or an AV graft (access used to artificially connect a vein with an artery, so that a higher blood flow is created to allow blood to be pumped out of the body to an artificial kidney machine, and returned to the body by tubes that connect the patient to the machine) that provides adequate blood flow. Follow your facility's policies and procedures and these clinical tips to protect and preserve the vascular access and avoid complications such as infection, stenosis, thrombosis, and hemorrhage: -Assess for patency at least every eight hours. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Auscultate the vascular access with a stethoscope to detect a bruit or swishing sound that indicates patency. -Check the patient's circulation by palpating his/her pulses distal to the vascular access; observing capillary refill in his/her fingers; and assessing him/her for numbness, tingling, altered sensation, coldness, and pallor in the affected extremity. -Assess the vascular access for signs and symptoms of infection such as redness, warmth, tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney disease are at increased risk of infection. -After dialysis, assess the vascular access for any bleeding or hemorrhage. Review of the facility's undated policy, Dialysis Communication Assessment, showed the following: -It is the policy of the facility to communicate open and effectively with any provider of dialysis for a resident of the facility; -Director of Nursing (DON) or designee will contact dialysis unit to establish the communication dialysis form that will facilitate the sharing of resident information; -A dialysis communication form will be used to send information to and from the facility to the dialysis center and back; -Upon return of the resident from the dialysis center, the nurse in charge of the resident will review the communication form and will obtain necessary post dialysis information; -If there are any questions regarding the completion of the form or needs of the resident, the nurse will call the dialysis center for a telephone report of any significant information needed; -The nurse will complete the post dialysis information on the dialysis communication form; -Completed form will be kept in the chart and/or scanned into the electronic health record; -The nurse will communicate any significant information (complications or concerns) to the medical practitioner and/or physician. (The dialysis policy did not address assessing the residents' fistulas to avoid complications such as infection, stenosis, thrombosis, and hemorrhage.) 1. Review of Resident #46's care plan, last updated 4/14/21, showed the following: -The resident was currently on dialysis; -The resident went to dialysis three times a week; -The resident had a dialysis fistula in left arm; -Continuity of care will be maintained between skilled nursing unit and dialysis center; -Communication will occur between skilled nursing staff and dialysis center related to the care needs of resident; -Monitor access site daily for signs and symptoms of infection; redness, warmth, swelling, etc.; -Monitor for signs of infection and communicate with the dialysis center any abnormal findings; -Check dialysis vascular access every eight hours; -Remove dressing from dialysis site four hours after applied; -Document return time from dialysis and mental status in comment section. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 12/23/21, showed the following: -His/Her cognition was intact; -He/She received dialysis. Review of the resident's face sheet showed diagnoses that included end stage renal disease (kidney failure), hypertension (high blood pressure) and renal osteodystrophy (skeletal abnormalities that occur in patients with chronic kidney disease). Review of the resident' February 2022 physician order sheet showed the following: -The resident had a dialysis fistula in his/her left arm; -Document mental status upon return from dialysis every Monday, Wednesday and Friday; -Remove dressing from dialysis site about four hours after return to the facility every Monday, Wednesday and Friday; -Every eight hours check dialysis vascular access (fistula). Palpate the vascular access to feel for a thrill or vibration. Auscultate the vascular access with a stethoscope to detect bruit, if not noted contact physician. Check circulation by palpating pulses distal to vascular access, observe capillary refill, and assess sensation and temperature of extremity. Notify physician if problems noted. Assess vascular access for signs and symptoms of infection and notify physician if signs of infection noted. Every day at 1:00 A.M., 9:00 A.M., and 5:00 P.M.; -Post dialysis assessment every Monday, Wednesday and Friday and document on dialysis facility form (communication form completed to maintain communication between the facility and the dialysis clinic). If you do not receive the form, there are blank ones in the drawer on the unit, pull one and fill out the bottom. On return, also check the vascular access for any bleeding or hemorrhage. Document the condition of the dressing in the comment section. Monitor blood pressure, pulse, temperature after treatment; -The resident will be picked up around 5:30 A.M. on Monday, Wednesday, and Friday for dialysis. Document the time he/she leaves in the comment section; -Document the return time from dialysis in the comment section. Review of the resident's Ancillary Administration Record, dated 2/1/22, showed the following: -No documentation staff conducted a post dialysis assessment as ordered. No evidence staff checked the vascular access for any bleeding or hemorrhage, no evidence staff assessed the dressing to the left arm fistula to ensure it was clean, dry and intact, no evidence staff monitored the resident's pressure, pulse, and temperature after treatments; -No documentation of the time the resident left the facility and returned from dialysis; -No documentation staff assessed the resident's mental status upon return from dialysis; -No evidence staff removed the dressing from the dialysis site after the resident's return from dialysis. Review of the resident's dialysis facility communication forms for February 2022 showed no communication form for 2/1/22. (The resident's physician's orders directed staff to complete a post dialysis assessment after dialysis and to document on dialysis facility form.) Review of the resident's Ancillary Administration Records, dated 2/4/22, 2/7/22, 2/9/22, 2/11/22, 2/14/22, and 2/16/22 showed the following: -No documentation to show status of vascular access, dressing assessment, or completion of dialysis facility communication form; -No documentation of the time the resident left the facility and returned from dialysis; -No documentation staff assessed the resident's mental status upon return from dialysis. Review of the resident's dialysis facility communication forms for February 2022 showed no communication forms completed for 2/4/22, 2/7/22, 2/9/22, 2/11/22, 2/14/22, and 2/16/22. Review of the resident's Ancillary Administration Record, dated 2/18/22, showed the following: -No documentation to show status of vascular access, dressing assessment, or completion of dialysis facility communication form; -No documentation of the time the resident returned from dialysis; -No documentation staff checked the resident's dialysis fistula every eight hours. Review of the resident's dialysis facility communication forms for February 2022 showed no communication form completed for 2/18/22. Review of the resident's Ancillary Administration Records, dated 2/21/22, showed the following: -No documentation to show status of vascular access, dressing assessment, or completion of dialysis facility communication form; -No documentation of the time the resident left the facility and returned from dialysis; -No documentation staff assessed the resident's mental status upon return from dialysis. Review of the resident's dialysis facility communication forms for February 2022 showed no communication form completed for 2/21/22. Review of the resident's Ancillary Administration Record, dated 2/22/22, showed no evidence staff checked the resident's dialysis fistula every eight hours. Review of the resident's Ancillary Administration Record, dated 2/23/22, showed the following: -No documentation to show status of vascular access, dressing assessment, or completion of dialysis facility communication form; -No documentation of the time the resident returned from dialysis; -No documentation staff assessed the resident's mental status upon return from dialysis. Review of the resident's dialysis facility communication forms for February 2022 showed no communication form completed for 2/23/22. Review of the resident's Ancillary Administration Records, dated 2/25/22, showed the following: -No documentation to show status of vascular access, dressing assessment, or completion of dialysis facility communication form; -No documentation of the time the resident left the facility and returned from dialysis; -No documentation staff assessed the resident's mental status upon return from dialysis. Review of the resident's dialysis facility communication forms for February 2022 showed no communication form completed for 2/25/22. During an interview on 2/14/22 at 2:38 P.M., the resident said the following: -He/She went to dialysis three times a week on Monday, Wednesday, and Friday; -Sometimes a nurse checked his/her fistula site when he/she returned from dialysis and sometimes they didn't; -The dialysis center didn't always send a communication form with him/her to take to the facility; -Staff check his/her fistula site at least once a day, but don't check it three times a day every day. During an interview on 2/22/22 at 3:10 P.M., Licensed Practical Nurse (LPN) D and LPN Z said the following: -Staff should check dialysis access sites at a minimum of three times a day; -They would have to look in the resident's chart to know the exact times to check the dialysis site and what other orders the residents had. During interviews on 2/25/22 at 8:30 A.M. and 3/17/22 at 2:06 P.M., the Director of Nursing (DON) said the following: -Nurses should check residents' dialysis fistula sites before and after every dialysis appointment and on every shift; -There is supposed to be a communication form that should come back to the facility with the resident after their dialysis appointment. The form includes an assessment of the resident and their dialysis fistula site from the dialysis center, and then the facility nurse is to assess the resident and fill in their assessment, sign it, document in the resident's electronic health record and communicate any questions with the dialysis center; -If the dialysis center does not send a communication form back to the facility with the resident, the nurse should call and ask for one; -The staff are expected to follow the physician orders for assessing dialysis residents and their dialysis fistula sites. During an interview on 3/17/22 at 1:56 P.M., the administrator said the following: -Nursing staff should chart assessments in the resident's electronic health record; -Nursing staff should assess dialysis residents upon their return to the facility after an appointment; assess the resident, their access site and get a set of vital signs; -Nursing staff should fill out a communication form sent from the dialysis center. If the dialysis center doesn't send a communication form, the staff should call the dialysis center and get one.

Based on interview and record review, the facility failed to implement an effective Quality Assurance (QA)/Quality Assurance Performance Improvement (QAPI) program when the facility did not have a director of nursing and no other nursing staff or nursing administration attended any QA/QAPI meetings. The facility census was 55. Review of the facility's undated Quality Assurance Process Improvement QAPI Program policy showed the following: Purpose: -To provide ongoing and comprehensive procedures that will guide the facility in monitoring resident care and services and will provide systems which facilitate the identification and correction of deficiencies and gaps in systems or processes; Goals: -The QAPI program will provide the structure for decision making and will guide our day to day operations; -The QAPI program will establish and maintain support and document ongoing monitoring and evaluation resident care and services; -The QAPI program encompasses all aspects of care including clinical care, quality of life, resident choice and care transitions; -The QAPI program will assist departments in continuously improving care and services by identifying opportunities to improve care and/or solve problems through the use of monitoring, tracking and investigation; -The QAPI program will provide for evaluation of the results of actions taken by individuals or departments to address identified opportunities to improve; -The facility administrator has ultimate responsibility for execution of the QAPI program; -The QA committee is composed of: -Department managers; -Medical director; -Pharmacy consultant; -A resident representative; -Other individuals as indicated by purposes and issues under discussion. -The QA committee determines the types of QA activities, including monitoring and evaluation processes, root cause analysis procedures and performance improvement plans and will approve an annual QAPI calendar; 1. Review of the facility's 2022 committee showed the following: Quality Assurance/Improvement Committee: -Administrator; -Medical Director; -Director of Nursing (DON); -Office Manager; -Pharmacist; -(meets quarterly). Compliance/Quality Improvement (QAPI) Committee: -Administrator; -DON; -Charge nurse (if available); -Social Service Director (SSD); -Minimum Data Set (MDS) Coordinator; -(meets weekly or every other week). During an interview on 2/15/22 at 12:05 P.M., the MDS coordinator said the following: -He/She was the only nurse in an administrative role until the Director of Nursing (DON) started on 2/11/22; -He/She did not attend any weekly meetings for falls, wounds, or weight loss; -He/She did not attend any QA or QAPI meetings because he/she was too busy and was excused. During an interview on 2/23/22 at 3:03 P.M., the administrator said the following: -The facility tried to have quarterly QA meetings; -Attendees for the Quality Assurance/Improvement Committee included the administrator, Medical Director, DON, Office Manager, and the pharmacist. The committee met quarterly; -Attendees for the Compliance/Quality Improvement (QAPI) Committee included the administrator, DON, charge nurse (if available), Social Service Director (SSD), and the MDS Coordinator (meets weekly or every other week); -The facility had not had a DON for the last six months, and no nursing administration person to attend the meetings; -The MDS Coordinator did not attend the QA or QAPI meetings because she was busy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that enhanced resident dignity for three residents (Residents #43, #28, and #41), in a review of 19 sampled residents. Facility staff also failed to cover two residents' (Resident #2 and #30) urinary catheter (tube leading from the urinary bladder to the outside to drain urine) drainage bags with a dignity/privacy cover. The facility census was 55. Review of the undated facility policy, Residents Rights Policy, showed the following: -These resident rights ensure that at least, each resident admitted to this facility is/has: -Fully informed, as evidenced by the resident's written acknowledgement, prior to or at this time of admission and during stay, of these rights and of all rules and regulations governing residents conduct and responsibilities; -Treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care for his/her personal needs; -The right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Review of the facility policy, Dignity, revised February 2021, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures; -Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example; a. Addressing the underlying motives or root causes for behavior; and b. Not challenging or contradicting the resident's beliefs or statements. 1. Review of Resident #43's face sheet showed the following: -Diagnosis of: Major depressive disorder, severe with psychotic symptoms, muscle spasm and chronic pain. Review of the resident's care plan, dated 7/11/19, showed the following: -Frequently incontinent of bladder; -Goal to remain clean, dry, and odor free; -Determine times when usually required toileting, assist to the bathroom at these times; -Provide privacy with toileting; -Toilet in advance of need. Review of the resident's care plan, updated 3/30/21, directed staff to transfer the resident to the wheelchair with a mechanical lift and two staff assist. Review of the resident's quarterly Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 12/24/21, showed the following: -Severe cognitive impairment; -Makes self understood and understands others; -Mild depression; -Required extensive physical assistance of two or more staff members for bed mobility; -Dependent on staff for transfers and toilet use. Observation on 2/16/22 at 7:41 A.M. to 8:25 A.M., in the resident's room showed the following: -The resident yelled I gotta go! Help Me! Please; -Licensed Practical Nurse (LPN) A told the resident, I'll be right there; -The resident continued to yell, and said, Oh my stomach is killing me! Please help me! I've got to go now; -LPN A told the resident, I'll be right back, I promise and went into another resident's room; -Certified Medication Technician (CMT) R walked past the resident's room. The resident yelled Help me! I've gotta go poop! I've gotta go now; -The Social Service Director walked down the hallway, heard the resident, walked into the resident's room and said, Do you have your call light on? There, I pushed it for you. No one wants to sit in their own poo! and walked back out of the room; -The resident yelled even louder Help! Please help me! Hurry; -Maintenance O stopped to ask the resident what he/she needed and then went and told LPN A; -LPN A came out of another resident's room and asked CMT R if he/she could help lay the resident down and told him/her that he/she would need someone else to assist with the resident; -CMT R went into the other resident's room and took him/her to breakfast; -The administrator came down the hallway and asked CNA K to go in the resident's room and turn the call light off and said, I know who it is - could you just go and turn the light off, it's red; -LPN A and CNA K went into the resident's room and transferred the resident to his/her bed via Hoyer lift (assistive device using a sling to transfer resident between wheelchair and with electrical or hydraulic power) and removed the resident's clothes; -The resident was incontinent of bowel and bladder; -CNA K placed two trash bags at the end of the bed and went to the sink and washed his/her hands. He/She removed the resident's soiled gown and incontinence brief and the resident said It's cold in here, with no clothes on it's real cold; -CNA K left the resident laying fully exposed while he/she went over to the sink to wash his/her hands and get more wet cloths; - CNA K performed peri care, applied barrier ointment to resident's perineal area, placed a clean gown on the resident and then covered the resident. 2. Review of Resident #28's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Care Plan, dated 3/4/21, showed the following: -Impaired level of cognitive function due to Alzheimer's disease; -At risk for episodes of agitation or fear due to confusion; -Reassure the resident when confused or upset; -Anticipate resident's needs; -Provide privacy; -Dress appropriately according to season and time of day; -Provide grooming, hygiene needs. Review of the resident's significant change in condition MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of heart failure, Alzheimer's disease, anxiety disorder, depression; -Required extensive physical assistance of two or more staff members for bed mobility; -Dependent on staff for transfers, eating, toilet use, and hygiene. Observation on 2/16/22 at 6:40 A.M., showed the following: -Resident in his/her room in bed and visible to anyone in the hallway; -Resident yelled for help; -Unidentified staff walked by and did not respond to the resident. Observation on 2/16/22 at 6:59 A.M.-7:33 A.M. (Continual observation), showed the following: -Resident in his/her room in bed; -At 6:59 A.M. the resident yelled for help, was moving his/her legs and covers. Activity Director/CNA and CNA K walked by the resident's room, but did not respond to the resident; -At 7:05 A.M. the resident continued to yell for help, pulled his/her covers up to his/her chest exposing bare skin from the abdomen to mid calf. The resident was only wearing socks, his/her private area was exposed and visible from the hall. Three staff walked by, but did not respond to the resident yelling for help; -At 7:06 A.M. the Transportation/Floor maintenance staff walked by the resident's room and did not respond to calls for help; -At 7:10 A.M. Licensed Practical Nurse (LPN) D walked by the resident's room while the resident was yelling help, but did not respond to the resident; -At 7:20 A.M. the resident continued to be exposed, now yelling hey; -At 7:24 A.M. Housekeeper FF walked by and did not respond to the resident calling out; -At 7:25 A.M. Certified Medication Technician (CMT) R propelled a resident to his/her room past the resident's room, walked back by the resident who continued to yell for help but did not respond; -At 7:26 A.M. Transportation/Floor maintenance staff, the Activity Director, and another unidentified staff member walked by the resident's room, the resident yelled out for help and did staff not respond to the resident; -At 7:28 A.M. the resident continued to be exposed, the Maintenance Director walked into the resident's room while the resident called out for help to deliver incontinence products and told the resident someone would be there in a minute and walked out of the room without covering the resident, pulling the curtain, or closing the door; -At 7:30 A.M. CMT R propelled another resident to his/her room, walking by the resident's room as Resident #28 called out for help. CMT R did not respond to Resident #28; -At 7:31 A.M. CNA K walked past the resident's room while the resident called out for help and did not respond to the resident; -At 7:33 A.M. LPN A responded to the resident, covered the resident with a blanket and the resident stopped yelling out. During an interview on 2/16/22 at 8:20 A.M., CNA K said the following: -Staff tried to respond to residents that yell out; -There are so many residents that yell out on the hall and they get to them as fast as they can; -Sometimes there are four residents continually yelling out at the same time. During an interview on 2/16/22 at 9:30 A.M., CMT R said staff should respond to residents when they call out for help. He/She did not because he/she was focused on getting the residents from the dining room. During an interview on 2/23/22 at 10:10 A.M., LPN D said all staff should acknowledge the residents any time they call out for help; 3. Review of Resident #41's face sheet showed the following: -The resident's diagnoses included posterior reversible encephalopathy syndrome (a condition that can cause headaches, seizures and visual disturbances; blurred vision to blindness), neuromyelitis optica (a condition that can cause blindness in one or both eyes, weakness or paralysis in the legs or arms, painful spasms, loss of sensation and bladder or bowel dysfunction), ischemic optic neuropathy (when blood does not flow properly to your eye's optic nerve, eventually causing lasting damage to this nerve and you suddenly lose your vision in one or both of your eyes). Review of the resident's care plan, dated 11/18/21, showed the following: -The resident required total assistance with all activities of daily living (ADL) task performance, anticipate resident's needs. Provide morning and evening care and provide privacy; -No evidence of a care plan focus to address the resident's visual deficit. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident's vision was severely impaired; no vision, sees only light, colors or shapes. Eyes do not appear to follow objects; -The resident did not reject care; -The resident was totally dependent on two or more staff for bed mobility, eating, dressing, bathing, transfers, personal hygiene, toileting and locomotion on the unit; -The resident had impairment on both sides of his/her upper extremities (shoulders, elbows, wrists, and hands) and lower extremities (hips, knees, ankles and feet); -The resident was always incontinent of bladder and bowel. Observation on 2/15/22 at 9:48 A.M. showed the following: -CNA K and Nurse Aide (NA) W transferred the resident to his/her bed from his/her wheelchair; -The two staff members removed the resident's pants and incontinence brief; -CNA K continued with peri care and cleaned the resident's groin and buttock with the window blind open to a staff parking lot; -CNA K stepped away from the bed, washed his/her hands while NA W stood beside the bed. CNA K retrieved more clean washcloths to continue cleaning the resident. During this time the resident lay in bed without clothes on from the waist down and the staff did not cover him/her with a blanket; -After CNA K and NA W finished changing and cleaning up the resident NA W pulled the blind closed. During an interview on 2/22/22 at 10:00 A.M., the resident said he/she would not want the blinds left open when the staff were changing him/her and leaving him/her naked for everyone outside to see him/her. The resident said that would be embarrassing and he/she did not know the staff had done that to him/her. During an interview on 2/23/22 at 12:15 P.M., CNA K said the following: -Residents should have privacy when staff provide care (change incontinence briefs, give a bed bath); -He/She forgot to close the blinds when providing care for the resident on 2/15/22; -Residents' bodies should be covered as much as possible during care or covered completely if he/she stepped away from the bed. 4. Review of Resident #2's face sheet showed the following: -The resident's diagnoses included acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), history of urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Extensive assistance of one staff member for hygiene and dressing; -Extensive assistance of two staff members for transfers, walking, and toileting; -Urinary catheter (a tube inserted into the bladder to drain urine) present. Review of the resident's care plan, last revised on 2/15/22, showed the following: -Resident required assistance with ADLs; -Change urinary catheter leg bag once weekly on Tuesday. During an observation on 2/14/22 at 12:18 P.M., the resident sat at the dining room table with his/her urinary drainage bag attached to the frame of his/her wheelchair without a dignity cover over the bag. Yellow urine was visible in the drainage bag. During an interview on 2/14/22 at 1:15 P.M., CNA I said he/she was not sure why the resident did not have a dignity cover over the urinary drainage bag. It was typical that the bags are covered. 5. Review of Resident #30's face sheet showed the following: -The resident's diagnoses include dementia, retention of urine, traumatic brain injury, history of falling, and artificial openings of urinary tract. Review of the resident's care plan, dated 3/15/16, showed the following: The resident had moderately impaired cognitive skills for daily decision making; -The resident required assistance with ADLs; -The supra pubic catheter (tube leading from the urinary bladder and the skin to the outside to drain urine) will remain patent and free from infections; -Apply leg bag in the morning and to dependent drainage bag at bedtime. Record review of the quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive assistance needed in activities of daily living; -Substantial/maximal assistance needed with self-care; -The resident has an indwelling catheter. Observation on 2/14/22 at 11:40 A.M., showed the resident sat in dining area in a recliner with his/her eyes closed. Other residents also sat in the dining area. The resident's urinary drainage bag, attached to the recliner, had visible urine in the bag and no privacy cover. Observation on 2/14/22 at 2:40 P.M., showed the resident lay in bed with his/her eyes closed. His/Her urinary drainage bag was attached to his/her bed with visible urine in the bag and no privacy cover. Observation on 2/14/22 at 2:45 P.M., showed the resident lay in bed with his/her eyes closed. His/her urinary drainage bag with urine visible in the bag, was attached to his/her bed and was without a privacy cover. During an interview on 2/14/22 at 3:00 P.M., CMT F said he/she not sure why the resident did not have a dignity cover over the urinary drainage bag. Observation on 2/15/22 at 10:00 A.M., showed following: -The resident lay in bed with his/her eyes closed; -The resident's urinary drainage bag was in an open lower bedside table drawer and contained dark urine; -There was no privacy cover and the drainage bag was visible from the doorway. 6. During an interview on 2/25/22 at 8:30 A.M., the Director of Nursing (DON) said the following: -She would expect staff to go in a resident's room and see what they need if they are calling out; -She would not expect a staff member to walk by a resident's room and not acknowledge the resident if they are calling out for help; -She would not expect staff to ignore the residents; -It was not acceptable for a resident to be lying naked in their room and to be exposed to people in the hallway; -Catheter bags should be covered to maintain residents' dignity; -When providing resident care the window blinds and privacy curtain should be pulled to provide privacy for the resident; -When leaving the resident's room cover the resident to ensure he/she is not exposed to people walking in or by the room. During an interview on 2/25/22 at 8:30 A.M., the administrator said the following: -Staff are expected to maintain a resident's dignity; -It was not acceptable to walk past the room of a resident that is calling out; -She would expect staff to go into the resident's room and see what they needed; -Many times a resident will call out and not know what they need, and the resident needs to be answered by staff to see if they can provide help.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs for two residents (Resident #41 and Resident #45), in a review of nineteen sampled residents, when Residents #41 and #45 yelled out for assistance periodically throughout the day because they did not have access to a call light. The facility census was 55. Review of the facility's Policy and Procedure for Call Light System, updated January 2022, showed the following: -The facility will maintain a call light system in the facility for all residents and staff members to use for assistance and/or emergencies; -All nursing staff will be educated and trained on constant checking of the monitors to ensure call lights are being answered timely and that each resident has their call light within reach of using; -No evidence to show the facility ensures that the staff are educated on the use of the call lights and correct placement of call lights for each resident. 1. Review of Resident #41's face sheet showed the following: -The resident's diagnoses included posterior reversible encephalon syndrome (a condition that can cause headaches, seizures and visual disturbances; blurred vision to blindness), neuromyelitis optica (a condition that can cause blindness in one or both eyes, weakness or paralysis in the legs or arms, painful spasms, loss of sensation and bladder or bowel dysfunction), pain, muscle spasm of the back, muscle weakness, unspecified lack of coordination, difficulty in walking, abnormalities of gait and mobility, low back pain, transverse myelitis in demyelinating disease (a condition that interrupts the messages the spinal cord nerves send throughout the body), mild cognitive impairment, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness, and ischemic optic neuropathy (when blood does not flow properly to your eye's optic nerve, eventually causing lasting damage to this nerve and you suddenly lose your vision in one or both of your eyes). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/21/21, showed the following: -The resident's vision was severely impaired; no vision, sees only light, colors or shapes. Eyes do not appear to follow objects; -The resident's cognition was severely impaired; -The resident was totally dependent on two or more staff for bed mobility, eating, dressing, bathing, transfers, personal hygiene, toileting and locomotion on the unit; -The resident had impairment in range of motion on both sides of his/her upper extremities (shoulders, elbows, wrists, and hands) and lower extremities (hips, knees, ankles and feet). Review of the resident's care plan, updated 11/18/21, showed the following: -The resident lacks some cognitive skills for daily decision making; -The resident required total assistance with all activities of daily living task performances. Anticipate the resident's needs. Provide morning and evening care and provide privacy; -No evidence of a care plan focus to address the resident's visual deficit or use of his/her call light. Review of the resident's call light log for February 2022 showed the resident's call light was not activated from February 7th at 2:42 P.M. through February 28th at midnight. Observation on 2/14/22 at 11:35 A.M., showed the following: -The resident sat in his/her wheelchair with a blanket covering his/her body up to his/her shoulders; -The resident's tent call light (a triangular shaped mechanical call pad, with a large, sensitive surface area that activates from any direction, that is used for residents who have difficulty using call cords) hung over the right arm of the wheelchair upside down. During an interview on 2/14/22 at 11:35 A.M. the resident said the following: -Sometimes it takes a long time for staff to come help him/her; -He/She did not have a call light; -He/She just yells out if he/she needed anything. Observation on 2/15/22 at 11:04 A.M., showed the following: -The resident called out for Certified Nurse Assistant (CNA) L and said, I need straightened out, can you help me; -The resident lay on his/her left side in bed with a blanket up to his/her shoulders and a tent call light sat beside him/her on the bed by his/her upper arm; -CMT P told the resident he/she was passing medications and would find someone, and then told an aide to go get CNA L; -The Social Service Director (SSD) stopped as she was walking past the resident's room and assisted the resident. During an interview on 2/15/22 at 12:28 P.M., CMT P said he/she was told in report that the resident hollered most of the night and the staff were in his/her room off and on throughout the night. Observation on 2/15/22 at 5:24 P.M. showed the resident sat in a broda chair (a special reclining/positioning chair). The resident yelled at staff to turn up the damn heat. The resident's tent call light was in the recliner and out of the resident's reach. Observations on 2/16/22 showed the following: -At 5:20 A.M., the resident lay on his/her left side in bed with a blanket covering his/her body up to his/her shoulders. The resident yelled, Hello, can you help me? The resident's tent call light was on top of his/her blanket by his/her elbow; -At 5:25 A.M., the resident continued to yell out for help; -At 5:28 A.M., the charge nurse, Registered Nurse (RN) C, walked past the resident's room and did not acknowledge the resident as the resident yelled, Hello, can you help me, hello?; -At 5:33 A.M., the resident continued to yell out for help and said, Hello, can you all help me? Hello, can you answer me? Can you help me or not; -At 5:38 A.M., Registered Nurse (RN) C went to the resident's room and asked what he/she needed. The resident said he/she wanted his/her legs pulled down and said his/her back hurt. RN C stretched the resident's legs, placed a pillow under his/her legs, repositioned the head of the bed and said he/she would get the resident some pain medication; -The resident told RN C, I apologize for hollering, but I hurt. Observation on 2/22/22 at 9:48 A.M., showed the resident lay in bed. The resident yelled for help and two staff members went into the resident's room and repositioned him/her. The resident's tent call light was in the recliner and out of the resident's reach. During an interview on 2/22/22 at 10:00 A.M., the resident said the following: -He/She could not use the tent call light or the bulb call light because of his/her hands (the resident's hands were contracted); -He/She just yells for help, the staff told him/her to just holler at them. Observation on 2/22/22 at 3:22 P.M., showed the resident lay on his/her left side in bed with a blanket up to his/her shoulders covering his/her arms and hands. The tent call light was placed on top of the blanket by the resident's left elbow/upper arm. Observation on 2/23/22 at 1:55 P.M., showed the resident was asleep in bed. The resident lay on his/her back with a blanket pulled up to his/her shoulders with his/her arms and hands covered. A bulb call light was clipped to his/her blanket. The tent call light was in the recliner next to the bed. During an interview on 2/23/22 at 10:10 A.M., Licensed Practical Nurse (LPN) D said the following: -The resident cannot use his/her tent call light; -He/She said the tent call light was to be clipped to the resident's chest so the resident could bump it with his/her head; -He/She does not think the resident was capable of raising his/her head to bump the tent call light. During an interview on 3/14/22 at 8:16 A.M., facility Physical Therapy Assistant I said the following: -The resident had a pressure call light (tent call light); -The call light should be placed on the resident's stomach or chest with his/her hands placed by the call light; -If the resident cannot feel the tent call light he/she would not know where the tent call light is because he/she cannot see; -Staff should be instructing the resident of the placement of the tent call light before leaving the resident's room. 2. Review of Resident #45's face sheet showed the following: -The resident had diagnoses of pain and dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of the resident's care plan, updated 11/19/21, showed the following: -He/She usually understood, but sometimes had trouble comprehending conversations. Ask what is bothering the resident, how you can make it right and validate the resident's feelings; -The resident had a visual deficit due to cataracts; -Arrange frequently used items in the same position on his/her bedside table; -He/She required assistance with ADL task performance as follows: supervision, set-up, cues at mealtime; assistance of one staff for bed mobility; extensive assistance of one staff for transfers, toileting, grooming, bathing and dressing; -Assistance of one to two staff with turning and positioning as scheduled or as needed; -Educate the resident on the use of the call light when needing assistance; -He/She will holler out at times momma help me. Review of the resident's annual MDS, dated [DATE], showed the following: -He/She understood others and can make him/herself understood; -He/She had severely impaired cognition; -He/She did not exhibit behaviors or reject cares; -He/She required extensive assistance from two or more staff members for bed mobility and dressing; -He/She was totally dependent on two or more staff members for transfers and toileting; -He/She was totally dependent on one staff member for personal hygiene, bathing and locomotion on and off the unit; -He/She used a wheelchair; Review of the resident's call light log for February 2022 showed the following: -The resident's call light was not activated from February 1st at 12:00 A.M. through February 28th at midnight. Observation on 2/14/22 at 12:04 P.M., showed the resident sat in his/her wheelchair, leaning toward the right side of his/her wheelchair, in his/her room. The resident yelled, mother help me, over and over again. The resident continued to yell out, mother help me, as several staff members walked past his/her room and did not acknowledge the resident. The resident's call light was clipped to the left arm rest of his/her wheelchair and not accessible to the resident. At 12:15 P.M., LPN A walked past the resident's room and told the resident he/she would be back. The resident continued to yell out, mother help me. Observations on 2/22/22 showed the following: -At 10:00 A.M., the resident sat in his/her wheelchair, leaning toward the right side of his/her wheelchair, in his/her room and yelled out, Mother help me. Mother help me, I need help. Mother help me, I need help bad. The resident's call light was attached to the left arm rest of his/her wheelchair. The call light hung on the outside of the wheelchair towards the back of the chair and not accessible to the resident; -At 10:04 A.M., Nurse Assistant (NA) W walked past the resident's room and did not acknowledge the resident; -At 10:06 A.M. the resident continued to yell out Mother help me. Mother help me. I hurt bad! Mother help me, mother help me, I hurt! -At 10:06 A.M. and 10:09 A.M., Social Service Staff AA walked past the resident's room and did not stop or acknowledge the resident; -At 10:10 A.M., NA Q walked past the resident's room and did not stop or acknowledge the resident; -At 10:12 A.M., the resident continued to yell out, Mother help me. Mother help me. Mother help me; -At 10:13 A.M., the SSD and NA Q walked past the resident's room and did not stop or acknowledge the resident; -At 10:14 A.M., NA Q dropped off dirty linens across the hall from the resident's room and did not stop or acknowledge the resident; -At 10:16 A.M., Social Service Staff AA walked past the resident's room and did not stop or acknowledge the resident; -At 10:17 A.M., the MDS/Care Plan Coordinator stopped and talked with the surveyor outside the resident's room but did not acknowledge the resident as the resident continued to yell out for help; -At 10:20 A.M., the resident continued to yell out, Mother help me. Mother help me. I hurt bad! Mother help me! The resident's call light remained attached to the left arm rest of his/her wheelchair. The call light hung on the outside of the wheelchair towards the back of the chair, out of reach of the resident. -At 10:21 A.M., CNA K walked past the resident's room and looked in the room, but did not stop or acknowledge the resident as he/she yelled out mother help me, I need help bad; -At 10:23 A.M., the resident yelled out with a louder raised voice, Mother Help Me; -At 10:23 A.M., CNA K walked past the resident, but did not stop or acknowledge the resident; -At 10:24 A.M., the resident continued to yell out, Mother help me. Come help me. Help me. Help me; -At 10:24 A.M., the SSD walked past the resident, but did not stop or acknowledge the resident. During an interview on 2/22/22 at 10:30 A.M., CNA K said the resident always yelled mother help me when he/she wants something, very seldom does the resident use his/her call light. The resident had a call light and it was within his/her reach at this time. Observation on 2/22/22 at 10:33 A.M., showed the resident's call light remained attached to the left arm rest of his/her wheelchair. The call light hung on the outside of the wheelchair towards the back of the chair out of reach of the resident. During observation and an interview on 2/22/22 at 10:20 A.M. and 10:33 A.M., the resident said the following: -It takes a long time to get help; -At 10:20 A.M., the resident's call light was attached to the back left arm rest hanging on the outside of the wheelchair towards the back and out of the resident's reach; -At 10:33 A.M., the resident's call light remained attached to the back left arm rest hanging on the outside of the wheelchair towards the back and out of reach; -He/She did not know where his/her call light was; -He/She could not reposition himself/herself to be able to reach the call light. Observation on 2/22/22 at 3:02 P.M., showed the resident lay in bed on his/her back sleeping. The resident's call light was on the floor and not within the resident's reach. During an interview on 2/23/22 at 10:10 A.M., LPN D said the following: -The resident could probably use his/her call light; -The resident cannot reposition him/herself without assistance; -All staff should acknowledge the resident any time he/she calls out for help; -The residents should always have their call light available and within their reach. 3. During an interview on 2/25/22 at 8:30 A.M., the Director of Nurses (DON) said the following: -When residents call out she would expect staff to go in the resident's room and see what they need; -Residents' call lights should be within reach at all times; -It is not acceptable for staff to ignore residents, it is not acceptable for staff to walk past and not acknowledge residents yelling out for help. During an interview on 2/25/22 at 8:30 A.M. the administrator said the following: -Resident #41's call light should be placed where he/she can hit it with his/her hands; -It was not acceptable for staff to walk past residents' rooms when they are yelling out for help; -Staff should acknowledge residents when they are yelling out for help.

Based on record review and interview, facility staff failed to ensure resident funds were placed in an account separate from the facility operating account and did not allow the residents/guardian the right to manage his/her financial affairs. The facility did not provide residents access to their funds as soon as possible for 20 residents (Resident #17, #29, #34, #47, #50, #200, #201, #202, #205, #206, #208, #209, #210, #211, #212, #213, #214, #215, #217 and #218). The facility also failed to ensure negative balances were not maintained for one deceased resident (Resident #229). The facility refunded more funds to the resident's responsible party than the resident maintained in the resident trust fund at the time of death, which resulted in refunding funds that belonged to other residents. The facility census was 55. 1. Record review of the facility's maintained Resident Accounts Receivable Aging Report for the period 02/01/21 through 02/28/22, dated 02/28/22, showed the following residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account #200 $1,617.00 #201 $ 121.40 #202 $1,013.77 #29 $3,260.13 #17 $4,410.00 #34 $8,580.22 #205 $3,927.00 #206 $3,553.46 #218 $ 32.28 #47 $1,359.13 #208 $ 753.20 #209 $ 105.00 #210 $1,098.24 #211 $1,015.00 #212 $ 7.00 #213 $ 952.00 #214 $ 620.00 #215 $ 7.00 #50 $ 136.84 #217 $2,322.00 Total $34,890.67 During an interview on 03/01/22 at 9:02 A.M., the Accounts Receivable Staff said he/she was told by the administrator not to pay any resident refunds, because the facility did not have the money and needed to pay bills, such as payroll, food, and utilities instead of resident refunds. 2. Review of Resident #229's medical record showed he/she expired on 7/26/21. Review of the Resident Trust Fund Current Balance Report, dated 7/31/21, showed the following: -The resident's primary pay source was private; -The resident's balance in the resident trust fund was $126.03. Review of the resident's trust fund ledger/statement showed on 8/10/21 a check was written in the amount of $138.01 to close the resident's account. The resident's balance was negative $11.98. (The facility refunded the resident $11.98 belonging to other residents who maintained funds in the resident trust fund account.) Review of the Resident Trust Fund Current Balance Report, dated 8/31/21, 9/30/21, 10/31/21, 11/30/21, 12/31/21, and 1/31/22, showed the resident's balance in the resident trust fund was negative $11.98. During an interview on 3/15/22 at 12:54 P.M., the Accounts Receivable Staff said Resident #229 had a haircut which had not posted as a withdrawal from his/her resident trust fund account prior to the funds being refunded to the resident's family. The facility usually waited until everything (deposits and withdrawals) had posted to the residents' accounts before funds were refunded, but sometimes the funds were refunded early and not all items had posted to show withdrawals from the account. During an interview on 3/18/22 at 2:15 P.M., the Administrator said she reviewed the Resident Accounts Receivable Aging Report monthly. She was aware remaining funds for Medicaid residents were to be refunded within 30 days. She was not aware of the five day timeframe in state regulations to refund funds upon discharge. The Accounts Receivable Staff was responsible for this. She was not sure why the funds were not refunded within the required timeframes.

Based on record review and interview, the facility failed to reconcile the resident trust fund bank balance and resident petty cash with the current balance of the resident trust fund ledgers. In addition, the facility failed to provide quarterly financial statements to one resident (Resident #21). The facility census was 55. 1. Review of the facility's reconciliation, dated January 2021, showed the reconciled balance (bank statement balance minus the outstanding deposits and withdrawals) was $30,310.76. Review showed no evidence the facility included the resident petty cash balance maintained in the facility in the monthly reconciliation. Review of the Resident Trust Fund Current Balance Report (report with each resident's account balance including funds in the checking account and resident petty cash), dated 1/31/21, showed the total balance in the resident trust fund was $30,173.45. (The facility failed to reconcile the bank statements and petty cash to the resident's trust fund ledgers to ensure the ending balances were equal. The facility's bank balance (without petty cash included) was greater than the balance listed on the resident trust fund current balance report.) 2. Review of the facility's reconciliation, dated February 2021, showed the reconciled checking account balance was $32,636.87. Review showed no evidence the facility included the resident petty cash balance in the monthly reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 2/28/21, showed the total balance was $32,499.56. 3. Review of the facility's reconciliation, dated March 2021, showed the reconciled checking account balance was $29,960.92. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 3/31/21, showed the total balance was $29,823.61. 4. Review of the facility's reconciliation, dated April 2021, showed the reconciled checking account balance was $45,863.55. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 4/30/21, showed the total balance was $45,726.24. 5. Review of the facility's reconciliation, dated May 2021, showed the reconciled checking account balance was $46,251.72. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 5/31/21, showed the total balance was $44,837.27. 6. Review of the facility's reconciliation, dated June 2021, showed the reconciled checking account balance was $46,588.26. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 6/30/21, showed the total balance was $46,336.95. 7. Review of the facility's reconciliation, dated July 2021, showed the reconciled checking account balance was $44,294.33. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 7/31/21, showed the total balance was $44,043.02. 8. Review of the facility's reconciliation, dated August 2021, showed the reconciled checking account balance was $45,339.30. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 8/31/21, showed the total balance was $45,087.99 9. Review of the facility's reconciliation, dated September 2021, showed the reconciled checking account balance was $47,826.13. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 9/30/21, showed the total balance was $47,574.82. 10. Review of the facility's reconciliation, dated October 2021, showed the reconciled checking account balance was $48,895.11. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 4/30/21, showed the total balance was $48,643.80. 11. Review of the facility's reconciliation, dated November 2021, showed the reconciled checking account balance was $49,798.56. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 4/30/21, showed the total balance was $49,547.25. 12. Review of the facility's reconciliation, dated December 2021, showed the reconciled checking account balance was $45,346.84. Review showed no evidence the facility included the resident petty cash balance in the reconciliation. Review of the Resident Trust Fund Current Balance Report, dated 4/30/21, showed the total balance was $44,969.53. 13. During an interview on 2/16/22 at 9:25 A.M., the Accounts Payable Staff said the following: -He/She was responsible for reconciling the resident trust fund; -He/She had not received any training regarding how to manage the resident trust fund; -He/She was not aware of any facility policies for the resident trust fund; -He/She reconciled the bank statements to a ledger of deposits and withdrawals from the account monthly. He/She did not include the resident petty cash in the monthly reconciliation and did not reconcile the balances to the resident trust fund ledgers. 14. Review of Resident #21's quarterly minimum data set (MDS), a federally required assessment instrument completed by facility staff, dated 11/19/21 showed the following: -Cognitively intact; -Independent decision making ability. During an interview on 2/15/22 at 9:28 A.M., the resident said he/she has only received approximately three financial statements since he/she has been a resident at the facility. He/She would like to receive his/her financial statements. During an interview on 3/15/22 at 12:54 P.M., the Accounts Receivable Staff said he/she had not sent out statements for the resident trust fund since November 2021. He/She used to send the statements monthly with the billing statements, but he/she had not had time to send them. During an interview on 3/18/22 at 2:15 P.M., the Administrator said staff were to send statements of the resident trust fund account quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident or his/her designee when the resident's account reached $200 less than the Supplemental Security Income resource limit of $5,000 (prior to [DATE] or $5,035 after [DATE]), for three residents (Residents #18, #226, and #227) who received Medicaid Benefit. The facility failed to refund resident funds within 30 days of discharge for four residents (Residents #55, #61, #219, and #225). The facility failed to provide a final accounting of resident trust fund balances within 30 days to the individual or probate jurisdiction administering the resident's estate for seven residents (Residents #202, #217, #220, #221, #222, #223, and #224). The facility census was 55. 1. Review of the facility's Resident Trust Fund Current Balance Reports showed the following for Resident #226: -The resident's primary pay source was Medicaid; -On [DATE], the resident's balance was $5,338.53; -On [DATE], the resident's balance was $5,405.42; -On [DATE], the resident's balance was $5,472.32; -On [DATE], the resident's balance was $6,939.28; -On [DATE], the resident's balance was $5,477.03; -On [DATE], the resident's balance was $5,543.99; -On [DATE], the resident's balance was $5,613.69; -On [DATE], the resident's balance was $5,680.32; -On [DATE], the resident's balance was $5,736.92; -On [DATE], the resident's balance was $5,813.52; -On [DATE], the resident's balance was $5,880.12; -On [DATE], the resident's balance was $5,896.72; -On [DATE], the resident's balance was $6,033.32. Review showed no documentation the facility notified the resident or his/her designee when the resident's account balance reached $200 less than the Supplemental Security Income resource limit. 2. Review of the facility's Resident Trust Fund Current Balance Report showed the following for Resident #18: -The resident's primary pay source was Medicaid; -On [DATE], the resident's balance was $5,245.81; -On [DATE], the resident's balance was $5,408.41; -On [DATE], the resident's balance was $5,490.81; -On [DATE], the resident's balance was $4,930.01; -On [DATE], the resident's balance was $5,018.41. Review showed no documentation the facility notified the resident or his/her designee when the resident's account balance reached $200 less than the Supplemental Security Income resource limit. 3. Review of the facility's Resident Trust Fund Current Balance Report, showed the following for Resident #227: -The resident's primary pay source was Medicaid; -On [DATE], the resident's balance was $4,883.41; -On [DATE], the resident's balance was $4,945.85. -On [DATE], the resident's balance was $5,068.29. Review of the resident's trust fund ledger/statement showed the resident's balance on [DATE] was $5,178.73. Review showed no documentation the facility notified the resident or his/her designee when the resident's account balance reached $200 less than the Supplemental Security Income resource limit. 4. Review of Resident #220's medical record showed he/she expired on [DATE]. Review of the Resident Trust Fund Current Balance Reports, dated [DATE], [DATE], [DATE], and [DATE], showed the following: -The resident's primary pay source was Hospice; -The resident's balance in the resident trust fund was $25.83. Review of the resident's trust fund ledger/statement showed on [DATE], the resident's beginning balance was $25.83. A check was written to MOHealthNet in the amount of $25.83 to close the resident's account on this date and not within 30 days as required. 5. Review of Resident #221's medical record showed he/she expired on [DATE]. Review of the Resident Trust Fund Current Balance Reports, dated [DATE], [DATE], [DATE], and [DATE], showed the following: -The resident's primary pay source was Medicaid; -The resident's balance in the resident trust fund was $189.02. Review of the resident's trust fund ledger/statement showed on [DATE], the resident's balance was $189.02. A check was written to MOHealthNet in the amount of $189.02 to close the resident's account on this date and not within 30 days as required. 6. Review of Resident #219's medical record showed he/she was discharged from the facility on [DATE]. Review of the Resident Trust Fund Current Balance Reports, dated [DATE], [DATE], and [DATE], showed the following: -The resident's primary pay source was hospice; -The resident's balance in the resident trust fund was $50.01. Review of the resident's trust fund ledger/statement showed on [DATE], the resident's beginning balance was $50.01. A check was written to MOHealthNet in the amount of $50.01 to close the resident's account on this date and not within 30 days as required. 7. Review of Resident #222's medical record showed he/she expired on [DATE]. Review of the Resident Trust Fund Current Balance Reports, dated [DATE], [DATE], [DATE], and [DATE], showed the following: -The resident's primary pay source was private; -The resident's balance in the resident trust fund was $37.15. Review of the resident's trust fund ledger/statement showed on [DATE], the resident's beginning balance was $37.15. A check was written to the resident's estate in the amount of $37.15 to close the resident's account on this date and not within 30 days as required. 8. Review of Resident #223's medical record showed he/she expired on [DATE]. Review of the Resident Trust Fund Current Balance Reports, dated [DATE], [DATE], and [DATE], showed the following: -The resident's primary pay source was private; -The resident's balance in the resident trust fund was $12.00. Review of the resident's trust fund ledger/statement showed on [DATE], the resident's balance was $12.00. A check was written to the resident's family member in the amount of $12.00 to close the resident's account on this date and not within 30 days as required. 9. Review of Resident #224's resident trust fund ledger/statement showed his/her balance on [DATE] was $65.00. Review of the resident's medical record showed he/she expired on [DATE]. Review of the Resident Trust Fund Current Balance Reports, dated [DATE], [DATE], and [DATE], showed the following: -The resident's primary pay source was private; -The resident's balance in the resident trust fund was $65.00. Review showed no evidence the facility refunded the resident's funds to the individual or probate jurisdiction administering the resident's estate after the resident's death on [DATE] and not within 30 days as required. 10. Review of Resident #202's resident trust fund ledger/statement showed on [DATE], his/her balance was $508.05. Review of the resident's medical record showed he/she expired on [DATE]. Review of the Resident Trust Fund Current Balance Report, dated [DATE], showed the following: -The resident's primary pay source was hospice; -The resident's balance in the resident trust fund was $508.05. Review of the resident's trust fund ledger/statement showed on [DATE] his/her balance was $508.05. Review showed no evidence the facility refunded the resident's funds after the resident's death on [DATE] and not within 30 days as required. 11. Review of Resident #217's resident trust fund ledger/statement showed on [DATE], his/her balance was $12.00. Review of the resident's medical record showed he/she expired on [DATE]. Review of the Resident Trust Fund Current Balance Report, dated [DATE], showed the following: -The resident's primary pay source was private; -The resident's balance in the resident trust fund was $12.00. Review of the resident's trust fund ledger/statement showed on [DATE], his/her balance was $12.00 Review showed no evidence the facility refunded the resident's funds to the individual or probate jurisdiction administering the resident's estate after the resident's death on [DATE] and not within 30 days as required. 12. Review of Resident #55's resident trust fund ledger/statement showed his/her balance on [DATE] was $12.00. Review of the resident's medical record showed he/she was discharged from the facility on [DATE]. Review of the Resident Trust Fund Current Balance Reports, dated [DATE], [DATE], and [DATE], showed the resident's balance in the resident trust fund was $12.00. Review of the resident's trust fund ledger/statement showed on [DATE], the resident's beginning balance was $12.00. A check was written to the resident in the amount of $12.00 to close the resident's account on this date and not within 30 days as required 13. Review of Resident #225's medical record showed his/her balance on [DATE] was $16.00. Review of the resident's medical record showed he/she was discharged from the facility on [DATE]. Review of the Resident Trust Fund Current Balance Reports, dated [DATE], [DATE], and [DATE], showed the resident's balance in the resident trust fund was $16.00. Review of the resident's trust fund ledger/statement showed the resident's balance on [DATE] was $16.00. Review showed no evidence the facility refunded the resident's funds after the resident's discharge from the facility on on [DATE] and not within 30 days as required. 14. Review of Resident #61's resident trust fund ledger/statement showed the following: -On [DATE], the resident's balance was $1539.80; -On [DATE], a deposit in the amount of $1,000 (description showed this was a transfer from bank). The resident's balance was $2,523.80; Review of the resident's medical record showed he/she was discharged on [DATE]. Review of the resident's trust fund ledger/statement showed the following: -On [DATE], the resident's balance was $2,523.93. -Review showed no deposits or withdrawals from the resident's trust fund between [DATE] and [DATE] (over one year). -On [DATE], a deposit in the amount of $1,000 (description showed receipt from other). The resident's balance was $3,523.93; -On [DATE], a deposit in the amount of $1,000 (description showed this was a transfer from bank). The resident's balance was $4,523.93; -On [DATE], a deposit in the amount of $1,000 (description showed this was a transfer from bank). The resident's balance was $5,523.93; -On [DATE], a withdrawal (the description showed a check was written to the resident to close his/her account; the resident moved to another facility) in the amount of $4,523.93. The resident's remaining balance was $1,000; -On [DATE], a deposit in the amount of $1,000 (description showed this was a transfer from bank). The resident's balance was $2,000; -On [DATE], a deposit in the amount of $1,000 (description showed this was a bank transfer). The resident's balance was $3,000; -On [DATE], a withdrawal (the description showed a check was written to the resident to close his/her account; the resident transferred to another facility) in the amount of $3,000. The resident's remaining balance was $0.00. 15. During interviews on [DATE] at 2:30 P.M., on [DATE] at 12:54 P.M., and on [DATE] at 8:15 A.M., the Accounts Receivable Staff said the following: -He/She had not received training on how to manage the resident trust fund, and had never seen any facility policies regarding the resident trust fund; -Residents #226 and #227 were their own responsible party, and Resident #18's family member was the resident's power of attorney (POA); -He/She did not provide written notice to Resident #226, #227 or to Resident #18's POA or document conversations regarding purchase of items when the residents were within $200 of the SSI resource limit. He/She did not know he/she was supposed to provide written notice or maintain documentation; -In [DATE], he/she knew there were several deceased residents who received Medicaid who had funds in the resident trust fund account. He/She sent their remaining funds in one lump sum to MoHealthNet; -He/She was not aware of the timeframe requirements to return funds upon death and discharge at that time; -The funds belonging to Residents #224, #202, #217, #225, and #50 had not yet been refunded. He/She had not had the time; -Resident #61 was discharged in 2020 and went to another facility. While a resident, he/she had set it up with his/her bank to have $1000 direct deposited into the resident trust fund account each month for his/her surplus. The $1000 was deposited for several months after the resident was discharged . Accounts Receivable Staff posted the $1000 each month to the resident's account to keep track of the funds. He/She refunded the money to the resident; -He/She tried to send the remaining funds to discharged residents within seven days, but he/she wasn't able to get that done due to his/her workload. During an interview on [DATE] at 2:15 P.M., the Administrator said the following: -She was aware remaining funds for Medicaid residents were to be refunded within 30 days. The Accounts Receivable Staff was responsible for this. She was not sure why the funds were not refunded within the required timeframes. -The social services staff and Accounts Receivable Staff discussed residents who were within $200 less of the SSI resource limit. The social services staff contacted the residents/families to discuss, however she was not sure they provided written notice.

Based on interview and record review, the facility failed to maintain a surety bond sufficient (an amount equal to at least one and one half times the average monthly balance of the residents' personal funds) to ensure protection of the resident funds. The facility census was 55. Record review of the facility's resident trust fund reconciled bank statement for the period of January 2021 through December 2021 showed an average monthly balance of $42,709.45. Calculation showed the facility required a bond amount of at least amount $64,500.00. (The facility was unable to provide a monthly accounting of the money maintained in the resident petty cash to include in the calculation.) Record review of the facility's current surety bond showed the facility held a bond in the amount of $20,000.00. During an interview on 3/18/22 at 2:00 P.M., the Accounts Payable Staff said the individual in his/her position prior to his/her employment was responsible for ensuring the surety bond was sufficient, however he/she was not made aware if this was his/her responsibility. He/She had not evaluated the resident trust to ensure the surety bond was sufficient prior to the survey. During an interview on 3/18/22 at 2:15 P.M., the Administrator said the individual who was responsible for ensuring the bond was sufficient left employment at the facility in July/August 2021.

**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 odor free environment by failing to ensure flooring and walls in resident rooms, furnishings, hallways, ceiling vents, and common areas were clean and in good repair. The facility census was 55. Review of the facility policy, Homelike Environment, revised February 2021, showed the following: -Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; -The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The characteristics include: a. clean, sanitary, and orderly environment; b. inviting colors and decor; c. personalized furniture and room arrangements; d. clean bed and bath linens that are in good condition; e. pleasant, neutral scents. 1. Observation on 02/14/22 between 10:05 A.M. and 4:45 P.M., during the life safety code tour of the facility, showed the following: -In the back dining area, a 12 inch by 12 inch ceiling vent was covered in a thick layer of dust; -In the beauty shop, a 12 inch by 12 inch ceiling vent was covered with a thick layer of dust; -In the back nurse's station, two 12 inch by 12 inch ceiling vents were covered with a thick layer of dust; -In the back bathroom by the nurse's station, a 4 inch by 4 inch ceiling vent was covered with a thick layer of dust; -In resident room [ROOM NUMBER], a 4 inch by 6 inch ceiling vent was covered with a thick layer of dust; -In resident room [ROOM NUMBER], a 4 inch by 6 inch ceiling vent was covered with a thick layer of dust; -In the front bathroom by the nurse's station, a 4 inch by 4 inch ceiling vent was covered with a thick layer of dust; -In the 200 hallway, an 18 inch by 18 inch ceiling vent was covered with a thick layer of dust; -In the special care unit shower, a 12 inch by 12 inch ceiling vent was covered with a thick layer of dust; -In the special care nurse's station, a 12 inch by 12 inch ceiling vent was covered with a thick layer of dust; -In the 100 hallway, three 12 inch by 12 inch ceiling vents were covered with a thick layer of dust; -In the hallway by the kitchen and laundry area, an 18 inch by 18 inch and two 12 inch by 12 inch ceiling vents were covered with a thick layer of dust. Observation in the kitchen area on 02/15/22 between 8:15 A.M. and 11:10 A.M., during the life safety code tour of the facility, showed 4 inch by 6 inch and a 4 inch by 4 inch ceiling vents were covered with a thick layer of dust. Observation on 2/14/22 to 2/16/22 showed the following: -room [ROOM NUMBER]- multiple areas on the door frame with paint missing as well as scuffs with paint missing on the bottom of the entry door; -room [ROOM NUMBER]- multiple scuffs with paint missing on the door, multiple areas of scuffed paint on the wall near the floor throughout the room, entry door frame scuffed up and missing paint; -room [ROOM NUMBER]- multiple paint scuffs on bathroom door and bedroom door with paint missing, wall behind door missing a chunk of the wall exposing the drywall, large amounts of paint gone above the trim by bathroom door, wall scarred by heater, heater scraped up and missing paint, dresser missing stain and scuffed around edges, doorframe scuffed with paint missing; -room [ROOM NUMBER]- bathroom and entry doors scuffed with paint missing, areas on wall missing paint behind the beds, both door frames scuffed up with missing paint; -room [ROOM NUMBER]- telephone wire running down wall with no cover on the phone box, wall scuffed up near the floor throughout the room, bathroom door scuffed and missing paint, entry door frame scuffed up and missing paint, bed 1 and 2 dresser scuffed exposing wood beneath the finish, white baseboard trim scuffed up throughout the room; -room [ROOM NUMBER]- door frame scuffed with paint missing, and the entry door with scratches; -room [ROOM NUMBER]- door frame scuffed with paint missing, and the entry door with scratches. Observation on 2/14/22 at 3:15 P.M., of the special care unit (SCU) showed the following: -room [ROOM NUMBER]- the sink countertop edge with chipped laminate exposing wood layer. The resident's door handle was loose and rubbed area on door exposing wood layer. Dark gray debris build up along the corners, floor and baseboards; -room [ROOM NUMBER]- floor tiles with dull finish. Dark streaked scuff marks, paint missing and exposing drywall on the walls. Cabinetry with worn finish. Privacy curtain with brown stain. Bathroom door jamb with chipped paint exposing the metal. Sink with broken stopper. Matted dark gray debris build up along the corners, floor, and baseboards; -room [ROOM NUMBER]- cabinetry with worn finish, drawers did not track or close. Dark gray debris build up along the corners, floor and baseboards; -room [ROOM NUMBER]- the sink countertop edge with chipped laminate exposing wood layer. Floor tiles with dull finish. Matted dark gray debris build up along the corners, floor, and baseboards. The walls with dark streaked scuff marks and paint missing exposing drywall. Cabinetry with worn finish, drawers did not track or close. Privacy curtain with brown stain. Ventilation cover not covering hole in wall and exposing drywall; -room [ROOM NUMBER]- floor tiles with dull finish. Matted dark gray debris build up along the corners, floor and baseboards. Scuffed marks on the walls; -room [ROOM NUMBER]- the sink countertop edge with chipped laminate exposing wood layer. Floor tiles with dull finish. Matted dark gray debris build up along the corners, floor, and baseboards. Dark streaked scuff marks on the walls. The toilet bowl was stained, missing screw cover where the safety hand rails attach to toilet. Ventilation cover not covering hole in the wall and exposed the drywall; -room [ROOM NUMBER]- the sink countertop edge with chipped laminate exposing wood layer. Matted dark gray debris build up along the corners, floor, and baseboards; -room [ROOM NUMBER]- floor tiles with dull finish. Matted dark gray debris build up along the corners, floor, and baseboards. Dark scuffed marks on the walls. Cabinetry with worn finish. Privacy curtain with brown stain; -room [ROOM NUMBER]- the sink countertop edge with chipped laminate exposing wood layer. Floor tiles with dull finish. Matted dark gray debris build up along the corners, floor, and baseboards. Dark streaked scuff marks on the walls. Ventilation cover did not cover a hole in the wall that exposed drywall. The room was occupied by a resident and had a strong urine odor; -room [ROOM NUMBER]- floor tiles with dull finish. Matted dark gray debris build up along the corners, floor, and baseboards. Dark streaked scuff on the walls; -The door frames to the resident rooms had missing paint and dark streaked scuff marks. Observation on 2/14/22 at 11:45 A.M. showed the brown recliner in the dining room/common area had a worn finish on both armrests, exposing the padding under the fabric covering. Observation on 2/14/22 at 11:55 A.M. of occupied resident room [ROOM NUMBER] showed a strong urine odor. room [ROOM NUMBER] was located immediately to the right of the SCU entrance doors. Observation on 2/15/22 at 11:46 A.M., showed the floor outside room [ROOM NUMBER] had drag marks from the fire doors on the hallway floor. Observation on 2/16/22 at 5:25 A.M., of the SCU showed a strong urine odor throughout the unit. Observation on 2/22/22 at 10:10 A.M., of the SCU showed a strong urine odor throughout the unit. During an interview on 3/2/22 at 11:09 A.M., CMT R said the following: - SCU resident rooms are supposed to be cleaned every day, but with call-ins housekeeping does the best they can - Nursing staff mop floors and tidy rooms as needed, especially for the resident in room [ROOM NUMBER] who frequently urinates in the trash can. During an interview on 3/22/22 at 9:17 A.M., the Accounts Payable Staff said the following: -The maintenance staff were aware of work orders for SCU; -The maintenance supervisor was working on repairs in SCU; -The administrator or accounts payable staff order supplies needed for repairs or the maintenance staff can pick up supplies at the local hardware store. During an interview on 3/2/22 at 11:13 A.M., the Housekeeping/Dietary/Laundry Supervisor said the following: - She would expect housekeeping staff to clean SCU resident rooms daily; - She would expect privacy curtains to be washed when soiled During an interview on 3/2/22 at 2:10 P.M., Floor Maintenance Staff said the following: -The floors currently need to be stripped and waxed; -The facility had a floor machine, but it does not do a good job; -The facility did not have it in the budget to purchase wax for the floors. During interviews on 2/15/22 at 3:50 P.M. and on 3/15/22 at 12:20 P.M., the Maintenance Supervisor said the following: -Maintenance staff was responsible for cleaning the ceiling vents. He was not aware of the ones found during the inspection. The ceiling vents are not on a monitoring schedule. -Repairs needed are filled out on a maintenance request form and placed in maintenance mailbox; -The needed repairs are then triaged and get completed typically within three days; -A repair could take longer if supplies are not available, but then completed within three days after supplies available; -The entire building gets painted two times a year and as the need arises; -Scuffed door frames, doors, residents walls, and base boards can be painted more often than twice a year when they are aware of the need. During interviews on 2/15/22 at 4:15 P.M. and on 3/15/22 at 11:33 A.M., the administrator said the following: -She expected the ceiling vents to be clean and dust free; -She would expect repairs to be completed within three days, as long as supplies are available. If supplies were unavailable within three days she expected the repair to be completed as soon as supplies were available; -She would expect maintenance to check the resident rooms monthly for painting and repair as needed and completed within a couple of weeks; -She would expect maintenance to check the units monthly for painting and repair as needed and complete within a couple of weeks; -She would expect maintenance to do a monthly walk through of the entire facility to assess needed repairs and repairs complete within a couple of weeks; -She would expect a monthly walk through of the entire facility to assess needed cleaning/painting and scuffed areas on the door frames/doors/walls and repairs complete within a couple of weeks; -She would expect the baseboards and corners of floors deep cleaned weekly by housekeeping to remove build-up of dirt and cleaned daily; -She would expect hallway floors swept and mopped twice daily by housekeeping and buffed with the buffer weekly by maintenance; -She would expect the resident rooms swept and mopped daily by housekeeping and the floors buffed by maintenance when a resident was not in the room, and when a room turned over and deep cleaned; -She would expect housekeeping or nursing (if no housekeeping) take out the trash at least three times a day to managing odors on the SCU; -She would expect housekeeping to clean the SCU if there is a strong smell of urine; if housekeeping is unavailable the charge nurse can access the cleaning supplies and nursing staff can clean and try to make the smell better; -She would expect housekeeping to clean the SCU three times a day; -She would expect SCU nursing staff to tidy up resident rooms and spot mop the floors. MO00170735 MO00171180 MO00172908

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident representative when four residents (Resident #2, #28, #42 and #48), in a review of 19 sampled residents, were transferred to the hospital. The facility census was 55. 1. During an interview on 2/16/22 at 4:25 P.M., the administrator said the facility did not have a policy regarding discharge notices for facility-initiated discharges. 2. Review of Resident #2's face sheet showed his/her admission to the facility on 1/13/21. Review of the resident's nurses notes, dated 1/11/22, showed the following: -The resident was being assisted by staff to stand and pull up his/her pants when he/she went limp, eyes rolled back in his/her head, and he/she stopped breathing; -Staff administered sternal rub and the resident started breathing again; -Upon assessment, breathing found to be labored with accessory muscle use; -Orders received to sent to the hospital via ambulance. Review of the resident's nurses noted, dated 1/26/22, showed the following: -While walking down the hall staff heard a crash then whimpering, upon entering the resident's room, found the resident on floor in front of the bed laying on his/her abdomen; -Resident complained of pain all over, denied hitting his/her head; -Resident assisted by two staff to lay on his/her back, was able to move both arms and legs; -Resident then assisted to stand to get into bed when he/she started to holler out that his/her right hip was hurting; -Orders received to sent to hospital via ambulance. Review of the resident's medical record showed no evidence facility staff provided written notice to the resident and/or his/her responsible party of the resident's transfers to the hospital on 1/11/22 and 1/26/22. 3. Review of Resident #28's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's nurses note, dated 11/14/21, showed the following: -At 8:25 A.M., the physician was updated about increase in bleeding; -Received order to send to the emergency room (ER) for evaluation and treatment. Review of the resident's discharge MDS, dated [DATE], showed the resident was discharged to an acute hospital. Review of the resident's medical record showed no evidence facility staff provided written notice to the resident and/or his/her responsible party of the resident's transfer to the hospital on [DATE]. 4. Review of Resident #42's face sheet, showed the resident was admitted to the facility on [DATE]. Review of the resident's nurses notes, dated 10/23/21, showed the following: -On assessment resident appears lethargic, not responding to staff communication; -Family here and resident not responding to them; -Received orders to send the resident to the ER. Review of the resident's discharge MDS, dated [DATE], showed the resident was discharged to an acute care hospital. Review of the resident's nurses notes, dated 12/06/21, showed the following: -Physician called as resident has high blood pressure, would look at staff but not answer, eyes glassy; -Gave order to send to ER; -Resident was admitted to the medical/surgical unit at the hospital. Review of the resident's discharge MDS, dated [DATE], showed the resident was discharged to an acute care hospital. Review of the resident's medical record showed no evidence facility staff provided written notice to the resident and/or his/her responsible party of the resident's transfers to the hospital on [DATE] and 12/6/21. 5. Review of Resident #48's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's nurses notes, dated 1/3/22, showed the following: -Resident leaning to the left and mouth drawn to the left; -Non responsive to verbal or tactile stimuli; -Resident would not open his/her eyes like he/she usually would; -Orders received to send resident to the ER. Review of the resident's discharge MDS, dated [DATE], showed the resident was discharged to the hospital on 1/3/22. Review of the resident's medical record showed no evidence facility staff provided written notice to the resident and/or his/her responsible party of the resident's transfer to the hospital on 1/3/22. 6. During an interview on 2/16/22 at 4:10 P.M., Licensed Practical Nurse (LPN) A said the following; -If the physician orders the resident to be sent to the hospital, the charge nurse contacts the resident's emergency contact to notify them, fills out a transfer sheet (resident information for the hospital and ambulance staff), prepares resident records needed by the ambulance and hospital, calls for the ambulance, and the hospital is called with a report; -He/She does not give the resident or resident representative a written notice of transfer or discharge; -He/She did not know if the resident or resident representative receives a written notice of transfer or discharge from anyone. During an interview on 2/16/22 at 4:25 P.M., the Director of Nursing (DON) said the following: -The facility does not give a written transfer or discharge notice to the resident or resident representative upon facility initiated discharges; -The facility does not have a policy for written transfer or discharge notices; -The facility staff did not know it was a requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative for four residents (Resident #2, #28, #42, and #48) in a review of 19 sampled residents, when the facility initiated a transfer to the hospital. The facility census was 55. Review of the undated facility policy Bed Hold showed the following: -If facility beds are 95% occupied, there will be a bed hold charge and the resident will be billed the daily rate to reserve the same bed; -If occupancy is under 95% there will be no charge to hold the bed and it will be available when the resident returns; -All residents regardless of pay source will be treated equally. 1. Review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's census report showed the following: -On 1/11/22 the resident was transferred to the hospital and was readmitted to the facility on [DATE]; -On 1/26/22 the resident was transferred to the hospital and was readmitted to the facility on [DATE]. Review of the resident's medical record showed no evidence the resident and/or resident representative was informed in writing of the facility's bed hold agreement at the time of transfer on 1/11/22 or 1/26/22 that included: -The duration of the state bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility; -The reserve bed payment policy; -The nursing facility's policies regarding bed-hold periods; -Permitting a resident to return. During an interview on 3/8/22 at 12:22 P.M., the resident representative said he/she was not informed in writing of the facility bed hold policy at the time of the resident's transfers to the hospital on 1/11/22 or 1/26/22. 2. Review of Resident #28's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's nurses note, dated 11/14/21, showed the following: -Received order to send to the emergency room (ER) for evaluation and treatment due to increased bleeding. Review of the resident's discharge MDS, dated [DATE], showed the resident was discharged to an acute hospital. Review of the resident's medical record showed no evidence the resident and/or resident representative was informed in writing of the facility's bed hold agreement at the time of transfer that included: -The duration of the state bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility; -The reserve bed payment policy; -The nursing facility's policies regarding bed-hold periods; -Permitting a resident to return. 3. Review of Resident #42's face sheet, showed the resident was admitted to the facility on [DATE]. Review of the resident's nurses notes, dated 10/23/21, showed the following: -Orders to send the resident to the ER; -Resident discharged to the hospital. Review of the resident's discharge MDS, dated [DATE], showed the resident was discharged to an acute care hospital. Review of the resident's nurses notes, dated 10/25/21, showed the resident readmitted to the facility. Review of the resident's nurses notes, dated 12/06/21, showed the following: -Order to send to ER; -Resident was admitted to the medical/surgical unit at the hospital. Review of the resident's discharge MDS, dated [DATE], showed the resident was discharged to an acute care hospital. Review of the resident's medical record showed no evidence the resident and/or resident representative was informed in writing of the facility's bed hold agreement at the time of transfer (for the 10/23/21 or the 12/6/21 discharge) that included: -The duration of the state bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility; -The reserve bed payment policy; -The nursing facility's policies regarding bed-hold periods; -Permitting a resident to return. 4. Review of the Resident #48's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's nurses notes, dated 1/3/22, showed the following: -Orders received to send resident to the ER. Review of the resident's discharge MDS, dated [DATE], showed the resident discharged to the acute hospital on 1/3/22. Review of the resident's medical record showed no evidence the resident and/or resident representative was informed in writing of the facility's bed hold agreement at the time of transfer that included: -The duration of the state bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility; -The reserve bed payment policy; -The facility's policies regarding bed-hold periods; -Permitting a resident to return. 5. During an interview on 2/16/22 at 4:10 P.M., Licensed Practical Nurse (LPN) A said the following; -If the physician orders the resident to be sent to the hospital, the charge nurse contacts the resident's emergency contact to notify them, fills out a transfer sheet (resident information for the hospital and ambulance staff), prepares resident records needed by the ambulance and hospital, calls for the ambulance, and the hospital is called with a report; -He/She does not give the resident or resident representative a written notice about a bed hold; -He/She does not know if the resident or resident representative gets a written notice about a bed hold from anyone. During an interview on 2/16/22 at 4:25 P.M., the Director of Nursing (DON) said the following: -He/She has confirmed with the Administrator and Social Services the facility does not give a written bed hold notice to the resident or resident representative upon facility initiated discharges; -The resident or resident representative is given the policy in their admission packet to the facility, but not with every discharge. During an interview on 2/16/22 at 12:30 P.M., the administrator said the following: -The facility has a bed hold policy; -If greater than 95% occupancy there is a bed hold charge and resident or resident representative is notified; -If less than 95% occupancy there is no bed hold charge, and resident will be accepted on return; -She did not know written notice had to be given with each discharge; -Residents and family receive the bed hold policy on admission but not with every discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete comprehensive assessments timely for one resident (Resident #207) in a review of 19 sampled residents and for three additional residents (Residents #306, #208, and #355). The facility census was 55. Review of the facility policy, Comprehensive Assessments and the Care Delivery Process, revised December 2016, showed the following: -Comprehensive assessments will be conducted to assist in developing person-centered care plans; -Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions; -Comprehensive assessments are conducted and coordinated by a registered nurse (RN) with appropriate participation of other health professionals; -These assessments are used to develop, review, and revise the resident's comprehensive care plan. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.17.1, revised October 2019, showed the following: -The Omnibus Budget Reconciliation Act (OBRA) required comprehensive assessments include the completion of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning; -Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status had occurred or a significant correction to a prior comprehensive assessment is required; -The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident's first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge; -The MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) completion date, but not later than. 1. Review of Resident #207's electronic medical record showed the following: -The resident was admitted to the facility on [DATE]; -The admission MDS showed a completion date of 2/15/22 (21 days after admission). 2. Review of Resident #306's electronic medical record showed the following: -The resident was admitted to the facility on [DATE]; -The facility had not completed an admission assessment for the resident (26 days since the resident's admission); -The facility failed to complete the resident's MDS admission assessment by the 14th day after admission. 3. Review of Resident #208's electronic medical record showed the following: -The resident was admitted to the facility on [DATE]; -The admission MDS showed a completion date of 2/15/22 (19 days after admission). 4. Review of Resident #355's electronic medical record showed the following: -The resident was admitted to the facility on [DATE]; -The facility had not completed an admission assessment for the resident (21 days since the resident's admission); -The facility failed to complete the resident's MDS admission assessment by the end of the 14th following admission. 5. During an interview on 02/14/22 at 11:37 A.M. and 2/24/22 at 10:28 A.M., the MDS coordinator said the following: -She had not had formal training on MDS completion; -She did not know what the RAI manual was; -There were 11 residents that have not had their MDS assessments completed, because she was behind. She doesn't have enough time, because she does all of the COVID-19 testing for the facility and other tasks that have been delegated to her; -She was responsible for completing the MDS and the Registered Nurse signs them. During an interview on 2/25/22 at 8:30 A.M., the Director of Nursing (DON) said the MDS coordinator should follow the RAI manual for completion of all MDS assessments. During an interview on 2/25/22 at 8:30 A.M., the administrator said MDS assessments should be completed when required by the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for three residents (Residents #11, #43 and #48), in a review of 19 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 55. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Shows consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of activities of daily living (ADL) decline or improvement); -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision of the care plan; -When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met; -If a significant change in status is identified in the process of completing any OBRA (Omnibus Budget Reconciliation Act of 1987) assessment except admission and SCSAs, code and complete the assessment as a comprehensive SCSA instead. Review of the facility policy, Change in a Resident's Condition or Status, revised May 2017, showed if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. 1. Review of Resident #11's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Minimal signs and symptoms of depression; -Limited physical assistance of one staff member for eating; -Extensive physical assistance of two or more staff members for bed mobility, transfers, and toilet use; -No signs or symptoms of pain; -No swallowing issues; -Antidepressant medication daily; -No oxygen use. Review of the resident's 5-day MDS (Medicare-required assessment), dated 10/20/21, showed the following: -Severe cognitive impairment; -Moderate signs and symptoms of depression; -Dependent on staff for transfers, eating, and toilet use; -Possible indicators of pain present, facial expressions and protective body movements daily; -Signs and symptoms of possible swallowing disorder: loss of liquids/solids from mouth when eating or drinking present, holding food in mouth/cheeks or residual food in mouth after meals present, coughing or choking during meals or when swallowing medications present, complaints of difficulty or pain with swallowing present; -No antidepressant medication; -Oxygen use. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Mild signs and symptoms of depression; -Extensive physical assistance of two or more staff for bed mobility; -Dependent on staff for transfers, eating, and toilet use; -Possible indicators of pain present, facial expressions and protective body movements daily; --Signs and symptoms of possible swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals present, coughing or choking during meals or when swallowing medications present, complaints of difficulty or pain with swallowing present; -No antidepressant medication; -Oxygen use. Review of the resident's medical record showed no evidence staff completed a significant change in status MDS after changes in the resident's conditions and abilities were assessed on the 10/20/21 5-day assessment, nor on the annual assessment. The facility did not complete a significant change in status assessment when the resident had new changes in cognitive abilities, decrease in ability to perform transfers, eating, and toilet use, displayed new signs and symptoms of depression while his/her antidepressant medication had been discontinued, new signs and symptoms of pain, new swallowing issues, and new oxygen use. 2. Review of Resident #48's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent on staff for bed mobility, transfers locomotion on and off the unit, eating, toilet use, hygiene, and bathing; -No signs of pain observed; -No swallowing issues; -No oxygen therapy. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Staff pain assessment showed facial expressions showed signs of pain, daily; -New, signs and symptoms of possible swallowing disorder: loss of liquids/solids from mouth when eating or drinking present, holding food in mouth/cheeks or residual food in mouth after meals present, coughing or choking during meals or when swallowing medications present, complaints of difficulty or pain with swallowing present; -New oxygen use. Review of the resident's medical record showed no evidence the staff completed a significant change in status MDS. The facility did not complete a significant change in status assessment when the resident had new signs of pain, new signs and symptoms of a swallowing disorder, and new oxygen as assessed on the 12/31/21 MDS. Review of the resident's Nurses Notes, dated 1/3/22, showed the resident discharged to the hospital. Review of the resident's Nurses Notes, dated 1/11/22, showed the following: -Returned from the hospital on 1/10/22; -Diagnosis hematuria (blood in the urine); -Resident had an urinary indwelling catheter draining dark blood at this time; -Noted to have two pressure ulcers on the resident's coccyx (tailbone) that first measures: 6.5 centimeters (cm) in length x 1.5 cm in width, the second measures 2 cm in length x 1 cm in width. Observation of the resident on 2/16/22 at 1:00 P.M., showed the following: -The resident in his/her bed with oxygen on at two liters, and a urinary indwelling catheter present; -Certified Nurse Assistant (CNA) K and the Activity Director provided care for the resident; -Dressing intact to the coccyx; -The resident grimaced in pain when turned or legs moved. Review of the resident's medical record showed no evidence staff completed a significant change in status MDS. The facility did not complete a significant change in status assessment when the resident continued to have signs of pain, symptoms of a swallowing disorder, oxygen use, and returned from the hospital on 1/10/22 with new indwelling urinary catheter and two new pressure ulcers as assessed in the nurse's notes and as observed. 3. Review of Resident 43's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required limited physical assistance of one staff member with bed mobility; -Required extensive physical assistance of two or more staff members for transfers, toilet use; -Limited range of motion in one lower extremity. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive physical assistance of one staff members bed mobility; -Dependent on staff for transfers, and toilet use; -Limited range of motion in both lower extremities. Review of the resident's medical record showed no evidence that staff completed a significant change in status MDS. The facility did not complete a significant change in status assessment when the resident had new changes in cognitive abilities, decrease in ability to perform bed mobility, transfers and toilet use, and limited range of motion in a second lower extremity as identified on the quarterly assessment dated [DATE]. Review of the resident's annual MDS, dated [DATE], showed the following -Cognitively intact; -No signs or symptoms of depression. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Mild depression. Review of the resident's medical record showed no evidence the staff completed a significant change in status MDS. The facility did not complete a significant change in status assessment when the resident had new changes in cognitive abilities, and new signs of depression as assessed in the MDS dated [DATE].4. 4. During an interview on 2/15/22 at 12:05 P.M., the MDS coordinator said the following: -He/She was responsible for completing the MDS process for all residents; -He/She completes a SCSA if there is a big change in a resident's condition, or if the resident starts on hospice; -He/She does not know how many areas or how many changes have to occur before a SCSA was required; -He/She has not had formal MDS training, had informal training at his/her last job; -He/She does not know about the RAI manual or if there was any manual on how to complete the MDS. During an interview on 2/25/22 at 8:30 A.M., the Director of Nursing (DON) said the following: -The MDS coordinator should follow RAI manual for completion of all MDS assessments; -A SCSA should be completed if the resident has two or more changes such as significant weight loss, functional ability decline, a fall with a fracture, or anything from baseline was a significant change. During an interview on 2/25/22 at 8:30 A.M., the administrator said a SCSA should be completed when required by the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs and risks to provide effective person-centered care that met professional standards of quality care, within 48 hours of admission to the facility for one resident (Resident #207) in a review of 19 sampled residents, one closed record review (Resident #55), and one additional resident (Resident #208). The facility census was 55. Review of the facility's Baseline Care Plan Policy, revised December 2016, showed the following: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; -The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; f. Preadmission Screening and Resident Review (PASARR) recommendation, if applicable; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; d. Any updated information based on the details of the comprehensive care plan, as necessary. 1. Review of Resident #55's face sheet showed the following: -The resident admitted to the facility on [DATE]; -The resident's diagnoses included: heart failure (a condition that affects the pumping power of the heart muscle), Type II diabetes with diabetic autonomic polyneuropathy ([NAME]) (diabetes is a chronic condition that affects the way the body processes blood sugar and [NAME] is a complication of diabetes that can affect many organ systems such as the gastrointestinal, genitourinary and cardiovascular systems), constipation, pain, benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland that can cause urination difficulty), and cerebral infarction (disrupted blood flow to the brain due to the blood vessels that supply it) due to thrombosis (a blood clot that forms inside your veins or arteries) of the right carotid artery (vessels in the neck that carry blood from the heart to the brain). Review of the resident's progress notes, dated 8/13/21 at 2:40 P.M., showed the following notes taken by facility staff from the referring facility: -The resident was forgetful and confused; -The resident was difficult to transfer and would need to be transferred with a hoyer lift (a mobility device used to transfer residents from place to place); -The resident had a urinary catheter (a tube inserted into the bladder to drain urine). Review of the resident's progress notes, dated 8/13/21 at 5:48 P.M., showed the following: -The resident arrived to the facility at 10:30 A.M.; -The resident was transferred to his/her recliner with a mechanical lift; -The resident was alert to place, day of the week, month, and year; -The resident could not answer questions regarding his/her health and would tell staff to ask his/her family; -The resident had a patent urinary catheter; -The resident fed self after tray set up. Review of the resident's closed record showed it did not contain a baseline care plan to meet the resident's immediate needs completed within 48 hours of facility admission. 2. Review of Resident #207's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included fracture of lumbosacral spine and pelvis (a broken bone in the lower spine and pelvic region), chronic congestive heart failure (a progressive condition that affects the pumping power of the heart muscle), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). Review of the resident's progress notes, dated 1/27/22 at 1:08 A.M., showed the following: -At 6:30 P.M., the resident arrived at the facility by ambulance; -Full code (cardiopulmonary resuscitation to begin if heart stops beating); -Alert and oriented; -Up with assist; -Lungs clear and on oxygen at two liters per minute by nasal cannula; -Dressing to sacral area (tailbone) intact; -Wore glasses; -Unable to do activities of daily living (ADLs); -Had apparatus in left arm to monitor blood sugars. Review of the resident's medical record showed it did not contain a baseline care plan to meet the resident's immediate needs completed within 48 hours of facility admission. 3. Review of Resident #208's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included diabetes mellitus, anxiety disorder, hypertension, and Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors). Review of the resident's progress notes, dated 1/28/22 at 5:55 P.M., showed the following: -Resident came from hospital around 3:15 P.M. in a wheelchair; -Therapy evaluated him/her and he/she was able to walk 92 feet with a walker; -He/She expected to go home; -He/She had no glasses or hearing aids, does have upper and lower teeth. Review of the resident's medical record showed it did not contain a baseline care plan to meet the resident's immediate needs completed within 48 hours of facility admission. 4. During an interview on 2/23/22 at 6:06 P.M., Licensed Practical Nurse (LPN) D said he/she did not know who was responsible for baseline care plans. During an interview on 2/24/22 at 10:28 A.M., the Minimum Data Set (MDS) coordinator said the baseline care plan should be completed by the admitting nurse the day of admission. During an interview on 2/25/22 at 8:30 A.M., the Director of Nursing said baseline care plans should be done within 24 hours of admission and are completed by nursing. During an interview on 2/25/22 at 8:30 A.M., the administrator said the facility has had new staff in the last six months and they were still learning how to do care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for three residents (Resident #2, #28, and #41), in a review of 19 sampled residents. The facility census was 55. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; 3-The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the IDT a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Reviews and revises the current care plan. 1. Review of the Resident #2's face sheet showed the resident's diagnoses include: fracture right femur, acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), history of urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), vascular dementia without behavioral disturbance (brain damage cause by multiple stroke; causes memory loss in older adults), major depressive disorder (a persistent feeling of sadness or loss of interest that can lead to behavioral or physical symptoms), Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (high blood pressure). Review of the resident's progress notes, dated 1/26/22, showed the resident had a fall that resulted in hospitalization related to a fractured hip. Review of the resident's February 2022 ancillary orders showed the following: -On 2/1/22 orders were written to record urinary catheter (a tube inserted into the bladder to drain urine) output each shift, and to change catheter leg bag once weekly on Tuesday; -On 2/3/22 an order was written to apply skin prep to coccyx (tailbone) and apply bordered foam dressing for protection daily and as needed if becomes soiled. Review of the resident's significant change MDS, a federally required assessment instrument completed by facility staff, dated 2/8/22, showed the following: -Severe cognitive impairment; -No behavior issues or rejection of care; -Limited assistance of one staff member for bed mobility, eating, and bathing; -Extensive assistance of one staff member for hygiene and dressing; -Extensive assistance of two staff members for transfers, walking, and toileting; -Total dependence of one staff member for locomotion on and off the unit; -Urinary catheter present; -One fall with major injury (fracture) since prior assessment; -One fall with injury since prior assessment. Review of the resident's care plan, last revised on, 2/15/22, showed the following: -Resident required assistance with activities of daily living (ADL's); -Potential for injury related to history of falls; -Fell on 1/23/22 with intervention to ensure call light was attached to clothing and to educate resident to call for assistance, physical therapy to evaluate, staff to ensure resident was on a toileting program; -At risk for skin breakdown related to decreased mobility, incontinence, edema, anemia or malnourishment; -Full skin assessment weekly on Tuesday; -No documentation of a fall with fracture on 1/26/22. -No documentation regarding the new orders received on 2/1/22 and 2/3/22 to record output each shift or apply a dressing to the resident's coccyx. Review of the resident's February 2022 ancillary orders showed the following: -On 2/18/22 an order was written to apply skin prep to heels and follow with bordered foam, change daily and as needed; -On 2/23/22 an order was written to change urinary catheter 16 Fr (French) 5-10 cc (size of catheter) monthly on the first and as needed. Review of the resident's care plan showed no documentation regarding the new orders received on 2/18/22 and 2/23/22 to treat the resident's heels or change the catheter monthly. 2. Review of Resident #28's care plan, updated 7/29/21, showed the following: -Nutritional Status: Resident was on a regular diet, no added salt, no concentrated sweets; -Provide diet per physician's order; -Weight bearing as tolerated, up with one to two staff assist. Review of the resident's physician's orders, dated 7/29/21, showed the resident on regular diet, no added salt, no concentrated sweets. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of heart failure, Alzheimer's disease, anxiety disorder, and depression; -Supervision with eating; -No chewing or swallowing problems. Review of the resident's nurses notes, dated 1/26/22, showed the following: -Physician contacted. Resident was not safe to transfer or eat since adding lorazepam (medication for anxiety) 2 milligrams (mg) three times per day; -Order received to decrease lorazepam 1 mg to two times daily. Review of the resident's nurses notes, dated 1/27/22, showed the following: -Resident not swallowing his/her food; -Pocketing food (holding food in cheeks), nothing was helping. Review of the resident's physician's orders, dated 1/27/22, showed the following: -Speech therapy evaluate and treat for difficulty chewing and swallowing: -Resident's diet changed to mechanical soft, nectar thick liquids, no added salt, and no concentrated sweets. Review of the resident's Speech Therapy Evaluation, dated 1/27/22, showed the following: -Resident had been on a regular diet/ thin liquids and ate independently with little to no nursing assistance; -Referral to Speech Language Pathologist (SLP) now due to nursing noticing episodes of resident choking on food, coughing, not responsive to food in his/her mouth, letting liquids/ food dribble out of his/her mouth during meals for the last two to three days; -Swallowing difficulties are likely caused by Alzheimer's disease and swallowing complications from it; -SLP was required now to evaluate resident and determine safe diet with decreased coughing/choking or signs and symptoms of aspiration and to educate caregivers; -Precautions: Aspiration risk, no thin liquids, sit 90 degrees during and 20 minutes after eating; -Coughing during evaluation on regular diet/thin liquids consistently occurred. Observation on 2/14/22 at 12:05 P.M., showed the following: -The resident sat in his/her recliner; -The resident had a Hoyer lift (mechanical lift) sling under him/her. During an interview on 2/14/22, at 12:10 P.M., Certified Nurse Aide (CNA) K said the resident had been using a Hoyer lift with two staff assistance for a couple of months. Record review showed the resident's care plan was not updated to include changes the resident was dependent with eating, on new aspiration precautions, his/her diet downgraded to mechanical soft, nectar thick liquids, intervention to sit at 90 degree angle during meals and 20 minutes after eating, and did not include the decline and need for the Hoyer lift for transfers. 3. Review of Resident #41's face sheet showed the resident's diagnoses included posterior reversible encephalopathy syndrome (a condition that can cause headaches, seizures and visual disturbances; blurred vision to blindness), neuromyelitis optica (a condition that can cause blindness in one or both eyes, weakness or paralysis in the legs or arms, painful spasms, chronic kidney disease, anxiety disorder, major depressive disorder, pain, muscle spasm of the back, muscle weakness, abnormalities of gait and mobility, low back pain, transverse myelitis in demyelinating disease (a condition that interrupts the messages the spinal cord nerves send throughout the body), mild cognitive impairment, cognitive communication deficit, other symptoms and signs involving cognitive functions and awareness, insomnia, ischemic optic neuropathy (when blood does not flow properly to your eye's optic nerve, eventually causing lasting damage to this nerve and you suddenly lose your vision in one or both of your eyes). Review of the resident's progress notes, dated 11/5/21, showed the following: -The physician was in facility this morning and made aware of resident's continuous yelling and hallucinations throughout the day and night; -The physician ordered to increase as needed (PRN) lorazepam (antianxiety medication) 1 milligram (mg) every six hours PRN to every four hours PRN. Review of the resident's progress notes, dated 11/7/21, showed the following: -The resident had hallucinations and yelled out all night; -Staff tried to speak with resident and tell him/her everything was okay but it did no good. Review of the resident's care plan, updated 11/18/21, showed the following: -The resident lacks some cognitive skills for daily decision making; -The resident requires total assistance with all activities of daily living task performance, anticipate resident's needs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident's vision was severely impaired; no vision sees only light, colors or shapes. Eyes do not appear to follow objects; -The resident's cognition was severely impaired; -The resident exhibited behavioral symptoms not directed toward others; -The resident was totally dependent on two or more staff for bed mobility, eating, dressing, bathing, transfers, personal hygiene, toileting and locomotion on the unit; -The resident took medications for anxiety and depression. Review of the resident's care plan showed it was not updated to address the resident's visual deficit and constant yelling out. 4. During an interview on 2/24/22 at 10:28 A.M., the MDS Coordinator said the following: -He/She updated the care plan with any falls and adaptive equipment as she was made aware of them; -He/She only knows about changes in the resident if someone puts an alert in the system or if she happens to notice something changed with a resident; -He/She did not get to go to the fall meetings, so she relied on administration or the Director of Nursing (DON) to let her know if something related to falls needs to be added to the care plan. During an interview on 2/25/22, at 8:30 A.M., the DON said the following: -The licensed staff could not access the care plan to update, change or edit care plans until 2/24/22, because they did not have access/permission in the electronic system; -Care plans should be re-evaluated after falls; -Care plan interventions should be re-evaluated in an ongoing process; -Care plans should be updated with any change and quarterly. During an interview on 2/25/22 at 8:30 A.M., the administrator said the MDS coordinator was responsible for updating the care plans, but all licensed nurses were expected to update the care plans as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #41's undated face sheet showed the following: -The resident's diagnoses included posterior reversible encephalopathy syndrome (a condition that can cause headaches, seizures and visual disturbances; blurred vision to blindness), neuromyelitis optica (a condition that can cause blindness in one or both eyes, weakness or paralysis in the legs or arms, painful spasms, loss of sensation and bladder or bowel dysfunction), muscle weakness, unspecified lack of coordination, difficulty in walking, abnormalities of gait and mobility and mild cognitive impairment. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was totally dependent on two or more staff for bed mobility, eating, dressing, bathing, transfers, personal hygiene, toileting and locomotion on the unit; -The resident had impairment on both sides of his/her upper extremities (shoulders, elbows, wrists, and hands) and lower extremities (hips, knees, ankles and feet); -The resident was always incontinent of bladder and bowel. Review of the resident's care plan, updated 11/18/21, showed the the resident required total assistance with all ADL's, anticipate resident's needs, provide morning and evening care, grooming and hygiene needs; Review of the resident's shower logs, dated 12/1/21 through 2/18/22, showed the following: -December 2021 showers given on: 12/3, 12/7, 12/14 and 12/31; -January 2022 showers given on: 1/4, 1/18, and 1/25; -February 2022 showers given on: 2/2; -The resident received eight showers in three months, (December 2021- February 2/18/22) and should have received 24 showers. Review of the resident's progress notes showed no evidence the resident refused showers/bathing. During an interview on 2/14/22 at 1:15 P.M., the resident said the following: -He/She doesn't get as many showers as he/she would like; -He/She doesn't know if he/she had a designated shower day; -Sometimes staff will clean him/her up in bed; -He/She does not always feel clean. 6. Review of Resident #37's care plan, dated 10/6/21, showed the following: - Resident requires assistance with ADL task performance as follows: supervision, set-up, cues at mealtime; one assist for bed mobility; one assist for transfer, ambulation, toileting, grooming, bathing and dressing; - Resident will remain clean, neat, dressed appropriately for the season and free of body odor daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No rejection of care; -Physical help needed in part of bathing activity. Review of resident's January 2022 shower log showed the following: -Showers received on 1/3/22, 1/10/22, 1/21/22, and 1/23/22; -The resident received four showers during the month of January. The resident missed four scheduled showers. Review of resident's February 2022 shower log showed the following: -Showers received on 2/9/22, 2/14/22, 2/18/22, and 2/21/22; -The resident received four showers during the month of February. The resident missed four scheduled showers. During interview on 2/14/22 at 11:16 AM, the resident said he/she will sometimes go a couple of weeks without getting a shower. 7. During an interview on 2/16/22, at 8:20 A.M. and 2/23/22 at 12:15 P.M., CNA K said the following: -Residents are scheduled to get two showers a week; -Sometimes only two aides work and cover all of the 200/300 hall and that is not enough staff to meet the residents' needs; -Residents don't always get two showers a week. During an interview on 2/16/2 at 2:22 P.M., LPN A said the following: -Showers should be given two times a week unless the resident refuses; -Oral care should be performed morning and night on each resident. During an interview on 2/16/22 at 3:12 P.M., LPN D said the following: -Showers are given two times a week to residents; -Oral care should be performed at least two times a day by the CNA's. During an interview on 2/25/22 at 8:30 A.M., the administrator said the following: -Residents should receive a minimum of two showers a week; -It should be documented on the shower papers, or in the nurses notes if a resident refused his/her shower/ bath; -She leaves it up to the charge nurses to make sure residents get two baths a week; -She did not know the showers were not getting done. MO00172908 MO00174210 MO00174442 MO00190937 Based on observation, interview and record review, the facility failed to ensure facility staff provided bathing and hygiene needs for six residents (Residents #6, #28, #37, #41, #43, #44), in a review of 19 sampled residents who were unable to perform their own activities of daily living (ADL's). The facility census was 55. Review of the undated facility policy, Routine Resident Care/ADL's, showed the following: -Routine care rendered by all nursing staff includes attention to physical, emotional, social, spiritual, and life style preferences according to individual job descriptions; -Residents are given routine daily care by a certified nursing assistant (CNA) under the supervision of a licensed nurse; -Routine care by a nursing assistant includes the following: a. Assisting resident in personal care, bathing, dressing, eating, and encouraging participation in physical, social, and recreational activities; c. Observing and recording all aspects of personal care including bathing, food intake, ambulation activities, elimination and vital signs in the resident care charting record and resident food/group intake record in the resident's medical record. Review of the undated facility policy, Showers and Nail Care, showed the following: -Each resident will be showered or tub bathed two times a week and as needed; -Bed baths are given on days residents do not received a shower or tub bath; -A resident has the right to refuse a shower or tub bath, and be given a bed bath; -Nursing will document on shower/tub bath refusals; -Resident's nail (fingers and toes) will be cleaned after their shower or tub bath; -A CNA will trim nails unless the resident is diabetic or on anticoagulant therapy; -Residents that are diabetic or on anticoagulant therapy will be trimmed by the nurse. 1. Review of Resident #43's face sheet showed diagnosis of major depressive disorder, severe with psychotic symptoms, muscle spasm and chronic pain. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive physical assistance of two or more staff members for bed mobility, transfers, hygiene, bathing, and toilet use. Review of the resident's Care Plan, updated 7/11/19, showed the following: -ADL's - resident requires assistance with all ADL tasks with one to two assist for bed mobility, transfer, toileting, grooming, bathing, and dressing. Review of the resident's shower/bath record, dated December 2021, showed the resident received a shower on 12/2/21 and 12/30/21, and no other dates for the month of December. There was no documentation the resident refused showers/bathing. The resident missed seven scheduled showers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Requires extensive physical assistance of two or more staff members for bed mobility, and hygiene; -Dependent on staff for transfers, bathing and toilet use; -Limited range of motion in both lower extremities. Review of the resident's shower/bath record, dated January 2022, showed the resident received a shower/bath on 1/4/22, 1/11/22 and 1/18/22 and no other dates for the month of January. There was no documentation the resident refused shower/bathing. The resident missed five scheduled showers. Observation on 2/14/22 at 11:57 A.M., showed the following: -The resident in his/her wheelchair in his/her room; -His/her hair was greasy, dry skin on legs and arms, and the resident's fingernails were long with brown debris under the nails. During an interview on 2/14/22 at 11:57 A.M., the resident said the following: -He/She was lucky to get one bath a week; -He/She would like more baths, at least two a week; -When he/she goes too long without a bath he/she feels itchy. Review of the resident's shower/bath record, dated 2/1/22-2/22/22, showed staff documented the resident received a shower/bath on 2/14/22 and 2/18/22 and no other dates during the month of February. There was no documentation the resident refused showers/bathing. The resident missed four scheduled showers. 2. Review of Resident #44's annual MDS, dated [DATE], showed the following: -He/She had severely impaired cognition; -He/She did not reject cares; -He/She had total dependence of two or more staff members for bed mobility, toilet use, personal hygiene, bathing and transfers; -He/She was always incontinent of bladder and bowel. Review of the resident's ADL care plan, last updated on 3/30/21, showed the following: -He/She required extensive to total assist with bathing, dressing and personal hygiene; -He/She will be kept clean, dry and well-groomed daily; -He/She to receive showers two times a week; -His/Her hair to be shampooed two times a week; -Partial bath to be given on days not showered at bedtime and after incontinence episodes; -Provide oral care two times a day and as needed; -No documentation to show the resident refused oral care or showers. Review of the resident's December 1, 2021 through February 18, 2022 shower logs showed the following: -December 2021 showers given on 12/2, 12/6, 12/13, 12/20, 12/23, and 12/27; -January 2022 showers given on 1/5 and 1/12; -February 2022 showers given on 2/2 and 2/16. The documentation showed the resident had 10 showers in 80 days and should have had 24 showers. Review of the resident's progress notes, dated December 1, 2021 through February 18, 2022, showed no evidence the resident refused baths or showers. Observation on 2/16/22 at 5:50 A.M., showed they resident lay in bed with dry, peeling lips and teeth with a white thick buildup in between and on his/her teeth. Observation on 2/16/22 at 7:54 A.M., showed the following: -Certified Nurse Aide (CNA) K and the activity director changed the resident's brief and transferred the resident to his/her wheelchair; -Staff took the resident to the dining room for breakfast; -Staff did not provide oral care or wash the resident's face or hands. During an interview on 2/22/22 at 10:50 A.M., the resident sat in his/her room in a wheelchair and said the following: -When asked if the resident had his/her teeth brushed on that day he/she shook his/her head no; -When asked if he/she had his/her teeth brushed in the last few days the resident shook his/her head no. During an interview on 2/23/22 at 12:15 P.M. CNA K said the following: -The Certified Medication Technician (CMT) was suppose to provide oral care for the resident; -The resident refused oral care by some staff, but will sometimes allow him/her to provide oral care; -He/She was probably in a hurry and that was why he/she did not provide oral care for the resident on 2/16/22. During an interview on 3/21/22 at 11:42 A.M. CMT R said the following: -The resident refused oral care most of the time, every once in a while he/she will allow the CMT to provide oral care; -LPN A can get the resident to let him/her provide oral care. During an interview on 3/21/22 at 11:48 A.M., LPN A said the following: -The resident will allow the LPN to provide oral care most of the time; -The resident will only allow a few staff to provide oral care for him/her. 3. Review of Resident #28's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Care Plan, dated 7/9/21, showed the following: -ADL: All Tasks required limited to extensive assistance of staff; -Anticipate resident's needs; provide care morning and evening; -Provide grooming and hygiene needs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of heart failure and Alzheimer's disease; -Required extensive physical assistance of two or more staff members for bed mobility, transfers, toilet use, and bathing; -Dependent on staff for hygiene; -Indwelling urinary catheter, frequently incontinent of bowel. Review of the resident's shower/bath record, dated December 2021, showed no evidence staff gave the resident a shower or bath. There was no documentation the resident refused showers/bathing. Review of the resident's shower/bath record, dated January 2022, showed the resident received two showers/baths for the month of January one on 1/12/22 and another 1/19/22. There was no documentation the resident refused showers/bathing. The resident missed seven scheduled showers. Review of the resident's shower/bath record, dated 2/1/22-2/22/22, showed staff documented one shower/bath on 2/1/22. Review showed documentation of refusals. The resident missed five scheduled showers. Observation on 2/14/22 at 12:04 P.M., showed the following: -Resident up in his/her room in his/her recliner; -His/her hair was long and greasy; -His/her facial hair was long and unkempt; -His/her finger nails were long with brown debris under the nails. 4. Review of Resident #6's face sheet showed the following: -The resident's diagnoses hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (muscle weakness or partial paralysis on one side of the body), dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's quarterly MDS, dated [DATE], showed the following: -No behavior symptoms or rejection of care; -Total dependence of two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Review of the resident's care plan, revised on 2/13/22, showed the following: -He/She was a total assist for activities of daily living (ADL's); -He/She will be free from oral irritation/dry mucus membrane/oral infection daily; -Swab mouth and tongue with strong hot tea, cooled, every shift to prevent tongue from coating; -Provide grooming/hygiene needs. Review of the resident's February 2022 physician order sheet showed the following: -Biotene moisturizing mouth mucosal spray, 2 sprays three times a day, ordered 10/7/21; -Swab mouth and tongue with strong hot tea, cooled, every shift to prevent tongue from coating, ordered 10/7/21. Review of the resident's February 2022 ancillary administration orders showed the following: -Biotene moisturizing mouth mucosal spray, 2 sprays by mucous membrane, three times a day - completed each shift; -Swab mouth and tongue with strong hot tea, cooled, every shift to prevent tongue from coating - completed each shift. Observation on 2/14/22 at 10:46 A.M., showed the resident lay in bed with his/her eyes closed. The resident's mouth was dry with brown crusty buildup on his/her lips and tongue. Observation on 2/15/22 at 10:12 A.M. showed the resident lay in bed. The resident's mouth was dry with brown crusty buildup on his/her lips and tongue. Observation on 2/15/22 at 1:37 P.M. showed LPN A performing oral care with brewed tea and oral swabs. Observation on 2/16/22 at 6:27 A.M. showed the resident lay in bed. The resident's mouth was dry with brown crusty buildup on his/her lips and tongue. Observation on 2/22/22 at 9:48 A.M. showed the resident lay in bed with his/her eyes closed. The resident's mouth was dry with brown crusty buildup on his/her lips and tongue. During an interview on 2/16/22, at 6:13 A.M., CNA N said oral care should be performed every day in the morning and before bed. During an interview on 2/16/22, at 2:22 P.M., Licensed Practical Nurse (LPN) A said the following: -Oral care should be performed morning and night on each resident; -The resident had an order to provide oral care every shift with strong brewed, cool tea; -Resident #6's oral care was performed by nursing staff. During an interview on 2/16/22 at 3:12 P.M., LPN D said the following: -Oral care should be performed at least two times a day by the CNA's; -Nursing was supposed to do oral care for Resident #6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to design and provide an activity program to meet the needs, interests, physical, mental, and psychosocial well-being for five residents (Residents #6, #11, #28, #43 and #48) in a review of 19 sampled residents. The facility census was 55. 1. Review of the Center for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.17.1, Chapter 3, revised October 2019, showed the following: -Most residents capable of communicating can answer questions about what they like; -Obtaining information about preferences directly from the resident, sometimes called hearing the resident's voice, is the most reliable and accurate way of identifying preferences; -If a resident cannot communicate, then family or significant other who knows the resident well may be able to provide useful information about preferences; -Quality of life can be greatly enhanced when care respects the resident's choice regarding anything that is important to the resident; -Interviews allow the resident's voice to be reflected in the care plan; -Information about preferences that comes directly from the resident provides specific information for individualized daily care and activity planning. 2. During an interview on 2/23/22 at 4:00 P.M., the administrator said there was no specific policy for bed/chair bound 1:1 activities. The activity director determines activities appropriate for each resident. 3. Review of the facility's Activity Calendar, dated February 2022, showed the following: -2/1/22, 10:00 A.M. Exercise; -2/2/22, 10:00 A.M. Jingo; -2/3/22, 10:00 A.M. Exercise; -2/4/22, No time listed, Resident Council; -2/5/22, No time listed, Social Time; -2/6/22, 1:30 P.M. [NAME] Creek; -2/7/22, 10:00 A.M. Fros-Toss; -2/8/22, 10:00 A.M. Exercise; -2/9/22, 10:00 A.M. Bingo; -2/10/22, 10:00 A.M. Exercise; -2/11/22, 10:00 A.M. Devotional Program; -2/12/22, No time listed, Social Time; -2/13/22, 1:30 P.M. United Methodist; -2/14/22, 1:00 P.M. Valentine Jingo; -2/15/22, 10:00 A.M. Exercise; -2/16/22, 10:00 A.M. Hot Potatoes Game; -2/17/22, 10:00 A.M. Exercise; -2/18/22, 10:00 A.M. Horse Racing Game; -2/19/22, No time listed, Social Time; -2/20/22, 1:30 P.M. First Presbyterian; -2/21/22, 10:00 A.M. Presidential Jingo Trivia; -2/22/22, 10:00 A.M. [NAME]-Ranger; -2/23/22, 10:00 A.M. Bull's Eye Game. 4. Review of Resident #6's face sheet showed the resident's diagnoses included cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), major depressive disorder (a persistent feeling of sadness or loss of interest that can lead to behavioral or physical symptoms), aphasia following cerebral infarction (a language disorder that affects a person's ability to communicate), hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side (muscle weakness or partial paralysis on one side of the body), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's significant change (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/22/21, showed the resident voiced it was somewhat important for him/her to listen to music, participate in activities involving animals, to keep up with the news, do things in groups of people, do his/her favorite activities, go outside when weather permits, and attend religious activities. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired decision making ability; -No behavior symptoms or rejection of care; -Total dependence of one staff member for locomotion on and off the unit; -Hospice care. Review of the resident's care plan, revised on 2/13/22, showed the following: -He/She had an altered level of cognitive function due to stroke, memory problems, impaired decision making skills and impaired ability to comprehend and make himself/herself understood; -Take him/her to all activities, he/she needs extra stimulation; -He/She will be encouraged to participate in activities of choice; -Honor his/her preferences for favorite activity, music, news programs, etc.; -Provide appropriate activities to accommodate resident's needs; -Potential for resident to exhibit inappropriate behavioral problem as evidenced by screaming/yelling out. Record review of the resident's medical record did not show any activity attendance documentation. Review of the activity attendance for church, dated 2/13/22, showed the resident did not attend. During the annual survey 2/14/22 - 2/16/22, and 2/22/22 - 2/23/22 daily observation showed the resident was in bed the majority of the time, and when up he/she sat at the bedside in his/her wheelchair. No individual activities were observed. 5. Review of Resident #11's face sheet showed his/her diagnoses include: dementia, major depressive disorder, and communication deficit disorder. Review of the resident's care plan, dated 3/29/18, showed the following: -Need for activities consistent with the resident's abilities and interest; -Will demonstrate satisfaction with level and type of activities provided; -Assess mental and physical abilities, interests, and desires; -Select appropriate activities; -Transport to activities that the resident might enjoy, music, programs that do not require participation; -Assess response to activities and adjust plan as needed; -One on one activities in room by activity aide. Talk about things he/she likes, take outside, assess current likes and dislikes; -Transport resident to stimulating activities that he/she might like, music type, church, movies, paper reading; -Just stop by to visit, encourage socialization; -Provide monthly activity calendar, and point out activities of interest; Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Somewhat important to listen to music he/she likes, keep up with the news, do things with groups of people, go outside, participate in religious services or practices; -Dependent on staff for transfers, locomotion on or off the unit. Record review of the resident's medical record did not show any activity attendance documentation. Review of the activity attendance for church, dated 2/13/22, showed the resident did not attend. Observation on 2/14/22, at 2:15 P.M. in the resident's room showed the following: -The resident lay in his/her in bed; -No television or music on. Observation on 2/15/22, at 2:00 P.M. in the resident's room showed the following: -The resident lay in his/her bed with his/her eyes closed; -No television or music on. Observation on 2/16/22, at 1:45 P.M. in the resident's room showed the following: -The resident lay in his/her bed with his/her eyes closed; -No television or music on. Observation on 2/16/22, at 2:40 P.M. in the resident's room showed the following: -The resident lay in his/her bed with his/her eyes closed; -No television or music on. Observation on 2/16/22, at 3:45 P.M. in the resident's room showed the following: -The resident lay in his/her bed with his/her eyes closed; -No television or music on. During annual survey 2/14/22 - 2/16/22, and 2/22/22 - 2/23/22 daily observation showed resident to be in his/her bed the majority of the time, and when up he/she was at bedside in his/her wheelchair or in the dining room for meals. No individual activities noted. 6. Review of Resident #28's face sheet showed his/her current diagnoses include: Alzheimer's disease, depressive episodes, anxiety disorder, and a mood disorder. Review of the resident's significant change in condition MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Verbal behaviors directed towards others; -Somewhat important to have books, newspapers, and magazines to read, listen to music he/she likes, keep up with the news, do things with groups of people, do favorite activities, go outside, participate in religious services or practices; -Required extensive physical assistance of two or more staff members for transfers; -Dependent on staff for locomotion on and off the unit. Review of the resident's care plan, dated 9/14/21, showed the following: -Resident had sense of initiative/involvement evidenced by ability to establish own goals; -Provide resident with a calm environment conducive to introspection; -Support resident's activity of choice and preference; -Resident liked to lay down after meals, limiting group activity participation; -Likes to nap in recliner. Record review of the resident's medical record did not show any activity attendance documentation. Review of the activity attendance for church, dated 2/13/22, showed the resident did not attend. Observation on 2/14/22 at 12:04 P.M., in the resident's room showed the following: -The resident sat in his/her recliner; -No television or music on. Observation on 2/15/22 at 9:39 A.M., in the resident's room showed the following: -The resident sat in his/her room in his/her wheelchair with his/her eyes closed; -No television or music on. Observation on 2/15/22 at 2:00 P.M., in the resident's room showed the following: -The resident lay in his/her bed with his/her eyes closed; -No television or music on. Observation on 2/16/22 at 1:15 P.M., in the resident's room showed the following: -The resident lay in his/her bed, awake; -No television or music on. During annual survey 2/14/22 - 2/16/2, and 2/22/22 - 2/23/22 daily observation showed resident to be in his/her bed or his/her recliner the majority of the time, and when up he/she was at bedside in high back wheelchair or in the dining room for meals. No individual activities were noted. 7. Review of Resident #43's face sheet showed diagnoses of mood disorder, major depressive disorder, severe with psychotic symptoms, muscle spasm and chronic pain. Review of the resident's care plan, dated 7/3/19, showed the following: -Need for activities consistent with resident's abilities and interest; -Will demonstrate satisfaction with level and type of activities provided; -Assess mental and physical abilities, interests, and desires; -Select appropriate activities; -Transport to activities that might enjoy, music, programs that do not require participation; -Assess response to activities and adjust plan as needed; -Transport to stimulating activities that she/he might like, music type, church, movies, and paper reading. -Just stop by to visit, encourage socialization; -Resident will verbalize or demonstrate improved mood state; -Encourage participation in leisure and self-care activities; -Identify activity and schedule preferences. Review of the resident's annual MDS, dated [DATE], showed the following -Cognitively intact; -Very important to listen to music he/she likes; -Somewhat important to be around animals, do things with groups of people, do favorite activities, go outside, participate in religious services or practices; -Requires extensive physical assistance of one staff member bed mobility, locomotion on or off the unit; -Dependent on staff for transfers, and toilet use. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment -Makes self-understood and understands others; -Mild depression. Record review of the resident's medical record did not show any activity attendance documentation. Review of the activity attendance for church, dated 2/13/22, the resident did not attend. Observation on 2/14/22 at 11:39 A.M., in the resident's room showed the following: -The resident sat in his/her wheelchair; -No television or music on. Observation on 2/15/22 at 9:39 A.M., in the resident's room showed the following: -Staff transferred the resident from his/her wheelchair to his/her bed; -No television or music on. Observation on 2/15/22 at 2:03 P.M., in the resident's room showed the following: -The resident lay in his/her bed with his/her eyes closed; -No television or music on. Observation on 2/15/22 at 8:15 A.M., in the resident's room showed the following: -The resident sat in his/her wheelchair with his/her eyes open facing the sink; -The room lights were not on and the room was dark; -No television or music on. Review of the activity attendance for church and devotional, dated 2/18/22, showed the resident did not attend. During an interview on 2/14/22 at 11:39 A.M., the resident said he/she just does what the staff tell him/her to do, There was not much going on around the facility. During annual survey 2/14/22 - 2/16/22 and 2/22/22 - 2/23/22 daily observation showed resident to be in his/her bed the majority of the time, and when up he/she was at bedside in his/her wheelchair or in the dining room for meals. No individual activities noted. 8. Review of Resident #48's care plan, last updated 1/6/17, showed the following: -Activities: Limited participation; -Resident had limited participation in recreation programs related to he/she had no desire to participate in group activities; -Resident will receive 1:1 visits when does not attend or participate in activities on or off the unit; -Praise for all efforts made; -Provides social/emotional support; -Communicate with interdisciplinary team any changes in mood and behavior; -Keep current activity calendar in room and remind of activities offered; -Praise resident for attendance and participation of activities; -If does not attend activities in Activity Hall provide in room visits 2 times a week for at least 15 minutes; -Attends select group activities, though not able to actively participate; -Attends music and church activities that do not require participation; -Takes naps in his/her chair or bed between meals; -Has television but it is seldom on, belongs to roommate; -Likes to watch staff and other residents. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Inattention fluctuates; -Altered level of consciousness always present does not fluctuate; -Somewhat important to have books, newspapers and magazines to read, music he/she likes; be around animals, keep up with the news, do things with groups of people, do favorite activities, go outside, and participate in religious services or practices; -Dependent on staff for bed mobility, transfers locomotion on and off the unit. Record review of the resident's medical record did not show any activity attendance documentation. Review of the activity attendance for church, dated 2/13/22, the resident did not attend. Observation on 2/14/22 at 11:30 A.M., in the resident's room showed the following: -The resident sat in his/her Broda chair (reclining chair on wheels) with his/her eyes open; -No television or music on. Observation on 2/15/22 at 9:40 A.M., in the resident's room showed the following: -The resident sat in his/her Broda chair; -No television or music on. Observation on 2/15/22 at 11:00 A.M., in the resident's room showed the following: -The resident sat in his/her Broda chair; -No television or music on. Observation on 2/15/22 at 2:08 P.M., in the resident's room showed the following: -The resident sat in his/her Broda chair with his/her eyes open; -No television or music on. Observation on 2/16/22 at 8:15 A.M., in the resident's room showed the following: -The resident sat in his/her Broda chair with his/her eyes open, facing the wall; -The room lights were off and the room was dark; -No television or music on. Observation on 2/16/22 at 1:00 P.M., in the resident's room showed the following: -The resident sat in his/her Broda chair with his/her eyes open; -No television or music on. Review of the activity attendance for church and devotional, dated 2/18/22, the resident did not attend. During annual survey 2/14/22 - 2/16/22 and 2/22/22 - 2/23/22 daily observation showed resident to be in his/her bed or his/her Broda chair in his/her room the majority of the time, and when he/she out of his/her room he/she was in the dining room for meals. No individual activities noted. 9. During an interview on 2/23/22, at 2:46 P.M., Licensed Practical Nurse (LPN) A said the following: -There was not a list of television programs, or preferred music for each resident that he/she knows of; -Staff try to talk to the dependent residents during care and meals; -The Activity Director tried to read mail to them if they receive mail. During an interview on 3/2/22 at 10:39 A.M., the activity director said the following: -She was pulled to the floor to work as a Certified Nursing Assistant (CNA) three to four times a week; -Lately she had been in her office performing activity director duties only one to two days a week; -She does not have a back up to do activities if she was not acting as the activity director; -There is no one specific to do activities if he/she is not working; -Church services are offered every Sunday in the main building; -There are no other organized activities on the weekends or in the evenings; -Games and cards are put out on the tables for residents to use as social times; -1:1 activities for dependent residents are provided by anyone that provides care for the resident through conversation; -A typical 1:1 activity that she would complete would be reading, playing music, taking the resident outside, and conversation; -She had not been able to complete many of the 1:1 visits; -There was not routine charting of activities or 1:1 visits; -The only activity charting takes place in the activities section of the MDS when needed for the assessment. During an interview on 2/23/22 at 2:45 P.M., the Administrator said the following: -The Activity Director gets pulled to work the floor with the CNAs often; -Staff are expected to turn on televisions or music for dependent residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing services to assist three residents (Resident #41, #43, and #48), in a review of 19 sampled residents and one additional resident (Resident #21) in attaining or maintaining their highest level of functioning. The facility failed to prevent the development of limited range of motion for residents who were not admitted with a limited range of motion, or prevent further worsening of limited range of motion or development/worsening of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The facility failed to develop restorative plans with goals, frequency of task, number of repetitions, or length of time, or direction to staff to meet the resident's needs. The facility census was 55. Review of the facility policy, Restorative Nursing Services, revised July 2017, showed the following: -Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services; -Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care; -Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care; -The resident or representative will be included in determining goals and the plan of care; -Restorative goals may include, but are not limited to supporting and assisting the resident in: a. Adjusting or adapting to change abilities; b. Developing, maintaining or strengthening his/her physiological and psychological resources; c. Maintaining his/her dignity, independence, and self-esteem; d. Participating in the development and implementation of his/her plan of care. 1. Review of Resident #41's undated face sheet showed the following: -The resident's diagnoses included neuromyelitis optica (a condition that can cause blindness in one or both eyes, weakness or paralysis in the legs or arms, painful spasms, loss of sensation and bladder or bowel dysfunction), pain, muscle spasm of the back, muscle weakness, unspecified lack of coordination, difficulty in walking, abnormalities of gait and mobility, low back pain, transverse myelitis in demyelinating disease (a condition that interrupts the messages the spinal cord nerves send throughout the body), and mild cognitive impairment. Review of the resident's physician order sheet showed no documentation for restorative services or positioning for the resident. Review of the resident's Restorative Tracking Logs for December 2021 showed the following: -Week of 12/1/21 through 12/4/21 no documentation staff provided restorative services; -Week of 12/5/21 through 12/11/21 no documentation staff provided restorative services. Review of Resident #41's quarterly MDS, dated [DATE], showed the following: -The resident was totally dependent on two or more staff for bed mobility, eating, dressing, bathing, transfers, personal hygiene, toileting and locomotion on the unit; -The resident had impairment on both sides of his/her upper extremities (shoulders, elbows, wrists, and hands) and lower extremities (hips, knees, ankles and feet); -The resident received pain medication as needed; -The resident's pain made it hard for him/her to sleep and limited his/her daily activities. Review of the resident's Restorative Tracking Logs for December 2021 showed the following: -Week of 12/19/21 through 12/25/21- one day of restorative therapy (passive range of motion to upper and lower extremities with positioning with wedges and pillows) provided on 12/24/21; -Week of 12/26/21 through 12/31/21- one day of restorative therapy provided on 12/28/21. Review of the resident's Restorative Tracking Logs showed no documentation the resident received restorative services for January 2022. Review of the resident's Restorative Tracking Logs for February 2022 showed the following: -Week of 2/1/22 through 2/5/22- no documentation staff provided restorative services; -Week of 2/13/22 through 2/19/22-staff provided restorative services on 2/17/22 and 2/18/22; -Week of 2/20/22 through 2/26/22- two days of restorative therapy provided on 2/23/22 and 2/26/22. Observation on 2/15/22 at 11:04 A.M., showed the resident called out for Certified Nurse Aide (CNA) L saying I need straightened out, can you help me? Observation on 2/16/22 at 5:20 A.M., showed the following: -The resident lay on his/her left side in bed yelling, Hello, can you help me; -At 5:38 A.M. Registered Nurse (RN) C went to the resident's room and asked what he/she needed. The resident replied he/she wanted his/her legs pulled down and said his/her back hurt. Review of the resident's care plan on 2/16/22 showed no evidence of a restorative therapy care plan focus. Review of the resident's restorative therapy care plan, updated on 2/22/22, showed the following: -Resident to participate in up to two programs of restorative therapy up to three times per week; -Goals: increase passive range of motion and decrease joint tightness; -Bed mobility with correct positioning; -Upper and lower extremity passive range of motion to be provided to the resident. During an interview on 2/16/22 at 5:20 A.M. and 5:47 A.M., CNA X and CNA Y said the resident yelled out a lot and wants his/her legs stretched. The CNAs said they could not do that for the resident because they did not work in the therapy department. CNA X said he/she was scared to stretch the resident's legs, because the resident had contractures. CNA X and CNA Y said they reposition the resident and place pillows between his/her knees and at his/her back. During an interview on 2/16/22 at 9:25 A.M., the Physical Therapy Assistant (PTA) said the following: -The resident had received physical therapy, but did not show progress and therefore was placed on a restorative program; -The resident should get restorative therapy at least three times a week; -He/She had trained some of the day aides on providing range of motion; -The resident's leg contractures happen when he/she gets fidgety and he/she draws up his/her legs; -CNAs should and can straighten and stretch the resident's legs if he/she makes that request. During an interview on 2/23/22 at 5:26 P.M., the resident said the following; -NA Q had been in his/her room a few minutes earlier and stretched his/her legs; -It makes him/her feel bad when staff won't help him/her stretch his/her legs out. During an interview on 2/23/22 at 10:10 A.M. Licensed Practical Nurse (LPN) D said he/she could not do range of motion exercises with the resident due to the resident having contractures. 2. Review of Resident #43's undated Face Sheet showed current diagnosis included muscle spasms and chronic pain. Review of the resident's admission MDS, dated [DATE], showed the resident had no limitations in range of motion in the upper or lower extremities. Review of the resident's Care Plan, dated 8/20/19, showed restorative therapy as needed for exercise to all extremities. Review of the resident's annual MDS, dated [DATE], showed the following: -Resident had limited range of motion in one lower extremity; -No therapy; -Restorative Nursing two days out of the last seven days for range of motion. The resident developed a new limit in his/her range of motion involving one leg. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident had limited range of motion in both lower extremities; -No therapy; -No restorative nursing. The resident developed limited range of motion in his/her second lower extremity. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident had limited range of motion in both lower extremities; -No therapy; -No restorative nursing. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Limited range of motion in both lower extremities; -No therapy; -Restorative nursing two days out of the last seven days for passive range of motion. Review of the resident's Care Plan, updated 3/30/21, showed the resident was non-weight bearing. The care plan did not show evidence of a restorative nursing plan. Review of the resident's Nurses Notes, dated 5/10/21, showed staff documented restorative therapy to work on contractures, range of motion for bilateral lower extremities. Review of the resident's annual MDS, dated [DATE], showed the following -Limited range of motion in both lower extremities; -Physical therapy started on 5/5/21; -Four days out of the last seven restorative nursing for passive range of motion. Review of the resident's Care Plan, updated 6/29/21, showed restorative therapy up to six times a week for up to two programs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Limited range of motion in both lower extremities; -No restorative nursing; -Schedule pain medication regimen; -PRN (as needed) pain medications received; -Resident has frequent severe pain. Review of the resident's Restorative Hand-off Form, undated, showed the following: -Referred by physical therapy; -Diagnosis: contractures; -Goals section blank; -Range of motion for bilateral lower extremities; -Intervention Classification: staff documented Active and/or Passive range of motion; -Specific Task: (please provide specific task with objective metrics such as device, distance, support, resistance, repetitions, techniques, equipment, time, restorative group, etc.)- staff documented: passive range of motion and positioning for lower extremity contracture; The restorative plan did not include goals, frequency of task, number of repetitions, or length of time, or objective direction to staff for the resident's program to meet the resident's needs. Review of the resident's medical record showed no documentation restorative nursing tasks were completed from 1/1/22-1/26/22. Review of the resident's Restorative Tracking Log, dated 1/23/22-1/29/22, showed the following: -1/27/22: Resident supine (on back) for bilateral lower extremity passive range of motion and stretching; -Resident only received one day of restorative nursing services, and the log did not show evidence of the frequency of task, number of repetitions, or length of time spent with the resident. Review of the resident's Restorative Tracking Log, dated 1/30/22-2/5/22, showed the following: -2/2/22: Resident seated for bilateral lower extremity range of motion abduction and knee extension to improve mobility; -2/3/22: Passive range of motion bilateral lower extremities, active range of motion for bilateral upper extremities. Resident complained of pain with touch that was required. -2/4/22: Passive range of motion, supine with positioning pillows/wedge to maintain range of motion; -Resident received three days of restorative nursing services. The documentation did not contain evidence of the frequency of task, number of repetitions, or length of time spent with the resident. Review of the resident's Restorative Tracking Log, dated 2/6/22-2/12/22, showed the following: -2/8/22: ROM passive stretching, resident seated passive stretching to bilateral lower extremities to increase range of motion; -2/9/22: Passive ROM/stretching, resident supine for passive range of motion to decrease contractures and skin breakdown; -2/10/22: Passive ROM stretching, resident supine for passive range of motion; -Resident received three days of restorative nursing services. The documentation did not contain evidence of the frequency of task, number of repetitions, or length of time spent with the resident. Review of the resident's Restorative Tracking log, dated 2/13/22-2/19/22, showed the following: -2/15/22 passive range of motion and positioning, resident seated for passive range of motion and position; -Resident received one day of restorative nursing services. The documentation did not contain evidence of the frequency of task, number of repetitions, or length of time spent with the resident. Review of the resident's Restorative tracking log, dated 2/20/22-2/23/22, showed no evidence restorative nursing was completed. Observation on 2/15/22, at 9:02 A.M.-9:37 A.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -LPN B and CNA K assisted the resident into bed with a mechanical lift; -CNA K began to turn the resident in bed and pushed his/her left leg, the resident screamed out in pain, Don't touch that leg; -The resident had contractures at the hips and knees bilaterally (the resident's legs would not straighten at the knees or hips, when lying flat in bed the resident's knees and hips were flexed). During an interview on 2/15/22, at 9:37 A.M., CNA K said the following: -The resident cannot straighten out his/her legs or hips; -The resident's contractures have gotten worse in the last year; -The resident yells in pain when you touch his/her legs or ankles, especially the right leg; -The resident had pain every time he/she is turned, and when transferred in and out of bed. 3. Review of Resident #48's undated Face Sheet showed current diagnosis of dementia and pain. Review of the resident's annual MDS, dated [DATE], showed the following: -No limited range of motion to upper and lower extremities -Restorative Nursing for passive range of motion one day. Review of the resident's quarterly MDS, dated [DATE], showed the resident did not receive restorative nursing (in the last seven days) or therapy (since last entry to the facility). Review of the resident's quarterly MDS, dated [DATE], showed the resident did not receive restorative nursing or therapy. Review of the resident's quarterly MDS, dated [DATE], showed the resident did not receive restorative nursing or therapy. Review of the resident's annual MDS, dated [DATE], showed the following: -Limited range of motion to both upper and both lower extremities; -No restorative nursing last seven days; -No therapy since last entry. New limited range of motion in all four extremities and no therapy or restorative nursing. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Limited range of motion to both upper and both lower extremities; -No restorative nursing last seven days; -No therapy since last entry. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Limited range of motion to both upper and both lower extremities; -No restorative nursing last seven days; -No therapy since last entry. Review of the resident's Care Plan, last updated 1/12/22, showed it did not contain evidence of the resident's contractures being addressed, it did not contain interventions to prevent worsening of the resident's contractures. Observation on 2/14/22 at 11:45 A.M., showed the following: -Resident in sat his/her Broda chair (reclining chair) in the dining room; -The resident's hands were contracted with fingers closed against palms of his/her hand and did not open. The resident had no splint, brace, or rolled cloth in his/her hand. Observation on 2/15/22 at 11:00 A.M., showed the following: -The resident sat in his/her room in his/her Broda chair; -The resident's hands were contracted with fingers closed against palms of his/her hand and did not open. The resident had not splint, brace, or rolled cloth in his/her hand. Observation on 2/16/22 at 6:33 A.M., showed the following: -Resident sat in his/her room in a Broda chair; -The resident's hands were contracted with fingers closed against palms of hand and did not open. There was no splint, brace, or rolled cloth in his/her hand; -The resident's feet and arms were crossed over her body. Observation on 2/16/22 at 1:00 P.M., showed the following: -The resident lay in bed; -CNA K and the Activity Director provided care. The Activity Director applied pressure to the resident's knees to open legs enough to provide perineal care. The resident could not fully abduct his/her legs (rotate to open legs; -The resident's knees and hips were contracted and remained bent and flexed as staff rolled the resident to one side and another to provide care. During an interview on 2/16/22 at 1:07 P.M., CNA K said the following: -The resident had contractures of his/her hips, knees, and hands; -These have gotten worse over the last year or two; -The resident did not have any kind of brace or splint for his/her hands; -Staff could roll up a wash cloth to put in his/her hands to prevent skin breakdown, but he/she doesn't usually have them; -He/She did not think restorative nursing or therapy worked with the resident. 4. Review of Resident #21's undated face sheet showed the following: -The resident's diagnoses include cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), hypertension (high blood pressure), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and major depressive disorder (a persistent feeling of sadness or loss of interest that can lead to behavioral or physical symptoms). Record review of the resident's restorative hand-off form (communication form from therapy to restorative services), dated 10/14/20, showed the following: -Goal: maintain ambulation with hemi-walker (a small, one-handed walker that is intended to be used by persons whose one-half of their body is weakened) and lower extremity strength; -Interventions classification: bed mobility and/or walking, active and/or passive range of motion (ROM); -Specific tasks: walk with hemi-walker, active ROM of upper extremity. Record review of the resident's restorative therapy tracking log showed the following: -One entry on 12/29/21 for therapeutic exercise and gait for the month of December 2021; -No entries for the month of January 2022 to show staff provided restorative services; -Week of 2/1/22 - 2/5/22: resident received three days of restorative nursing services. The documentation did not contain evidence of the frequency of task, number of repetitions, or length of time spent with the resident; -Week of 2/7/22 - 2/12/22: resident received three days of restorative nursing services. The documentation did not contain evidence of the frequency of task, number of repetitions, or length of time spent with the resident; -Week of 2/13/22 - 2/19/22: resident received three days of restorative nursing services. The documentation did not contain evidence of the frequency of task, number of repetitions, or length of time spent with the resident; Review of the resident's physician order sheets, dated 2/21/22, showed restorative therapy orders for up to six times a week for up to two programs, with an original order date of 2/16/21, (the order was not specific to what restorative should include). Review of the resident's quarterly minimum data set (MDS), a federally required assessment instrument completed by facility staff, dated 2/19/22 showed the following: -Balance unsteady, only able to steady with staff assistance; -Ambulates with on staff assist with walker; -Functional limitation upper and lower extremity, one side only; -Restorative therapy for active range of motion, transfer training and walking. Record review of restorative therapy tracking log showed no entries to show staff provided restorative services for the week of 2/20/22 - 2/23/22. Review of the resident's care plan, revised on 2/19/22, showed a note of restorative therapy up to six times a week for up to two programs. This entry was created on 2/16/21. Observations of the resident during annual survey showed the following: -On 2/15/2022 at 9:28 A.M., the resident sat in his/her wheelchair in his/her room watching TV. The resident had a left hand contracture and had a small stuffed animal in his/her contracted hand; -On 2/16/22 at 11:30 A.M., the resident sat in his/her wheelchair in the dining room. The resident had a left hand contracture and had a small stuffed animal in his/her contracted hand; -On 2/22/22 at 4:20 P.M., the resident sat in his/her wheelchair in his/her room watching TV. The resident had a left hand contracture and had a small stuffed animal in his/her contracted hand. During an interview on 2/15/22 and 2/22/22, at 9:28 A.M. and 4:20 P.M., the resident said the following: -He/She had a left hand contracture from a stroke; -He/She had not walked since last year, (one of the resident's modules for restorative care was walking with a hemi-walker); -He/She placed a small stuffed animal in his/her left hand to keep his/her hand from tightening up; -He/She at times gets restorative therapy, once a week on good weeks; -He/She would like more restorative therapy. 5. During an interview on 2/23/22 at 11:10 A.M., the therapy coordinator said the following: -The therapy department used to be in charge of the restorative program and had a full time restorative aide; -The contract was over November 2021; -Restorative therapy orders are written by whichever discipline discharges the resident from therapy services; -A restorative program order consists of up to six times a week with a specific amount of programs addressed; -A program is the specific modalities to be addressed by restorative program; -If a resident develops a contracture, or a contracture worsens, they are evaluated by therapy and a restorative program written; -Every person referred to therapy for a contracture will have restorative therapy orders written; -She would prefer restorative to be done at least three times a week. During an interview on 2/23/22 at 11:25 A.M., the restorative aide said the following: -He/She took over the restorative program after the therapy person left at the end of 2021; -If the restorative order directed services up to six times a week, he/she would see the resident at least three times a week; -No one specific oversaw the restorative program, he/she gets the resident orders from therapy in the form of a hand-off form; -If a resident declines in ability to do ADL's or develops a contracture, the resident was referred to therapy. During an interview on 2/23/22, at 3:20 P.M., and 2/24/22, at 10:28 A.M., the MDS coordinator said the following: -She coordinates the paperwork for restorative nursing; -Restorative aides turns in their documentation to him/her for the MDS; -She will get the hand-off form from the therapy department and pass that form on to the restorative aide; -The hand-off form gives orders from the therapy department for frequency and modalities to be addressed; -She doesn't know if all residents at risk for contractures or worsening of contractures are on therapy or restorative nursing. During an interview on 2/16/22 at 4:00 P.M., 2/23/22, at 3:03 P.M., and 2/25/22, at 8:30 A.M., the Director of Nursing (DON) said restorative plans should be specific, with frequency, when to start and stop, how many repetitions, and if a hand contracture was present the resident should have a roll or something in their hand. If a resident has contractures he/she should have a restorative nursing program to address the contractures if the resident was not on therapy caseload. Residents #41, #43, #48, and #21 should be on a restorative nursing program. She would expect a CNA to provide range of motion for any resident. During an interview on 2/25/22, at 8:30 A.M., the administrator said the following: -The MDS coordinator over sees the restorative program; -Restorative collaborates with the therapy department; -The facility took over the restorative program when the therapy contracted restorative program ended; -The facility restorative aide meets weekly with the MDS coordinator and therapy; -Therapy was involved to help prevent contractures or worsening of current contractures, would hand off to restorative nursing for maintenance; -Therapy should write on the restorative plan how often the resident should receive restorative services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to appropriately assess and reassess the safety and effectiveness of bed rails in use for 11 residents (Residents #2, #207, #28, #11, #18, #48, #45, #47, #41, #43, and #6), in a review of 19 sampled residents. The facility census was 55. Review of the undated facility policy, Restraint Use and Use of Assist Handles, showed the following: -The need of each resident for restraint use is assessed on admission, quarterly (during care plan reviews), and as needed; -The Device Decision Guide will be used to determine whether or not a device is a restraint and if it should be used; -If it is determined not to be a restraint, it will be care planned for its purpose; -A side rail form should also be completed each time any change in side rail use is made; -A physician order will be signed for use of one or two assist handles on a resident bed; -When a need for an assist handle arises, instruct the resident as to their purpose and correct use; -Inform maintenance of the need for side rails to be placed on bed and inform the Director of Nursing (DON); -When side rails are indicated, the bed must be kept in lowest position, except when care is being provided; -Inspect assist handles for problems and report any malfunction; -Informed consent is placed in the admission record section of the resident's chart; -Informed consent will be reviewed quarterly by care plan coordinator and family and Informed Consent Form will be dated and initialed by care plan coordinator and by resident or responsible party. Review of the Food and Drug Administration's Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm; -Assessment by the health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when patients or parts of their body are caught between rails and mattress, more serious injury from falls when patients climb over rails, skin bruising, cuts and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an ongoing assessment of the patient's physical and mental status and closely monitor high-risk patients; -Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail; -Reduce the gaps between the mattress and side rails; -A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent, regular basis. 1. Review of Resident #41's face sheet showed the resident's diagnoses included neuromyelitis optica (a condition that can cause blindness in one or both eyes, weakness or paralysis in the legs or arms, painful spasms, loss of sensation and bladder or bowel dysfunction), pain, muscle spasm of the back, muscle weakness, unspecified lack of coordination, difficulty in walking, abnormalities of gait and mobility, low back pain, transverse myelitis in demyelinating disease (a condition that interrupts the messages the spinal cord nerves send throughout the body), mild cognitive impairment. Review of the resident's care plan, dated 11/18/21, showed the following: -The resident lacks some cognitive skills for daily decision making; -The resident required total assistance with all activities of daily living task performance; -Mechanical bed with two transfer handles and air mattress with bolster overlay; -Assist with transfers and positioning. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 12/21/21, showed the following: -The resident's vision was severely impaired; no vision sees only light, colors or shapes. Eyes do not appear to follow objects; -The resident's cognition was severely impaired; -The resident was totally dependent on two or more staff for bed mobility and transfers; -The resident had impairment on both sides of his/her upper extremities (shoulders, elbows, wrists, and hands) and lower extremities (hips, knees, ankles and feet). Observation on 2/15/22 at 9:48 A.M., showed staff provided cares to the resident and rolled the resident side to side to change his/her incontinence brief. The resident had 1/8 bed rails in the raised position on both sides of his/her bed. The resident at no time attempted to use the bed rail on either side of the bed to assist the staff with positioning, and the staff did not encourage the resident to use the bed rails. The resident's hands remained positioned in closed fists and held close to his/her chest. During an interview on 2/22/22 at 10:00 A.M., the resident said the following: -He/She could not use the bed rails because of his/her hands (the resident's hands were contracted); -He/She was not strong enough to pull himself/herself over. Review of the resident's medical record showed no documentation the facility had completed an assessment to indicate the use of the bed rails on the resident's bed, and no evidence of an informed consent signed by the resident or resident representative. 2. Review of Resident #18's current care plan, dated 9/6/18, showed the following: -The resident required assistance with ADL task performance as follows: one to two assist for bed mobility and transfers; -Mechanical bed with two transfer handles. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Total dependence on staff for transfers; -Required extensive assistance from two or more staff with bed mobility; -Bed rails not used. Review of the resident's physician order, dated 1/25/22, showed an order for mechanical bed with two transfer handles. Observation on 2/16/22 at 5:26 A.M., showed the resident lay in bed sleeping. The resident's bed had two 1/8 bed rails in the raised position. Observation on 2/16/22 at 8:30 A.M. showed Certified Nurse Aide (CNA) K and the Activity Director assisted the resident to get out of bed. When staff lowered the resident's bed rail, the resident said, Don't hit my head! During an interview on 2/22/22 at 11:33 A.M., the resident said he/she had never tried using his/her bed rails. Review of the resident's medical record showed no evidence staff completed an assessment to evaluate the resident's risk of entrapment in bed rails, evaluation of bed rails, obtained informed consent from the resident/responsible party for bed rail use, or interventions tried prior to installation of the bed rails. 3. Review of Resident #45's face sheet showed his/her diagnoses included dementia without behavioral disturbances and psychotic disorder with delusions (a mental disorder in which a person loses touch with reality and has false beliefs). Review of the resident's care plan, last updated 11/19/21, showed the following: -He/She required assistance with Activities of Daily Living (ADL) task performance as follows: one assist for bed mobility; extensive assist of one for transfers; -Assist of one to two persons with turning and positioning as scheduled or as needed. Review of the resident's annual MDS, dated [DATE], showed the following: -He/She understood others and could make himself/herself understood; -He/She had severely impaired cognition; -He/She required extensive assistance from two or more staff for bed mobility; -He/She was totally dependent on two or more staff for transfers. During an interview on 2/23/22 at 10:10 A.M., Licensed Practical Nurse (LPN) D said the resident could not reposition himself/herself without assistance. Observation throughout the survey of the resident's bed showed 1/8 grab bars on both sides of the resident's bed. Review of the resident's medical record showed no documentation the facility had completed an assessment to indicate the use of 1/8 grab bars on the resident's bed, and no evidence of an informed consent signed by the resident or resident representative. 4. Review of Resident #2's face sheet showed diagnoses include fracture right femur, vascular dementia without behavioral disturbance (brain damage cause by multiple stroke; causes memory loss in older adults), and Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions). Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Limited assistance of one staff member for bed mobility; -Extensive assistance of two staff members for transfers; -Lower extremity impairment on one side only; -Fall with fracture in last two-six months; -Bed rails were not utilized. Review of the resident's care plan, last revised 2/15/22, showed the following: -Potential for injury related to history of falls; -Goal to be free from fall for three months; -No indication of use of bed rails on the resident's care plan. Observation on 2/16/22 at 5:30 A.M., showed the resident lay in bed. The resident had 1/8 bed rails on his/her bed. Observation on 2/22/22 at 9:52 A.M., showed the resident sat in his/her wheelchair next to his/her bed. The resident had 1/8 bed rails on his/her bed. Review of the resident's medical record showed no documentation the facility completed an assessment to indicate the use of the bed rails on the resident's bed, and no indication of informed consent signed by the resident or resident representative. 5. Review of Resident #207's face sheet showed diagnosis of fracture of lumbosacral spine and pelvis (a broken bone in the lower spine and pelvic region). Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Extensive assistance of two staff for bed mobility and transfers; -Lower extremity impairment, one side only; -Fall with fracture in last two-six months; -Bed rails were not utilized. Review of the resident's care plan status on 2/23/22 noted no base line or comprehensive care plan had been completed. Observation on 2/16/22 at 5:32 A.M., showed the resident lay awake in bed. The resident had 1/4 bed rails on his/her bed. Review of the resident's medical record showed no documentation the facility completed an assessment to indicate the use of bed rails on the resident's bed, and no indication of informed consent signed by the resident or resident representative. 6. Review of Resident #28's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of Alzheimer's disease; -Required extensive physical assistance from two or more staff for bed mobility and transfers. Review of the resident's Care Plan, last reviewed 1/3/22, showed it did not contain evidence of directions for application or use of bed rails. Observation on 2/15/22 at 9:39 A.M., showed the resident sat in his/her wheelchair. The resident had two quarter size plastic bed rails on his/her bed in the raised position. Observation on 2/16/22 at 5:47 A.M., showed the resident lay in bed with his/her eyes closed. The resident had two quarter size plastic bed rails in the raised position. Review of the resident's medical record showed no evidence staff completed an assessment to evaluate the resident's risk of entrapment in bed rails, evaluation of bed rails, obtained informed consent from the resident/responsible party for bed rail use, or interventions tried prior to installation of the bed rails. 7. Review of Resident #11's Face Sheet showed diagnoses include dementia, major depressive disorder, and communication deficit disorder. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Extensive physical assistance of two or more staff for bed mobility; -Dependent on staff for transfers. Review of the resident's Care Plan, last reviewed 11/19/21, showed mechanical bed with transfer handles. Observation on 2/16/22 at 5:32 A.M., showed the resident lay in bed with his/her eyes closed. The resident had two small metal bed rails (1/8) in a raised position on both sides of the head of his/her bed. Observation on 2/16/22 at 1:45 P.M., showed the resident lay in bed with his/her eyes closed. The resident's bed had two small metal bed rails in the raised position on both sides of the head of the bed. Review of the resident's medical record showed no evidence staff completed an assessment to evaluate the resident's risk of entrapment in bed rails, evaluation of bed rails, obtained informed consent from the resident/responsible party for bed rail use, or interventions tried prior to installation of the bed rails. 8. Review of Resident #48's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Inattention and altered level of consciousness always present does not fluctuate; -Dependent on staff for bed mobility and transfers; -Limited range of motion to both upper and both lower extremities. Review of the resident's Care Plan, last updated 1/12/22, showed the following: -Broda chair (reclining wheelchair) for resident's locomotion; -Mechanical lift with two staff for transfers; -No evidence for direction/use of bed rails. Observation on 2/16/22 at 5:23 A.M., showed the resident in bed with his/her eyes closed. The resident had two 1/4 bed rails on his/her bed in the raised position. Observation on 2/16/22 at 1:00 P.M., showed the resident lay in bed. The resident had two quarter sized plastic bed rails in the raised position. Review of the resident's medical record showed no evidence staff completed an assessment to evaluate the resident's risk of entrapment in bed rails, evaluation of bed rails, obtained informed consent from the resident/responsible party for bed rail use, or interventions tried prior to installation of the bed rails. 9. Review of Resident #47's care plan, dated 10/28/21, showed the following: -Required extensive assistance with transfers and bed mobility; -Mechanical bed with transfer handles. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive assistance from two or more staff members with bed mobility and transfers; -Bed rails not used. Observation on 2/16/22 at 5:42 A.M., showed the resident sat on the edge of bed. The resident had 1/8 bed rails on both side of his/her bed in the raised position. Review of the resident's medical record showed no evidence staff completed an assessment to evaluate the resident's risk of entrapment in bed rails, evaluation of bed rails, obtained informed consent from the resident/responsible party for bed rail use, or interventions tried prior to installation of the bed rails. 10. Review of Resident #43's face sheet showed the resident's diagnoses included major depressive disorder, severe with psychotic symptoms, muscle spasm and chronic pain. Review of the resident's Care Plan, updated 3/30/21, showed the following: -The resident required assistance with all ADL tasks with one to two assist for bed mobility and transfer; -Provide 1/2 side rails to bed to assist with positioning and comfort. -Non-weight bearing; -Transfer to wheelchair with mechanical lift and two staff assist. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required extensive physical assistance of two or more staff members for bed mobility; -Dependent on staff for transfers; -Limited range of motion in both lower extremities. Observation on 2/15/22 at 9:37 A.M., showed the resident lay in bed with two small white metal bed rails (1/8) in the raised position at the head of the resident's bed. Observation on 2/16/22 at 6:36 A.M., showed the resident in bed with two small white metal bed rails in the raised position at the head of the resident's bed. Review of the resident's medical record showed no evidence staff completed an assessment to evaluate the resident's risk of entrapment in bed rails, evaluation of bed rails, obtained informed consent from the resident/responsible party for bed rail use, or interventions tried prior to installation of the bed rails. 11. Review of Resident #6's face sheet showed diagnoses include cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), aphasia following cerebral infarction (a language disorder that affects a person's ability to communicate), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (muscle weakness or partial paralysis on one side of the body), and dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired decision making ability; -Total dependence of two staff for bed mobility and transfers; -Upper extremity impairment, one side only; -Bilateral lower extremity impairment; -History of falls since prior MDS assessment; -Bed rails were not utilized. Review of the resident's care plan, revised on 2/13/22, showed the following: -He/She has an altered level of cognitive function due to stroke, memory problems, impaired decision making skills and impaired ability to comprehend and make himself/herself understood; -He/She is a total assist of two staff for bed mobility and transfers; -Mechanical low bed with transfer handles; -Potential for injury related to falls; -Potential for resident to exhibit inappropriate behavioral problem as evidence by screaming/yelling out. Observation on 2/14/22 at 10:46 A.M., showed the resident lay in bed. The resident had 1/8 bed rails in the raised position on his/her bed. Observation on 2/16/22 at 6:27 A.M., showed the resident lay in bed. The resident had 1/8 bed rails in the raised position on this/her bed. Observation on 2/22/22 at 10:22 A.M., showed the resident lay in bed. The resident had 1/8 bed rails in the raised position on his/her bed. Review of the resident's medical record showed no documentation the facility completed an assessment to indicate the use of bed rails on the resident's bed and no indication of informed consent signed by resident or resident representative. 12. During an interview on 2/16/22 at 5:50 A.M., CNA X said the following: -Most residents had some kind of bed rail, either the small metal one (1/8 rail) or the quarter sized plastic one; -He/She did not know who decided if the resident required a bed rail; -He/She did not know if any residents were at risk for entrapment; -He/She was not sure if he/she knew what entrapment risk meant. During an interview on 2/16/22 at 2:22 P.M., LPN A said the following: -The facility did not have any residents with bed rails; -Staff did not conduct bed rail assessments since there were no bed rails in the building; -The 1/8th and 1/4th rails on the beds were grab bars used by the residents for bed mobility, turning, and transfers. During an interview on 2/16/22 at 3:12 P.M., LPN D said the following: -He/She was not sure who completed the bed rail assessments if needed; -The facility did not have any bed rails in the building; -The 1/8th and 1/4th rails were for transfers, positioning and bed mobility and were not considered bed rails. During an interview on 3/15/22 at 12:20 P.M., the maintenance supervisor said the following: -Staff had not measured potential entrapment zones (between the bed and the bed rails) for any resident; -There was no specific schedule for inspecting equipment of any kind. During interviews on 2/15/22 at 11:15 A.M. and on 2/25/22 at 8:30 A.M., the administrator said the following: -The facility did not have bed rails on any of the beds in the building; -The rails on the beds were transfer assist devices; -The facility did not complete entrapment risk assessments or consents for the transfer assist devices. -The maintenance supervisor checked the beds for entrapment zones when he checked the beds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for two residents (Resident #28, and #43) in a review of 19 sampled residents and three additional residents (Resident #14, #21 and #54). Staff failed to provide routine showers to ensure good personal hygiene and prevent body odors and failed to respond timely to call lights. The facility census was 55. Review of the facility's undated policy, Staffing Plan, showed the following: -Consideration is given to the patients' and resident's needs when the composition of the nursing staff is determined; -Nursing services are provided 24 hours a day, seven days a week; -Sufficient personnel are assigned and on duty to assure safe, effective nursing care, including relief personnel during vacations, holidays, emergencies, and sick leaves; -Time schedules indicated the number of and classification of nursing personnel are developed; -These schedules are maintained and posted for each unit for every shift; -A staffing pattern is developed that considers the needs of the resident/patient populations; -When staffing falls below normal numbers, attempts will be made to call in help; -Nursing staff will be scheduled extended shifts and not be allowed to leave their unit until the proper personnel relief including: RN's, LPNs, Certified Medicine Technicians (CMTs), Certified Nurse Aide (CNAs) and Nurse Aide (NAs), unit helpers and feeding assistants; -Emergency Plan will be activated including use of ancillary staff to assist in necessary areas as training provides as needed; -All contracted nursing agencies will be notified; -If unavailable, nursing administration will be called to provide coverage and to assure safe levels of care and adherence to state requirements. Review of the facility policy, Policy and Procedure for Call Light System, updated January 2022, showed the following: -The facility will maintain a call light system in the facility for all residents and staff members to use for assistance and or emergencies; -All nursing staff will be educated and trained on constant checking of the monitors to ensure call lights are being answered timely and that each resident has their call light within reach of using; -The system will allow each charge nurse or Special Care Unit (SCU) supervisor to carry beepers with them while on duty during their shift; -The beepers will alert the charge nurse immediately when assistance is needed; -Computer monitors are also displayed at each nurse's station as well on the East and [NAME] halls for a visual alert for CNA's to see, in order to know which room has called for assistance; -The first initial green light call which will alert staff when a resident has called for assistance and will go directly to the charge nurse beepers; -If this call is not answered within three minutes a second call or yellow call will go to the charge nurse or SCU supervisor that this light has not been answered; -At five minutes a red call signal will alert the charge nurse or SCU supervisor, displaying a resident has had their call light on for at least a total of eight minutes; -These calls will also be displayed on the computer monitor according to color; -The Director of Nursing (DON) and/or administrator have the ability to run a report to monitor the time and effectiveness of the call light system for all units of the facility. Review of the undated facility policy, Routine Resident Care/ADLs, showed the following: -Routine care rendered by all nursing staff includes attention to physical, emotional, social, spiritual, and life style preferences according to individual job descriptions; -Residents are given routine daily care by a certified nursing assistant (CNA) under the supervision of a licensed nurse; -Routine care by a nursing assistant includes the following: a. Assisting resident in personal care, bathing, dressing, eating, and encouraging participation in physical, social, and recreational activities; b. Providing privacy and personal space for residents; c. Observing and recording all aspects of personal care including bathing, food intake, ambulation activities, elimination and vital signs in the resident care charting record and resident food/group intake record in the resident's medical record. Review of the undated facility policy, Showers and Nail Care, showed the following: -Each resident will be showered or tub bathed two times a week and as needed; -Bed baths are given on days residents do not receive a shower or tub bath; -A resident has the right to refuse a shower or tub bath, and be given a bed bath; -Nursing will document on shower/tub bath refusals; -Residents' nails (fingers and toes) will be cleaned after their shower or tub bath; -A CNA will trim nails unless resident is diabetic or on anticoagulant therapy; -Residents that are diabetic or on anticoagulant therapy will be trimmed by the nurse. Review showed the facility assessment did not address how many staff the facility should have. 1. Review of Resident #14's shower sheets, dated December 2021 and January 2022, showed the following: -The resident received baths on 12/4/21, 12/6/21, 12/13/21, 12/18/21 and 12/20/21; -The resident received baths on 1/4/22, 1/6/22, 1/13/22, 1/18/22 and 1/20/22; -The resident missed three baths/showers in December; -The resident missed four baths/showers in January; -The resident was scheduled to get a bath/shower two times a week. Review of the resident's February 2022 shower sheets showed the residents received baths on 2/1/22, 2/8/22, 2/15/22 and 2/22/22. The resident missed three showers in February. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Minimal depression; -Decision making ability was left blank; -Extensive assistance by one staff member for personal hygiene, dressing, and bathing; -Extensive assistance by two staff members for toileting; -The resident is frequently incontinent of bowel and bladder. Review of the resident's call light log showed on 2/10/22 the resident activated his/her call light at 11:28 P.M. and it was answered at 00:17 A.M. (49 minutes). Observation on 2/14/22 at 12:44 P.M., showed the resident's fingernails were approximately 1/4 inch long and had food debris under the fingernails and around the nail bed. During an interview on 2/14/22 at 12:44 P.M., the resident said the following: -Sometimes it takes a long time to get his/her call light answered; -He/She does not always get his/her bath; -He/She was supposed to get two baths a week; -He/She would like two baths a week; -His/Her fingernails were dirty and needed to be trimmed. 2. Review of Resident #21's face sheet showed the resident's diagnoses include cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area), hypertension (high blood pressure), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and major depressive disorder (a persistent feeling of sadness or loss of interest that can lead to behavioral or physical symptoms). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No behavior symptoms or rejection of care; -Independent decision making ability; -Extensive assistance by one staff member for dressing, toileting, and bathing; -Limited assistance by one staff member for personal hygiene; -Occasionally incontinent of bladder. Review of the call light log printed on 6/22/22 showed the following: -On 2/12/22 the resident activated his/her call light at 6:30 A.M. and it was answered at 6:58 A.M. (28 minutes); -On 2/13/22 the resident activated his/her call light at 6:24 A.M. and it was answered at 6:53 A.M. (29 minutes); -On 2/14/22 the resident activated his/her call light at 6:48 A.M. and it was answered at 7:38 A.M. (50 minutes); -On 2/14/22 the resident activated his/her call light at 8:16 A.M. and it was answered at 8:40 A.M. (24 minutes); -On 2/15/22 the resident activated his/her call light at 6:10 A.M. and it was answered at 6:25 A.M. (15 minutes); -On 2/15/22 the resident activated his/her call light at 6:42 A.M. and it was answered at 6:53 A.M. (11 minutes). During an interview on 2/15/22 at 9:28 A.M., the resident said the following: -His/Her call light does not get answered by CNA L, CNA L will come in and answer his/her roommate's call light but not his/hers; -Today he/she turned on his/her call light at 6:10 A.M. and it did not get answered by CNA L; -He/She [NAME] like there was not enough staff to meet the residents' needs; -The facility was short staffed on every shift; -Overnight shift only had one nurse and one CNA on the hall. 3. Review of Resident #54's face sheet showed the resident's diagnoses included congestive heart failure (a progressive condition that affects the pumping power of the heart muscle), essential hypertension (high blood pressure), chronic pain, generalized anxiety (severe, ongoing anxiety that interferes with daily activities), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Independent decision making; -Supervision only for completion of personal hygiene; -Limited assistance by one staff member for dressing and toileting; -Occasionally incontinent of bladder. During an interview on 2/15/22 at 10:00 A.M., the resident said that on the night shift it can take anywhere between 15 minutes to an hour for the call light to be answered. He/She did not feel like there was enough staff across the board to meet all of the residents' needs. Review of the call light log printed on 2/22/22 showed on 2/11/22 the resident activated his/her call light at 5:14 A.M. and it was answered at 6:01 A.M. (47 minutes). 4. Review of Resident #43's face sheet showed diagnoses of major depressive disorder, severe with psychotic symptoms, muscle spasm and chronic pain. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required extensive physical assistance of two or more staff members bed mobility, transfers, hygiene, bathing, and toilet use. Review of the resident's Care Plan, updated 7/11/19, showed ADL's - resident required assistance with all ADL tasks with one to two assist for bed mobility, transfer, toileting, grooming, bathing, and dressing. Review of the resident's shower/bath record, dated December 2021, showed the resident received a shower on 12/2/21 and 12/30/21, and no other dates for the month of December. There was no documentation the resident refused showers/bathing. The resident missed seven scheduled showers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required extensive physical assistance of two or more staff members for bed mobility, and hygiene; -Dependent on staff for transfers, bathing, and toilet use; -Limited range of motion in both lower extremities. Review of the resident's shower/bath record, dated January 2022, showed the resident received a shower/bath on 1/4/22, 1/11/22 and 1/18/22 and no other dates for the month of January. There was no documentation the resident refused shower/bathing. The resident missed five scheduled showers. Review of the resident's nurses notes, dated 12/1/21-2/22/22, showed no evidence of the resident receiving a bath or shower. Observation on 2/14/22 at 11:57 A.M., showed the following: -The resident sat in his/her wheelchair in his/her room; -His/her hair was greasy, there was dry skin on legs and arms, and the resident's fingernails were long with brown debris under the nails. During an interview on 2/14/22 at 11:57 A.M., the resident said the following: -He/She was lucky to get one bath a week; -He/She would like more baths, at least two a week; -When he/she goes too long without a bath he/she feels itchy. Review of the resident's shower/bath record, dated 2/1/22-2/22/22, showed staff documented the resident received a shower/bath on 2/14/22 and 2/18/22 and no other dates during the month of February. There was no documentation the resident refused showers/bathing. The resident missed four scheduled showers. 5. Review of Resident #28's care plan, dated 7/9/21, showed the following: -ADL: All Tasks required limited to extensive assistance of staff; -Anticipate resident's needs; provide care morning and evening; -Provide grooming and hygiene needs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of heart failure and Alzheimer's disease; -Required extensive physical assistance of two or more staff members for bed mobility, transfers, toilet use, and bathing; -Dependent on staff for personal hygiene; -Indwelling urinary catheter, frequently incontinent of bowel. Review of the resident's shower/bath record, dated December 2021, showed no evidence staff gave the resident a shower or bath. There was no documentation the resident refused showers/bathing. Review of the resident's shower/bath record, dated January 2022, showed the resident received two showers/baths for the month of January on 1/12/22 and 1/19/22. There was no documentation the resident refused showers/bathing. The resident missed seven scheduled showers. Review of the resident's shower/bath record, dated 2/1/22-2/22/22, showed staff documented the resident received one shower/bath on 2/1/22. There was no documentation the resident refused showers/bathing. The resident missed five scheduled showers. Observation on 2/14/22 at 12:04 P.M., in the resident's room showed the following: -The resident sat in his/her recliner; -His/her hair was long and greasy; -His/her facial hair was long and unkempt; -His/her finger nails were long with brown debris under the nails. 6, During an interview on 2/16/22 at 8:20 A.M., and 2/23/22 at 12:15 P.M., CNA K said the following: -Residents are scheduled to get two showers a week; -He/She does not feel two aides on the 200 hall was enough staff to meet the needs of the residents; -Residents did not always get checked on or incontinent briefs changed every two hours; -Residents did not always get two showers a week; -Sometimes it takes a while to answer call lights; -Most all the residents on the 200 hall required total care and transfers with a Hoyer lift. During an interview on 2/16/22 at 2:22 P.M., LPN A said the following: -Residents are given a bath two times a week unless the resident refuses; -He/She does not feel like he/she has enough staff to meet the residents' needs; -Many times housekeeping and activities have to help with nursing tasks to make it through the day; -Call lights should be answered within a couple of minutes. During an interview on 2/16/22 at 3:12 P.M., LPN D said the following: -Call lights should be answered in less than three minutes; -If a call light goes off longer than a few minutes the color on the monitor changes to yellow and then to red if it continues to go off longer than 10 minutes. During an interview on 2/25/22 at 8:30 A.M., the DON said the following: -Residents should be checked at a minimum every two hours. -Minimum showers should be two times a week. During an interview on on 2/23/22 at 3:03 P.M. and on 2/25/22 at 8:30 A.M., the administrator said the following: -Adequate staffing had been identified as a problem and have a process improvement plan in Quality Assurance committee; -Residents should receive a minimum of two showers a week; -It should be documented on the shower papers, or in the nurses notes if a resident refused his/her shower/ bath; -It was left up to the charge nurses to make sure the residents are getting two baths a week; -She was unaware the residents were not receiving two baths a week; -She was unaware of the requirements for call lights. MO 00170735 MO 00171180 MO 00171181 MO 00172210 MO 00173431 MO 00174442 MO 00176039 MO 00176164 MO 00179843

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to adequately document appropriate diagnoses/behaviors to justify the implementation or continued used of antipsychotic medications for two residents with a diagnosis of dementia (Residents #28 and #42), in a review of 19 sampled residents. The facility census was 55. Review of the facility policy Antipsychotic Medication Use, revised December 2016, showed the following: -Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; -The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; -The Attending Physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions; -Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use; -The interdisciplinary team will: -Re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered or discontinued; -Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication; -Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident; -Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): -Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves); -Schizo-affective disorder (a mental health condition including schizophrenia and mood disorder symptoms); -Schizophreniform disorder (schizophrenia that only lasts one to six months); -Delusional disorder (a belief or altered reality that is persistently held despite evidence to the contrary); -Mood disorders (when your general emotion state is distorted or inconsistent with circumstances and interferes with your ability to function); -Psychosis (a disconnection from reality) in the absence of dementia; -Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania; -Tourette's Disorder (a disorder involving repetitive movements or unwanted sounds); -Huntington Disease (an inherited condition in which nerve cells in the brain break down causing muscular, cognitive, behavioral and psychological problems); -Hiccups (not induced by other medications); -Nausea and vomiting associated with cancer or chemotherapy; -Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: -The behavioral symptoms present a danger to the resident or others; -The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); -For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: -Not due to a medical condition or problem (e.g., headache or joint pain, fluid or electrolyte imbalance, pneumonia, hypoxia, unrecognized hearing or visual impairment, medication side effect, or polypharmacy) that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued; -Persistent or likely to reoccur without continued treatment; -Not sufficiently relieved by non-pharmacological interventions; -Not due to environmental stressors (e.g., alteration in the resident's customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response, physical barriers) that can be addressed to improve the psychotic symptoms or maintain safety; -Not due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses) that can be expected to improve or resolve as the situation is addressed; -Antipsychotic medications will not be used if the only symptoms are one or more of the following: -Wandering; -Poor self-care; -Restlessness; -Impaired memory; -Mild anxiety; -Insomnia (inability to sleep); -Inattention or indifference to surroundings; -Sadness or crying alone that is not related to depression or other psychiatric disorders; -Fidgeting; -Nervousness; -Uncooperativeness. Review of drugs.com showed the following: -Risperidone (antipsychotic medication to treat schizophrenia and bipolar disorders) - not approved for use in older adults with dementia-related psychosis. Risperidone may increase the risk of death in older adults with dementia-related psychosis and is not approved for this use. -Haldoperidol (antipsychotic medication to treat schizophrenia) - not approved for use in older adults with dementia-related psychosis. Haloperidol may increase the risk of death in older adults with dementia-related psychosis and is not approved for this use. -Seroquel (quetiapine) (antipsychotic medication to treat schizophrenia, bipolar disease, and can be used with antidepressants for treatment of major depressive disorder) - not FDA (Food and Drug Administration) approved for use in psychotic conditions related to dementia. Quetiapine (Seroquel) may increase the risk of death in older adults with dementia-related psychosis. 1. Review of Resident #28's face sheet showed diagnosis of Alzheimer's disease, anxiety disorder and depression, restlessness or agitation, conduct disorder, disruptive mood disorder, and impulse control disorder. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/22/21, showed facility staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of heart failure, Alzheimer's disease, anxiety disorder, and depression; -No behavioral symptoms; -No antipsychotic or antianxiety medications; -Antidepressant medication daily. Review of the resident's physician's orders, dated 6/29/21, showed the following: -Risperidone 0.5 mg daily in the morning, diagnosis unspecified dementia with behavioral disturbance; -Risperidone 1 mg daily at bedtime, diagnosis unspecified dementia with behavioral disturbance. The resident did not have an approved diagnosis for the use of risperidone. Review of the resident's nurses notes, dated 7/8/21, showed staff notified the physician of behaviors, risperidone increased to three times per day. The resident did not have an approved diagnosis for the use of risperidone. Review of the resident's physician's orders, dated 7/8/21, showed order for risperidone increased to 1 mg three times a day for unspecified dementia with behavioral disturbance. The resident did not have an approved diagnosis for the use of risperidone. Review of the resident's nurses notes, dated 7/12/21, showed to decrease risperidone to two times a day. Review of the resident's physician's orders, dated 7/11/21, showed risperidone decreased to 1 mg two times a day. The resident did not have an approved diagnosis for the use of risperidone. Review of the resident's nurses notes, dated 7/12/21, showed orders increase risperidone to 1.5 mg in the morning and evening and 1 mg around noon. The resident did not have an approved diagnosis for the use of risperidone. Review of the resident's physician's orders, dated 7/12/21, showed the following: -Risperidone increased to 1 mg daily at noon and 1.5 mg morning and evening (three times a day with smaller dose at noon); -The resident did not have an approved diagnosis for the use of risperidone. Review of the resident's significant change in condition MDS, dated [DATE], showed the following: -Verbal behaviors directed towards others; -Behavioral symptoms improved; -Antipsychotic, antianxiety and antidepressant medication daily; -Received antipsychotic medication on routine basis, no gradual dose reduction attempted or documented. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No behavioral symptoms; -No antipsychotic medication, antianxiety medication one day out of the last seven, and antidepressant medication daily. Review of the resident's physician's orders, dated 12/31/21, showed haloperidol 0.5 mg IM (injection given in the muscle) now for restlessness and agitation. The resident did not show an appropriate diagnosis for the use of haloperidol. Review of the resident's physician's orders, dated 1/4/22, showed haloperidol 2.5 mg IM every 8 hours for 14 days for restlessness and agitation. The resident did not show an appropriate diagnosis for the use of haloperidol. Review of the resident's nurses notes, dated 1/11/12, showed the following: -Physician here to see resident; -Haldoperidol 2 mg three times per day. Review of the resident's physician's orders, dated 1/11/22, showed haloperidol 2 mg by mouth three times per day for anxiety and agitation, diagnosis violent behavior. The resident did not show an appropriate diagnosis for the use of haloperidol. Review of the resident's nurses notes, dated 1/14/22, showed the following: -Physician here to see resident; -Resident presenting completely sedated, drooling, unable to sit up, unable to eat; -Physician orders to discontinue haloperidol 2 mg three times a day; -New orders haldoperidol 1 mg every eight hours PRN for 14 days. Review of the resident's physician's orders, dated 1/14/22, showed haloperidol 1 mg every 8 hours PRN for disruption and or impulse yelling. The resident did not show an appropriate diagnosis/behaviors for the use of haloperidol. Review of the resident's nurses notes, dated 1/31/22, showed the following: -Resident up in wheel chair, wanted coffee; -Did not like the coffee; -Tried to hit staff with the coffee cup; -Verbally abusive to nurse; -Psychiatric nurse practitioner here; -New orders for Seroquel 12.5 mg two times daily. The resident did not have an appropriate diagnosis/behaviors for the use of Seroquel. Review of the resident's physician's orders, dated 1/31/22, showed Seroquel 12.5 mg two times daily, diagnosis dementia without behavioral disturbance. The resident did not show an appropriate diagnosis for the use of Seroquel. Review of the resident's significant change in condition MDS, dated [DATE], showed the following: -Other behaviors not directed towards others; -Behavioral symptoms worsened; -Antipsychotic, antianxiety, and antidepressant medication daily; -Received antipsychotic on routine basis, no gradual dose reduction done or documented. Review of the resident's Medication Administration Record, dated February 2022, showed Seroquel (quetiapine)12.5 mg two times daily. The resident did not show an appropriate diagnosis for the use of Seroquel. During an interview on 3/22/22 at 11:00 A.M., the resident's physician said the following: -The facility tries to control behaviors in the special care unit; -Residents with dementia and behaviors require psychotropic medications; -Antipsychotic medications are sometimes ordered for residents with dementia; -He adjusts the doses as needed, increases with behaviors, decreases if seem to be getting too much. 2. Review of Resident #42's face sheet showed the resident is greater than [AGE] years old. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnoses include Alzheimer's, dementia, anxiety, depression, diabetes mellitus, history of a stroke; -Antipsychotic medication daily; -Routine antipsychotic medication received. Review of the resident's Physician's Orders Sheet, dated 2/7/22, showed risperidone 0.5 mg daily for behavior management, for diagnosis of altered mental status. The resident did not have a diagnosis appropriate for the use of risperidone. 3. During an interview on 2/23/22 at 10:22 A.M., Licensed Practical Nurse (LPN) D said the following: -He/She does not know who tracks psychotropic medications in the facility; -Charge nurses call the physician if the residents have behaviors to get orders for psychotropic medications; -He/She does not know who tracks medications for appropriate use of antipsychotic medications. During an interview on 2/23/22 at 2:45 P.M., the Director of Nursing (DON) said the following: -She started at the facility on 2/11/22, so she was not sure the facility's process before 2/11/22; -The DON or a designee, someone in the facility is expected to track all psychotropic medication use; -All antipsychotics should have an appropriate diagnosis or adequate documentation of hallucinations, delusions, or symptoms that warrant their use; -Antipsychotic medications should be avoided if possible in the elderly. During an interview on 2/23/22 at 3:15 P.M., the administrator said the following: -Charge nurses call the physicians with any resident behaviors and the physicians dictate the medications needed; -Physicians and Pharmacist review medications for appropriateness.

Based on observation, interview, and record review the facility failed to remove and destroy expired medications for four residents (Residents #35, #36, #41 and #46) in a review of 19 sampled residents. The facility also failed to destroy expired stock supply of over the counter medications. The facility census was 55. Review of the facility policy, Storage of Medications, revised April 2007, showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals shall be stored in the packaging, container or other dispensing systems in which they are received; -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be returned to the dispensing pharmacy or destroyed; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location; -Medications must be stored separately from food and must be labeled accordingly. 1. Observation of the Special Care Unit (SCU) refrigerator on 02/16/22 at 07:25 A.M., showed the following: -Five Tylenol (pain reliever and fever reducer) 650 (mg) suppositories, expired 7/21; -Six Bisacodyl (laxative) 10 mg suppositories, expired 11/20; -Pneumovax 23 (vaccine to prevent pneumonia) syringe labeled with Resident #36's name, expired 1/27/22. 2. Observation of the west hall medication room on 2/23/22 at 1:30 P.M., showed the following expired over-the-counter medications: -Fleets enema (laxative) expired 10/21; -Vitamin D3 (supplement) 125 micrograms (mcg) approximately 1/2 bottle of 250 tablets, expired 12/21; -Folic Acid (supplement) 400 mcg - unopened bottle of 100 tablets, expired 12/21; -Azo urinary (medication used to help cleanse and protect the urinary tract) 33 caplets, expired 12/21. Observation of the west hall nurses' medication cart on 2/23/22 at 1:50 P.M., showed a bottle of hydrogen peroxide (antiseptic) 3/4 full, expired 8/21. 3. Observation of the east hall Certified Medication Technician (CMT) medication cart on 2/23/22 at 2:00 P.M., showed the following: -One card of ondansetron Hcl (anti-nausea medication) 4 milligrams (mg), as needed every four hours, 18 tablets labeled with Resident #46's name, dispensed on 1/5/21 and expired on 1/6/22; -One bottle of multivitamins with minerals, approximately 1/4 full opened on 3/10/21 and expired 11/21; -One card of potassium chloride (supplement) extended release 10 milliequivalents (mEq), 15 tablets labeled with Resident #41's name, dispensed on 10/25/21, expired on 12/31/21; -One canister of Thicken Up (a powder used to thicken liquids), expired on 10/27/21; -One opened bottle of bismatrol (anti-diarrhea mediation), expired on 6/21; -One opened bottle of mineral oil (lubricant laxative), expired on 1/22. During an interview on 2/23/22 at 2:15 P.M., CMT G said the following: -It is the responsibility of each CMT and nurse to check the medication rooms for expired medications; -The pharmacist also does a monthly check; -He/She was not sure how the medications that were expired were not discovered and destroyed. During an interview on 3/10/22 at 1:16 P.M., the administrator said the following: - The CMTs and charge nurses are responsible for checking medication rooms for expired medications of each unit; - The Director of Nursing (DON) oversees expired medications on each unit; - The pharmacist also helps with expired medications on each unit when he/she comes once a month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three staff members (Feed Aide/Activity Aide BB, Feed Aide CC and Feed Aide DD) had successfully completed a State-approved training program for feeding assistants and failed to ensure these staff members were not providing feeding assistance to five residents (Residents #11, #18, #28, #44, and #48) in a sample of 19 residents with complicated feeding problems. The facility census was 55. Review of the undated facility policy, Paid Feeding Assistant, showed the following: -The regulation requires that paid feeding assistants must work under the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN), and they must call the supervisory nurse in case of emergency; -Therefore, a facility that has received a waiver and does not have either an RN or LPN available in the building cannot use paid feeding assistants during those times; Interdisciplinary Team (IDT) Assessment of Resident Eligibility for Feeding Assistance: -When determining whether a resident may be assisted by a paid feeding assistant, facility staff must base resident selection on the IDT's current assessment of the resident's condition and the resident's latest comprehensive assessment and plan of care; -Appropriateness should be reflected in the resident's comprehensive care plan; -Paid feeding assistants are only permitted to assist residents who have no complicated eating or drinking problems as determined by their comprehensive assessment; -Examples of residents that a paid feeding assistant may assist include residents who are independent in eating and/or those who have some degree of minimal dependence, such as needing cueing or partial assistance, as long as they do not have complicated eating or drinking problems; -Paid feeding assistants are not permitted to assist residents who have complicated eating problems, such as (but not limited to) difficulty swallowing, recurrent lung aspirations, or who receive nutrition through parenteral or enteral means; -Nurses or nurse aides must continue to assist residents who require the assistance of staff with more specialized training to eat or drink; -Paid feeding assistants may assist eligible residents to eat or drink at meal times, snack times, or during activities or social events as needed, whenever the facility can provide the necessary supervision. 1. Review of Feed Aide/Activity Aide BB's employee file showed no documentation he/she completed a State-approved training course for paid feeding assistants. 2. Review of Feed Aide CC's employee file showed no documentation he/she completed a State-approved training course for paid feeding assistants. 3. Review of Feed Aide DD's employee file showed no documentation he/she completed a State-approved training course for paid feeding assistants. 4. Review of Resident #11's face sheet showed the resident's diagnoses include: dementia, gastro-esophageal reflux disease (when stomach acid frequently flows back into the tube connecting your mouth and stomach), recurrent pneumonitis (infection of the lungs due to inhalation of food or emesis), dysphagia (difficulty swallowing), and history of abnormal weight loss. Review of the resident's care plan, updated 10/15/19, showed the following: -Nutritional Status: Requires pureed diet with nectar thick liquids; -Assess response to diet and request order for modification as needed; -Allow time to swallow, do not rush; -Offer small bites, remind to swallow if needed; -Feed/position at 90 degrees when eating; -Support head/torso in upright position when eating; -Monitor for signs and symptoms of aspiration and notify physician accordingly; -Adequate servings of offered foods and fluids to maintain adequate nutrition and hydration; -Pureed diet with nectar thick liquids, nutritional supplements as ordered. Review of the resident's Physician's Orders, dated 10/13/21, showed the resident was on a pureed diet with nectar thickened liquids. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/4/22, showed staff assessed the resident as: -Severely cognitively impaired; -Dependent on staff for eating; -Held food in mouth/cheeks or residual food in mouth after meals; -Coughed or choked during meals or when swallowing medications; -Mechanically altered diet. 5. Review of Resident #18's care plan, dated 9/6/18, showed the following: - Resident requires assistance with Activities of Daily Living (ADL) task performance as follows: one to two assist for eating; - Monitor for signs/symptoms of choking, aspiration, etc. Report immediately of any concerns; - Pureed diet, aspiration precautions (sit upright in chair at 90 degrees, provide 30 minute rest period prior to and after feeding, use straw for liquid, use right side of mouth, check cheek for pocketing); Review of the resident's annual MDS assessment, dated 11/11/21, showed staff assessed the resident as: - Severely cognitively impaired; - No rejection of care; - Required total dependence of one to two staff members with transfers, dressing, eating, toileting, personal hygiene, and bathing; - Coughed or choked during meals or when swallowing medications. Review of resident's physician orders, dated 1/25/22, showed an order for mechanical soft diet, thin liquids, drink with cup. No straw. Hold cup in right hand. 6. Review of Resident #28's care plan, updated 7/29/21, showed the following: -Nutritional Status: Resident is on a regular diet, no added salt, no concentrated sweets; -Resident's disease symptoms will be managed as evidenced by no loose stools, abdominal cramping or bowel distention; -Provide diet per physician's order; -Cater to food preferences; -Encourage resident participation in meal choices. Review of the resident's physician's orders, dated 7/29/21, showed the resident was on a regular diet, no added salt, no concentrated sweets. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of heart failure, Alzheimer's disease, anxiety disorder, depression; -Required supervision with eating; -No chewing or swallowing problems. Review of the resident's nurses notes, dated 1/26/22, showed the following: -Physician contacted, resident is not safe to transfer or eat since adding lorazepam (medication for anxiety) 2 milligram (mg) three times per day; -Order received to decrease lorazepam 1 mg to two times daily. Review of the resident's nurses notes, dated 1/27/2022, showed the following: -Resident not swallowing his/her food; -Pocketing food (holding food in cheeks), nothing was helping. Review of the resident's physician's orders, dated 1/27/22, showed the following: -Speech therapy evaluate and treat for difficulty chewing and swallowing: -Resident's diet changed to mechanical soft, nectar thick liquids, no added salt, no concentrated sweets. Review of the resident's Speech Therapy Evaluation, dated 1/27/22, showed the following: -Resident with a history of dysphagia (difficulty swallowing); -Dependent on nursing care for ADL's; -Resident had been on a regular diet/thin liquids and ate independently with little to no nursing assistance; -Referral to SLP (Speech Language Pathologist) now due to nursing noticing episodes of resident choking on food, coughing, not responsive to food in his/her mouth, letting liquids/ food dribble out of his/her mouth during meals for the last two to three days; -Swallowing difficulties are likely caused by Alzheimer's disease and swallowing complications from it; -SLP was required now to evaluate resident and determine safe diet with decreased coughing/choking or signs and symptoms of aspiration and to educate caregivers; -Precautions: Aspiration risk, no thin liquids, sit 90 degrees during and 20 minutes after eating; -Coughing during evaluation on regular diet/thin liquids consistently occurred. 7. Review of Resident #44's face sheet showed resident had diagnoses that included moderate intellectual disabilities and cerebral palsy (a birth defect that causes abnormal brain development, movement, muscle tone (floppy or rigid limbs) and posture). Review of the resident's care plan, updated on 3/30/21, showed the following: -He/She required a pureed diet with honey thick liquids; -Aspiration precautions; -Offer small bites, remind to swallow if needed; -Allow time to swallow, do not rush; -When eating, feed resident at 90 degree position; -Monitor for signs and symptoms of aspiration and notify physician accordingly. Review of the resident's physician order sheet, dated 11/15/21, showed the following: -Pureed diet with honey thick liquid; -Aspiration precautions. Review of the resident's annual MDS, dated [DATE], showed staff assessed the resident as: -Severely impaired cognition; -Dependant of one staff member for eating; -He/She had the following signs and symptoms of possible swallowing disorder: loss of liquids/solids from mouth when eating or drinking and held food or residual food in mouth/cheeks in mouth after meals; -Required substantial/maximal assistance to eat with a helper doing more than half the effort. 8. Review of the Resident #48's face sheet showed the resident had diagnoses which included dementia, asthma, gastro-esophageal reflux disease, and dysphagia. Review of the resident's care plan, updated 1/24/21, showed the following: -Nutritional Status: At risk for poor nutritional status related to difficulty swallowing secondary to dysphagia; -Resident will be adequately nourished as evidenced by absence of significant weight loss; -Provide diet per physician's order; -Nectar thicken liquids, pureed no concentrated sweets diet, may have pureed regular dessert if request; -Edentulous (no natural teeth); -Fed by staff. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -New, signs and symptoms of possible swallowing disorder: loss of liquids/solids from mouth when eating or drinking present, holding food in mouth/cheeks or residual food in mouth after meals present, coughing or choking during meals or when swallowing medications present, complaints of difficulty or pain with swallowing present; -Mechanically altered therapeutic diet; -Dependent on staff for eating. Review of the resident's physician's orders, dated 1/11/22, showed orders for a pureed diet, no concentrated sweets, nectar thick liquids, may have regular pureed dessert upon request. 9. Observation on 2/14/22 at 12:20 P.M., showed Feed Aide DD assisted Residents #18, #28 and #48 with lunch. During an interview on 2/14/22 at 12:22 P.M., Feed Aide DD said the following: -He/She was not a CNA; -He/She watched videos and signed a check off sheet to be trained as a feed aide; -Resident #48 was on nectar thickened liquids; -He/She did not know which residents were on aspiration precautions. 10. Observation on 2/15/22 at 11:08 A.M. showed Feed Aide CC assisted Resident #18 with lunch. During an interview on 2/15/22 at 11:08 Feed Aide CC said the following: -He/She was not a CNA; -He/She watched movies to be a feeding assistant; -Resident #18 was served regular liquids and ground meat. 11. During an interview on 2/15/22 at 9:30 A.M., Feed Aide/Activity Aide BB said the following: -He/She was not a CNA; -He/She watched training videos to get trained as a feed aide. Observation on 2/15/22 at 11:15 A.M., showed Feed Aide/Activity Aide BB assisted Residents #44 and #11 with lunch. Observation on 2/16/22 at 11:45 A.M., showed the following; -Resident #11 sat in his/her wheelchair parallel to the dining room table; -Staff served the resident a pureed diet of meat, carrots, cauliflower, chocolate pudding, and two nectar thickened drinks; -Feed Aide BB fed the resident his/her meal; -Feed Aide BB mixed the resident's meat with his/her carrots and cauliflower; -The resident occasionally coughed during the meal. Observation on 2/22/22 at 11:50 A.M., showed the following: -Resident #11 sat in his/her wheelchair at the dining room table; -Staff served the resident a pureed meal with nectar thick liquids; -Feed Aide BB fed the resident; -The resident occasionally coughed and belched during the meal. During an interview on 2/15/22 at 11:15 A.M., Feed Aide/Activity Aide BB said Resident #44 had a pureed diet and Resident #11 had nectar thickened liquids. 12. During an interview on 2/15/22 at 11:43 A.M., the Speech Therapist said Residents #11, #28 and #48 were on aspiration precautions. During an interview on 2/16/22 at 11:48 A.M., the MDS coordinator said the following: -Most of the residents that are fed by staff are in this dining room (east dining room); -There are aspiration risk residents in both the east and west dining rooms; -Paid feeding assistants watch feeding videos and are supervised when they first start for their training; -Paid feeding assistants help feed residents that are on aspiration precautions and mechanically altered diets. During an interview on 2/23/22 at 3:03 P.M., the Director of Nursing (DON) said paid feeding assistants have to attend a state approved training course. During an interview on 2/23/22 at 5:00 P.M., the administrator said when the previous DON was at the facility, as long as a licensed practical nurse (LPN) supervised the feed aides, the feed aides were okay to feed altered diets.

Based on interview and record review, the facility failed to provide/designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis, and provide an RN eight consecutive hours a day, seven days a week. The facility census was 55. Review of the facility's undated policy, Staffing Plan, showed the following: -Nursing services are provided 24 hours a day, seven days a week; -At least one registered nurse (RN) is on duty eight hours a day, seven day a week. (Due to recent staffing shortages, if a RN is unavailable for eight hours a day, seven days a week, a licensed practical nurse (LPN) will be utilized); -When staffing falls below normal numbers, attempts will be made to call in help; -Nursing staff will be scheduled extended shifts and not be allowed to leave their unit until the proper personnel relief including: RN's -All contracted nursing agencies will be notified; -If unavailable, nursing administration will be called to provide coverage and to assure safe levels of care and adherence to state requirements. 1. Review of the RN/LPN/CMT schedule, dated 1/8/22-1/16/22, showed no RN coverage on 1/8/22, 1/10/22, 1/11/22, 1/12/22, 1/14/22, 1/15/22 and 1/16/22. Review of the RN/LPN/CMT schedule, dated 1/17/22-1/22/22, showed no RN coverage on 1/17/22, 1/19/22, 1/20/22, 1/21/22 and 1/22/22. Review of the RN/LPN/CMT schedule, dated 1/23/22-1/31/22, showed no RN coverage on 1/24/22, 1/25/22, 1/26/22, 1/28/22, 1/29/22, 1/30/22 and 1/31/22. Review of the RN/LPN/CMT schedule, dated 2/1/22-2/6/22, showed no RN coverage on 2/2/22, 2/3/22, 2/5/22, and 2/6/22. Review of the RN/LPN/CMT schedule, dated 2/7/22-2/11/22, showed no RN coverage on 2/7/22, 2/8/22, and 2/9/22. Review of the RN/LPN/CMT schedule, dated 2/12/22-2/18/22, showed no RN coverage on 2/12/22 and 2/13/22. During an interview on 2/14/22 at 10:15 A.M., the administrator said the following: -The facility had not had a director of nursing (DON) for the last six months; -The previous DON left in August or September 2021; -The new DON started 2/11/22, worked that day, and was out for a personal reasons 2/14/22; -The facility had one RN that works the night shift, part time; -The facility did not have a RN everyday for eight consecutive hours; -No RN's are doing the DON duties; -The facility does not have a staffing waiver for DON or RN coverage; -She did not know there was a process to obtain waivers for RN or nursing coverage; -The new DON will take over all the DON duties and serve as the RN for the days she is at the facility.

Based on observation, interview, and record review, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution. The facility census was 55. Observations in the kitchen on 2/15/22 between 10:30 A.M. and 2:00 P.M. showed the following: -The four-plex outlet, located above the food preparation table by the food processor, was soiled with food debris; -Brown debris was splattered along the wall above this food preparation table, behind the food processor, blender and wall-mounted knife rack; -Dusty and black debris on the vent cover for the ceiling mounted HVAC units throughout the kitchen; -A buildup of black debris on the fan cover and inside the fan in the reach-in double refrigerator unit; -Black mold-like debris on the wall, metal conduits, and floor under the dishwashing counter in the dishwashing room; -The wall in the dishwashing room next to the sink with the sprayer was pealing and not cleanable. An area approximately 12 inches by 3 inches of black/gray mold-like substance was on the wall in this area; -A black mold-like substance on the caulking where the wall met the backsplash for the dishwashing counter; -A buildup of black mold-like substance on a 1 foot by 1 foot ceiling vent upon entrance into the dishwashing room; -A buildup of black mold-like debris on the ceiling vent by the dishwasher; -A buildup of black mold-like debris on the wall around the mop sink in the corner of the dishwashing room; -A heavy buildup and runs of yellow grease on the wall behind the tilt skillet; -A buildup of grease on the back edge of the tilt skillet; -Grease and debris on the four extinguishing nozzles and metal conduit under the rangehood; -The wall mounted metal boxes for the rangehood extinguishing system and the wall in this area were heavily soiled. A plastic container with serving utensils (tongs and spoons) sat directly next to the soiled boxes; -A heavy buildup of debris on the floor and on the junction box mounted to the food preparation counter, and on the electrical cords/plugs in this area; -Dried food and dusty, greasy debris on the top surface of the plate warmer; -Dried food debris on the control knobs and door handle on the range and double convection oven, on the refrigerator handles, along the edge of the upright freezer, and on the tilt skillet handle; -A heavy buildup of debris on the flexible conduit and spring for the soup kettle located next to the tilt skillet; -Buildup of dusty, dirty debris on the floors at the base of the walls throughout the kitchen; -A heavy buildup of loose dirt and debris on the floor in the doorways from the kitchen to the dining room and service hallway; -A black, mold-like substance on the floor in front of and under the steamtable; -A buildup of dusty and sticky debris along the top and handles of a small plastic tote containing coffee filters and coffee, located next to the coffee maker; -A buildup of greasy and dusty debris on the sprinkler piping located next to the wall by the coffee maker; -A buildup of black, mold-like debris on the vent and inside the vent of the window mounted air conditioning unit located above the food preparation counter; -The wall above and below the handwashing sink, and the wall-mounted soap dispenser were soiled; -A heavy buildup of dust and debris on the metal conduit and piping under the handwashing sink; -The wall behind the three-compartment sink had peeling paint and was not cleanable; -Debris scattered on the ceiling throughout the kitchen; -The floor, wall, conduit and piping under the sink next to the range was heavily soiled. Review on 2/15/22 of a cleaning schedule posted in the kitchen, showed staff were to clean areas including the air conditioner, ceiling vents, coffee maker area, and fans. Review of a cleaning schedule daily reminders posted in the kitchen included the following: -Clean up any mess made at the time of making it; -Wipe off dishwasher counter and wall after each meal; -Sweep and mop kitchen afternoon/evening. During interviews on 2/15/22 at 10:45 A.M. and 12:55 P.M., Dietary Aide MM said staff did they best they could to keep the kitchen clean. The facility was having staffing troubles in the kitchen so staff were doing the best they could, but they were tired. Staff weren't able to clean along the floors and walls like they used to because they don't have enough help. During an interview on 2/15/22 at 10:00 A.M., the Dietary Manager said she was trying to hire additional dietary staff but it had been difficult. Staff used to clean the walls, ceilings, baseboards in the kitchen yearly, but they haven't had time. The main priority was ensuring residents got served their meals. During interview on 3/18/22 at 2:15 P.M., the administrator said the Dietary Manager was responsible to ensure the cleaning in the kitchen was completed. The Dietary Manager told her the dietary staff was doing the best they could to keep the kitchen clean in addition to cooking with the staff they had. In November 2021, they discussed using housekeeping staff to clean the kitchen, but then they had to utilize those housekeeping staff who were CNAs to help feed the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility failed to ensure facility staff washed their hands after each direct resident contact when indicated by professional standards for one resident (Resident #207) in a sample of 19 residents and one additional resident (Resident #1). The facility also failed to ensure procedures were implemented to address prevention of Tuberculosis (TB) for six employees, in a review of ten sampled employees hired since the previous survey. The facility census was 55. Review of the facility's undated policy,Tuberculosis Testings, showed the following: -The licensed nurse will administer the purified protein derivative (PPD) skin test as directed upon the first day of orientation to all employees and volunteers. The licensed nurse will also be responsible for administration of the second test step and record keeping. This test record will be kept with each employee or volunteer file. This DON designee will also be responsible to assure that ANNUAL testing is completed upon HIRE and properly recorded. -If the initial result is 0-9 mm, the second test should be given at least one week and no more than three weeks after the first test. (The policy did not direct the facility staff to administer the first step of the tuberculin skin test (TST) prior to start date (first date of compensation) and to ensure the first step was read on or before the new employee's start date.) 1. Review of Dietary Staff KK's employee file showed he/she was hired on 10/4/21. Review of Dietary Staff KK's Initial Employment and Annual Tuberculosis Testing showed the following: -First tuberculin skin test (TST) administered on 9/29/21, results read on 10/1/21; -No evidence a second TST was administered within three weeks after the first TST was administered on 9/29/21 to complete the two-step TST, and no evidence of a two-step TST prior to employment. 2. Review of Unit Helper LL's Initial Employment and Annual Tuberculosis Testing showed the following: -Hire date 5/17/21; -First TST administered on 5/7/21, results read on 5/9/21; -No evidence a second TST was administered within three weeks after the first TST was administered on 5/7/21 to complete the two-step TST, and no evidence of a two-step TST prior to employment. 3. Review of Secretary/Restorative Aide's employee file showed he/she was hired on 7/22/19. Review of Secretary/Restorative Aide's Initial Employment and Annual Tuberculosis Testing showed the following: -He/She received a one-step TST on 1/11/19, 1/7/20, 1/7/21 and 1/5/22; -No evidence a two-step TST completed prior to or within three weeks after employment. 4. Review of Social Services Staff AA's employee file showed he/she was hired on 1/14/22. Review of Social Services Staff AA's Initial Employment and Annual Tuberculosis Testing showed the following: -First TST administered on 1/12/22, results read on 1/14/22; -No evidence a second TST was administered within three weeks after the first TST was administered on 1/14/22 to complete the two-step TST, and no evidence of a two-step TST prior to employment. 5. Review of Nurse Assistant Q's employee file showed the following: -He/She was hired on 4/13/21; -No evidence of anyTST'ss completed. 6. Review of Registered Nurse (RN) C's employee file showed he/she was hired on 3/15/21. Review of RN C's Initial Employment and Annual Tuberculosis Testing showed the following: -First TST administered on 3/9/21, results read on 3/11/21; -No evidence a second TST was administered within three weeks after the first TST was administered on 3/9/21, and no evidence of a two-step TST prior to employment. 7. During an interview on 3/18/22 at 2:00 P.M., the Minimum Data Set (MDS) Coordinator said the facility had not had a director of nursing (DON) for months so licensed staff worked together as a team to administer and read the employee TB tests. She was not responsible for tracking the testing, but administered the TB tests to new hires if the administrator or Office Manager/Human Resources staff asked him/her to administer the test. The new staff were directed to go to a charge nurse 48 hours after the test was administered so the charge nurse could read the results. He/She and other licensed nurses/charge nurses read the results when the new staff approached them for the results. He/She did not track or provide any information to the new staff about receiving the second TB test after the first test was read. During an interview on 3/18/22 at 2:15 P.M., the administrator said the former DON used to be responsible for the employee TB testing. When the former DON left employment at the facility in August 2021, the MDS Coordinator was responsible for the employee TB testing. When a new staff were at the facility completing pre-hire paperwork, she or the Office Manager/HumanResourcess staff sent the new staff to the MDS Coordinator or another licensed nurse (if the MDS Coordinator was not in the building) to administer the TB test. The MDS Coordinator was responsible to ensure the results of the TB tests were read and the second test was given. The Office Manager/Human Resources staff was responsible for overseeing this process. During an interview on 3/18/22 at 3:25 P.M., the Office Manager/Human Resources Staff said she completed a new hire checklist at pre-hire which included the TB tests. She gave the form to the MDS Coordinator or a licensed nurse who was available to complete the TB tests. The nurse administered the TB test and then told the new employee when they were to come back to the facility so a nurse could read the results. He/She was not sure who was responsible for ensuring the new employee received the second TB test. 8. Review of the facility's Handwashing Policy, updated 1/1/22, showed the following: -Proper handwashing technique is used for the prevention of transmission of infectious disease; -All personnel working in the facility are required to wash their hands before and after resident contact or use 60% alcohol-based sanitizer, before and after performing any procedure, after sneezing or blowing nose, after using the toilet, before handling food, and when hands become obviously soiled. 9. Review of Resident #207's face sheet showed the following: -The resident's diagnoses include fracture of lumbosacral spine and pelvis (a broken bone in the lower spine and pelvic region), chronic congestive heart failure (a progressive condition that affects the pumping power of the heart muscle), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), and diabetes mellitus (a group of diseases that result in too much sugar in the blood). Review of the resident's February 2022 physician order sheet showed the following: -Clean open area to coccyx (tailbone) with wound cleanser, apply hydrogel (an insoluble hydrophilic gel used to treat wounds) and cover with a dry dressing daily; -Cleanse areas on malleous (outer ankle) with wound cleanser, apply calmoseptine (a moisture barrier that protects and helps skin irritations) and cover with bordered foam dressing to bilateral outer ankles daily. Observation on 2/15/21 at 1:40 P.M., showed the following: -The resident lay on his/her right side in bed for a dressing change to his/her coccyx; -Licensed Practical Nurse (LPN) D removed the old soiled wound dressing. The dressing had a quarter size amount of light brown drainage; -LPN D washed his/her hands and applied new gloves; -LPN D cleansed the wound on the resident's coccyx with wound cleanser; -LPN D removed his/her soiled gloves, washed his/her hands, and applied new gloves; -LPN D repositioned the resident with his/her gloved hands; -LPN D applied hydrogel to the wound on the coccyx with a Q-tip; -With the same gloved hand that touched the resident's hip, LPN D touched the center of the clean dressing and applied the dressing directly to the resident's coccyx wound; -The wound on the resident's coccyx was noted to have a small open pink area, with the majority of the wound covered in white tissue; -LPN D gathered his/her supplies/trash and threw them away; -LPN D removed his/her soiled gloves and washed his/her hands. During an interview on 2/16/22 at 3:12 P.M., LPN D said the following: -He/She was not sure why he/she touched the center of the clean dressing with a soiled glove, prior to applying the dressing to the resident's wound; -He/She should not have touched a clean dressing with a soiled glove. 10. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Diagnoses include diabetes mellitus (a group of diseases that result in too much sugar in the blood), hemiplegia and hemiparesis following cerebral infarction affecting left side, cerebrovascular accident (damage to the brain from interruption of its blood supply). -Cognitively intact; -Frequently incontinent of bowel and bladder; -Extensive assistance of two staff members for toileting. Observation on 2/16/22 at 7:03 A.M., showed the following: -The resident lay in bed; -He/she was incontinent of stool; -CNA K provided frontal peri-care; -With gloved hands, Activity Director/Certified Nurse Aide (CNA) provided rectal peri-care; -Activity Director/CNA did not remove his/her soiled gloves; -While wearing the same gloves, the Activity Director/CNA applied a clean incontinence brief and pulled up the resident's pants; -Activity Director/CNA and CNA K transferred the resident from his/her bed to his/her wheelchair using the mechanical lift; -Activity Director/CNA removed gloves and washed hands. During an interview on 3/2/22 at 10:39 A.M., the Activity Director/CNA said the following: -Gloves should be changed after each resident contact and hands washed; -He/she does not know why he/she did not remove his/her soiled gloves and apply a different pair after washing his/her hands. 11. During an interview on 2/25/22 at 8:30 A.M., the Director of Nursing said the following: -She would expect all staff to wash their hands when performing resident care; -She would expect all staff to wash their hands as much as needed; -She would expect all staff to wash their hands between a contaminated task and a clean task. 12. Review of the facility policy, Legionella Policy and Water Management, revised January 2021, showed the following: -The facility is committed to the prevention, detection and control of water-borne contaminants; -1. As part of the infection prevention and control program, our facility has a water management program which is overseen by the maintenance department and the water management team; -The water management team: a. Administrator; b. Maintenance; c. Director of Nursing; d. Medical Director; -2. The team is to identify areas in the water system where Legionella can grow and spread in order to reduce the risk of Legionnaire's disease; -3. The CDC water prevention toolkit and ASHRAE recommendations have been used in developing a water management program; -4. A detailed description and diagram of the water system in the facility will include: a. Water intake-come from the city; b. Cold water delivery-chillers; c. Heating-boilers; d. Hot water delivery-hot water heaters; e. Waste-out to sewer; -5. Identification of areas in the water system that could encourage the growth and spread of Legionella include: a. Water heaters; b. Filters; c. Showerheads; d. Hoses; e. Personal humidifiers; f. Medical machines such as CPAP; -6. Situations that could arise and lead to Legionella: a. Construction; b. Water main breaks; c. Changes in water source; d. Scale or sediment and stagnation; e. Water temperatures; f. Water pressure; g. Inadequate disinfection. -7. Measures used to control the spread of Legionella: a. Diagram of where control measures are applied; b. Monitor control limits; c. Documentation of the program; -8. The Water Management Program will be reviewed at least annually or as needed: a. The control limits are consistently not met; b. A major maintenance project; c. Water service change; d. Any diagnosis of disease associated with the water system. Record review showed no evidence facility staff identified areas in the water system where Legionella can grow and spread in order to reduce the risk of Legionnaire's disease according to their policy. During interview on 2/23/22 at 11:40 A.M., the Maintenance Supervisor said the following: -He has worked in the facility for three years and has been the Maintenance Supervisor for one year; -He does not do anything in regards to monitoring for Legionella. He was never told to do it. During interview on 2/23/22 at 5:00 P.M., the administrator said the Maintenance Supervisor was responsible for the water management program. MO00171180 MO00171181 MO00172908

Based on observation, interview, and record review, the facility failed to maintain the wireless call light system to ensure staff carried functioning pagers to alert them to residents' calls for staff assistance. The facility census was 55. Review of the facility policy, Policy and Procedure for Call Light System, updated January 2022, showed the following: -The facility will maintain a call light system in the facility for all residents and staff members to use for assistance and/or emergencies; -All nursing staff will be educated and trained on constant checking of the monitors to ensure call lights are being answered timely and that each resident has their call light within reach of using; -The system will allow each charge nurse or Special Care Unit (SCU) supervisor to carry beepers with them while on duty during their shift; -The beepers will alert the charge nurse immediately when assistance is needed; -Computer monitors are also displayed at each nurse's station as well on the East and [NAME] halls for a visual alert for CNAs to see, in order to know which room has called for assistance; -The first initial green light call which will alert staff when a resident has called for assistance and will go directly to the charge nurse beepers; -If this call is not answered within three minutes, a second call or yellow call will go to the charge nurse or SCU supervisor that this light has not been answered; -At five minutes, a red call signal will alert the charge nurse or SCU supervisor, displaying a resident has had their call light on for at least a total of eight minutes; -These calls will also be displayed on the computer monitor according to color; -Each charge nurse's cart will have a supply of batteries for the beepers; -The call light system will be tested weekly to ensure proper working condition; -If a charge nurse leaves the hall for any reason, the beeper will be passed off to the medication technician on duty or the charge nurse or supervisor in the facility, and that staff member will be in charge of ensuring CNAs are answering call lights in a timely manner; -If a call light is not working properly and cannot be fixed immediately, the resident will be temporarily moved to another room where the call light is functioning properly; -Staff is to notify the Director or Nursing (DON) and administrator of the faulty call light; -The DON and/or administrator have the ability to run a report to monitor the time and effectiveness of the call light system for all units of the facility. 1. Observation and interview on 2/16/22 at 6:15 A.M., showed the following: -A buzzing/vibrating sound at the nurses station; -Certified Medication Technician (CMT) I said the vibrating sound was the call light pager that was on the desk somewhere. The call light pager sounds when the call lights are in overtime; -Observation showed CMT I pushed a medication cart down the hall. Neither CMT I or any other staff responded to the call light pager. 2. Observation on 2/23/22 at 9:38 A.M., showed the call light pager vibrated as it sat on the nurses station desk. Additional observation showed no staff at the desk to acknowledge the call light pager. 3. Observation on 2/23/22 from 5:39 P.M. to 5:46 P.M., at the west nurses' desk showed a pager sat on the nurses desk. No staff were present in the area. 4. Observation on 2/23/22 at 6:48 P.M., at the west nurses' desk showed a pager sat on the nurses desk. The pager vibrated on the desk. No staff were present in the area. During interviews on 2/16/22 at 4:30 P.M. and 2/23/22 at 12:15 P.M., CNA K said the following: -The staff used to have pagers, but they came up missing one day and staff just don't have them anymore; -The wireless call light does not turn on the light over the resident's door; -The only way staff can tell a call light has been turned on is by looking at the monitor; -There was no audible noise when a call light is on; -For the 200 hall, monitors are at the end of the hall between 200 and 300 hall and there is one at the nurses desk; -Staff do not know if call lights are on if they are in a resident room or giving a shower; -If the call light goes to overtime it rolls over to the pager the charge nurse or the administrator had. During an interview on 2/23/22 at 10:00 A.M., Licensed Practical Nurse (LPN) A said the following: -CNA's used to have pagers to carry for the call light system; -The facility can not get pagers anymore; -Now there are just a few pagers that vibrate when a call light goes into overtime; -The charge nurse tried to carry the pager, or someone in administration will help and carry the pager; -A staff member was expected to have to pager to answer the call lights in overtime or make the CNAs aware of the call light. During an interview on 2/22/22 at 1:28 P.M., the DON said all staff used to have pagers that alerted them when a resident's call light was on. She was not sure why they don't all have them anymore. Now the staff have to go to the monitors and check them to see when a call light was on. During interviews on 2/23/22 at 5:00 P.M. and 2/25/22 at 8:30 A.M., the administrator said the following: -Each charge nurse should carry a pager; -The charge nurses should have the pagers near them; -The call light system was not audible; -When a call light is on, it is visible on the monitors and at the nurses desk; -The CNA staff used to carry the pagers; -Some of the pagers were broken and the CNA staff were not using them consistently; -The pagers were very expensive to replace; -She did not know what the requirements were for the facility's call light system in regards to their exception granted by the Department of Health and Senior Services. MO 001742100

Based on observation, interview and record review, the facility failed to ensure staff provided services that met professional standards of quality for medication administration for one additional resident (Resident #1). The facility census was 80. 1. Review of the undated facility policy, titled Guidelines for Insulin and Blood Glucose Monitoring showed the following: -See the following page for insulin administration guidelines (there were no additional pages); -The policy did not address how to prepare insulin for administration. 2. Review of the website, www.levemir.com, showed the following: -Keep the insulin pen at room temperature and not refrigerated; -Do not store the insulin pen that you are using in the refrigerator; -Wipe the port of the insulin pen with an alcohol wipe; -Screw the pen needle firmly onto the pen; -Dial up two units on the pen; -Point the pen needle up towards ceiling and tap on it gently; -Press button on bottom all the way; -If necessary, repeat until you see a drop of insulin come out. 3. Review of Resident #1's July 2019 Physician Order Sheet (POS) showed the following: -Diagnoses included diabetes; -Levemir (long acting medication used to treat diabetes) 10 units (U), scheduled for 6:00 A.M. to 11:00 A.M. Observation on 07/10/19 at 8:02 A.M. showed the following: -Registered Nurse (RN) G removed the resident's open, in use Levemir insulin pen from the refrigerator; -RN G did not clean the port of the insulin pen and applied the needle; -RN G did not prime the insulin pen; -RN G turned the dial to 10 and administered the insulin to the resident; -RN G returned the resident's Levemir insulin pen to the refrigerator. During interview on 07/10/19 at 8:44 A.M., RN G said the following: -The port of the insulin pen should have been cleaned with an alcohol wipe; -No one had told him/her to prime the insulin pen before administering the insulin; -He/She thought all insulin was to be refrigerated. During interview on 07/11/19 at 4:30 P.M., the Director of Nursing said the following: -Staff should clean the end of the insulin pen off with alcohol before putting the needle on the insulin pen; -She was not aware staff should prime the insulin pen prior to administering the insulin; -She was not aware Levemir insulin was not to be refrigerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a policy and procedure, based on current standards of practice, to address the care of residents receiving dialysis services. The facility failed to monitor the dialysis access sites for one resident (Resident #4), in a review of 18 sampled residents, and for one additional resident (Resident #57) according to standards of practice. The facility identified two residents received dialysis services. The facility census was 80. 1. During interview on 7/11/19 at 5:10 P.M., the Administrator said the facility did not have a policy for monitoring residents receiving dialysis. 2. Review of Nursing Management: The Journal of Excellence in Nursing Leadership, October 2010, Volume 41, Issue 10, Caring for a Patient's Vascular Access for Hemodialysis showed the following: -A patient in end-stage kidney disease relies on dialysis to mechanically remove fluid, electrolytes, and waste products from the blood. For the most effective hemodialysis, the patient needs good vascular access with an arteriovenous (AV) fistula or an AV graft (access used to artificially connect a vein with an artery, so that a higher blood flow is created to allow blood to be pumped out of the body to an artificial kidney machine, and returned to the body by tubes that connect the patient to the machine) that provides adequate blood flow. Follow your facility's policies and procedures and these clinical tips to protect and preserve the vascular access and avoid complications such as infection, stenosis, thrombosis, and hemorrhage: -Assess for patency at least every eight hours. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Auscultate the vascular access with a stethoscope to detect a bruit or swishing sound that indicates patency. -Check the patient's circulation by palpating his/her pulses distal to the vascular access; observing capillary refill in his/her fingers; and assessing him/her for numbness, tingling, altered sensation, coldness, and pallor in the affected extremity. -Assess the vascular access for signs and symptoms of infection such as redness, warmth, tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney disease are at increased risk of infection. -After dialysis, assess the vascular access for any bleeding or hemorrhage. 3. Review of the Resident #4's July 2019 physician's order sheets (POS) showed the following: -Diagnoses included end stage renal disease (complete failure of the kidneys) and dependence on renal dialysis; -Resident has dialysis fistula, left arm, scheduled every day for 6:00 A.M. to 2:00 P.M., 2:00 P.M. to 10:00 P.M. and 10:00 P.M. to 6:00 A.M. (the order was not specific as to what was to be done at these times). Review of the resident's care plan, dated 12/27/18, showed the following: -Diagnoses included renal disease: -The resident was on dialysis; -The resident attended a dialysis clinic three times per week; -Staff were to monitor access site daily for signs and symptoms of infection (redness, warmth, swelling, etc); -Staff were to monitor hemodialysis (HD; process of purifying the blood of a person whose kidneys are not working normally) site for thrill and bruit (important sound and indicator of how well the dialysis fistula is functioning). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 6/25/19 showed the following: -Cognitively intact; -The resident received dialysis. Review of the resident's July 2019 Medication Administration Record (MAR) showed the following: -Resident has dialysis fistula, left arm; -Staff documented their initials in the time boxes for 6:00 A.M. to 2:00 P.M. for 07/01/19 through 07/11/19; -Staff documented their initials in the time boxes for 2:00 P.M. to 10:00 P.M. for 07/01/19 through 07/11/19; -There was no time boxes for 10:00 P.M. to 6:00 A.M.; -It was not clear what action staff was performing related to the dialysis fistula. Review of the resident's medical record showed the following: -No documented daily assessments of the resident's dialysis shunt/fistula; -No documented assessment of the resident's dialysis shunt/fistula when he/she returned from dialysis. During an interview on 7/11/19 at 2:44 P.M. and 7/17/19 at 5:00 P.M., Licensed Practical Nurse (LPN) Y said the following: -The resident received dialysis treatments; -He/She was not aware of any specific assessments of the resident's dialysis shunt/fistula completed daily or when the resident returned from dialysis; -He/She documented his/her initials on the resident's MAR for the 2:00 P.M. to 10:00 P.M. shift on 07/01/19, 07/02/19, and 07/07/19, and for the 6:00 A.M. to 2:00 P.M. shift on 07/07/19; the documentation just showed he/she was aware the resident had a fistula; -He/She did not complete assessments or observations of the resident's access site. During interview on 7/11/19 at 3:00 P.M., Certified Medication Technician (CMT) Z said the following: -The resident attended dialysis three days a week; -When the resident returned from dialysis, he/she had not been told he/she needed to notify the nurse so an assessment could be completed; -He/She had not seen a nurse complete an assessment on the resident regarding his/her dialysis for several months. 4. Review of Resident #57's care plan, dated 10/08/14, showed the following: -The resident was on dialysis; -The resident attended a dialysis clinic weekly on Monday, Wednesday and Friday; -Staff was to monitor access site daily for signs and symptoms of infection (redness, warmth, swelling, etc); -Staff was to check the resident's occlusive dressing every shift to the permacath site (left groin) to make sure it is intact; reinforce or change as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No documentation to show the resident received dialysis. Review of the resident's July 2019 POS showed the following: -Diagnoses included hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, kidney failure, dependence on renal dialysis, sepsis (life-threatening condition that arises when the body's response to infection causes injury to its own tissues) due to staphylococcus (bacterial infection), bacteremia (presence of bacteria in the blood stream) and human herpes virus infection (viral infection); -The resident had a permacath (insertion is the placement of a special IV line into the blood vessel, threaded into the right side of the heart, used for dialysis treatments); -Check the occlusive dressing every shift to the permacath site (left groin) to make sure it is intact; reinforce or change as needed, scheduled for every day, 6:00 A.M. to 2:00 P.M., 2:00 P.M. to 10:00 P.M. and 10:00 P.M. to 6:00 A.M. Review of the resident's July 2019 Medication Administration Record (MAR) showed no documentation staff monitored the resident's permacath for signs and symptoms of infection. Review of the resident's July 2019 Ancillary MAR showed the following: -Check occlusive dressing every shift to permacath site (left groin) to make sure it stays intact. Reinforce or change as needed, scheduled for 6:00 A.M. to 2:00 P.M., 2:00 P.M. to 10:00 P.M. and 10:00 P.M. to 6:00 A.M.; -Staff documented they checked the dressing daily. LPN Y documented his/her initials on 7/12/19 for the 10:00 P.M. to 6:00 A.M. shift and 7/15/19 for the 2:00 P.M. to 10:00 P.M. shift. During an interview on 7/11/19 at 2:44 P.M. and 7/17/19 at 5:00 P.M., LPN Y said the following: -The resident received dialysis treatments; -He/She was not aware of any specific assessments of the resident's dialysis shunt/fistula completed daily or when the resident returned from dialysis; -He/She did not know if the resident had a permacath or fistula; -He/She documented he/she monitored the resident's dressing site and the dressing was intact, but he/she did not know what a permacath was or how the resident received dialysis. 5. During interview on 7/11/19 at 3:48 P.M. and 7/18/19 at 8:00 A.M., the Director of Nursing (DON) said the following: -Licensed staff should complete an assessment of residents that attend dialysis after they return from their treatments; -Care staff should notify the licensed staff when the residents return from dialysis so the nurses can assess the residents; -She expected staff to follow physician orders and care plans for monitoring and to document accordingly; -There was no specific form for monitoring. Staff should document on the MAR or in the progress notes. During interview on 7/11/19 at 5:10 P.M., the Administrator said the following: -She did not have any expectation of staff monitoring residents receiving dialysis; -She expected staff to follow physician orders.

Based on observation, interview, and record review, the facility failed to administer medications with an error rate of less than 5 percent (%) for two additional residents (Residents #11 and #49). There were 36 opportunities for error with two errors, which resulted in an error rate of 5.56%. The facility census was 80. 1. Review of the facility policy, dated 12/12/2012, titled Administration of medication, showed the following: -All medications are administered safely and appropriately to overcome illnesses, relieve symptoms and help in diagnoses; -Wash hands before and after each administration of medication; -Check Medication Administration Record (MAR); -Read each order entirely; -Remove each medication from drawer. Read label three times: when removing from drawer, before pouring and after pouring. 2. Review of the Level I Medication Aide Student Manual, dated February 1998, Lesson 10, Unit IV Preparation and Administration, Outline II, D. Compare label of medication bottle or unit dose package with the medication card or medication sheet - information must match. 1. Check the resident's name, 2. Check the name of the drug, dosage form and designated route of administration, 3. Check the expiration date, 4. Check the label three times, compare with the Medication Administration Record (MAR); they must match, a. check when taking medication from storage, b. check before removing medication from the package, c. check when returning medication to storage. Review of the Level I Medication Aide Student Manual, dated February 1998, Lesson plan 10, unit IV preparation and administration, Outline VI Seven Rights of Medication Administration, To avoid medication errors, remember the 7 rights of medication administration. A. Right resident, B. Right drug, C. Right dosage form, D. Right dose, E. Right route, F. Right time, G. Right charting. 2. Review of Resident #11's July 2019 Physician Order Sheets (POS), showed the following: -Diagnoses included Parkinson's disease (degenerative disorder of the central nervous system that affects motor development); -Valporic acid (medication used for the treatment of convulsions, migraines and bipolar disorder) 250 milligrams (mg)/5 milliliters (ml), give 2.5 ml twice daily, scheduled for 6:00 A.M. to 11:00 A.M. Observation on 7/10/19 at 6:45 A.M. showed the following: -Certified Medication Technician (CMT) H removed the resident's pharmacy bottle of valporic acid from the medication cart; -CMT H prepared a 5 ml dose of the resident's valporic acid in a plastic measuring cup; -The surveyor had to stop CMT H from administering an over dose of the resident's valporic acid to the resident. During interview on 7/10/19 at 6:48 A.M., CMT H said the following: -He/She did not realize the dose of valporic acid to be administered was 2.5 ml; -He/She must have read the label wrong when he/she saw the 5 ml on the label. During interview on 7/17/19 at 9:35 A.M. the resident's physician said the following: -He expected staff to follow physician orders; -If staff continued to administer an over dose of the medication, it could cause the resident to be lethargic and have an elevated blood level which would not be therapeutic. 3. Review of Resident #49's Physician Order Sheets (POS), dated July 2019, showed the following: -Diagnoses included cognitive communication deficit and heartburn; -Omeprazole (a medication used to treat conditions caused by stomach acid such as heartburn. A type of drug that blocks stomach acid. Should be given on a empty stomach) 20 mg capsule delayed release. Give one capsule by mouth once daily before meals. Observation on 7/10/19 at 6:46 A.M., showed the following: -CMT S prepared the resident's medication; -The resident sat at the dining room table eating; -CMT S gave the resident omeprazole 20 mg while the resident was eating; -The resident ate sausage, scrambled eggs, and pancakes. During an interview on 7/10/19 at 6:49 A.M., CMT S said the following: -Omeprazole was for acid reflux; -Omeprazole was supposed to be given before meals so the medication had time to coat the stomach prior to anything else; -He/She was running behind but normally gave the resident all his/her medications at once. 4. During interview on 7/11/19 at 5:00 P.M. the Director of Nursing (DON) said the following: -She would expect staff to follow physician orders; -If the physician ordered a medication to be given prior to meals staff should give the medication prior to meals; -She would expect staff to check the medication administration record and label of the medication and make sure given the correct amount prior to administration; -She would expect staff to ask questions if they were unsure about any medications. During interview on 7/11/19 at the Administrator said she would expect staff to follow physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accurately label insulin to facilitate consideration of precautions and safe administration for one additional resident (Resident #1). The facility census was 80. 1. Review of the undated facility policy, titled Guidelines for Insulin and Blood Glucose Monitoring did not address how to properly handle or store insulin products. 2. Review of Resident #1's [DATE] Physician Order Sheet (POS) showed the following: -Diagnosis included diabetes; -Obtain blood sugar (a finger stick procedure to determine the amount of sugar in the blood) twice daily, scheduled for 6:00 A.M. to 9:00 A.M. and 7:00 P.M. to 9:00 P.M.; -Novolog (short acting medication used to treat diabetes) per sliding scale (an amount determined based on the results of the blood sugar check), 0 units (U) if blood sugar is 0 - 150, 2 U if blood sugar is 151 - 200, 4 U if blood sugar is 201 - 250, 6 U if blood sugar is 251 - 300, 8 U if blood sugar is 301 - 350, notify physician if blood sugar is less than 70 or greater than 350. Review of the resident's [DATE] Medication Administration Record (MAR) showed the following: -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 192; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 160; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 159; staff documented administering the resident 4 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 151; staff documented administering the resident 2 U of Novolog insulin. Review of the resident's [DATE] POS showed the following: -Obtain blood sugar twice daily, scheduled for 6:00 A.M. to 9:00 A.M. and 7:00 P.M. to 9:00 P.M.; -Novolog per sliding scale, 0 U if blood sugar is 0 - 150, 2 U if blood sugar is 151 - 200, 4 U if blood sugar is 201 - 250, 6 U if blood sugar is 251 - 300, 8 U if blood sugar is 301 - 350, notify physician if blood sugar is less than 70 or greater than 350. Review of the resident's [DATE] MAR showed the following: -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 166; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 195; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 176; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 6:00 A.M. to 9:00 A.M. the resident's blood sugar was 162; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 171; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 156; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 204; staff documented administering the resident 4 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 152; staff documented administering the resident 2 U of Novolog insulin. Review of the resident's [DATE] POS showed the following: -Obtain blood sugar twice daily, scheduled for 6:00 A.M. to 9:00 A.M. and 7:00 P.M. to 9:00 P.M.; -Novolog per sliding scale, 0 U if blood sugar is 0 - 150, 2 U if blood sugar is 151 - 200, 4 U if blood sugar is 201 - 250, 6 U if blood sugar is 251 - 300, 8 U if blood sugar is 301 - 350, notify physician if blood sugar is less than 70 or greater than 350. Review of the resident's [DATE] MAR showed the following: -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 174; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 160; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 153; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 6:00 A.M. to 9:00 A.M. the resident's blood sugar was 156; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 185; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 225; staff documented administering the resident 4 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 178; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 219; staff documented administering the resident 4 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 177; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 172; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 166; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 6:00 A.M. to 9:00 A.M. the resident's blood sugar was 186; staff documented administering the resident 2 U of Novolog insulin. Review of the resident's [DATE] POS showed the following: -Obtain blood sugar twice daily, scheduled for 6:00 A.M. to 9:00 A.M. and 7:00 P.M. to 9:00 P.M.; -Novolog per sliding scale, 0 U if blood sugar is 0 - 150, 2 U if blood sugar is 151 - 200, 4 U if blood sugar is 201 - 250, 6 U if blood sugar is 251 - 300, 8 U if blood sugar is 301 - 350, notify physician if blood sugar is less than 70 or greater than 350. Review of the resident's [DATE] MAR showed the following: -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 185; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 189; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 179; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 176; staff documented administering the resident 2 U of Novolog insulin; -On [DATE] at 7:00 P.M. to 10:00 P.M. the resident's blood sugar was 226; staff documented administering the resident 4 U of Novolog insulin. Observation on [DATE] at 7:10 A.M. of the medication room refrigerator showed the following: -An open, in use Novolog insulin vial for the resident in a plastic drinking cup (there was no pharmacy provided box with labeling or dispense date); -Written on the vial was an open date of [DATE] (the open date on the vial to the date of inspection was 119 days). Review of the manufacturer's information for Novolog insulin suggests after opening a vial or pen of Novolog, throw away an opened vial or pen after 28 days of use, even if there is insulin left in the vial or pen. (per the manufacturer's suggestion, the insulin should have been discarded on [DATE]). During interview on [DATE] at 8:44 A.M., Registered Nurse (RN) G said the following: -Nurses should label insulin when opened because insulin was only good for 28 days after it had been opened; -He/She did not know why the insulin had not been discarded because based on the written open date, the insulin was expired. During interview on [DATE] at 10:02 A.M., RN R said evening shift nurses were responsible for monitoring the insulin open dates and to discard if they were expired. During interview on [DATE] at 4:30 P.M., the Director of Nursing said the following: -Insulin should be dated when the vials and/or pens were opened; -She expected staff to document the open date on the vial and/or pen; -She expected staff to follow the manufacturer's suggested discard time frame and discard any expired insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided four residents (Residents #33, #51, #134 and #70), in a review of 18 sampled residents, and one additional resident (Resident #71), who were unable to perform their own activities of daily living, the necessary care and services to maintain good oral hygiene. The facility census was 80. 1. Review of the facility policy, Guidelines for Providing Resident Care, dated 12/12/12, showed the following: -All residents unable to adequately do activities of daily living (ADLs) are to have assistance with brushing their teeth, combing hair, and washing peri-area (genitals) each A.M.; -Residents who are nothing by mouth (NPO), must be given oral care a minimum of every four hours. 2. Review of the Nurse Assistant in a Long-Term Care Facility manual, 2001 revised edition, showed the following: -A clean mouth and properly functioning teeth are essential for physical and mental well-being of the resident. Oral hygiene prevents infections in mouth, removes food particles and plaque, stimulates circulation of gums, eliminates bad taste in mouth; thus food is more appetizing; -Give oral care before breakfast, after meals, and also at bedtime; -Specific observations to make: tooth decay, any loose or broken teeth, red or swollen gums, sores or white patches in the mouth or on the tongue, changes in eating habits, and poorly fitting dentures. 3. During a group interview on 7/09/19 at 1:25 P.M., 12 cognitively intact residents said the following: -They felt rushed by staff with personal cares; -Their teeth did not always get brushed. 4. Review of Resident #70's care plan, dated 3/18/15, showed the following: -The resident had impaired level of cognitive function due to Alzheimer's disease; -Requires extensive assistance with personal hygiene; -Oral care twice daily and as needed; -Resident was edentulous (lacking teeth); -Chapstick applied to lips twice daily for maintenance. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/11/19, showed the following: -Rarely or never understood or made needs known -Totally dependent on one staff for personal hygiene. Observation on 7/08/19 at 2:24 P.M. showed the following: -The resident lay in his/her bed; -Certified Nurse Assistant (CNA) W entered the resident's room to provide care; -The resident's lips were dry and flaky; -CNA W did not provide oral care or apply Chapstick to the resident's lips. Observation on 7/9/19 at 8:20 A.M., showed the following: -The resident lay in his/her bed; -Nurse Assistant (NA) J entered the resident's room to provide care and get the resident up for breakfast; -The resident's lips were dry and flaky; -NA J did not provide oral care, or apply Chapstick to the resident's lips. During interview on 7/9/19 at 8:45 A.M., NA J said he/she did not know where the supplies were to perform the resident's oral care. During interview on 7/11/19 at 3:00 P.M., Certified Medication Technician (CMT) H said the following: -He/She did not know anything about applying Chapstick to the resident's lips for maintenance; -He/She did not know if the resident had any Chapstick available. 4. Review of Resident #71's care plan, dated 6/19/18, showed the following: -The resident had dementia; -He/She required extensive assistance with all ADLs, including personal hygiene; -Set up and assist with oral care twice daily and as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively impaired; -Required extensive assistance from one staff for personal hygiene. Observation on 7/10/19 at 7:44 A.M. showed the following: -The resident lay in his/her bed; -CNA W entered the resident's room to provide care and get the resident up; -The resident's lips were dry and flaky; -CNA W did not provide oral care. During interview on 7/08/19 at 2:30 P.M. and 7/10/19 at 8:00 A.M., CNA W said the following: -Staff should provide oral care in the mornings and at night; -He/She should have assisted the resident with oral care. 5. Review of Resident #33's care plan, revised 4/12/19, showed the following: -The resident had severe cognitive impairment; -The resident will have needs and preferences met on a daily basis; -The resident requires extensive assistance with personal hygiene; -The resident has his/her own teeth. Provide oral care twice a day and as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Short and long-term memory problems; -Cognition for daily decision making severely impaired; -Requires extensive assistance of one staff for personal hygiene. Observation on 7/8/19 at 3:25 P.M. showed the resident lay in his/her bed. His/her mouth was dry. A white substance was noted around his/her lips and particles were present on his/her teeth. Observation on 7/10/19 at 7:46 A.M. showed the following: -CNA AA and CNA BB assisted the resident with morning cares, dressed the resident, and transferred him/her to his/her wheelchair; -CNA AA took the resident out of the room and to the hallway; -CNA AA and CNA BB did not provide oral care before taking the resident out of the room. During an interview on 7/11/19 at 10:22 A.M., CNA AA said he/she normally brushes the resident's teeth when he/she gets residents up in the morning. He/She did not brush the resident's teeth yesterday morning. 6. Review of Resident #51's quarterly MDS, dated [DATE], showed the following: -Cognition intact; -Required extensive assistance of two staff for personal hygiene. Review of the resident's care plan, revised 6/7/19, showed the following: -The resident requires assist with most ADLs; -Encourage participation in ADL care; -The resident requires extensive assistance with personal hygiene. Observation on 7/10/19 at 8:15 A.M. showed the following: -The resident lay in his/her bed; -CNA O and CNA P assisted the resident with morning cares, dressed the resident, and transferred him/her to his/her wheelchair; -CNA O took the resident out of the room and to the dining room; -CNA O and CNA P did not provide oral care before taking the resident out of the room. During an interview on 7/11/19 at 9:28 A.M., CNA O said he/she did not brush the resident's teeth yesterday. During an interview on 7/11/19 at 9:30 A.M. CNA P said he/she did not brush the resident's teeth yesterday. 7. Review of Resident #134's discharge MDS, dated [DATE], showed the following: -Cognition intact; -Required extensive assistance from two staff for personal hygiene. Review of the resident's care plan, dated 7/5/19, showed the resident required assistance with personal hygiene. Observation on 7/10/19 at 7:11 A.M. showed the following: -The resident lay in his/her bed; -CNA O and CNA P assisted the resident with morning cares, dressed the resident, and transferred him/her to his/her wheelchair; -CNA O took the resident out of the room and to the dining room; -CNA O and CNA P did not provide oral care before taking the resident out of the room. During an interview on 7/11/19 at 9:28 A.M., CNA O said he/she did not brush the resident's teeth yesterday. During an interview on 7/11/19 at 9:30 A.M. CNA P said he/she did not brush the resident's teeth yesterday. 8. During interview on 7/11/19 at 3:50 P.M., the Director of Nursing (DON) said the following: -Staff should provide oral care to residents when getting the resident up for the day, after meals and at bedtime; -Staff should provide oral care to dependent residents every two hours. During interview on 7/11/19 at 5:15 P.M., the Administrator said staff should provide oral care to residents in the mornings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure six nurse aides (NA) (NA T, NA I, NA U, NA J, NA K and NA V), of 13 sampled NAs completed a nurse aide training program within four months of employment in the facility as a nurse aide. The facility census was 80. 1. Review of the facility employee roster on [DATE] showed NA T, NA I, NA U, NA J, NA K and NA V were current employees. 2. Review of the undated facility policy, titled Nurse Aide Qualifications and Training Requirements, showed the following: -Nurse aides must undergo a state-approved training program; -Nurse aide is defined as an individual providing nursing or nursing-related services to residents in the facility who are not licensed health professionals, registered dietitians, or someone who volunteers to provide such services without pay; -The facility will not use an individual as a nurse aide for more than four months full time, temporary, per diem, or other basis unless that individual is competent to provide nursing and nursing related service or has completed a training program and competency evaluation program or a competency evaluation program approved by the state. 3. Record review of NA J's employee file showed the following: -His/Her date of hire was [DATE]; -There was no documentation NA J had completed the nurse aide training program. Observations on [DATE] at 12:25 P.M. showed NA J working, providing direct care to residents in the facility. During interview on [DATE] at 12:30 P.M. NA J said the following: -He/She had worked at the facility for four months; -He/She was currently in CNA classes; -He/She was not scheduled to test until sometime in August. Review of the state agency CNA registry for NA J on [DATE] showed the following: -CNA certification on [DATE], expired on [DATE]; -No documentation NA T was certified as a CNA (six months and 15 days from the date of hire). 4. Record review of NA K's employee file showed the following: -His/Her date of hire was [DATE]; -There was no documentation NA K had completed the nurse aide training program. Review of the state agency CNA registry for NA K on [DATE] showed no documentation NA K was certified as a CNA (seven months and 29 days from the date of hire). 5. Record review of NA V's employee file showed the following: -His/Her date of hire was [DATE]; -There was no documentation NA V had completed the nurse aide training program. Review of the state agency CNA registry for NA V on [DATE] showed no documentation NA V was certified as a CNA (six months and 16 days from the date of hire). 6. Record review of NA U's employee file showed the following: -His/Her date of hire was [DATE]; -There was no documentation NA U had completed the nurse aide training program. Review of the state agency CNA registry for NA U on [DATE] showed no documentation NA U was certified as a CNA (four months and 21 days from the date of hire). 7. Record review of NA T's employee file showed the following: -His/Her date of hire was [DATE]; -There was no documentation NA T had completed the nurse aide training program. Review of the state agency CNA registry for NA T on [DATE] showed no documentation NA T was certified as a CNA (four months and five days from the date of hire). 8. Record review of NA I's employee file showed the following: -His/Her date of hire was [DATE]; -There was no documentation NA I had completed the nurse aide training program. Observations on [DATE] at 1:25 P.M. showed NA I working, providing direct care to residents in the facility. Review of the state agency CNA registry for NA I on [DATE] showed no documentation NA I was certified as a CNA (four months and five days from the date of hire). During interview on [DATE] at 2:00 P.M. NA I said the following: -He/She had worked at the facility for four months; -He/She was currently in CNA classes; -He/She was not scheduled to test until sometime in August. During interview on [DATE] at 3:48 P.M., the Director of Nursing (DON) said the following: -She knew NAs were to be certified within four months of hire; -She provided the training and was responsible for overseeing the certifications; -Staffing had been an issue recently and sometimes they had to cancel class and have the NAs working instead of attending class; -She was not aware the certifications were really behind. During interview on [DATE] at 5:15 P.M., the Administrator said the following: -The DON was responsible for ensuring NAs are certified within four months of hire; -She expected NAs to be certified within four months of hire; -She was not aware the certifications were behind or exceeded the four months from hire requirement.

Based on interview and record review, the facility failed to ensure Certified Nurse Aides (CNA) received the required annual 12 hours in-service education training. The facility census was 80. 1. During an interview on 7/16/19 at 2:00 P.M. the Administrator said the facility did not have a policy for CNA 12 hour training/documentation. 2. Review of CNA L's employee file showed the following: -Date of hire was 9/12/07; -No record of inservice education since his/her orientation at date of hire. 3. Review of CNA M's employee file showed the following: -Date of hire was 4/27/11; -No record of inservice education since his/her orientation at date of hire. 4. Review of CNA N's employee file showed the following: -Date of hire was 8/05/96; -No record of inservice education since his/her orientation at date of hire. During interview on 7/11/19 at 3:56 P.M. the Director of Nursing said the following: -She was not completing a performance review providing 12 hours of inservice education in a year for the staff; -The facility was not doing training with CNAs based on evaluations or for 12 hours annually; -He/She was new to the position and did not know the 12 hours inservice education was required; -The facility completes inservices, but they had been swamped, so not many had been done; -The facility did not track individual records of the inservices; -He/She could not remember when the last inservice that was held. During interview on 7/11/19 at 5:00 P.M. the Administrator said the facility provided inservices for staff but did not monitor the exact number of hours provided to each staff member.

Based on observation, interview, and record review, the facility failed to serve foods at an appetizing temperature. The facility census was 81. 1. During an interview on 07/08/19 at 03:09 P.M., Resident #50 said foods were not always served at the right temperatures. During an interview on 7/8/19 at 3:00 P.M., Resident #2 said food that was supposed to be hot was cold to lukewarm, and did not taste good. During a group interview on 7/09/19 at 1:25 P.M., Resident #37 said hot foods were served cold and cold foods were served at room temperature. Residents #17, #26, #2, #59 and #8 agreed with Resident #37. 2. Observation on 07/08/19 between 11:28 A.M. and 12:55 P.M. showed the following: -Staff served the lunch meal which included barbeque hamburgers and potato salad; -Staff placed individual bowls of potato salad on a serving tray on the counter by the silverware during the meal service. Staff served the potato salad prepared in individual bowls to the residents. (The potato salad was made with mayonnaise and milk base products). -At 12:55 P.M., review of the test tray, received after staff served the last resident, showed the temperature of the barbeque hamburger was 109 degrees Fahrenheit. The hamburger was cool to taste. The temperature of the potato salad was 60 degrees Fahrenheit. 3. Observation on 07/09/19 at 12:09 P.M. showed the following: -Staff served the lunch meal which included pork roast with gravy and chocolate refrigerator dessert. (The chocolate refrigerator desert was made with milk-based products); -At 12:09 P.M., review of the test tray, received after staff served the last resident, showed the temperature of the pork roast was 108 degrees Fahrenheit. The pork roast was cool to taste. The temperature of the chocolate refrigerator dessert was 60 degrees Fahrenheit. 4. During interview on 07/09/19 at 12:20 P.M., the dietary manager said the following: -The chocolate refrigerator desert was made with milk; -The potato salad was made with mayonnaise and milk; -Staff only took the temperatures of food before they served the meal; -She expected hot food to be at least 120 degrees Fahrenheit and the cold foods to be at least 41 degrees Fahrenheit at the time of service. She was not aware those temperatures were not being met. During interview on 07/09/19 at 12:37 P.M., the administrator said she expected the food temperatures at the time of meal service to meet regulation.

Based on observation and interview, the facility failed to follow proper sanitation and food handling practices in the kitchen. The facility census was 81. Observation on 07/08/19 between 11:25 A.M. and 4:24 P.M. showed the following: -The double convection ovens had a thick buildup of black debris on the bottom of each oven; -Dietary Staff F wrapped silverware in napkins for the supper meal, prepared the cold side of resident food trays, and delivered the trays to the dining room for staff to serve to the residents. He/She wore a ball cap on his/her head backwards. The sides and back of his/her longer hair were not covered. He/She also had a beard and did not wear a beard restraint. Observation on 07/09/19 at 7:02 A.M. showed the double convection ovens had a thick buildup of black debris on the bottom of each oven. During interview on 07/09/19 at 12:20 P.M., the dietary manager said there was a cleaning schedule on the refrigerator in the kitchen. The convection oven had not been cleaned since 06/04/19. She noticed on 07/08/19 the convection oven needed cleaned. Cleaning it just got put off. She expected staff to wear hair nets in the food preparation areas. During interview on 07/09/19 at 12:37 P.M., the administrator said she expected staff to clean the convection oven as often as needed so it did not get a buildup of debris. She expected staff to wear hair nets and beard restraints at all times when in the kitchen area during food service and in preparation areas. If a ball cap is worn, it is to be worn properly and hair is to be contained in the ball cap.

Based on observation, interview, and record review, the facility failed to follow infection control practices while performing blood glucose monitoring and during medication administration for three additional residents (Residents #1, #32, and #76). Staff failed to use a barrier during glucometer use, touched medications with bare hands and administered the contaminated medications and did not wash hands before preparing resident medications. The facility also failed to maintain and implement a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) and failed to provide documented assessments for such an outbreak. The facility census was 80. 1. Review of the facility's policy Checking Blood Sugars and Cleaning Glucometers, dated 11/05/12, showed to take a clean tray with paper towel on top with individual resident's supplies into the resident's room. The glucometer should be obtained from the resident's drawer, removed from plastic container, and placed on a paper towel; 2. Review of the facility's policy Administration of Medication, dated 12/12/12, showed staff were to wash hands before and after each administration of medication. 3. Review of the Certified Medication Technician (CMT) manual, revised 2008, showed the following: -When preparing tablets and capsules from a bubble card or other container, punch or pour directly into the medication cup; -Hand hygiene is the most effective method of preventing the spread of infection. -Perform hand hygiene before and after contact with each resident. -When giving the medication cup to the resident, remember if your hands have contact with the resident, your hands must be washed before you give medication to the next resident. Alcohol gel is a good substitute for cleaning your hands if you are not near a sink. 4. Record review of the undated facility policy, ICC Prevention and control of Legionnaire's Disease, showed the following: -The facility was to conduct an environmental assessment of the facility's water system; -The assessment was to include facility characteristics, hot and cold water supplies, cooling and air handing systems and any chemical treatment systems; -The documentation should be reviewed on a periodic basis to ensure it is consistent with current standards of practice; -Store and distribute potable cold water at less than 68 degrees; -Store hot water above 140 degrees; -Legionella bacteria occur commonly in nature and can be found in all natural water sources; -The facility will produce a suitable and sufficient written assessment that identified the risk of exposure and any necessary precautionary measures; -The facility will review the assessment on regular periods not to exceed 24 months or whenever there is reason to believe that the original assessment not longer be valid. The facility was unable to provide documentation that showed implementation of a comprehensive assessment and/or water testing program. During an interview on 7/8/19 at 11:05 A.M., the administrator said the following: -She was responsible for the Legionella policy; -The facility used a city water source for the facility; -The facility had tested the water in the facility, because as far as she was aware, the facility was not at risk for Legionella. 5. Review of Resident #1's July 2019 Physician Order Sheets (POS) showed the following: -Diagnosis of diabetes; -Accuchecks (a finger stick procedure where a droplet of blood is obtained for testing to determine the amount of sugar in the blood) twice daily, scheduled for 6:00 A.M. to 9:00 A.M. Observation on 07/10/19 at 7:52 A.M. showed the following: -Registered Nurse (RN) A entered the resident's room with supplies to complete the resident's accucheck; -RN A sat the supplies directly on the resident's bedside table without a barrier while he/she washed his/her hands; -RN A cleaned the resident's finger with an alcohol pad, stuck the resident's finger with the lancet (finger stick device), obtained a blood droplet from the resident's finger and applied the blood droplet on the test strip in the glucometer for testing; -After obtaining the blood glucose reading, RN A removed the blood filled test strip from the glucometer and placed the glucometer directly on the resident's counter without a barrier while he/she washed his/her hands; -RN A returned to the nursing station, sat the glucometer directly on the medication cart without a barrier. 6. Review of Resident #32's July 2019 POS showed the following: -Diagnosis of diabetes; -Accuchecks weekly on Monday. Observation on 07/10/19 at 7:45 A.M. showed the following: -RN A sat the supplies to complete the resident's accucheck directly on the dining room table without a barrier while he/she spoke to the resident and explained the procedure; -RN A cleaned the resident's finger with an alcohol pad, stuck the resident's finger with the lancet (finger stick device), obtained a blood droplet from the resident's finger and applied the blood droplet on the test strip in the glucometer for testing; -After obtaining the blood glucose reading, RN A removed the blood filled test strip from the glucometer and placed the glucometer directly on the dining room table without a barrier while he/she gathered the supplies to be discarded; -RN A returned to the nursing station, sat the glucometer down on the medication cart without a barrier. 7. Review of Resident #76's July 2019 POS showed the following: -Diagnosis of atrophy of the thyroid, hypothyroidism, hypertension (high blood pressure), dementia, Alzheimer's disease, gastro-esophageal reflux disease (GERD) (stomach disorder), macular degeneration (eye disorder), herpesviral vulvovagnitis (viral infection of the vulva and vagina) and pain; -Divalproex (medication used to treat seizure disorder and mood disorders) 125 milligrams (mg) daily, scheduled for 6:00 A.M. to 11:00 A.M.; -Acyclovir (an antiviral medication) 400 mg twice daily, scheduled for 6:00 A.M. to 11:00 A.M.; -Namenda (medication used to treat dementia) 10 mg twice daily, scheduled for 6:00 A.M. to 11:00 A.M.; -Ranitidine (an antacid) 150 mg twice daily with food, scheduled for 6:00 A.M. to 11:00 A.M.; -Levothyroxine (medication to treat hypothyroidism) 200 micrograms (mcg) daily, okay to administer with food, scheduled for 6:00 A.M. to 11:00 A.M.; -Tylenol X-Strength (pain medication) 500 mg, two tablets twice daily, scheduled for 6:00 A.M. to 11:00 A.M.; -Lisinopril (medication to treat high blood pressure) 10 mg daily, scheduled for 6:00 A.M. to 11:00 A.M.; -Occuvite with lutein (multi-vitamin to promote eye health) one tablet twice daily, scheduled for 6:00 A.M. to 11:00 A.M. Observation on 07/10/19 at 6:59 A.M. showed the following: -Certified Medication Technician (CMT) B did not wash or sanitize his/her hands; -He/she removed tablets of the following medications from the medication cards and placed them into a plastic medication cup. The medications included divalproex, acyclovir, Namenda, ranitidine, levothryoxine, Tylenol X-Strength, lisinopril, and Occuvite with lutein; -CMT B, with his/her bare hands, removed the divalproex capsule from the plastic medication cup, touching the other medications in the cup and the inner part of the plastic medication cup, and placed the capsule in a separate plastic medication cup; -CMT B placed the remaining medications in a plastic medication sleeve for crushing, crushed the medications and emptied the contents back into the medication cup; -CMT B, with his/her bare hands, removed the divalproex capsule from the plastic medication cup, opened the capsule and emptied the contents into the plastic medication cup with the crushed medications; -CMT B administered the medications to the resident. During interview on 07/10/19 at 08:45 A.M., CMT B said the following: -He/She was aware he/she was not to contaminate medications before administration to the residents; -He/She was aware he/she was to wash or sanitize his/her hands between resident medication administrations; -He/She did not realize he/she had forgotten to wash or sanitize his/her hands before preparing Resident #76's medications; -He/She did not think to place the resident's divalproex capsule in another medication cup or use a spoon to remove the capsule to prevent contaminating the remaining medications in the medication cup. 8. During interviews on 07/11/19 at 5:00 P.M. and 7/18/19 at 9:30 A.M., the Director of Nursing (DON) said the following: -She expected staff to use universal precautions and not to touch medications with their bare hands; -She expected staff to use a barrier, like paper towels, to set supplies on while testing resident's blood sugars.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an effective pest control program to address flies in the facility. The facility census was 80. 1. Review of the facility's pest control policy dated 10/10/19, showed the following: -The facility will maintain a clean, homelike, pest free facility; -The facility will obtain the services of a professional pest control to maintain the building; -Services will be provided monthly on the inside and twice a year on the outside and as needed; -If pest control services are needed more frequently than once per month, the administrator or maintenance department will be responsible to contact the company. 2. Review of the facility's pest and sanitation report book showed the following: -On 6/3/19 at 12:30 P.M. the pest control company came and sprayed for flies at the dumpsters, kitchen, and exit doors as a preventative treatment. Pest activity said non applicable (N/A). The maintenance director and pest control signed and dated the form; - On 7/2/19 at 12:30 P.M. the pest control company came and sprayed for flies at the dumpsters, kitchen, and dining as a preventative treatment. Pest activity said N/A. The maintenance director and pest control signed and dated the form. 3. Observation on 7/8/19 at 12:30 P.M. showed flies on the 200, 300, and 400 halls, around the nurses station, and in the west dining room. Observation on 07/08/19 at 2:41 P.M. of occupied resident room [ROOM NUMBER] showed several flies on the walls and ceiling. Observation on 07/08/19 at 2:45 P.M. of occupied resident room [ROOM NUMBER] showed two flies were observed on one table and three flies on a window seal near where the residents who occupied the room sat. Observation on 07/08/19 at 2:47 P.M. of occupied resident room [ROOM NUMBER] showed three flies landing on the bed and counter by sink. Observation on 07/08/19 at 3:23 P.M. of occupied resident room [ROOM NUMBER] showed multiple flies were noted flying or sitting on a table near the resident's television. Observation on 07/08/19 at 2:47 P.M. of occupied resident room [ROOM NUMBER] showed the following: -A fly landed on Resident #10's hand; -The resident batted the fly away. During interview on 07/08/19 at 2:49 P.M., Resident #10 said the following: -He/She frequently had to bat at flies to keep them away; -Flies were particularly bothersome during meals. During interview on 07/08/19 at 3:06 P.M., Resident #50 said flies were everywhere in his/her room. During group interview on 7/09/19 at 1:15 P.M., residents said the following: -Five flies were on the door frame of the exterior door leading to the smoking area; -Resident #55 said the flies at the facility were terrible; -Resident #37 said he/she had a fly swatter to kill the flies himself/herself; the therapy department used a salt gun to shoot at and kill flies in the therapy room; -Resident #82 said the flies were thick in his/her room and about the facility; -Resident #26 said the flies had been an issue for quite a while; -Resident #69 said he/she was not sure where the flies were coming from. Observation on 7/10/10 at 12:53 P.M. showed the following: -Resident #83 was incontinent of bowel; -Certified Nurse Aide (CNA) O and CNA P performed perineal and catheter care; -Two flies flew around the resident during cares and landed on the resident's head, legs, and hands; -A fly landed on CNA P's face; -CNA P swatted the flies away from the resident and him/herself. During interview on 7/10/19 at 12:55 P.M. CNA P said flies were a problem. Flies landed on residents, belongings in their rooms and food. Observation on 7/11/19 at 9:20 A.M. at the west nurses station showed the following: -Flies flew around the nurses' station; -An unidentified resident sat in a chair at the nurses' station; -Flies landed on the resident's face, hands and head. Observation on 07/11/19 at 9:25 AM showed the following: -A blue salt gun lay on the desk in therapy; -Multiple flies in the therapy room flying around staff and residents. During an interview on 7/11/19 at 9:25 A.M. physical therapist Q said the following: -He/She used the salt gun when residents were not in the therapy area; -Flies were an issue in the facility this summer. During interview on 711/19 at 10:03 A.M., Registered Nurse (RN) R said the following: -There are flies throughout the building; -The flies landed on the staff, the residents, and the residents' food. During interview on 7/11/19 at 9:53 A.M., the Maintenance Director said the following: -The facility changed their pest control company a couple months ago because they didn't feel the other company was doing any good; -The pest control company came to the facility monthly; -He/She had not called the pest control company to get extra help with the increased amount of flies in the facility; -He/She relied on the pest control company to determine the needs of the facility for pest and insects; -The facility had numerous flies but the facility was in the middle of the corn field and flies were going to be an issue. During interview on 7/16/19 at 3:50 P.M., the Administrator said the following: -She would expect the maintenance supervisor to call the pest control company for more frequent services if flies or any other pest were an issue; -If residents complained about flies or any other pest she would expect maintenance to get the pest control company to the facility to spray.