Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 9 residents (Resident #70) observed during medication administration. Failure to determine whether SAM is a safe practice has the potential to result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Self-Administration of Medications occurred on 03/27/25. This policy, revised May 2024, stated, . Missouri Slope is committed to respecting resident's rights to self-administer medication, after an interdisciplinary assessment, when and if they desire and are able to. In order to facilitate this each resident will be evaluated for their ability to do so safely. Review of Resident #70's medical record occurred on 03/26/25 and identified a physician's order for Genteal Tear Solution (artificial tears) 1 drop in both eyes twice a day. The current care plan stated, . [Resident name] has impaired cognitive function/dementia . moderate to severe cognitive impairment . has an ADL [activities of daily living] self-care performance deficit & limited physical mobility. Observation on 03/26/25 at 8:22 a.m. identified a medication aide (MA) asked Resident #70 if she had taken her eye drops. The resident replied Yes. When asked about the eye drops, the MA stated, The resident keeps them in her room and puts them in herself. The MA signed off the eye drops as administered in Resident #70's medication administration record (MAR). Resident #70's medical record lacked a SAM assessment and a provider order stating the resident may keep the eye drops at bedside. During an interview on 03/27/25 at 1:45 p.m., an administrative nurse (#1) confirmed the record lacked a SAM assessment for Resident #70's eye drops.

Based on observation, record review, policy review, professional reference, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 9 resident's observed during medication administration. Failure to document medications after administration, does not reflect the actual time of administration or any refusals which may cause adverse effects for the resident. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 836, stated, . Administering Medications Safely . Document medication administration after giving it, not before. Review of the facility policy titled Medication Administration occurred on 03/27/25. This policy, dated December 2024, stated, . Proper steps for identification of medication and identification of resident should be carried out each time medications are administered. Medications should not be pre-dished for future medication passes . Right documentation . - Observation on 03/26/25 at 8:09 a.m., identified a Medication Aide (MA) (#9) administered medications to a resident in the dining room. The MA (#9) returned to the medication cart and retrieved an unlabeled cup of medications from the top drawer. The MA stated, I usually dish medications right away for residents that have pills from the narcotic drawer. When asked what narcotic the MA dished the MA stated, Die-something. A review of Resident #45's medication record identified an order for Diphenoxylate/Atropine, a controlled medication for treatment of diarrhea. The MA took the unlabeled medication cup to Resident #45's room where the resident was in the bathroom. The MA returned to the cart with the medication cup and asked a nurse what she should do with them. The nurse stated, you have to hold onto them now until the resident is available. The MA (#9) returned to Resident #45's room, waited for the resident to be available, administered the medications, and returned to the cart. Observation of the medication administration record (MAR) identified the MA already documented the medication as administered prior to administering the medications. During an interview on 03/27/25 at 1:15 p.m., an administrative nurse (#1) stated she expected staff to document medications after administration.

Based on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 9 residents (Resident #44 and #70) observed during medication administration. Four medication errors occurred during staff administration of 41 medications, resulting in a nine percent error rate. Failure to properly prepare and administer medications may inhibit the effectiveness of the medication and may have a negative impact on the resident's overall health. Findings include: Review of the facility policy titled Medication Administration occurred on 03/27/25. This policy, dated December 2024, stated, . Medications included in this definition may include those administered orally . optic . c. right dosage d. right route. e. right time. f. right documentation . A resident may refuse a medication. This should be documented on the eMAR [electronic medication administration record] and the nurse notified. The physician should be notified of repeated refusals. Review of administration instructions found at Timolol Maleate Eye Drops, Solution 0.5% Novartis . Package Insert, 25 June 2020, https://www.novartis.com/sgen/sites/novartis_sg/files/TimololMaleate-Jun2020.SIN-App110920.pdf stated, . If more than one topical ophthalmic drug is being used, the drugs should be administered at least 5 minutes apart. - Review of Resident #44's medical record occurred on 03/26/25. Physician's orders included Timolol Maleate Solution (an eye drop to reduce eye pressure) 0.5% 1 drop in the right eye twice a day and Lubricant eye drops 2 drops in both eyes four times a day. Observation on 03/26/25 at 8:47 a.m. showed a medication aide (MA) (#9) administered Timolol eye drops in both of Resident #44's eyes, waited 20 seconds, and administered 1 drop of the lubricant eye drops in both eyes. When asked to confirm the dosage of the Timolol eye drops, the MA referred to the pharmacy label on the medication box which showed 1 drop in the right eye only. The MA (#9) confirmed the administration error. The MA also failed to wait the appropriate length of time before administering the lubricant drops and failed to administer 2 drops as ordered. - Review of Resident #70's medical record occurred on 03/26/25. A physician's order stated Polyethylene Glycol Powder (a laxative mixed with water) 8.5 grams by mouth once daily. Observation on 03/26/25 at 8:22 a.m. showed a MA (#9) dispensed 8.5 grams of laxative powder into a 6-ounce cup, filled it with ice water, and brought it to Resident #70. The resident stated the water was too cold and I don't want too much. The MA returned to the medication cart, wasted the medication, and placed half of the 8.5-gram dose into a plastic cup. The MA (#9) filled the glass with tap water per resident's request, administered the lower dose to the resident, and documented administration of the full dose in Resident #70's medication administration record (MAR). The MA (#9) failed to report to the charge nurse the resident's refusal of the full dose before administering a different dose. During an interview on 03/27/25 at 1:15 p.m., an administrative staff member (#1) confirmed she expected medications to be administered as ordered and report a refusal or request to the charge nurse and provider.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Resident #116 and #164) requiring enhanced barrier precautions (EBP). Failure to practice infection control standards related to EBP and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene, Artificial Nails occurred on 03/27/25. This policy, revised December 2024, stated, . Hand hygiene is considered the single most important procedure for preventing the spread of health-care associated infections. The use of gloves does not eliminate the need for hand hygiene. Indications for Hand Hygiene . 7. After removing gloves. Review of the facility policy titled Isolation, Standard Precautions, and Enhanced Barrier Precautions occurred on 03/27/25. This policy, dated September 2024, stated, . In addition to Standard Precautions, use Enhanced Barrier Precautions when providing high contact cares for residents at increased risk of an MDRO [multidrug-resistant organism] acquisition; includes residents with . indwelling medical devices. Use gowns and gloves for high contact direct cares including . device care . examples of devices include . central line. remove PPE [personal protective equipment] and discard appropriately and perform hand hygiene before leaving room. - Review of Resident #116's medical record occurred on all days of survey. The current care plan stated, . is on Enhanced Barrier Precautions due to history of an MDRO . indwelling medical device . Observation on 03/25/25 at 8:32 a.m. showed a sign on Resident #116's door indicating enhanced barrier precautions, and the resident resting in bed. A nurse (#2) entered the resident's room, donned a gown, gloves, and a facemask, and removed the resident's oxygen mask. The nurse (#2) removed her gloves, and without performing hand hygiene, prepared a suction kit, donned the sterile gloves from the kit, and suctioned Resident #116's tracheostomy (a surgically placed airway). The nurse (#2) changed her gloves without performing hand hygiene and performed tracheostomy cares. The nurse (#2) then changed her gloves without performing hand hygiene, prepared Resident #116's nutritional supplement and tubing, changed her gloves without performing hand hygiene, flushed the feeding tube, administered medications, and connected the resident's nutritional supplement. The nurse (#2) removed her gloves, and without performing hand hygiene, retrieved a walkie talkie from her pocket to call for assistance, cleaned up the supplies, removed her gown, washed her hands, and exited the room. The nurse (#2) failed to perform hand hygiene before and after glove changes. During an interview on 03/27/25 at 10:00 a.m., an administrative nurse (#1) confirmed she expected staff to perform hand hygiene after removing gloves and before donning new gloves. - Review of Resident #164's medical record occurred on all days of survey. The current care plan stated, . is on Enhanced Barrier Precautions due to indwelling medical device, PICC [Peripherally Inserted Central Catheter] . A physician order stated, Aztreonam 2 GM [grams] [an antibiotic medication] . Infuse . intravenously [IV] . every 8 [eight] hours . Observation on 03/25/25 at 2:35 p.m. showed a sign on Resident #164's door indicating EBP. A nurse (#8) donned a mask and gloves, entered Resident #164's room, connected an antibiotic IV infusion set to the resident's PICC line, and started the antibiotic administration via an IV pump. The nurse (#8) removed her gloves and mask, performed hand hygiene, and exited the resident's room. At 3:10 p.m., the nurse (#8) donned a new mask and gloves, entered Resident #164's room, and disconnected the IV tubing from the resident's PICC line. While wearing the mask and gloves, and carrying the antibiotic infusion set, the nurse exited the resident's room. The nurse (#8) failed to wear a gown during Resident #164's PICC line IV antibiotic infusion, failed to discard the infusion set in the residents' room, and failed to remove her mask and gloves and perform hand hygiene prior to exiting the resident's room. During an interview on 03/25/25 at 4:45 p.m., an administrative nurse (#1) confirmed all nurses are trained on appropriate PPE use and medication administration for residents with PICC lines and on EBP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide care in a manner and environment that maintains or enhances residents' quality of life for 5 of 9 residents (Residents #3, #44, #45, #70, and #112) observed during medication administration and in 3 of 8 dining rooms (1st floor C/D wing, 2nd floor C/D wing, and 4th floor C/D wing). Failure to refer to residents by their preferred name and dispose of bags containing trash/dirty linens prior to entering dining rooms does not promote resident dignity or respect. Findings include: Review of the facility policy titled Promoting Dignity and Resident Rights occurred on 03/27/25. This policy, dated December 2024, stated, . All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Staff members should converse with the resident while doing cares . Speak respectfully to residents . Observations of medication administration on 03/26/25 showed a medication aide (MA) (#9) using endearing terms as follows: - 8:09 a.m. Called Resident #45 Hon, Sweetheart, [NAME]. Resident #45's current care plan stated . My preferred name: [Resident's name]. - 8:22 a.m. Called Resident #70 Hon. Resident #70's current care plan stated . My preferred name: [Resident's name]. - 8:32 a.m. Called Resident #112 Hon. Resident #112's current care plan stated . My preferred name: [Resident's name]. - 8:38 a.m. Called Resident #3 Hon, Sweetheart. Resident #3's current care plan stated . My preferred name: [Resident's name]. -8:47 a.m. Called Resident #44 Hon, [NAME], My Dear, Sweetie, [NAME]. Resident #44's current care plan stated . My preferred name: [Resident's name]. During an interview on 03/27/25 at 1:15 p.m., an administrative staff member (#1) confirmed she expected staff to call residents by their preferred name unless care planned otherwise. - Observation on 03/24/25 at 4:40 p.m. showed an unidentified certified nurse aide (CNA) carrying a bag of garbage, while he/she pushed Resident #126's wheelchair to the 1st floor C/D dining room and up to a table where two residents were sitting. - Observation on 03/25/25 at 8:30 a.m. showed a CNA (#3) completed Resident #4's morning cares, gathered two bags of garbage and dirty linen, and exited the room carrying the bags while she assisted the resident to a table with two residents who were eating breakfast in the 4th floor C/D dining room. - Observation during the breakfast meal on 03/25/25, showed an unidentified CNA brought an unidentified resident to the dining table in the second floor C/D dining room holding a bag of soiled linen and garbage. - Observation on 03/26/25 at 8:01 a.m. showed a CNA (#7) stood in the first floor C/D dining room next to Resident #85 holding a bag of garbage and a bag of dirty linen. Resident #85's table mate had her breakfast tray in front of her. During an interview on 03/26/25 at 11:45 a.m., a nurse manager (#4) stated she expected staff to dispose of dirty linen/garbage before taking residents to the dining room or activities.

Based on observation and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 6 of 8 nutrition stations (first floor A/B and C/D, second floor A/B and C/D, and third floor A/B and C/D). Failure to ensure food is safe from contamination by resident ice packs has the potential to result in a foodborne illness or adverse effects for residents, visitors, and staff. Findings include: When requested, the facility failed to provide a policy for storage of ice packs. Observation of the nutrition stations on 03/24/25 showed the following items stored with food items: - 2:25 p.m. First floor A/B nutrition station freezer, two blue gel cooling packs with a resident label, alongside ice cream cups. First floor C/D nutrition station freezer, two unlabeled blue gel cooling packs alongside a box of snack breads. - 2:38 p.m. Second floor A/B nutrition station freezer, one unlabeled blue gel cooling pack alongside ice cream cups. Second floor C/D nutrition station freezer, one unlabeled blue gel cooling pack alongside ice cream cups, a piece of a resident's ice cream cake in a ziploc bag, and two dishes of what a dietary aide identified as dessert from Saturday. An administrative nurse (#5) stated staff should not store cooling packs in nourishment freezers. - 2:46 p.m. Third floor A/B nutrition station freezer, two unlabeled blue gel cooling packs alongside ice cream cups. Third floor C/D nutrition station freezer, two unlabeled blue gel cooling packs alongside ice cream cups. A staff nurse (#6) stated cooling packs are not supposed to be in there [nourishment freezers] and should be kept in the nurse's station freezer. During an interview on 03/27/25 at 1:15 p.m., an administrative staff member (#1) confirmed she expected staff to store gel packs in the nurse's station freezer designated for that purpose.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 36 sampled resident (Resident #69 and #138). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled, Care Plan (Plan of Care), occurred on 02/15/24. This policy, dated August 2023, stated, . The plan of care is reviewed at least monthly by nursing, quarterly with completion of MDS [Minimum Data Set] assessment and annually at interdisciplinary care conferences. Nursing plans of care are to be kept current by licensed staff members and remain consistent with the attending physician's plan of medical care, and the changing needs of the residents. - Review of Resident #138's medical record occurred on all days of survey. Diagnoses included hemiplegia. The current care plan identified the following: . Restorative therapy to Assist to move through tolerated range, supporting joints above & [and] below area: Lower Extremity exercises 6x's/ [times per] week. During an interview on 02/14/24 at 5:28 p.m., an administrative nurse (#1) confirmed the facility discontinued restorative therapy for Resident #138 and failed to remove it from the care plan. - Review of Resident #69's medical record occurred on all days of survey and identified diagnoses of depressive episodes and insomnia. Current physician's orders, dated 01/28/22 and 05/16/23, stated, DULoxetine HCl Capsule Delayed Release Particles [an antidepressant]. Trazadone [an antidepressant] tab [tablet] 50mg [milligrams]. The current care plan identified the following: . uses psychotropic medications R/T [related to] depression, and anxiety. Hx [history] of insomnia. Educate resident's family/caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor/record/report to MD [medical doctor] prn [as needed] side effects and adverse reactions of psychoactive medication. The facility failed to identify some serious side effects staff should observe for when taking multiple antidepressants on Resident #69's care plan. During an interview on 02/15/24 at 2:19 p.m. a licensed nurse (#4) confirmed Resident #69's care plan failed to address the side effects related to the use of antidepressants. During an interview on 02/15/24 at 2:53 p.m. a medication assistant (MA) (#2) failed to verbalize the side effects/symptoms Resident #69 could experience related to antidepressants. During an interview on 02/15/24 at 3:00 p.m. a nurse (#3) failed to verbalize the side effects/symptoms Resident #69 could experience related to antidepressants.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #379) with orders for a knee immobilizer. Failure to follow physician's orders and the care plan for application, and report refusals of application, placed Resident #379 at risk for falls and discomfort/pain. Findings include: Review of the facility policy titled Care Plans (Plan of Care) occurred on 02/15/24. This policy, revised August 2023, stated, . develop and implement a baseline and/or comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events . Review of Resident #379's medical record occurred on all days of survey. Diagnoses included left patellar (kneecap) fracture. The current physician's orders stated, . Keep immobilizer in place to LLE [left lower extremity] until cleared by ortho [orthopedics] . The current care plan stated, . alteration in musculoskeletal status R/T [related to] left patellar fracture . Resident has immobilizer in place to L leg . An orthopedic daily progress note, dated 02/06/24, stated, . fell onto his left knee sustaining a closed nondisplaced vertically oriented left patella fracture. Plan: . Weight bearing: as tolerated with knee immobilizer in place. Review of the treatment administration record for February 12 - 15, 2024, showed staff documented the knee immobilizer in place on all days during all shifts. The medical record lacked documentation by staff of the resident's refusal to wear the knee immobilizer. Observations of Resident #379 showed the following: * 02/13/24 at 7:58 a.m., seated in wheelchair without a knee immobilizer to the left leg. * 02/13/24 at 12:27 p.m., laying in bed without a knee immobilizer to the left leg. * 02/13/24 at 3:53 p.m., two certified nurse aides (CNAs) (#5 and #6) transferred the resident from the bed to wheelchair with a mechanical sit to stand lift. The CNAs (#5 and #6) failed to place the left knee immobilizer on Resident #379's left leg. During an interview on 02/13/24 at 3:53 p.m., the CNAs (#5 and #6) stated they were unsure about placement of the knee immobilizer for Resident #379. One CNA (#6) stated, I did see it on him yesterday, he should be wearing it. Both CNAs reported access to the care plans on either the tablet or on the computers in the hallway. During an interview on 02/13/24 at 4:00 p.m., a certified occupational therapy aide (#7) stated Resident #379 refused to wear the knee immobilizer on two occasions. During an interview on 02/13/24 at 4:55 p.m., an administrative nurse (#4) stated she expected staff to place the immobilizer to Resident #379's left knee as ordered and care planned, and communicate/document any resident refusals.

Based on record review and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #138) reviewed for restorative therapy received the services developed by the therapy staff. Failure to follow up on a request to the provider for restorative nursing/therapy services may adversely affect the resident's ability to maintain range of motion (ROM), strength, and mobility. Findings include: Review of Resident #138's medical record occurred on all days of survey. Diagnosis included hemiplegia. The current care plan stated, . impaired functional mobility as evidenced by Inability to achieve full functional ROM, Decreased ability to self-perform ADLs [activities of daily living] R/T [related to] intracranial injury. A quarterly Minimum Data Set [MDS] dated 11/22/23 identified bilateral functional limitation in range of motion to upper and lower extremities. Random observations of cares during all days of survey showed Resident #138's knees in a bent position. Progress notes identified the following: * 01/20/24 at 1:57 p.m.: Update of resident's status given to wife. She requested his restorative therapy program be resumed due to his stiffness. Fax sent to [provider] with request for therapy. * 02/02/24 at 6:06 p.m.: Late Entry: Order request sent to [provider name] office requesting an order for PT [physical therapy] to evaluate resident for Restorative therapies per wife request [wife's name]. * 02/14/24 at 6:08 p.m.: Another request for PT evaluation placed in file for resident to be evaluated by PT for Restorative therapies. During an interview on 02/14/24 at 5:28 p.m., an administrative nurse (#1) confirmed the resident is currently not receiving restorative therapy. The medical record lacked evidence of an order for restorative therapy for Resident #138.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision for 2 of 6 sampled residents (Resident #135 and #166) observed for safe transfers. Failure to provide appropriate and sufficient supervision during mechanical lift transfers (Resident t#166) and follow fall interventions (Resident #135) placed residents at risk for accidents, falls, and/or injuries. Findings include: Review of the facility policy titled Transfer/Locomotion occurred on 02/15/24. This policy, dated November 2023, stated, . 4. Always use 2 staff during transfer. Review of the facility policy titled Fall (Resident) Guidelines occurred on 02/15/24. This policy, revised June 2023, stated, . The nurse should make changes to the care plan and [NAME] as determined by the team to prevent further incidents of fall. - Review of Resident #166's medical record occurred on all days of survey and included a diagnoses of dementia. The current care plan stated, TRANSFER: hoyer [full body mechanical lift] for all transfers. Observation on 02/14/24 at 8:13 a.m. showed one certified nurse aide (CNA) (#3) transferred Resident #166 to the wheelchair utilizing the ceiling lift [full body mechanical lift]. The CNA (#3) failed to ensure two staff completed the lift transfer. During an interview on the afternoon of 02/15/24 an administrative staff member (#1) confirmed he/she expected staff to follow facility policy when using the ceiling lift. - Review of Resident #135's medical record occurred on all days of survey. A care plan intervention, dated 01/10/24, stated, . Wheelchair within reach at all times. A Fall Note, dated 01/22/24, stated, . Wheelchair and walker were not within reach and resident may have been self-transferring. Observation on the afternoon of 02/12/24, during early afternoon showed Resident #135's wheelchair not within reach. Without staff present, the resident ambulated per self from the recliner to the wheelchair. Observations on 02/12/24 at 4:35 p.m. and on 02/12/24 at 4:20 p.m. showed Resident #135 resting in the recliner. Staff failed to place the wheelchair within the resident's reach. During an interview on 02/15/24 at 12:45 p.m. an administrative staff member (#1) confirmed he/she expected facility staff to implement fall interventions as care planned.

Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to provide respiratory care for 1 of 11 sampled residents (Resident #163) receiving oxygen by nasal cannula. Failure to administer oxygen according to the physician's order may result in complications and compromise the residents' respiratory status. Findings include: Review of a policy/procedure titled Oxygen occurred on 02/15/24. This policy/procedure, revised December 2023, stated, . Turn the oxygen on as ordered by the physician . Review of Resident #163's medical record occurred on all days of survey and identified a diagnoses of dependence on supplemental oxygen. A physician's order, dated 11/14/23, stated, Oxygen continuously at 1 LPM [liters per a minute] to maintain saturations above 88%. Observations on 02/12/24 at 11:11 a.m., 02/13/24 at 4:14 p.m., and 02/14/24 at 12:15 p.m. showed Resident #163 in a recliner without oxygen. During an interview on 02/12/24 at 11:14 a.m., Resident #163 reported facility staff removed their continuous oxygen on the morning of 02/12/24 and did not notify the resident of the reasoning. During an interview on 02/13/24 at 4:28 p.m., an administrative staff member (#9) confirmed Resident #163 should be on continuous oxygen per physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident and staff interview, the facility failed to provide care and services to control pain for 1 of 3 sampled residents (Resident #17) investigated for pain management. Failure to administer pain medication as scheduled may have contributed to Resident #17 experiencing increased and/or unresolved pain. Findings include: Review of the facility policy titled Medication Administration occurred on 02/15/24. This policy, dated December 2023, stated, . Scheduled medications may be given up to 1 hour before and 1 hour after the designated time. Review of Resident #17's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], identified intact cognition and frequent pain rated 5 on a 0-10 scale, which affected her sleep and day to day activities occasionally and interfered with therapy activities almost constantly. Resident #17's care plan stated, . potential for pain R/T [related to] chronic back pain, diabetes, PVD [peripheral vascular disease]. Resident's pain score goal is 0 [on a scale of 0-10]. Administer analgesic as per orders & [and] monitor for relief obtained. Monitor/document for probable cause of pain. Remove/limit causes where possible. Physician orders included: * 01/28/24, HYDROCO/APAP [hydrocodone/acetaminophen] [narcotic and non-narcotic analgesic combination] TAB [tablet] 5-325MG [milligram] TAKE 1 TABLET BY MOUTH EVERY 6 HOURS AROUND THE CLOCK FOR SEVERE PAIN (Related Diagnoses: FIBROMYALGIA [a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbances] * 02/07/24, Gabapentin [treats nerve pain] Oral Capsule 100 MG . Give 1 capsule by mouth three times a day related to FIBROMYALGIA During an interview on 02/12/24 at 2:50 p.m., Resident #17 stated, Sometimes my meds [medications] are given late, like up to an hour late, and my pain meds wear off. The resident complained of hip, back, and shoulder pain and restless legs, and stated, I can wait up to two hours to get my pain meds. A report provided by an administrative nurse (#1) on 02/15/24 at 2:14 p.m. showed the exact time staff administered a medication and revealed the following: * February 1-15, hydrocodone/apap given between 62 minutes to 133 minutes after the scheduled time on 11 of 58 occasions * February 7-15, Gabapentin given between 63 to 117 minutes after the scheduled time on nine of 23 occasions During an interview on 02/15/24 at 2:18 p.m., an administrative nurse (#1) stated she expected staff to administer medications 60 minutes before/after their scheduled administration time.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled residents (Resident #286) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident as risk of receiving unnecessary medications and experiencing adverse drug effects. Findings include: Review of the facility policy titled Medications-Psychotropic and Antipsychotic Medication Use occurred on 02/15/24. This policy, dated August 2023, stated, . The attending or prescribing health care provider must document the diagnosed specific condition and indication for the PRN medication in the medical record. When the extended use of a PRN psychotropic mediations is indicated (beyond 14 days), additional orders must be obtained. Nursing staff will automatically send Health Care Provider a pre-made PRN Psychotropic Fax prior to day 14 if indication for use continues and there is no specific time frame for the PRN. Review of Resident #286's medical record occurred on all days of survey. A physician's order, dated 01/27/24, included Ativan (antianxiety) 0.25 milligrams every four hours as needed for agitation. The physician renewed the order for the prn Ativan on 02/13/24 (4 days late). During an interview on 02/15/24 at 10:30 a.m., an administrative nurse (#1) confirmed Resident #286's PRN Ativan failed to be reevaluated within 14 days.

Based on record review, review of facility policy, and staff and family interviews the facility failed to provide the required specialized rehabilitative services for 1 of 6 sampled residents (Resident #156) with orders for physical therapy evaluation and treatment. Failure to provide physical therapy services as ordered for Resident #156 may result in impaired strength, impaired mobility, and increased pain. Findings include: Review of the facility policy titled Physician Orders occurred on 02/15/24. This policy, revised April 2023, stated, . It is the policy of [Facility Name] to complete physician orders in a timely manner to ensure appropriate care . Review of the facility policy titled Physical Therapy, Occupational Therapy, and Speech Therapy occurred on 02/15/24. This policy, revised April 2024, stated, . To provide therapeutic environment for residents through written communication to Nursing staff to sustain functioning and/or prevent deterioration as able. During an interview on 02/12/24 at 4:40 p.m., Resident #156's representative indicated the resident was not getting therapy to get stronger and help with his leg pain. Review of Resident #156's medical record occurred on all days of survey. Diagnoses included [NAME] Nile virus encephalitis [inflammation of the brain], myalgia [muscle ache and pain], and generalized weakness. A physician's order, dated 01/16/24, stated, PT [physical therapy] to evaluate and treat, focus on lower extremities. A physician's recertification progress note, dated 01/16/24, stated, . Needs Physical therapy with focus on the lower extremities, specifically the right lower extremity. ROS [review of systems] . Musculoskeletal: Positive for myalgias. Neurological: Positive for weakness. Physical/Results . Musculoskeletal . Comments: Significant weakness of bilateral lower extremities, right slightly greater than left. Has some contraction of right ankle noted as well. Mild pain in bilateral legs. The medical record lacked documentation of a physical therapy evaluation or treatment plan. During an interview on 02/15/24 at 11:40 a.m., an administrative nurse (#1) confirmed the facility failed to ensure physical therapy completed an evaluation and/or treatment plan for Resident #156.

Based on observation, record review, review of facility policy and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #138) observed for medication administration via feeding tube and 1 of 1 sampled resident (Resident #91) on transmission-based precautions (TBP). Failure to follow infection control standards during medication administration and with TBP has the potential to transmit infections to residents, staff, and visitors. Findings include: MEDICATION ADMINISTRATION Review of the facility policy titled Medication Assistant Scope of Practice occurred on 02/14/24. This policy dated February 2023, stated, . If a medication is dropped, it should be discarded. Observation on 02/13/24 at 12:04 p.m., showed a staff nurse (#11) prepared medication for Resident #138. The staff nurse (#11) dropped a Guaifenesin tablet on the top of the cart. Using bare hand contact, picked up the pill, placed it into the medication cup, and administered it to the resident. TRANSMISSION BASED PRECAUTIONS Review of the facility policy titled Isolation occurred on 02/15/24. This policy, revised January 2024, stated, . Transmission Based Precautions will be used for the care of persons with infections from highly transmissible . pathogens that cannot be controlled with Standard Precautions. It includes . Enteric Contact . Procedure: . 2. Gloves . wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. B. Remove gloves after use, before touching noncontaminated items . C. Wash hands immediately after removal to avoid transfer of microorganisms . 4. Gown/Apron . B. Remove a soiled gown/apron as promptly as possible and wash hands to avoid transfer of microorganisms . Review of the facility policy titled C-diff (Clostridium Difficile) - GI [gastrointestinal] (Enteric) Isolation occurred on 02/15/24. This policy, revised February 2024, stated, .GI (Enteric precautions are taken to prevent infections that are transmitted primarily by direct or indirect contact with fecal material. Procedure: . 3. Handwashing is the most important preventative measure. Hand sanitizer is not effective against C-Diff. Wash hands with soap and water prior to leaving the resident's room. Review of the facility policy titled Hand Hygiene, Artificial Nails occurred on 02/15/24. This policy, revised November 2023, stated, . Hand hygiene is considered the single most important procedure for preventing the spread of health-care associated infections . A. Indications for Hand Hygiene: . 8. Soap and water should be used . after caring for a patient with known or suspected C. difficile. Review of Resident #91's medical record occurred on all days of survey. Diagnoses included C. Difficile. A nursing progress note, dated 01/24/24 at 1:22 p.m., stated, . Resident had the suprapubic catheter placed today. Observation on 02/12/24 at 12:48 p.m. showed an isolation sign on Resident #91's door. The sign stated, . Gastrointestinal (Enteric) . Wear gloves when entering room . Wear gown when entering room . Remove PPE [personal protective equipment] and wash hands with soap and water before leaving room . Observation on 02/14/24 at 9:25 a.m., showed a nurse (#8) entered the room in a gown and gloves. The nurse (#8) removed the soiled dressing from the suprapubic site, removed gloves, and performed hand hygiene. The nurse (#8) donned clean gloves, cleansed suprapubic catheter site and suprapubic tube with gauze sponge moistened with soap and water, and without removing gloves or performing hand hygiene, placed a new split gauze, reached into the pocket of her uniform top, removed a roll of tape, pushed up glasses, taped the split gauze, and placed the tape back in her uniform pocket. The nurse (#8) removed her gloves, washed her hands with soap and water, removed her isolation gown, performed hand hygiene with hand sanitizer, and left the room. The nurse (#8) failed to remove her soiled gloves and perform hand hygiene after cleaning the suprapubic catheter site and tube, and before touching other items. The nurse failed to remove all PPE at once and wash her hands with soap and water before exiting Resident #91's room. During an interview on 02/14/24 at 3:25 p.m., an administrative nurse (#1) stated she expected staff to change gloves and perform hand hygiene when moving from dirty to clean tasks, and remove all PPE at one time, then wash hands with soap and water prior to exiting Resident #91's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of information provided by the complainant, record review, review of facility policies, and staff interview, the facility failed to promote care in a manner that maintained or enhanced the resident's dignity for 1 of 1 sampled resident (Resident #163) transported without appropriate attire. Failure to ensure the resident was dressed appropriately during transport does not promote mental well-being and may lead to a resident's loss of dignity. Findings included: Review of the facility policy titled Promoting Dignity and Resident Rights occurred on 02/16/23. This policy, revised September 2022, stated, . it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality . All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Review of the facility policy titled Nursing Service occurred on 02/16/23. This policy, revised April 2022, stated, . Missouri Slope respects the equality, rights and dignity of all . residents are treated with care, compassion, respect and consideration at all times . Information provided by the complainant, dated 01/30/23, stated, . Patient was at [name of surgery center] for procedure . Pt. [patient] was brought . from Nursing home with no pants on, only covered in bath blankets. Given the fridged [sic] temperatures outside, I am concerned the resident was not dressed appropriately to be out in below freezing temperature with no pants or winter coat. When I asked the resident why he wasn't dressed with pants he replied 'he didn't know'. I called the nurse at the nursing home . and asked if she was aware of the situation. Her response was that she was aware he was sent here in only bath blankets as he had a bath this morning. Review of Resident #163's medical record occurred on all days of survey. A comprehensive Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assistance with dressing and self care. A nursing progress note, dated 1/30/2023 at 11:15 a.m., stated, Resident left facility at 11:15 a.m., via transportation driver. The facility investigation and follow up included the following: * 01/30/23, a nursing supervisor (#2) documented, It was reported that resident had been transported to his appointment with a lap blanket over his brief . he was not wearing pants or jacket . his lack of appropriate clothing was not addressed by the charge nurse or the Certified Nursing Assistant [CNA] when he was brought up to the front nurses station to meet transportation . the transportation driver had noticed the lack of appropriate clothing when the resident was in the vehicle and offered the resident a pair of sweat pants that were in the van . the resident's lack of appropriate clothing was concerning and investigation into same occurred .[nurse (#3)] stated she did not realize the resident did not have pants on as he had a bath blanket over him. [CNA (#4)] stated the nurse told her to wrap him in blankets because they would not want him dressed for the procedure . that is why he was dressed that way. * 01/31/23 at 2:20 p.m., an administrative nurse (#1) had a phone call with Resident #163's family, who shared concern with the resident's attire when transported to his appointment. During an interview on 02/16/23 at 03:03 p.m., a nursing supervisor (#2) confirmed the facility transported Resident #163 to the same day surgery center in a brief and bath blankets. She would expect the facility to dress residents appropriately. The facility failed to maintain Resident #163's dignity by transporting him in a van to public areas wearing clothing not appropriate for the weather conditions.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 12 sampled residents (Resident #50) with orders for oxygen therapy. Failure to ensure oxygen is provided as ordered may result in increased shortness of breath and complicate the resident's respiratory status. Findings include: Review of the facility policy titled Oxygen occurred on 02/15/23. This policy, reviewed January 2023, stated, Oxygen will be administered to residents for comfort, to improve tissue oxygenation, and to prevent or reverse hypoxia [deficiency in the amount of oxygen reaching the tissues]. Oxygen Tank Use. Check the pressure gauge to ensure the presence of adequate oxygen contents. If less than 500 psi [pressure per square inch] remains in tank, get a new tank. verify that oxygen is flowing to the resident. Review of Resident #50's medical record occurred on all days of survey. Diagnoses included pulmonary fibrosis (scarred lung tissue), chronic respiratory failure with hypoxia (heart or lungs are unable to maintain adequate oxygen levels), and dependence on supplemental oxygen. A physician's order, dated 12/21/21, stated, Titrate [adjust the oxygen liter flow rate] O2 [oxygen] to keep sats [saturations] greater than or equal to 90% . Observation during the noon meals on 02/14/23 and 02/15/23 showed Resident #50 seated in a wheelchair at the dining room table with a nasal cannula in place attached to a portable oxygen tank located on the back of the wheelchair. During both observations the needle on the oxygen tank regulator registered in the red, indicating an empty tank. During an interview the afternoon of 02/15/23, an administrative staff member (#1) stated she would expect staff to replace Resident #50's oxygen tank when empty.

Based on review of resident council meeting minutes, review of facility policy, confidential resident/family/group interviews, and staff interview, the facility failed to ensure sufficient nursing staff and related services available to meet the residents' needs for 9 of 36 sampled residents (Resident A, B, C, D, E, F, G, H and I), 2 supplemental residents (Resident J and K), and 8 of 8 Resident Council residents (Resident L, M, N, O, P, Q, R and S) who required staff assistance. Failure to provide sufficient staffing and answer call lights in a timely manner increased the risk for falls, discomfort, incontinence, and skin breakdown. Findings include: Review of the facility policy titled Call lights occurred on 02/16/23. This policy, revised March 2022, stated, . ensure residents have access to the call light . staff will routinely check that the call light is within reach of the resident and secured as needed . staff members are to respond to an activated call light and if assist cannot be provided, the appropriate staff should be notified . inform the resident if you cannot meet the need and assure them you will notify the appropriate personnel . Review of the facility policy titled Promoting Dignity and Resident Rights occurred on 02/16/23. This policy, revised September 2022, stated, . it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . when interacting with a resident, pay attention to the resident as an individual . respond to requests in a timely manner . converse with the resident while doing cares . speak respectfully to residents . maintain resident privacy . assist residents to participate in activities of choice . During interviews, residents and family members stated the following: - 02/13/23 at 10:36 a.m., Resident K stated, There are times it takes staff up to an hour to answer the call light. When I have to sit in my BM [bowel movement] that long, then I get skin problems and open areas. - 02/13/23 at 01:15 p.m., Resident A stated, The call lights aren't answered in a timely manner with wait times past 10 minutes. I was left on a bed pan for one hour before any staff came to help me. I had pressed the call light multiple times for assistance off the bed pan, and the CNA [certified nursing assistant] refused to help me to the bathroom. - 02/13/23 at 2:31 p.m., Resident J stated, They are short staffed, the staff tell me so, and sometimes can take a while to answer [call light], like up to a half hour. - 02/13/23 at 2:48 p.m., Resident B stated, I don't get to bed soon enough and get a good night's rest. It takes a while for them [staff] to come and get me ready for bed. - 02/13/23 at 3:05 p.m., Resident C stated, Sometimes it can take half an hour to answer [call light]. They have a lot of travel staff and those from out of state can be rude. - 02/14/23 at 8:46 a.m., Family member (#1) for Resident F stated, I have concern with turnover and travel staff, who don't seem to care as much, can be rough with transfers, and don't take time to read the care plan and be aware of [Resident F's] needs. - 02/14/23 at 09:45 a.m., Resident H stated, The biggest problem is lack of help. They are short staffed and have a lot of travel staff. There are times it takes 15 to 30 minutes or longer to answer my call light and if they come in, they turn off my call light and say they will get someone or do not return. It has resulted in my incontinence. They have a lot of staff that do not know how to take care of me. - 02/14/23 at 10:44 a.m., Resident D stated, My issue is that once I am placed on the toilet it takes a half hour or longer to get staff to come take me off. - 02/14/23 at 12:07 p.m., Resident E stated, The CNA tells me I call too much and moved my call light away, or tells me I just went to the bathroom and to just pee in my brief, that is what they [briefs] are there for. - 02/14/23 at 12:08 p.m., Family member (#2) for Resident E stated, [Resident E] is supposed to call when needs to get up. I have noticed the call light to be on the wall behind the bed or not in reach several times. I have concerns only with the staff, mostly travel staff, who don't know the residents and there is no consistency as they float all over. - 02/15/23 at 10:46 a.m., Family member (#4) for Resident I stated, Staffing is an overall concern with the resident's care. During observations over the past three or four weeks, the oxygen concentrator flow rates have varied by two or three liters above or below the ordered two liters, depending on the staff working . the portable oxygen tank on the back of [Resident I's] wheelchair has been found empty multiple times. [Resident I] has had periods of times without oxygen, and we have had to notify staff. Family member (#5) stated, I observed many times when [Resident I] put on the call light waiting 15 to 30 minutes or longer before a CNA enter the room, turning off the call light, stating they will 'find someone to help' and do not return. I then went out to the hallway to search for staff to help. Family members (#4 and #5) stated, We observed the staff putting [Resident I] on the toilet and waited 45 minutes for staff to return to assist resident. [Resident I] stated they were very uncomfortable sitting on the toilet a long time. Family member (#5) stated, I visited and observed [Resident I] sitting in the wheelchair with no call light in reach, attempting to stand up, and go to the bathroom. I put the call light on and waited over 15 minutes for staff to come and take [Resident I] to the bathroom. Family members (#4 and #5) stated, We are concerned about the call light not being available, the wait times, the incontinence issues and the risk for falls. - 02/15/23 at 12:09 p.m., Family member (#3) for Resident G stated, It takes at least 20 minutes for staff to answer the light and often I hear, 'I'm not [Resident G's] CNA today, I'll see who it is, and then it takes another 20 minutes or longer for them to come. Family member (#3) also stated, When it takes too long to answer a call light, I will often search for staff in the hallways to get assistance for [Resident G] or other residents. During a group interview on 02/15/23 at 10:36 a.m., [Residents L, M, N,O, P, Q, R, and S] discussed the following: * Staffing shortages are on all units. If a floor is short staffed, they [administration] reassign a staff member to a floor that is short, leaving other units with less staff. * It takes a lot to do or go somewhere around here. You have to go through a lot of hoops. Staff do not always get to us on time to take us to activities, or other events due to lack of staff. We are frustrated, as it has affected where we choose to go, and many of us decide not to attend some activities. * Call lights are not answered in a timely manner, at times it takes 20 to 30 minutes, or longer, to get help. Staff often come into our rooms when the call light is on, turn off the call light, and tell us they will 'be right back' and they do not return. It happens on all shifts, all floors. * Resident O stated, I had a soiled brief and pants, the CNAs assisted me to the toilet. I was left sitting on the toilet for 45 minutes or more, on three separate occasions, and was upset and embarrassed. * Resident P stated, One time, I turned the call light on when I was in pain and I waited 30-45 minutes to get pain medication. During an interview in the afternoon of 02/16/23, an administrative staff member (#1) stated, I am aware of the staffing problems, and I am working on solutions.