Every finding on record at Carnegie Village Rehabilitation & Health Care Cent

Based on observation, interview and record review, the facility failed to store food appropriately in the kitchen. This practice has the potential to affect all residents, visitors, and employees who eat at the facility. The facility census was 68 residents.Review of the facility's undated policy titled Food Storage (Dry, refrigerated, and frozen) showed:-All food items must be labeled.-The labels must include the name of the food and the date by which it should be sold, consumed, or discarded.1. Observation on 7/17/25 at 9:14 A.M. of the initial kitchen showed:-In the refrigerator, there was cut cantaloupe in a plastic container and was not dated.-In freezer K:--A large package of hot dogs was in its original packaging that was left open to air and the package was not covered or closed in any way and was not dated.--Chicken tenders were in a plastic storage container that the lid was not closed all the way and the container was not dated.--There was a plastic storage container of tater tots and a plastic storage container of fries that were not dated.-On a dry storage shelf, there was a large bag of cheerios and a large bag of bran flakes that were opened, wrapped in plastic wrap, and were not dated.Observation on 7/22/25 at 10:47 A.M. of the kitchen showed:-The cantaloupe was no longer present.-The hot dogs in freezer K were wrapped in cellophane and dated 7/22/25.-The chicken tenders were in a plastic storage container that the lid was not closed all the way and the container was dated 7/21/25.-The fries were dated 7/17/25.-The tater tots were no longer present.-The large bags of cheerios and bran flakes were dated July 2025. During an interview on 7/23/25 at 9:16 A.M. the Dietary Manager said:-Anyone in dietary who opens items should cover and date the items.-All opened packages should be in a container or wrapped in cellophane.-He/She had not noticed the container lids not staying closed and maybe it was because they were in the freezer, which could make the lids pop up. During an interview on 7/23/25 at 2:31 P.M., the Administrator said opened food should be covered and dated.

Based on observation and interview, the facility failed to ensure the audible signal from the call light at the west and east nurse's stations, was loud enough to be heard above ambient (surrounding on all sides) noise such as televisions which were on at the adjacent day rooms and in the adjacent resident rooms and conversations which happened at the nurse's stations. This practice potentially affected 10 residents in rooms where the call lights were activated. The facility census was 68 residents.1 1. Observation on 7/22/25 from 2:55 P.M. to 3:16 P.M. showed:-The call lights from resident rooms 116, 208, 200, 201, and 205 were activated.-There were two quick sounding beeps.-30 seconds went by and it beeped twice again.-The room number showed up on the wall device where the sound came out.-The sound repeated every 30 seconds in the same soft tone at the [NAME] nurse's station.During an interview on 7/22/25 at 3:23 P.M., Licensed Practical Nurse (LPN) A said:-If there were televisions on in resident room [ROOM NUMBER] and in the day room and there were conversations at the nurse's station, the call light could be hard to hear.Observation on 7/22/25 from 3:23 P.M. to 3:48 P.M. showed:-The call lights from resident rooms 145, 154, 158, 162, and 143 were activated.-There was no audible sound at the nurse's station. 2. During an interview on 7/22/25 at 3:48 P.M., Certified Nurse's Aides (CNA) A said sometimes the residents kept the televisions loud and at those times, he/she or other staff could not hear the call lights signal above the volume of the televisions.During an interview on 7/22/25 at 3:52 P.M., the Director of Nursing (DON) said the nursing staff have not mentioned that the call light signal was too low in volume.During an interview on 7/23/25 at 1:29 P.M., the Administrator said the volume of the call lights system had been at that level since the system was installed. During an interview on 7/23/25 at 1:36 P.M., LPN B said if there were televisions on and if there were conversations at the East nurse's station, it was difficult to hear the call light signal.During an interview on 7/23/25 at 1:39 P.M., LPN A said there should be a way to distinguish between the doors which also activate the call light screen at the nurse's stations, and the call light signals from the resident rooms, because after a while all the tones sound the same.

Based on observation and interview, the facility failed to maintain commodes in the following resident rooms (rooms 107, 100, 167, 162, 140, 132, and 124) free of numerous indentations and scratches which rendered the commodes not easily cleanable. This practice potentially affected 7 residents who resided in those rooms. The facility census was 68 residents.1. Observation on 7/21/25 with the Maintenance Director showed:-At 1:51 P.M. there were numerous indentations on the commode seat in resident room [ROOM NUMBER].-At 1:59 P.M. there were numerous indentations on the commode seat in resident room [ROOM NUMBER].-At 2:29 P.M. there were numerous indentations on commode seat in resident room [ROOM NUMBER].-At 2:41 P.M. there were numerous indentations on the commode seat in resident room [ROOM NUMBER].Observation on 7/22/25 with the Maintenance Director on 7/22/25 showed:-At 9:29 A.M., there were numerous indentations on the commode seat in resident room [ROOM NUMBER].-At 9:58 A.M., there were numerous indentations and scratches on the commode seat in resident room [ROOM NUMBER].2. During an interview on 7/21/25 at 1:51 P.M. the Maintenance Director said none of the housekeepers informed him/her about the damaged commode seats.During an interview on 7/22/25 at 9:59 A.M., Housekeeper A said:-He/She had not notified the Maintenance Director about the scratches and indentations on the commode seats in the past because he/she did not know he/she needed to.-At 10:44 A.M. there were numerous indentations and scratches on the commode seat in resident room [ROOM NUMBER].During an interview on 7/23/25 at 2:44 P.M., the Housekeeping Supervisor said: -If the housekeepers found anything with the commode seats, they were supposed to notify the maintenance department through the maintenance log.-Housekeeping employees were not informed that damaged commode seats were something they needed to look for.

Based on observation, interview, and record review, the facility failed to ensure oxygen and respiratory equipment was kept in a sanitary condition when not in use for three sampled residents (Resident #7, #8, and #33) and failed to ensure one sampled resident's (Resident #33) oxygen was at the correct setting out of 17 sampled residents. The facility census was 68 residents.An oxygen policy was requested and not provided by the time of exit. 1. Review of Resident #7's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure with Hypoxia (when the lungs cannot properly exchange gases).Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 6/20/25 showed: -He/She was cognitively intact.-He/She had respiratory failure.-Oxygen therapy was not checked.Review of the resident's care plan dated 6/18/25 showed:-He/She had the potential for altered respiratory status related to respiratory failure.-Staff was to provide oxygen to keep saturations above 90%.Review of the resident's Physician's Order Sheet (POS) dated July 2025 showed a physician order for Oxygen one to three liters per nasal cannula (the tubing that delivers oxygen through a resident's nose) to maintain oxygen above 90% as needed for dyspnea (difficulty breathing).Observation on 7/17/2025 at 11:36 A.M. showed:-The oxygen tubing hanging over the back of a chair. -There was a storage bag in the resident's room.-The oxygen tubing was not in the bag. During an interview on 7/17/25 at 11:40 A.M. the resident said:-He/She was not currently using oxygen.-He/She only wore the oxygen at night.-The staff had to put the oxygen on and take it off of him/her.Observation on 7/18/25 at 3:00 P.M. showed:-The oxygen was running and the tubing was sitting on the floor not in a bag.-The resident was not in the room.Observation on 7/22/25 at 2:35 P.M. showed:-The oxygen was running and the tubing was sitting on the floor. -The resident was just coming into the room from the hallway. 2. Review of Resident #8's face sheet showed he/she was admitted on [DATE] with a diagnosis of chronic respiratory failure.Review of the resident's care plan dated 4/14/25 showed:-He/She had an altered respiratory status.-He/She used oxygen at night.-Staff was to have provided oxygen as ordered two liters per nasal cannula at night and as needed due to chronic respiratory failure. Review of the resident's Quarterly MDS dated [DATE] showed:-He/She was cognitively intact.-He/She had respiratory failure.-Oxygen therapy was not checked.Review of the resident's POS dated July 2025 showed physician order for Oxygen at two liters per nasal cannula at night due to chronic respiratory failure.Observation on 7/17/2025 at 10:20 A.M. showed:-The resident was resting in bed.-His/Her oxygen tubing was hanging off the back of a chair.-His/Her oxygen tubing was not in the oxygen bag.-He/She was not using oxygen.Observation on 7/17/25 at 11:36 A.M. showed:-The oxygen tubing was hanging over the back of a chair, it was not in a bag.During an interview on 7/17/25 at 11:36 A.M. the resident said:-He/She wore oxygen at night.-The staff put the oxygen on him/her and took the oxygen off of him/her.Observation on 7/18/25 at 3:00 P.M. showed:-The resident's oxygen was running and the tubing was sitting on the floor.-The resident was not in the room.Observation on 7/22/25 at 2:35 P.M. showed:-The resident's oxygen was running and the tubing was sitting on the floor.-The resident was not in the room. 3. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Chronic Obstructive Pulmanary Disease (COPD a group of lung diseases that make it difficult to breathe.-Acute Respiratory failure.-Tracheostomy status (trach a surgical procedure that created an opening in the trachea (windpipe) to help with breathing).-Dependence on supplemental oxygen.Review of the resident's POS dated July 2025 showed the following orders:-Oxygen at five liters per trach continuously every shift.-Humidify oxygen per trach every shift.-Dispose of suction catheter tubing after each use.-Maintain suction set up at bedside.-Review of the resident's Treatment Administration Record (TAR) dated July 2025 showed the following orders:-Humidified oxygen per trach every shift.-Maintain suction set up (for trach) at bedside every shift.-Dispose of suction catheter tubing after each use.-Oxygen at five liters via trach continuous every shift.Review of the resident's care plan dated 7/8/2025 showed:-He/She had a tracheostomy related to a motor vehicle accident.-Staff was to have a suction machine at bedside.-Staff was to administer humidified oxygen as prescribed.-He/She had oxygen therapy related to trach status and acute respiratory failure.-His/Her oxygen via trach was to have been five liters continuously.-Staff was to suction the resident as needed.Review of the resident's admission MDS dated [DATE] showed: -He/She had COPD.-He/She had Respiratory Failure.-Oxygen was not checked.-Trach care was not checked.-Suctioning was not checked.Observation on 7/17/25 at 1:00 P.M. showed:-His/Her suction tube was in a drawer of his/her night table, without a cap on the end.-His/Her suction machine was sitting on the floor without a barrier between it and the floor.Observation on 7/21/25 at 2:39 P.M. showed:-His/Her suction tube was in a drawer of his/her night table, without a cap on the end.-His/Her suction machine was sitting on the floor without a barrier between it and the floor.-A plastic container of distilled water (purified water that had been boiled to remove impurities and minerals - used to humidify the resident's oxygen) was opened without a date written on it showing when it had been opened, 1/3 of the water had been used.Observation on 7/22/25 at 1:30 P.M. showed:-His/Her suction tube was in a drawer of his/her night table, without a cap on the end.-A plastic container of distilled water (used to humidify the resident's oxygen) was opened without a date written on it showing when it had been opened, 1/3 of the water had been used.-His/Her oxygen was set at seven liters per minute.During an interview on 7/22/25 at 1:30 P.M. Licensed Practical Nurse (LPN) A said:-He/She did not know what to do to cap the suction tubing, but it should not have been left in the resident's drawer without something covering the end of the tubing.-The resident's oxygen should have been set at five liters per minute not the seven.-He/She then turned the oxygen setting to five liters per minute.-The distilled water container should have had a date on it when it was opened and disposed of after 72 hours.-The resident's suction machine should never have been on the floor there was enough room to have set it on the resident's night table.-Anyone who walked into the room should have seen the resident's oxygen was set at seven liters per minute not the five liters that the physician had prescribed, should have ensured there was a cap on the suction tubing not left it in a drawer, not put the suction machine on the floor, and should have dated the distilled water and written the date that it had been opened on it.4. During an interview on 7/22/25 at 1:30 P.M. LPN A said:-Anyone who went into a resident's room should have ensured that oxygen was shut off when not in use.-Oxygen should have been stored in a clean bag not laying on the floor or over the back of a chair.-The Director of Nursing (DON) had provided education to the staff regarding oxygen equipment. During an interview on 7/23/25 at 11:00 A.M. Certified Nursing Assistant (CNA) B said:-Oxygen tubing should never have been on the floor or laying over the back of a chair.-When not in use it should have been in a clean bag.-The oxygen should not have been running if the resident was not wearing it.-He/She had seen oxygen tubing laying on the resident's floor in their rooms more than once.-The nurse was responsible for ensuring oxygen was set at the correct setting.-The resident's suction machine should not have been sitting on the floor, maybe on the nightstand.-The suction tubing should have been capped off.-Distilled water should have had a date written on it when it had been opened.-He/She did not know how long distilled water was good for after having been opened, as the nurse took care of it.-The DON and Assistant Director of Nursing (ADON) had provided education to the staff regarding oxygen equipment.During an interview on 7/23/25 at 11:10 A.M. Certified Medication Technician (CMT) A said:-Oxygen tubing should never have been on the floor or hanging over a resident's chair.-The nurse was responsible for ensuring that the oxygen setting was correct.-The suction machine should have been on the nightstand never on the floor. -Suction tubing should have had some kind of cap on it not just sitting in the drawer, the nurse who had used the suction was responsible for ensuring it was capped off.-Distilled water if opened should have had the date that it had been opened written on it.-He/She did not know how long opened distilled water was good for as the nurses were responsible for it. -The ADON had provided education on oxygen and respiratory equipment.During an interview on 7/23/25 at 11:45 A.M. Registered Nurse (RN) A said:-A suction machine should never have been on the floor, it should have been on the night stand.-Tubing for suctioning the resident should have been capped off when not in use, he/she did not know what to do to cap it off but it should not have been left open sitting in the drawer.-Oxygen tubing should have been stored in a bag if not in use.-He/She had seen oxygen tubing sitting on the floor with the oxygen running.-The nurse was responsible for ensuring the resident's oxygen was set at the correct setting.-Distilled water should have had a date written on it when it was opened.-He/She was not sure how long distilled water was good for after it was opened.-The ADON had provided education on oxygen and respiratory equipment. During an interview on 7/23/25 at 2:20 P.M. the DON said:-When not in use oxygen tubing should have been in a bag.-The nurse was responsible for ensuring the oxygen was at the correct setting as prescribed by the physician. -The suction machine should not have been on the floor it should have been on the resident's nightstand.-The suction tubing should not have been sitting the resident's drawer it should have been capped off. -After distilled water had been open it should have had the date that it was opened written on it and it was good for 72 hours.-The nurses were responsible for the oxygen and respiratory equipment.-The ADON had provided education on oxygen and respiratory equipment.

Based on interview and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to follow their policy to provide Tuberculosis (TB-a communicable disease that affects the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for four employees (Employees E, G, J, and K) out of ten employees sampled for TB screening and for one sampled resident (Resident #52) out of five residents sampled for TB screening; failed to ensure one sampled resident's (Resident #33) foley catheter bag (a flexible tube inserted into the bladder to drain urine) was kept in a sanitary condition by allowing the foley bag to touch the floor; failed to ensure staff were using appropriate Personal Protective Equipment (PPE - safety gear worn to reduce exposure to substances) for one sampled resident (Resident #33) who was on Enhance Barrier (EBP - an infection control strategy that used gloves and gowns during high-contact resident care to reduce the spread of multidrug resistant organisms (MDROs) out of 17 sampled residents. The facility census was 68 residents.Review of the facility's policy titled Tuberculosis Screening – Employees dated 2019 showed:-Employees would be tested for TB upon hire.-Initial testing was a two-step procedure with the first TB skin tests (TST) given before beginning work and the second TST given seven to 21 days after the first TST, if the first test was negative. Review of TB Screening, Testing and Treatment of U.S. Health Care Personnel on the Centers for Disease Control and Prevention's website showed instructions to repeat a TST within one to three weeks after an initial negative TST. Review of the facility's policy titled Infection Prevention and Control Program dated 2019 showed:-TB screening was to be done on admission consistent with state requirements. Review of 19 Code of State Regulations (CSR) 20-20.100 TB testing for residents and workers in long-term care facilities, paragraph three, showed:-All new long-term care facility employees who work ten or more hours per week should have the first of two TSTs within one month prior to starting employment in the facility.-The results of the TSTs should be read within 48-72 hours from administration.-If the initial TST result is zero to nine millimeters (mm) induration, a second test is administered one to three weeks later, unless documentation is provided indicating a two-step TST was completed in the past and at least one subsequent annual test within the past year. 1. Review of the facility's list of employees hired since the facility's last annual survey showed:-Employee E was hired on 1/27/25.-Employee G was hired on 1/13/25.-Employee J was hired on 5/12/25.-Employee K was hired on 5/19/25. Review of the above employees' TB testing forms showed:-Employee E's first TST was administered on 1/15/25 and read on 1/17/25 with results documented as 0 mm.-Employee E's second TST was administered on 1/23/25, which was one day early and was read on 1/25/25 with results documented as 0 mm.-Employee G's first TST was administered on 12/3/24 and read on 12/5/24 with results documented as 0 mm.-Employee G's second TST was administered on 12/10/24, which was two days early and was read on 12/12/24 with results documented as 0 mm.-Employee J's first TST was administered on 5/8/25 and read on 5/10/25 with results documented as 0 mm.-Employee J's second TST was administered on 5/12/25, which was five days early and was read on 5/14/25 with results documented as 0 mm.-Employee K's first TST was administered on 5/19/25 and read on 5/21/25, which was not prior to hire with results documented as 0 mm.-Employee K's second TST was administered on 5/27/25, which was one day early and was read on 5/29/25 with results documented as 0 mm. During an interview on 7/22/25 at 1:24 P.M., the Infection Preventionist said regarding employee TB testing:-He/She sets up pre-employment physicals prior to the employees starting work but after background checks cleared, which included their initial TST.-He/She is responsible for the TSTs.-He/She gets the employees' phone numbers so he/she can have them come to him/her to read the results 48-72 hours after it was administered.-He/She does the employees' second TST seven to ten days from when the first TST was read.-He/She tells the new employees when to come back to him/her for the second TST and when to have it read.-He/She documents on his/her calendar when the employees had their TST and when they were read as well as on the employee TB screening tool.-Employee E was going out of town, so his/her second TST was administered one day early.-Employee G's second TST was done early because he/she administered the second TST seven days from the date it was administered and not seven days from the date the first TST was read.-He/She documented the wrong date for Employee J's second TST administration and read dates.-Employee J's first TST should have been dated as administered on 5/22/25 and read on 5/24/25.-Employee K's second TST was done early because he/she went by the administration date and not the read date. During an interview on 7/23/25 at 2:31 P.M., the Director of Nursing (DON) said:-The infection preventionist was responsible for completing the new employee TSTs.-The employees should have their first TST completed prior to working their first day.-They should administer the second TST one to two weeks after the first.-They were going by one week from the first TST administration date and not necessarily one week from the date the first TST was read. 2. Review of Resident #52's entry tracking form showed the resident was admitted to the facility on [DATE]. Review of the resident's immunization page showed:-The resident's first TST was dated as administered 10 days after admission instead of the day of admission on [DATE], had no read date, and had results documented as 0 mm.-On 7/23/25 at 11:14 A.M., the resident's second TST was documented as pending. Review of the resident's Treatment Administration Records (TAR) dated July 2025 showed:-The resident's first TST was administered on 7/9/25 at 4:29 A.M. and read on 7/10/25 at 6:11 P.M., which was less than 48 hours and no results were documented.-The resident's second TST was administered on 7/18/25 at 4:55 P.M. and read on 7/19/25 at 4:07 P.M., which was less than 48 hours and no results were documented. During an interview on 7/22/25 at 12:47 P.M., Registered Nurse (RN) A said:-Upon a resident's admission to the facility, the admitting nurse should pull up batch orders, mark admission batch orders, and select Tb testing orders which includes the administration of the first TST date upon admission.-The nurse should read the first TST two-three days later.-Then the second step comes up in the electronic health record to be done a week later.-They document all TST administrations and readings on the TARs. During an interview on 7/23/25 at 2:31 P.M., the DON said:-The Infection Preventionist did a lot of the residents' TSTs.-If the Infection Preventionist did not administer the TST within 24 hours of the resident's admission, the floor nurse should do it.-The first TST should be read within 48-72 hours by the Infection Preventionist or the floor nurse.-They should administer the second TST one to two weeks after the first.-They were going by one week from the first TST administration date and not necessarily the date the when the first TST was read.-Any nurse that does a resident's first TST should enter it as an order and should document the administration of the TST and then the reading of the TST on the TAR for both the first and second TST.-The Infection Preventionist was supposed to transfer the first and second TST information over to the immunization tab. 3.Review of the facility's policy, Catheter Care, Urinary, dated 12, 2024 showed:-The purpose of this procedure was to prevent catheter-associated urinary tract infections.-The urinary drainage bag must have been held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary blader.-Be sure the catheter tubing and drainage bag were kept off the floor. Review of the facility's undated policy, Infection Prevention and Control Manual-Enhanced Barrier Precautions, showed:-Enhanced Barrier Precautions (EBP) was an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes.-EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition such as residents that had wounds or an indwelling medical device.-High contact resident care activities where a gown and gloves should have been used included:-Caring for a resident with an indwelling medical device. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE]with the following diagnoses:-Methicillin Resistant Staphylococcus Aureus Infection (MRSA – a staph infection (an infection caused by bacteria on the skin) that was resistant to antibiotics).-Open wound left lower leg.-Open wound right lower leg.-Tracheostomy status (a surgical procedure that creates a small opening in the neck, directly into the trachea (windpipe) to facilitate breathing).-Gastrostomy status (a tube inserted through the abdominal wall into the stomach to deliver nutrition, fluids and medications). Review of the Physician's Order Sheet dated July 2025 showed the following orders:-EBP with dressing, bathing, device care or wound care every shift, dated 7/8/25.-Suction trach every shift and as needed.-Urinary catheter for neurogenic bladder, dated 7/9/25. Review of the resident's Treatment Administration Record (TAR) dated July 2025 showed the following Physician's orders:-Ondansetron Hydrocholoride (medication used to control nausea) tablet 4 milligram (mg) via gastrostomy tube (G-tube) every morning and evening for nausea or vomiting control, dated 7/8/25.-Levaquin (antibiotic used to treat infections) 500 mg tablet via G- tube one time a day for right ankle infection (MRSA), dated 7/9/25.-ProSource liquid (nutritional supplement) 30 milliliters via G-tube every morning and at bedtime for wounds, dated 7/8/25.-MiraLax (used to treat constipation) 17 grams via G-tube once a day for bowel care in 8 ounces of liquid, dated 7/8/25. Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool completed by the facility for care planning) dated 7/8/25 showed:-Not able to complete Brief Interview for Mental Status (BIMS).-He/She had a Neurogenic Bladder (a dysfunction of the bladder).-He/She had MDRO.-He/She had respiratory failure (when the lungs could not properly exchange gases).-He/She had an indwelling catheter.-He/She had a feeding tube.-He/She had a tracheostomy, and was on oxygen, needed suctioned. Review of the resident's care plan dated 7/8/25 showed:-He/She had a catheter related to neurogenic bladder, dated 7/16/25.-Staff was to preform catheter care every shift. -Staff was to position the catheter bag below the level of the bladder and away from the door. -He/She required a tube feeding due to traumatic brain injury. -He/She had a tracheostomy related to motor vehicle accident. Observation and interview on 7/17/25 at 10:00 A.M. showed:-A Certified Nursing Assistant (CNA) (declined to give his/her name and did not have a name badge on facing front, not able to obtain the CNA's name) had emptied the resident's foley.-He/She did not have a gown on while emptying the foley.-The Foley bag was touching the floor without a barrier.-The was an EBP sign on the resident's door which showed; staff was to wear gown and gloves when doing cares on that resident.-He/She said he/she had worn gloves while emptying the urine out of the foley.-He/She said the EBP sign was for the Nurses. Observation on 7/21/25 at 8:57 to 9:20 A.M. with RN B showed:-The resident had a tracheostomy, foley, and a feeding tube. -The Nurse administered water into the feeding tube.-The Nurse administered the following medications via the feeding tube;-Ondansetron Hydrocholoride, Levaquin, ProSource liquid, and MiraLax.-The Nurse wiped secretions out of the corner of the tracheostomy mask with a gauze.-The Nurse adjusted the resident's tracheostomy mask which provided oxygen to the resident.-The resident's bed was in the lowest position and his/her foley bag was touching the floor.-The Nurse had worn gloves but did not wear a gown while administering medications to the resident or doing cares on his/her tracheostomy. During an interview on 7/21/25 at 9:25 A.M. RN B said:-He/She would not have done anything differently during the medication administration.-He/She should have followed the protocol on the EBP sign on the resident's door and worn a gown while administering medications and doing cares on the resident's tracheostomy mask.-The facility had not provided education about working with tracheostomies, he/she had worked with feeding tubes and tracheostomies before and was the one who trained the new employees.-The facility had not had a skills fair since the last survey more than a year ago. Observation on 7/22/25 at 1:30 P.M. with Licensed Practical Nurse (LPN) A showed:-The resident's bed was in the lowest position with the foley touching the floor. 4. During an interview on 7/22/25 at 1:45 P.M. Licensed Practical Nurse (LPN) A said:-The resident did not try to get out of bed his/her bed could have been raised a few inches so that the foley was not touching the floor.-Any nursing staff who had been in the room should have seen that the foley was touching the floor and put a barrier between the foley and the floor such as a wash basin or towel.-While doing cares with the resident staff should have followed the directions on the EBP sign on his/her door and wore a gown and gloves while doing cares with the resident. -The DON had provided education with the staff concerning the foley placement and wearing PPE for residents who were on EBP. During an interview on 7/23/25 at 11:00 A.M. CNA B said:-A resident's foley bag should never touched the floor.-The resident's bag should be not touching the floor there should be a barrier.-Everyone who goes into the room should have ensured the foley was not touching the floor. -If there was a sign on a resident's door stating they were on EBP and you did cares you needed to wear the PPE on the sign. -DON or Assistant Director of Nursing (ADON) has provided education on EBP and foleys. During an interview on 7/23/25 at 11:10 A.M. Certified Medication Technician (CMT) A said:-A resident's Foley should not touch the floor, you should have raised up the bed or put a barrier between the foley and the floor. -If there was a sign on the door stating they needed to wear PPE for EBP, the staff should have worn the appropriate PPE while preforming cares on the resident.The DON and ADON had provided the education about EBP and foleys. During an interview on 7/23/25 at 11:30 A.M. RN A said:-A resident's foley should not have touched the floor it should have been in a privacy bag and not touched the floor. -There should have been a barrier between the foley bag and the floor such as a towel or wash basin.-The ADON has provided education many times about wearing PPE if there was a sign on the resident's door while doing cares.-The ADON has provided education to the staff about correct placement of the resident's foley bag.-Any staff who walked into the resident's room should have ensured the foley was not touching the floor. During an interview on 7/23/25 at 2:31 P.M. the DON said:-The staff have received education on what PPE they should wear if a resident was on EBP.-There were signs on the resident's door what PPE should be worn by staff when performing cares.-A resident's foley should not have been touching the floor, the staff should have placed a barrier or raised the resident's bed a few inches.-Nursing staff who entered the room should have seen the foley was touching the floor. -The ADONs have provided education about EBP and foleys.

Based on observation and interview, the facility failed to ensure the lids of the dumpsters were closed on 7/22/25 and 7/23/25. The facility census was 68 residents.1. Observation on 7/22/24 at 11:09 A.M., and 3:48 P.M., showed the dumpsters in the dumpster area had the lids open. Observation on 7/23/25 at 11:46 A.M. and 12:49 P.M. showed the dumpsters in the dumpster area had the lids open. During an interview on 7/23/25 at 12:43 P.M., the Dietary Manager (DM) said:-He/She had to constantly remind personnel form other departments within the facility and personnel in the dietary department to keep the lids closed.-He/She expected any staff from any department to close the lids once they dumped trash in the dumpsters. During an interview on 7/23/25 at 2:31 P.M., the Administrator said facility staff should shut the lid of the dumpsters.

Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for one sampled resident (Resident #1). Licensed Practical Nurse (LPN) A failed to visualize the resident when performing the required midnight census safety rounds and Certified Nursing Assistant (CNA) A failed to visualize the resident when doing two-hour nightly rounds. As a result, the resident self exited into the facility courtyard after dark, without staff awareness and fell from his/her wheelchair out of six sampled residents. The facility census was 62 residents. On 6/3/25, the facility Administration was notified of the past noncompliance which occurred on 5/31/25. Facility staff had subsequently been educated on hourly checks to courtyard, abuse, neglect, and two-hour rounding by CNAs. Alarms were ordered for the courtyard doors and additional lighting installed in the courtyard. The deficiency was corrected on 6/1/25. Review of the facility's Midnight Census policy dated 12/24 showed: -It was the policy of the facility to complete an accurate count of all residents in the facility at midnight each night. -This count was known as the Midnight Census. -This manual count was to be completed each night at midnight by the nurse in charge. -A midnight census was essential to the tracking of residents for accountability for clinical and bookkeeping purposes. -All disciplines should be aware of the daily midnight census. -Each resident would be visualized for accuracy of the count and the resident's presence or absence and the changes in the past 24 hours would be noted on the Midnight Census Report. 1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Parkinson's disease (a progressive disorder that affects movement and coordination). -Alzheimer's disease (a progressive, irreversible brain disorder that slowly affects memory, thinking skills, and the ability to carry out basic tasks). -Difficulty walking. -Reduced mobility. -Insomnia (a sleep disorder which caused difficulty going to sleep, staying asleep and waking early). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 3/7/25, showed he/she was cognitively intact. Review of the resident's Care Plan Report dated 2/28/25 showed: -He/She had activity preferences including taking care of plants/garden; going outside and getting fresh air when the weather was good; being alone and doing things by him/herself. -He/She had decreased mobility. Interventions included staff participation for transfers. -He/She had Parkinson's disease. Interventions included monitoring for risk of falls; mobility as tolerated; monitoring for poor balance, poor coordination and insomnia. Review of the Resident's Fall Incident Report dated 6/1/25 at 4:35 A.M. showed: -The resident was able to make his/her needs known. -He/She had gone out in the courtyard and was found lying face down on the concrete walkway. -He/She was found around 4:30 A.M. according to staff, after they did not find him/her in his/her room during regular room checks by his/her CNA. -He/She initially said he/she had gone outside around 8:00 P.M., but staff said this was not accurate. -He/She stated he/she went outside to find a spot to plant his/her tomato plant, he/she stood up and fell. -He/She did not know why he/she stood up. -He/She didn't remember the time he/she went out to the courtyard. -The staff state he/she was visiting with another resident until around 9:00 P.M. and that resident collaborated the same time. -The CNA stated he/she helped the resident to bed around 9:30 P.M. -The CNA stated when he/she did rounds, the resident was in bed until the 4:00 A.M. check, which occurred between 4:00 A.M. and 4:30 A.M. -When he/she was found by CNA A, the charge nurse was alerted and the resident was checked for injuries. -Staff stated neuro checks were within normal limits; blood pressure was noted to be low. -Ambulance was called per protocol for unwitnessed fall since the resident was on an anticoagulant. -Staff reported the resident was up more during the night, but had only tried to go out on the courtyard a couple times. -Staff stated they had never noticed him/her trying to leave the facility. -New interventions would be added when the resident returned from the hospital. Review of the resident's Progress Notes dated 6/1/25 at 6:58 A.M. showed: -He/She was found outside in the courtyard lying face down on the concrete walkway. -He/She did not tell staff he/she was going outside. -He/She went outside to find a place to plant his/her tomato plant. -He/She stood up and fell, but did not remember why he/she stood up. -He/She moved all extremities and denied any pain. -His/Her daughter stated his/her symptoms of Parkinson's, memory and cognition had worsened greatly. -He/She was encouraged to leave the door to his/her room open for more frequent monitoring and to not go to the courtyard late at night without staff knowledge. Review of the resident's Progress Notes dated 6/1/25 at 5:30 P.M. showed: -The resident was alert and able to have a conversation. -He/She was asked if he/she remembered when he/she had gone out in the courtyard and he/she could not remember the exact time he/she went out. -He/She did recall being in another resident's room crocheting prior to going to his/her room. -The other resident he/she was visiting thought he/she had left his/her room around 9:00 P.M. -He/She voiced that he/she was going out in the courtyard to see where he/she could plant the tomato plants he/she had gotten while out of the facility with his/her daughter the day before. -He/She said he/she didn't yell for help and did not have his/her cell phone with him/her. -He/She did attempt to get him/herself up and was unable to do so. -He/She could not give a time frame for how long he/she was outside. During an interview on 6/2/25 at 9:30 A.M. the resident said: -He/She went out to the courtyard to see where he/she was going to plant his/her tomato plant. -He/She did not tell anyone he/she was going outside. -He/She did not call out for help because he/she didn't think anyone would hear him/her. -He/She fell because he/she stood up from his/her wheelchair. He/She probably should not have stood up. -He/She did not remember telling staff not to wake him/her during the night. During an interview at 11:43 A.M. CNA A said: -He/She found the resident in the courtyard. -The staff would do rounds every two hours, but did not typically check the courtyard. -He/She did not remember what time he/she last saw the resident up and around. -When rounding, he/she would stop near the resident's bathroom to check him/her, since he/she was continent, so he/she would not wake the resident up. -The resident had said not to bother him/her unless he/she needed something. -He/She could see the resident's feet in his/her bed from by the bathroom. -He/She came to work around 10:00 P.M. -The resident was very active at night sometimes, but usually stayed in his/her room. Sometimes he/she would be laying down or sometimes stay up knitting. -There was a light in the courtyard, but not very bright. -The resident was far enough back from the exit door in the courtyard that he/she would not have been seen if someone had glanced out. -The resident used his/her wheelchair to get around, but thought he/she could do more than he/she actually could. -He/She went in the resident's room at 4:30 A.M., because something just told him/her to check and see if the resident was there. -He/She swore he/she saw the resident's feet in bed during the previous rounds. -He/She went to the nurse and the nurse had not seen the resident. -He/She got another CNA to assist him/her looking for the resident. -He/She decided to check the courtyard because the resident liked to go out there. -He/She found the resident face down and his/her wheelchair was behind him/her. -The resident was awake. -The resident said he/she had a tomato plant and was trying to find a spot to plant it. -The staff did rounds to check the residents every two hours, which is what they are trained to do. During an interview at on 6/2/25 at 12:00 P.M. Physician A said: -He/She was advised of the situation with the resident that morning. -The resident would sometimes go around in the facility during the evenings. -He/She had been working with the resident due to his/her difficulty sleeping, trying different medications. -He/She was not sure how mobile the resident was at night. -He/She had been having very thorough conversations with the resident about his/her sleep concerns; he/she was able to make his/her needs known. -The expectation would be that the resident was checked per the facility protocol during the night. During an interview on 6/2/25 at 1:10 P.M. CNA B said: -He/She assisted CNA A with the resident. -He/She started his/her round around 4:00 A.M. and CNA A came to him/her and said the resident was not in his/her room. -He/She checked all of the rooms in his/her hall and the resident was not in any of the other rooms. -He/She asked CNA A if he/she had checked the staff bathroom and it had been checked by the nurse. -They rechecked all of the resident rooms. -The previous week he/she had stopped the resident from going out to the courtyard around midnight because he/she was looking for his/her knitting bag, which was on the back of his/her chair. -The resident was a little forgetful. -They found the resident in the courtyard, face down on the ground, with his/her wheelchair to the side of him/her and folded on the ground. -The resident said he/she was out there trying to figure out where he/she was going to put his/her tomato plant. -Rounding was done every two hours and that meant laying eyes on the residents to make sure they were breathing. -The staff had not been checking the courtyard at night. During an interview on 6/2/25 at 1:30 P.M. Licensed Practical Nurse (LPN) A said: -When he/she was doing rounds at around 8:00 P.M. the resident was awake and laying in his/her bed. -The resident liked to go visit the other residents throughout the facility. -CNA A made rounds every two hours and said he/she walked in the resident's room and saw his/her feet. -The resident did not want to be awakened during the night, and did not want the light turned on. -During 4:00 A.M. rounds CNA A went further in the resident's room and found him/her missing. -The staff began looking for the resident; they checked all of the resident rooms and the bathrooms. -The resident was found in the courtyard. -He/She had no idea the resident had been going outside at night without staff knowledge. -The staff had never had anyone go out to the courtyard at night and and never thought of checking the courtyard. -If all the residents were in their beds, there would be no need. -The resident was awake when he/she was found, and denied pain. -The resident was sent to the hospital due to being on a blood thinner. -Rounding to check residents should be done every two hours. During an interview on 6/3/25 at 11:00 A.M. Resident #3 said: -He/She knew the resident and there were times the resident would try to get him/her to go with him/her to the courtyard. -The resident had been in the courtyard the night before he/she fell. -The resident was a night person; sometimes he/she would go to bed in the early morning hours. -He/She knew the resident went out at night, but did not think the staff were aware. During an interview on 6/3/25 at 11:10 A.M. Resident #2 said: -The resident had come to see him/her the night he/she fell, and left his/her room around 10:00 P.M. or a little before. -The resident did not ask him/her to accompany him/her to the courtyard that night, but had asked him/her earlier in the day. -The resident was a night owl and sometime would come visit him/her at 8:00-9:00 P.M. -He/She did not know if the staff knew the resident had been going out in the courtyard. During an interview on 6/3/25 at 12:30 P.M. the Director of Nursing (DON) said: -There was not an assignment for staff to check the courtyard. -He/She did not think the resident could have been out there long or he/she would have developed hypothermia (low body temperatures), since he/she was not a big person. -He/She was used to it being the standard that the charge nurse physically counted the residents at midnight and that was his/her expectation. -CNA A should have gone in and visualized the resident. -The resident did not wish to be awakened during the night because he/she didn't sleep well. -The resident stayed up later than people were used to. -The resident typically stayed in his/her room and staff had to encourage him/her to come out. He/She was just settling in to the facility. -The resident was excited about his/her plant as this was an activity he/she could do with the other residents. -The resident was starting to have more issues with his/her memory. During an interview on 6/3/25 at 1:00 P.M. the Administrator said: -The facility did not have a specific policy on rounding. -CNA A said he/she rounded every two hours and he/she saw the resident's feet in his/her bed at 2:00 A.M. -CNA A peeked at the resident in his/her room at 10:00 P.M., 12:00 A.M. and 2:00 A.M. At 4:30 A.M. he/she was not in his/her bed. -The resident had asked not to be bothered at night. -They had caught the resident trying to go out late at night before but it was not unusual for him/her to be up late at night. -If the resident had gone through the dining room exit to the courtyard, the staff would have seen him/her. He/She went out the other exit to access the courtyard. -There had been some changes in the resident's cognition, but he/she was not an elopement risk. -The resident would go outside and sit in the courtyard for hours taking pictures of flowers. -He/She had been excited he/she could have his/her own tomato plant. -The facility did not lock the doors to the courtyards because another facility had gotten in trouble for doing so. -The courtyard had lighting. -The expectation was that rounding was done every two hours and maybe more if needed. -The charge nurse did not check residents' room-to-room at midnight. It was his/her expectation that this would be done. -It had not previously been a practice to check the courtyard at night, so they never did it. -CNA A should have gone into the room to check the resident. -The staff had seen the resident go outside before; it was a known thing. -It was his/her expectation that staff would follow the midnight census policy. -The resident's vital signs were within normal limits, when he/she was found. He/She did not say he/she was upset or cold. -The resident denied calling for help even though there were windows surrounding the courtyard. MO00255085 MO00255111 1

Based on observation, interview and record review, the facility failed to prevent the misappropriation of 30 tablets of 2 milligrams (mg) Hydrocodone (an opioid pain medication used to treat moderate to severe pain) belonging to one sampled resident (Resident #2) out of four sampled residents. The facility census was 66 residents. The Administrator was notified on 9/18/24 of Past Non-Compliance which occurred on 9/3/24. An all nursing staff in-service was completed on drug diversion and working under the influence of drugs/alcohol by 9/3/24. The resident's missing medications were replaced and paid for by the facility. The deficiency was corrected 9/3/24. Review of the facility's Controlled Substance Policy revised 5/23 showed: -Controlled substances were subject to special handling, storage, disposal and record-keeping requirements. -The facility would maintain compliance with these special provisions. -Such drugs were to be accessible only to authorized nursing and pharmacy personnel. -The Director of Nurses (DON) was responsible for the control of such drugs. -Drugs listed in Schedules II, III, and IV (drugs that are regulated by the Drug Enforcement Administration, categorized based on their medical use, potential for abuse and risk of dependence) were to be stored under double-lock conditions. -The key to the separately locked storage area was not the same key used to gain access to other drugs. -The medication nurse or Certified Medication Technician (CMT) where applicable on duty at the time would maintain possession of the key. The key must remain in possession of the licensed nurse or CMT where applicable that completed the count at all times during their shift. Should it be necessary to give the keys to another licensed nurse or CMT, a count would be done to verify the inventory. A count would be done again when the keys were returned to the original licensed nurse or CMT. -A physical inventory of the controlled substance medications would be made at the change of each nursing shift. Shift verification count sheets/packages should be made at the change of each shift. -The person performing the inventory would sign to verify that the inventory was done. All controlled substances were to be counted every shift. The count was to be performed by the on-coming licensed nurse or CMT and the off-going licensed nurse or CMT. The on-coming nurse or CMT would be responsible for looking at the medication to verify the amount of medication present at the time of the count. The off-going nurse or CMT would be responsible for viewing the Controlled Substance Proof of Use Record to verify the amount on the record at the time of the count. Both nurses or CMT would sign on the Narcotic Sign In & Out Sheet that the count was completed. -Any discrepancy in the inventory of a controlled substance was to be reported to the DON immediately. The DON was responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. The discrepancy of a controlled substance was to be reported to the Administrator and the Regional Nurse immediately. If a discrepancy was not reconciled, the DON was to document the details on the audit record, including the possible shift or persons responsible for the discrepancy and the efforts made to reconcile it, 1. Review of Resident #2's Admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Sickle cell disease with crisis (a condition in which red blood cells become abnormally shaped like crescents or [NAME], rather than the usual round shape). -Critical illness myopathy (a condition that affects patients who have been critically ill and have had prolonged immobility, characterized by muscle weakness). Review of the resident's Order Summary Report dated 9/18/24 showed: -He/She had an order for Hydromorphone HCl 2 mg tablet. Give 1 tablet by mouth every 3 hours as needed for pain. -He/She had an order for Hydromorphone HCl 2 mg tablet. Give 2 tablets by mouth every 3 hours as needed for pain. Review of the resident's Medication Administration Record (MAR) for the dates of of 9/2/24 and 9/3/24 showed: -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/2/24 at 9:00 A.M. for pain, which was given by Licensed Practical Nurse (LPN) B. -The resident received Hydrocodone HCL 2 mg 1 tablet on 9/2/24 at 1:01 P.M. for pain, which was given by LPN B. -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/2/24 at 5:00 P.M. for pain, which was given by LPN B. -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/2/24 at 8:32 P.M. for pain, which was given by LPN A. -The resident received Hydrocodone HCL 2 mg 1 tablet on 9/3/24 at 2:15 A.M. for pain, which was given by LPN A. -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/3/24 at 5:45 A.M. for pain, which was given by LPN A -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/3/24 at 9:05 A.M. for pain, which was given by LPN B. Review of the resident's Care Plan dated 9/3/24 showed he/she was prescribed opioid medication. Interventions were to give the medication as ordered and monitor for side effects. Review of the facility Narcotic Diversion timeline investigation dated 9/3/24 showed: -The DON was notified by LPN B the narcotic card count was one card short. He/She believed that a card of Dilaudid (Hydromorphone HCL) 2 mg was missing. He/She stated he/she had counted the cart with the other nurse in the building and all the other medications were accounted for. -The DON received a text from LPN A stating he/she needed to talk to him/her. -The DON called LPN A, who stated he/she had left the facility as he/she had to take his/her child to school. He/She stated LPN B accused him/her of taking a card of narcotics because the count was off and he/she was offended. He/She was told he/she would need to take a urine drug screen and he/she stated he/she would come take the test. -LPN B was interviewed and statement obtained. -Registered Nurse (RN) A was interviewed and statement obtained. -All medication carts, narcotic drawers and medication rooms were cleaned and organized. Narcotic counts verified for all 3 medication carts. -Audit was completed of narcotic book against the MAR. -The DON spoke with pharmacist at the facility's pharmacy and requested to be sent a list of the narcotics sent to the facility after 6:00 P.M. on 9/2/24. He/She stated he/she was unable to run that report and would have his/her supervisor contact him/her. He/She requested the pharmacy send out a new card of Dilaudid 2 mg tabs that the facility would be paying for and the resident was not to be billed. -The Medical Director was notified of the missing narcotics. Resident #2 was his/her own person and notified of the missing narcotic and that they would be replacing it for him/her. -The Administrator called and sent multiple messages to LPN A explaining why he/she needed to come to the community to give his/her statement and complete a drug test. -LPN A returned to the facility around lunch time and was interviewed by the Administrator and DON. He/She stated he/she didn't know what happened to the card that LPN B said was missing when they counted the cards. -There were 22 cards when LPN A took the cart from LPN B at the start of his/her shift. LPN B verified there were 22 cards when he/she took the cart and he/she only removed one empty card for the resident. -LPN A stated he/she couldn't remember for sure, but that he/she was pretty sure he/she did not give his/her keys to anyone else during his/her shift. -LPN A was notified that he/she was being suspended pending investigation. -After interviews and investigation, the only person who had access to the medication that was missing was LPN A. Based on this and the behavior during the investigation, it was believed that he/she was the nurse that took the medications. Review of LPN A's written statement dated 9/3/24 showed: -When LPN B came into work that morning, he/she gave him/her report and counted with him/her. All of his/her counts were correct, but then he/she started asking about a card of 30 hydromorphone that he/she said was missing. He/she told him/her he/she didn't know anything about that, the only card he/she took out was a card for hydromorphone for another resident, but he/she did not remember for which one. -LPN B kept stating that it was missing and that the card was there when they counted the evening before. He/she told him/her he/she did not remember and he/she asked how he/she could not remember. He/She continued to tell him/her he/she did not remember, and then he/she said he/she knew he/she took it so just to say that he/she did. -He/She told him/her he/she didn't take anything and would do whatever possible to show he/she did not take it. -At that point, he/she had already given report and counted with him/her. -LPN B threw the keys down and said he/she would not take the cart. -He/She told him/her he/she had class that morning and had to leave. At that point, LPN B walked away and he/she left. Review of LPN B's written statement dated 9/3/24 at 10:56 A.M. showed: -On 9/2/24 at 6:35 P.M., he/she counted the medication cart #2. There were 22 cards left in the cart. The night nurse accepted the count and took the keys. -On 9/3/24 around 6:40 A.M. he/she counted the cards and there were only 20 cards. The night nurse said there were 21. -He/She confirmed there were only 20 cards there. -He/She attempted to call the Assistant Director of Nursing (ADON) and received voice mail. -He/She told the night nurse to wait until they talked to the ADON or DON, but he/she said he/she was not waiting, that he/she had class and left. -He/She and the RN A counted 20 cards. He/She later realized the card for hydromorphone was missing for Resident #2 and reported that to the DON. -Confirmed from the pharmacy that 2 cards were sent on 8/31/24 for 60 tablets. Review of the pharmacy packing slip dated 9/3/24 showed 60 2 mg tablets of Hydromorphone were delivered to the facility for Resident #2 to replace missing medications. During an interview on 9/18/24 at 10:55 A.M., the Administrator said: -The facility's system caught the medication problem. -A card count was done and then the pills were counted at shift changes. -LPN B counted with LPN A at 6:00 P.M. the night of 9/2/24, and the next day, he/she relieved him/her on the same cart. -LPN A had just come off orientation and this was the first shift he/she worked alone. -The counting could not have been done differently. -His/Her expectation was that when people came to work, they did not steal drugs. -Other staff did not have access to the keys. The expectation was that the narcotic boxes were kept locked and only the nurse had the key, -The nurses were trained to do the narcotic count each shift. This was never something that was not done. During an interview on 9/18/24 at 12:15 P.M., RN A said: -There was a process for the narcotic counts. -After report the off-going and on-coming nurses would count the cards and pills. -If something was off, the DON should be called. -When medications were delivered, they would come in plastic bags and the nurse and the pharmacy staff sign off on the count. -If the pharmacy were called, they would know who signed off on the medications. -He/She had not had any issues with that. -LPN B worked the previous day. When LPN A came in that night, they did the count together, and the count was accurate at that time. -LPN A worked the night shift. -LPN B came in the next morning and worked at the same hall with the same medication cart. -He/She heard the two of them talking about a medication card being missing. -LPN A said one of the cards had gone down to zero medications, so he/she removed it. -A card would have the resident's name on it. Normally when the card got down to zero medications, the staff person would sign it and remove it. -LPN B said there was not a page in the narcotic book for the card and the card was not subtracted, so he/she called the DON and told LPN A not to leave. -LPN A said he/she had a class to go to and left anyway. -He/She then did the count with LPN B, which was accurate except for the missing card. -Only the nurse for that medication cart had access to the keys for the cart. The box where the narcotics were kept had a separate key from the cart. During an interview on 9/18/24 at 12:30 P.M., LPN B said: -LPN A came to work at 6:00 P.M. that night. LPN A worked nights and he/she worked days. -They counted the medication cards and there were 21. -The next day, he/she came to work at the same cart and noticed a medication card was missing. -When he/she noticed the card was missing, LPN A did not stay to count the individual pills. -This was possibly LPN A's fourth week at work. He/She had worked at the facility almost 3 years. -He/She had never had this happen before at that facility. -They looked for the missing card and could not find it. -He/She contacted the DON immediately. -The DON asked him to count with RN A, since LPN A had left. -Only he/she and LPN A had access to the medication keys. -The staff were not supposed to let anyone else have the keys. -He/She was called in to the office and he/she wrote a statement and told the DON the same thing. During an interview on 9/18/24 at 1:10 P.M., Resident #2 said: -He/She was getting all of his/her pain medication. -He/She did not know about any missing medications. During an interview on 9/18/24 at 2:00 P.M., RN B said: -When he/she came to work, he/she would not take the cart until the medications are counted. -If there was a discrepancy, they should call the DON. -It would not have been possible for a full card of medications to be missing. -When a card was emptied, it was recorded in the narcotic book. -He/She had three keys, one for the cart and two for the narcotic boxes in the cart. -Each key only worked on a specific drawer. -Cart keys only would open specific carts and did not interchange. -Nobody else would hold his/her keys while he/she was working. -He/She would only give his/her keys to the ADON or DON. -He/She never would take lunch away from the facility premises so he/she would not have to turn the keys over to someone else. Observation on 9/18/24 at 2:00 P.M. with RN B showed a medication cart, narcotic drawers, keys and demonstration of how they worked. During an interview on 9/18/24 at 2:05 P.M., the ADON said: -The day it was reported the narcotics were missing, LPN B realized there was a discrepancy and that a card was missing and the count was off. -The nurses counted the medications every shift. -LPN B did what he/she was supposed to do, which was contact him/her and the DON. -There was no way the card could have been lost. -The medication cart was locked. -If the count was wrong, unless the resident left the facility, nothing would be destroyed. -LPN A had just completed orientation. He/She would have been the only one who had access to that cart that night. -If a staff person gave the keys to someone else, they should count the medications together. During an interview on 9/18/24 at 2:15 P.M., LPN A said: -He/She was aware of the missing narcotics. -He/She offered to work that night. -He/She counted the narcotics with LPN B and worked through the night. -He/She passed possible 2-3 as needed medications that night. -His/Her count was right, but LPN B said a card was missing and accused him/her of taking the card. -He/She called the DON and told him/her what LPN B was saying and that it was not his/her place to say that. -His/Her medication cart was visible in the hallway at all times. -He/She had to go to a class that day, so he/she left the facility. -Between 11:00 A.M. and 11:30 A.M., he/she got a call from the DON or the Administrator; he/she could not remember who. -The Administrator asked him/her why he/she didn't stay when he/she got off work and he/she had already told the DON. -They asked him/her a lot of questions. He/She said he/she had to pick up his/her child from school, so he/she had to leave. -He/She did not think anyone had access to his/her keys. He/She had them on the counter when he/she was charting. Only he/she and one other nurse were working that night. He/She did not remember who the other nurse was. -He/She had not really had training specific to the facility for doing the narcotic count. -This was not his/her first night off orientation. -He/She had not heard back from the facility and assumed he/she was fired. During an interview on 9/18/24 the DON said: -LPN A said he/she did not give anyone else the keys. -The nurses were supposed to count the medication cards; how many cards were added or removed, and then they count the individual pills on each card and compare against the individual residents' narcotic sheets. -LPN B got really agitated because of the missing medication. -He/She did everything he/she was supposed to do and called him/her when he/she found the discrepancy. -They asked LPN A to come to the facility at 10:45 A.M. and he/she didn't come until 12:45 P.M. -This would have been the first shift LPN A worked by him/herself. He//She picked up the extra shift. -There were cameras at the front of the facility. LPN A made multiple trips to his/her car during that shift. He/She worked from 6:00 P.M. to 6:00 A.M. This was not a normal pattern for a nurse. He/She took the keys with him/her. -Every narcotic box had a key with a number on it, and the medication cart had another key with a number and a matching number on the cart,; they are not interchangeable. -There was no master key for the medication carts. -The keys were the nurse's responsibility. MO00241543

Based on interview and record review, the facility failed to contact Emergency Medical Services (EMS), check code status, initiate and provide cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped) for one sampled resident (Resident #1) who was a full code status. On [DATE], Registered Nurse (RN) A and Agency Licensed Practical (LPN) A found the resident without spontaneous respirations and pulse. RN A and LPN A did not check the resident's code status, initiate CPR, or contact EMS. As a result the resident died . The facility census was 66. The Regional RN was notified on [DATE] at 12:03 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the Administrator became aware of the violation of the facility's CPR policy. The facility in-serviced the staff and agency staff on the CPR policy and procedures. The IJ was corrected on [DATE]. Record review of the facility's CPR policy, dated [DATE], showed the following: - Personnel have completed training on the initiation of CPR/Basic Life Support (BLS) in victims of sudden cardiac arrest (cessation of respirations and/or pulse). - If an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR BLS shall initiate CPR unless: - It is known that a Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) order that specifically prohibits CPR and/or external defibrillation exists for that individual. 1. Review of Resident #1's Admission Record showed the resident: -Was admitted on [DATE], readmitted on [DATE]. -Had diagnoses including: --Malignant neoplasm (a cancerous tumor) of the bladder. --Secondary neoplasm of the lung. --Neoplasm related pain. --Malignant neoplasm of the intra-abdominal lymph nodes. -Advanced directive indicated 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 Order Summary Report, dated [DATE], showed FULL CODE order, dated [DATE]. Review of the resident's undated Care Plan showed: -Focus: Advanced Directive/End of Life Care Plan, the resident is not at or approaching end of life at this time. -Goal: Wishes for advanced directives and end of life care be honored. -Interventions: --Full code status. --Ensure resident's wishes are honored in regard to any advanced directives. --Life sustaining treatment decisions per the resident. -Focus: Wishes to return home. -Goal: Will be discharged to his/her home safely. -Interventions: Anticipated length of stay, two to four weeks. Review of the resident's Progress Note, dated [DATE] at 5:06 A.M., showed: -Resident unresponsive and pulseless. -No apical or radial pulse detected and confirmed with second nurse. -Nurse Practitioner notified. -Voicemail left with on call supervisor. -Spouse notified and was coming to the facility. Review of the resident's Progress Note, dated [DATE] at 8:02 A.M., showed: -Social services contacted the spouse. -Spouse stated the resident was ready to go home. During an interview on [DATE] at 10:45 A.M., the administrator said: -Resident #1 was a full code. -RN A called the on call clinical supervisor and was told to verify Resident #1's code status and start CPR if indicated. During an interview on [DATE] at 11:26 A.M., the Social Services Designee (SSD) said there was discussion of a DNR, but the resident and family had chosen full code status. During an interview on [DATE] at 5:00 P.M. Certified Nursing Assistant (CNA) A said: -When he/she came to work on the evening of [DATE], he/she was told to keep a close eye on Resident #1 because the resident had fallen. -Throughout his/her shift he/she checked on the resident about every two hours. -At around 2:30 A.M. he/she reported to RN A the resident had not gotten up since going to bed. -He/She was told by RN A they would physically check on the resident about 5:00 A.M. -At approximately 4:00 A.M. CNA A and RN A checked on the resident together. -RN A used his/her stethoscope to check the resident and indicated the resident was okay. -Around 5:00 A.M. CNA A and RN A went in Resident #1's room and RN A determined the resident had passed away. -He/She did not know the code status of the resident. -He/She was not able to access the medical record to determine the code status of the resident. -He/She observed RN A use his/her stethoscope to assess the resident, as well as check for a pulse, check the resident's eyes, and perform a rub to the resident's chest prior to stating he/she thought the resident was gone. -The resident felt warm to touch when he/she touched the resident at the time RN A was assessing the resident. -Anyone can initiate CPR. -CPR should be initiated when a person is found with no respirations, not breathing or does not have any vital signs assessed. -He/She feels CPR should have been initiated on Resident #1, especially now he/she knows the resident was a full code. -If he/she would have known the resident was a full code, he/she would have started CPR. -He/She was CPR certified. -Felt as if he/she trusted the nurse to know the code status and to not wake the resident, but felt he/she should have attempted to wake the resident anyway. -RN A did not appear to be concerned about contacting EMS or performing CPR on the resident. During an interview on [DATE] at 3:56 P.M., RN A said: -He/She has worked in acute care for [AGE] years. -He/She was checking on Resident #1 every two hours. -He/She checked on the resident at 4:00 A.M. and had no concerns at that time. -For some reason he/she felt the need to check the resident at 4:45 A.M. -Resident #1 had terminal cancer that spread in the body. -He/She printed the face sheet to call the family and that is when he/she noticed the resident was a full code. -He/She didn't initiate CPR, because he/she didn't know how long the resident had been deceased . -He/She knew the resident was terminal and thought the resident just died . -The first call he/she made was to the nurse practitioner (NP). -He/She told the NP the resident was found deceased in bed. -The NP responded OK. -There was no mention or discussion of the resident's code status with the NP. -He/She would have never believed the resident was a full code, but it wasn't his/her choice. -The spouse did not believe him/her when he/she called the spouse to inform of the resident's death. -The spouse said he/she was coming to the facility to make sure. -He/She waited by the entrance of the facility for the spouse. -Upon entering the resident's room, the spouse was so grief stricken and almost pulled the resident off the bed. -Neither family member inquired if CPR was done or if EMS had been contacted. -He/She did not disclose CPR was not initiated or EMS was not contacted. -Once he/she discovered the resident was a full code, he/she did not initiate CPR or EMS. He/she didn't know how long the resident had been deceased and he/she didn't think it would bring the resident back. -He/She felt doing CPR on the resident would be elder abuse or desecration of a corpse. -He/She did not know the policy for CPR, but staff are to apparently let 911 stop the code. -The resident was pronounced deceased by him/her and the other nurse. -When asked when CPR should be initiated, he/she said in the acute setting he/she would call a code blue and a team comes. -When asked when CPR is needed, he/she said when a person is dead, but more recently dead rather than not knowing how long they had been dead. -There is no way of knowing if a person is a code or not, although he/she had access to the medical record and charted in the medical record. -The only way he/she located the code status was to pull up the resident's face sheet. -He/She typically did not pull up face sheets for the residents he/she was providing care. -Each nurse was responsible to locate information related to the code status of a resident and to do CPR if indicated. -It was his/her responsibility to determine the code status of the resident prior to pronouncing the resident deceased . -Emergency services and CPR should have been initiated when the resident was found unresponsive. -It was his/her responsibility to know the policy for CPR and advanced directives. During an interview on [DATE] at 3:06 P.M., Agency Licensed Practical Nurse (LPN) A said: -He/She was not assigned to provide care for Resident #1 on [DATE]. -On [DATE] around 5:00 A.M., RN A located him/her on the hall he/she was assigned and asked if LPN A would come verify a death. -LPN A finished the task he/she was performing on a resident, then went to Resident #1's room. -He/She did not verify Resident #1's code status prior to entering the room. -He/She assessed Resident #1 to be absent of breath sounds, heartbeat, and pulse. -He/She did not document his/her assessment and findings in the resident's medical record. -Once he/she verbalized his/her findings to RN A, he/she went back to his/her assigned hall. -He/She did not check the resident's code status, because he/she believed RN A would have known the resident's code status prior to asking him/her to verify the resident's death. -At no time did he/she discuss the resident's code status with RN A. -He/She was certified to perform CPR. -The charge nurse is responsible for starting CPR. -I guess I don't know the procedure if doing a second check under another nurse. -He/She knows now verification of code status for a resident can be done by any nurse. -He/She should have checked the resident's code status before going to the resident's room. -He/She would have notified RN A of the resident's code status, initiated emergency services, and CPR. -He/She was unsure how long RN A waited to come get him/her after discovering the resident without signs of life. -RN A displayed no signs of urgency when RN A came to find him/her. -He/She did not know who or how the resident was pronounced deceased . -He/She was unaware of the resident's code status until he/she was leaving and overheard RN A discussing the resident's passing with another nurse. During an interview on [DATE] at 3:29 P.M., Assistant Director of Nursing (ADON) A said: -RN A contacted him/her on [DATE] at 5:02 A.M. in reference to Resident #1. -He/She directed RN A to check the code status of the resident and to initiate CPR if indicated. -RN A responded OK. -Upon giving RN A the directive, he/she expected RN A to check the resident's code status and initiate CPR as indicated. -He/She has no idea why RN A did not initiate CPR for Resident #1. -It was documented in the resident's medical record he/she was deceased at 5:06 A.M. and the NP was notified. -He/She was unsure who actually pronounced the resident deceased . -As soon as he/she came into the building on that morning he/she discovered the resident was deceased and RN A did not perform CPR. -Although he/she did not feel the outcome would have been different, the policy was not followed. -He/She expected RN A to initiate CPR and 911. -LPN A should have checked the code status as well. -RN A and/or LPN A should have started CPR. -According to what he/she has been able to ascertain the resident was checked on at 4:00 A.M. and was alive at that time. -When staff entered the room at approximately 4:45 A.M. the resident was found unresponsive and without signs of life. -RN A documented in the resident's medical record at 5:06 A.M. the resident was deceased and all parties notified of the resident's death. During an interview on [DATE] at 5:00 P.M. ADON B said: -He/She was notified of the failure on the morning of [DATE] at around 6:00 A.M. -The resident was a full code and expected one or both nurses to initiate CPR and 911. -There was no reason for CPR to not be initiated. -Everybody knows CPR not being initiated was a failure. -The facility does not understand why RN A did not initiate CPR, especially after given the directive to do so by the on call supervisor. During an interview on [DATE] at 6:20 P.M. Family Member #1 said: -There was an expectation for the staff to perform life saving measures for the resident. -He/She was with the resident on [DATE] until around 7:00 P.M. -During the visit the resident was laughing and seemed to be improving. During an interview on [DATE] at 6:43 P.M. Family Member #2 said: -The resident was supposed to have CPR. -He/She was with Family Member #1 on [DATE]. -During the visit with the resident, he/she was laughing and was doing good. -He/She got a call from Family Member #1, who was delirious on the phone. -It took about five to six minutes for them to get to the facility. -The nurse did not disclose how the resident passed away or any measures taken at the time of his/her death. -He/She was concerned about not seeing anything in the room that indicated CPR was performed or attempted. -The doctors said the resident was getting better with his/her cancer treatment. -The family did not expect the resident to pass away. During an interview on [DATE] at 11:50 A.M., the Regional RN said: -Resident #1 was found by RN A unresponsive on [DATE] at 4:45 A.M. -RN A and LPN A both checked the resident for signs of life and verified there were none present. -RN A contacted the on call clinical supervisor and was instructed to verify Resident #1's code status and initiate CPR if indicated. -RN A reported checking Resident #1's code status at approximately 5:00 A.M. -RN A reported he/she did not initiate CPR and should have. -On the morning of [DATE] the facility identified the problem. RN A and LPN A were both suspended on [DATE]. MO00232671

Based on interview and record review, the facility failed to provide transportation to two scheduled follow up appointments for one sampled resident (Resident #2) out of four sampled residents. The facility census was 68 residents. A policy for outside appointments was requested from the facility's Director of Nursing (DON). He/she reported the facility had no policies related to outside appointments for residents. 1. Review of Resident #2's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 9/25/23, showed: -The resident scored a 05 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions. --This showed the resident had severe cognitive impairment. Review of the resident's face sheet, undated, showed: -The resident was admitted to the facility on [DATE] with the following diagnoses: --Cancer of the left eye. --Aftercare following surgery of eye removal. --Acquired absence of eye. --Skin transplant status. Review of the resident's care plan, dated 9/18/23, showed the resident had an activity of daily living (ADL) deficit related to neoplasm (a growth that developed in the body) of his/her left eye resulting in the removal of his/her left eye and an allogenous skin transplant (a skin graft harvested from a human, but not from the recipient patient) on 9/7/23. Review of the hospital discharge/referral paperwork (page three), dated 9/18/23, and showed: -On 9/25/23 at 11:30 A.M., the resident had a scheduled appointment with the Ear, Nose and Throat (ENT) physician. -On 10/5/23 at 9:00 A.M., the resident had a scheduled appointment with a cancer center. During an interview on 10/11/23 at 8:40 A.M., the resident said: -He/she had a biopsy which showed cancer around his/her left eye. -He/she had chemotherapy (a drug treatment that uses powerful chemicals to kill fast-growing cells in your body) and radiation but ended up losing his/her eye anyway. -He/she had no follow up appointments since arriving at the facility. During an interview on 10/11/23 at 10:59 A.M., a Nurse Practitioner (NP) said: -He/she was familiar with the resident. -He/she was not in charge of follow up appointments. -The resident should have follow up appointments as ordered by the physician. -The admission and rehabilitation unit nurse checked the hospital discharge paperwork for any follow up appointments. During an interview on 10/11/23 at 11:57 A.M., Licensed Practical Nurse (LPN) A said the nurses were in charge of making any follow up appointments. During an interview on 10/11/23 at 12:06 P.M., LPN B said: -He/she had recently started working with the resident. -The resident's graft site was cleaned daily with no issues. During an interview on 10/11/23 at 12:28 P.M., the DON said: -The resident had an appointment on 9/25/23. -The discharge paperwork said the appointment was at 11:30 A.M. -The time was incorrect on the paperwork and the correct time was at 10:00 A.M. -The notification of the wrong time was not timely enough for the transportation company to get the resident to the appointment. -The rehab nurse was trying to reschedule the appointment and was getting the run around. -The facility could not get confirmation from the doctor office of the rescheduled appointment for 9/26/23. -The appointment for 9/26/23 was never actually scheduled. -He/she had no knowledge of the appointment scheduled for 10/5/23. -There was no documentation of phone contacts prior to 10/5/23. During a three way phone call on 10/11/23 at 1:23 P.M., the Assistant DON (ADON) said: -There was confirmation from the transportation company that the resident was dropped off for the 9/26/23 appointment. -The transportation company did not pick up the resident. -The issue was playing phone tag with the cancer center social worker. -The calls to the cancer center dropped off and then went to a fax line. -He/she gave his/her personal cell phone number to the cancer center. -He/she left a voicemail with the ENT surgeon. -He/she was unaware of an appointment for 10/5/23. During an interview on 10/11/23 at 1:52 P.M., Nurse LPN C said: -The hospital discharge paperwork showed the resident had a follow up appointment scheduled for 11:30 A.M. on 9/25/23. -The physician's office left a message with the facility receptionist requesting the appointment be moved to 10:00 A.M. on 9/25/23. -It was too short of notice for the transportation company to change their schedule and could not take the resident to the 10:00 A.M. appointment on 9/25/23. -He/she made calls to the cancer center on 9/25/23, 9/27/23 and 9/28/23 to attempt to reschedule the missed appointment. -No follow calls were made to the cancer center 9/29/23 through 10/4/23. During an interview on 10/11/23 at 2:20 P.M., the DON said: -He/she expected to be notified if a resident had missed any appointments. -He/she expected to be notified of any issues with follow up appointments. -He/she would reach out his/herself to the cancer center to get appointment scheduled. During an interview on 10/11/23 at 2:25 P.M., the Administrator said no one at the facility was aware of the 10/5/23 appointment until the cancer called the facility on 10/9/23. During an interview on 10/12/23 at 9:35 A.M., the cancer center social worker said: -He/she had been contacting the facility phone number and spoke to the ADON and LPN C. -He/she also called the facility and spoke to the facility receptionist and gave messages to the ADON. -He/she talked to the ADON and LPN C regarding rescheduling appointments for the resident. -He/she received on message from the ADON on 10/10/23 around 2:00 P.M. and returned that call on 10/10/23 around 4:00 P.M. but had to leave a message regarding rescheduling at both the ENT and cancer center. -The electronic chart showed the resident's appointments on 9/26/23 and 10/5/23 as a no show. -The resident's appointments were on the hospital discharge paperwork provided to the facility. MO00225745

Based on observation, interview, and record review, the facility failed to ensure infection control to prevent cross contamination when staff failed to sanitize the access point of insulin pens prior to attaching the needle for two supplemental residents (Residents #26 and #38); to ensure infection control, including hand hygiene during wound dressing change for one sampled resident (Resident #46); to provide urinary catheter (a small tube inserted into the bladder to drain urine) care in a manner to prevent urinary tract infection and to ensure infection control practices were implemented to prevent cross contamination during perineal care on one sampled resident (Resident #32); to ensure hand hygiene during catheter care, colostomy (a surgically created opening for the large intestine, through the abdomen) care and wound care, failed to keep catheter tubing (clear tube that drains urine from the catheter to the catheter drainage bag) off the floor; to use a barrier for supplies during wound care for one sampled resident (Resident #67) and to ensure hand hygiene during perineal (peri - genital and anal area) care for one sampled resident (Resident #37) out of 18 sampled residents and two supplemental residents. The facility census was 70 residents. A policy for insulin administration was requested and not received at the time of exit. Review of the product information guide for Lantus Insulin (a long acting insulin) updated 6/2022 showed: -Wipe the rubber stopper with alcohol prior to attaching the administration needle. Review of the product information guide for Novolog Insulin (a fast acting insulin) updated 2/2023 showed to wipe the rubber stopper with alcohol prior to attaching the administration needle. 1. Review of Resident #38's September 2023 Medication Administration Record (MAR) showed: -He/she had a diagnosis of Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -He/she had a physician's order for Novolog 5 units with meals three times daily. Observation on 9/13/23 at 7:03 A.M. with Licensed Practical Nurse (LPN) C showed: -He/she obtained the resident's blood glucose level. -He/she removed the resident's Novolog Insulin pen from the medication cart, applied the needle to the insulin pen without sanitizing the rubber stopper with alcohol, and dialed up 5 units of insulin. 2. Review of Resident #26's September 2023 MAR showed: -He/she had a diagnosis of diabetes. -He/she had a physician's order for 15 units Novolog with meals three times daily and 22 units Lantus in the morning. Observation on 9/13/23 at 7:12 A.M. with LPN C showed: -He/she obtained the resident's blood glucose level. -He/she removed the resident's Novolog Insulin pen from the medication cart, applied the needle to the insulin pen without sanitizing the rubber stopper with alcohol, and dialed up 15 units of insulin. -He/she removed the resident's Lantus Insulin pen from the medication cart, applied the needle to the insulin pen without sanitizing the rubber stopper with alcohol, and dialed up 22 units of insulin. 3. During an interview on 9/13/23 at 7:34 A.M., LPN C said he/she would not have done anything differently related to infection control during medication pass. During an interview on 9/14/23 at 8:49 A.M., LPN C said he/she should have sanitized the insulin pens with alcohol prior to attaching the needles. During an interview on 9/14/23 at 1:05 P.M., the Director of Nursing (DON) said: -He/she expected staff to follow manufacture guidelines related to insulin pen medication administration. -Staff should sanitize the top of the insulin pen with alcohol prior to attaching the needles. 4. Review of the undated facility Changing Dressing/Treatment Checklist showed: -Staff should removed gloves, wash hands, and don clean gloves after removing an old dressing and before cleaning a wound. -After completing wound care, staff should wash their hands before exiting the resident's room. Review of Resident #46's Admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/30/23 showed he/she: -Was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 1 out of 15. -Had one unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer (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). Observation on 9/12/23 at 8:54 A.M. showed LPN B: -Entered the resident's room and placed the resident's wound care supplies on top of the desk without sanitizing the surface and without a barrier. -After washing his/her hands, he/she sanitized the resident's bedside table with a bleach wipe, then transferred the resident's wound care supplies from the top of the desk to the bedside table without a barrier. -Without washing or sanitizing his/her hands, he/she donned clean gloves, said he/she had sanitized the scissors outside the resident's room with bleach wipes, placed a towel barrier on the floor under the resident's foot, then after removing the resident's sock, cut the dressing dated 9/11/23 to remove the dressing. -After removing the old dressing, with the same gloved hands, he/she cleansed the resident's wound with wound cleanser and gauze, then pat dry. -LPN B then removed his/her gloves, sanitized his/her hands, donned clean gloves, applied the dressing to the resident's wound, put the resident's sock on the resident's foot, removed his/her gloves, put the dirty scissors and bottle of wound cleanser on the resident's desk without a barrier, gathered the trash from the wound care, picked up the supplies, and without washing or sanitizing his/her hands, touched the door handle, exited the resident's room, placed the scissors, bottle of hand sanitizer, and bottle of wound cleanser on top of the treatment cart without a barrier, then walked to the soiled utility room, touched the door handle, opened the door, and threw away the wound care trash. -LPN B then walked back to the bathroom near the resident's room to wash his/her hands, sanitized the scissors, then put the bottle of wound cleanser which he/she had taken into the resident's room in a drawer in the treatment cart without sanitizing the bottle. During an interview on 9/12/23 at 9:08 A.M., LPN B said he/she could not think of anything he/she would have done differently during wound care. During an interview on 9/14/23 at 8:32 A.M., LPN B said: -He/she should have put a barrier down on the desk and the bedside table prior to putting wound care supplies on them. -He/she should have changed his/her gloves and washed his/her hands after removing the old dressing and before doing the wound care treatment. -He/she should have washed or sanitized his/her hands prior to leaving the resident room. -He/she should have cleaned off the wound care bottle before storing it in the treatment cart. During an interview on 9/14/23 at 1:05 P.M., the DON said: -Staff should wash their hands when entering and when exiting a room. -Staff should wash their hands and change their gloves after removing an old dressing before cleaning the wound. -Staff should have hand a barrier to place the supplies on. -Staff should have sanitized anything taken in the room before storing in the treatment cart. 46890 5. Review of the facility policy and procedure for Catheter Care revised on 1/2017 showed: -Purpose of this procedure is to prevent catheter-associated urinary tract infection. -Use standard precautions when handling or manipulating the drainage system. -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. -Wash hands. -Clean the catheter with downward (away from the body) strokes. A policy and procedure was requested from the facility for Perineal Care and was not provided prior to exit. Review of the facilities skills check list for Perineal Care not dated showed perineal care should start on front side then to back side of resident using different part of washcloth for each stroke from front to back. 6. Review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Clostridium Difficile (C-diff- a disruption of normal healthy bacteria in the colon, causing diarrhea, abdominal pain and fever). -Urinary Tract Infection (UTI) due to urinary catheter. Review of the residents admission MDS dated [DATE] showed: -He/she was cognitively intact. -He/she needed total assist of two caregivers for bed mobility, transfers and toileting. -He/she had a urinary catheter. -He/she was always incontinent of bowels. -He/she had UTI in last thirty days. -He/she was on an antibiotic. Review of the resident's care plan dated 9/2/23 showed: -He/she required isolation precautions for C-diff. -He/she had a urinary catheter with goal to maintain dignity. Interventions included catheter care every shift and as needed and monitor for signs and symptoms of UTI. -He/she has history of UTI's with interventions to give antibiotics as ordered, check at least every two hours for the need of catheter care and monitor for signs and symptoms of UTI. -He/she had self-care deficits with goal to maintain dignity. Interventions included the resident required two staff to turn and reposition in bed, the resident required two staff for toileting. Observation on 9/11/23 at 9:45 A.M. of Certified Nursing Assistant (CNA) A providing perineal care and urinary catheter care showed: -He/she washed his/her hands, put isolation gown on and then gloved. -He/she laid the resident on his/her back while the resident was in bed and rolled the soiled brief down between his/her legs. The resident's brief had visible diarrhea stool. -He/she opened drawers of bedside table without removing soiled gloves to retrieve disposable wipes. -He/she turned the resident onto his/her left side and repeatedly wiped the resident's buttocks in a back and forth direction with two separate wipes during perineal care after cleaning diarrhea stool from the area. The resident's perineal area was noted to have redness and irritation. -He/she removed gloves washed hands with soap and water and put on new gloves. -He/she placed the resident on his/her back and repeatedly used a circular motion around the genital area then toward the urinary opening and down urinary catheter tubing, moving away from the resident's body with same disposable wipe. -He/she then removed disposable gown, gloves and washed hands. During an interview on 9/12/23 at 10:20 A.M. CNA A said: -He/she would have been more prepared and laid out needed supplies before starting perineal care. -He/she would have used a new wipe with each swipe of the perineal area going from front to back. -He/she would have started from cleanest to dirtiest. -He/she would have used a separate wipe to clean catheter tubing. -He/she had Catheter Care and Perineal training upon hire in April 2023. During an interview on 9/14/23 at 9:15 A.M. LPN C said: -He/she would use disposable wipes one way, one swipe, one time during perineal care. -He/she would use disposable one disposable wipe to wipe away from the urinary opening, one swipe and discard. -He/she would use new disposable wipe to wipe catheter tubing one way, one swipe outward away from the urinary opening. -He/she would expect the CNA's to use proper infection control during perineal and catheter care. During an interview on 9/14/23 at 9:22 A.M. Assistant Director of Nursing (ADON) B said: -He/she would expect infection control practices be used during perineal and catheter care. -He/she would be responsible to make sure staff maintain infection control practices. -He/she would be responsible for educating nursing staff on infection control practices with perineal and catheter care. During an interview on 9/14/23 at 1:04 P.M. DON said: -He/she would expect staff to follow infection control practices with perineal care and catheter care. -He/she would expect staff change gloves and wash hands before touching a clean surface from a dirty surface to prevent cross contamination. -He/she would expect staff to use one disposable wipe one way, one swipe, one time during perineal care and use a separate wipe when cleaning the catheter tubing away from the urinary opening. 09895 7. Review of Resident #37's significant change MDS dated [DATE] showed: -He/she was admitted to the facility on [DATE]. -He/she was occasionally incontinent of urine. -He/she had two unstageable pressure ulcers that were present on his/her facility admission. Observation on 9/13/23 at 4:17 A.M. showed: -Following completion of the residents peri care CNA C did not remove his/her gloves and sanitize/wash his/her hands and proceeded to fasten the resident's brief and place covers over the resident. -CNA C then removed his/her gloves and left the resident's room without first washing/sanitizing his/her hands. 8. Review of Resident #67's admission MDS dated [DATE] showed: -He/she was admitted to the facility on [DATE]. -He/she had no pressure ulcers. -He/she had a urinary catheter and an ostomy (a surgical procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a prosthetic known as a pouch or bag). Review of the resident's physician's order's dated 9/5/23 showed: -Cleanse right buttock with normal saline or wound cleanser, pat dry, apply collagen, cover with dry dressing one time a day every Tuesday, Thursday and Saturday and as needed for wound care. -Clean left heel with normal saline or wound a, pat dry, apply collagen, cover with dry dressing one time a day every Tuesday, Thursday and Saturday and as needed for wound care. -Catheter 18 French (fr -a type of urinary catheter that is kept in place with a balloon), 30 cubic centimeter (cc) balloon. -Colostomy care each shift. Observations on 9/11/23 at 9:21 A.M.,12:42 P.M. and 2:08 P.M. and on 9/12/23 at 11:08 A.M. showed the resident's catheter tubing was on the floor. Observation on 9/12/23 at 11:08 A.M. showed: -He/she had a pressure ulcer on his/her left heel, that was about 3/4 inches long and one and 3/4 inches wide that was open with red tissue in the wound bed. -Registered Nurse (RN) A placed supplies for the resident's wound care, including scissors, wound care spray and dressings, directly on the resident's night stand without use of a barrier. -RN A then placed a clean bath towel on the resident's overbed table and moved the resident's wound care supplies from his/her night stand to the his/her overbed table. During an interview on 9/12/23 at 11:32 A.M. RN A said: -He/she should have not put the resident's wound care supplies on his/her night stand without first placing a barrier for infection control. -He/she put a clean towel on the resident's overbed table and then moved the resident's wound care supplies from the resident's night stand to his/her overbed table. -He/she did not use the scissors during the resident's wound care and he/she wiped the scissors with a disinfectant wipe before placing them back in the treatment cart. Observation on 9/13/23 at 4:52 A.M. showed: -CNA D entered the resident's room and placed gloves on his/her hands without first washing/sanitizing his/her hands. -He/she wiped around the catheter insertion with a peri wipe (a pre moistened disposable wipe). -He/she did not get another peri wipe and wipe down the resident's catheter away from his/her body to cleanse the outside of the resident's catheter. -He/she did not remove his/her gloves and wash his/her hands before going out of the room to get supplies. -He/she reentered the resident's room, turned on the water at the resident's sink and brought a styrofoam cup with water to CNA C. -CNA C poured the water into the resident's colostomy pouch, poured the water back out, closed the resident's colostomy pouch and then without first removing his/her gloves and washing/sanitizing his/her hands, he/she arranged the resident's covers over him/her. -CNAs C and D then both removed their gloves and left the resident's room without first washing/sanitizing their hands. During an interview on 9/13/23 at 5:51 A.M. CNA D said: -He/she had entered the resident's room and did not wash/sanitize his/her hands before putting on gloves. -He/she removed the resident's covers and then he/she did not first remove his/her gloves, sanitize his/her hands and put on clean gloves before doing the residents catheter care. -He/she did not wipe down the residents catheter away from his/her body. -He/She removed his/her gloves and left the resident's room without washing/sanitizing his/her hands, got a styrofoam cup, filled it with water at the resident's sink, then gave the styrofoam cup to CNA D. -He/she then put on gloves without first washing/sanitizing his/her hands and assisted in placing the resident's covers on him/her. -He/she then left the resident's room without first washing/sanitizing his/her hands. During an interview on 9/13/23 at 5:59 A.M. CNA C said: -He/she had entered the resident's room and did not wash/sanitize his/her hands before putting on gloves. -He/she emptied feces from the resident's colostomy bag, rinsed the resident's colostomy bag with water, fastened the resident's colostomy he/she had used in cleansing the resident's bag and then touched the resident's covers with the gloved hand with feces on the index finger. -He/she then removed his/her gloves and left the resident's room without first washing/sanitizing his/her hands. During an interview on 9/14/23 at 1:05 P.M. the DON said: -During catheter care the CNAs should have wiped down the entire length of the residents' catheter. -During wound care, the licensed nurse should have used a barrier for supplies before placing the supplies on a surface in the resident's room. -During colostomy care the CNA should have practiced good hand hygiene and should not have touched the resident's covers with the same gloves used for colostomy care. During an interview on 9/4/23 at 2:31 P.M. the DON said he/she expected nursing staff to keep catheter tubing off the floor.

Based on interview and record review, the facility failed to have parameters listed in the medication orders for any medication containing Acetaminophen (an over-the-counter pain medication) or three sampled residents (Resident #12, Resident #17, and Resident #25) out of 18 sampled residents. The facility census was 70 residents. Review of the facility's undated Medication Administration-Oral checklist did not include parameters for medications. Review of the undated product information insert guide for Acetaminophen showed directions not to administer more than 3 grams (gm - 1 gm is equal to 1000 milligrams (mg)) in a 24 hour period. 1. Review of Resident #25's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 7/10/23 showed the resident used opioids (are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief) 7 out of 7 days in the the look-back period. Review of the resident's Order Summary Report dated 9/12/23 showed the following orders: -Acetaminophen 325 mg give two tablets by mouth three times a day for pain. -The order did not include the parameters of not to exceed 3 gm Acetaminophen in 24 hours from all sources. 2. Review of Resident #17's Quarterly MDS dated [DATE] showed the resident used opioids 7 out of 7 days in the the look-back period. Review of the resident's Order Summary Report dated 9/12/23 showed the following orders: -Hydrocodone-Acetaminophen (a narcotic pain reliever) 10-325 mg (Hydrocodone 10 mg with Acetaminophen 325 mg in one tablet). Give one tablet by mouth every four hours as needed for pain. -Acetaminophen Extended Release 650 mg give one tablet by mouth every 4 hours as needed for pain. -Neither order contained the parameters of not to exceed 3 gm Acetaminophen in 24 hours from all sources. 3. Review of Resident #12's Quarterly MDS dated [DATE] showed the resident used opioids 7 out of 7 days in the the look-back period. Review of the resident's Order Summary Report dated 9/12/23 showed the following orders: -Hydrocodone-Acetaminophen 10-325 mg. Give one tablet by mouth every four hours as needed for pain. -Acetaminophen Extended Release 650 mg give one tablet by mouth every 6 hours as needed for pain. -Neither order contained the parameters of not to exceed 3 gm Acetaminophen in 24 hours from all sources. 4. During an interview on 9/13/23 at 3:12 A.M., Licensed Practical Nurse (LPN) A said: -All medications that have Acetaminophen in them need to have the parameter of not to exceed 3 gm of Acetaminophen in 24 hours from all sources in the medication order. -When a medication did not have the parameters of not to exceed 3 grams in 24 hours he/she would add this parameters. -The nurse who entered the orders should have caught this. -More than 3 gm of Acetaminophen in 24 hours could be toxic. During an interview on 9/13/23 at 6:47 A.M., LPN B said: -All Acetaminophen containing medications needed to have the not to exceed three grams of Acetaminophen in 24 hours from all sources as a parameter. -When it was discovered that an Acetaminophen order did not have the parameter the physician would be would be notified and the parameters clarified with the doctor. -It was important to have this because more than 3 gm of Acetaminophen could be toxic to the liver. During an interview on 9/13/23 at 3:12 A.M., Certified Medication Technician (CMT) A said: -All medications that have Acetaminophen in them would have the parameter of not to exceed three grams of Acetaminophen in 24 hours from all sources in the medication order. -When a medication did not have the parameters of not to exceed 3 grams in 24 hours from all sources he/she would have notified the charge nurse. During an interview on 9/13/23 at 6:53 A.M., LPN C said: -All medications that have Acetaminophen in them need to have the parameter of not to exceed three grams of Acetaminophen in 24 hours from all sources in the medication order. -When a medication did not have the parameters of not to exceed 3 grams in 24 hours he/she would contact the doctor and have the order clarified. During an interview on 9/13/23 at 7:00 A.M., Assistant Director on Nursing (ADON) B said: -All medications that have Acetaminophen in them need to have the parameter of not to exceed 3 gm of Acetaminophen in 24 hours from all sources in the medication order. -The doctor would have been contacted to get the parameters once it was discovered the order did not have the parameters. During an interview on 9/14/23 at 1:04 P.M., the Director of Nursing (DON) said: -It was his/her expectation that all orders that contained Acetaminophen would have the parameter of not to exceed three grams of Acetaminophen in 24 hours from all sources. -It was his/her expectation that all nurses would have ensured that this parameter was added to all orders that contained Acetaminophen. -It was his/her expectation that when the parameter was missing on an order the nurse that discovered the error would have contacted the doctor and received the order to add the parameter. -It was ultimately his/her responsibility to ensure that all medications that contained Acetaminophen had the parameter on all the orders.

Based on interview and record review, the facility failed to ensure reconciliation of a Schedule II (a drug having medical usefulness, but also a high potential for abuse) narcotic drug (an opioid - a medication which acts on the central nervous system (CNS) to relieve pain) for one sampled resident (Resident #27) out of 20 sampled residents. The resident's Medication Administration Record (MAR) showed blank spaces which were discrepancies from the resident's Controlled Drug Receipt/Record/Disposition Form. The facility census was 70 residents. On 9/14/23, the Administrator was notified of the past noncompliance which took place over a period of time to include 8/29/23 through 9/8/23. Narcotic documentation discrepancies were discovered during audits by the Corporate Nurse Manager. Education to address the problem was provided to facility staff, including the Director of Nursing (DON) and Acting Director of Nursing (ADON) A and ADON B on 9/1/23 and 9/2/23. An internal audit was conducted on 9/8/23 and problems with narcotic documentation were identified with Resident #27. Re-education was provided as needed to those nurses responsible for the resident's narcotic medication administration after the initial education dates. The deficiency was corrected on 9/8/23. Review of the facility's Controlled Substance Policy, revised May, 2023 showed: -Drugs listed in Schedules II, III (medication with a moderate to low potential for dependence), and IV (medications with a low potential for abuse/low risk of dependence) are to be stored in double locked conditions. The key to the separately locked storage is not the same as the key used to gain access to other drugs, and the medication nurse or Certified Medication Technician (CMT), where applicable, on duty will maintain possession of the key. -A physical inventory of Schedules II, III, and IV medications will be made at the change of each nursing shift and performed by the on-coming licensed nurse or CMT, where applicable, and the off-going licenses nurse or CMT. The on-coming nurse or CMT, where applicable, will be responsible for looking at the medication to verify the amount of medication at the time of the count. The off-going nurse or CMT will be responsible for viewing the controlled substance Proof of Use Record to verify the amount on the record at the time of the count. Both nurses (or CMTs where applicable) will sign on the Narcotic Sign In and Out Sheet that the count was completed. -The licensed nurse or CMT, where applicable, will sign the medication out on the Controlled Substance Proof of Use form immediately and will document the medication on the Medication Administrator Record immediately after administering the drug. The Controlled Substance Proof of Use record is to be kept in the Controlled Medication Book and the completed records are to be placed in the resident's permanent record. Copies of the Narcotic Sign In and Out Records are to be given to the Director of Nurses (DON) when completed. -Any discrepancy in the inventory of controlled substances is to be reported to the DON immediately. The DON is responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. The discrepancy of a controlled substance is to be reported to the Administrator and the Regional Nurse immediately. 1. Review of Resident #27's Admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that include: -Low back pain. -Type II Diabetes Mellitus with Diabetic Neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). -Post traumatic osteoarthritis, right ankle and foot. Review of the resident's Pain Medication Care Plan, dated 8/28/23, showed: -The resident was on pain medication related to chronic back pain, neuropathy, and disease processes. -Staff were to provide medications as ordered, review for pain medication efficacy, and monitor for adverse side effects from pain medication. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/4/23 showed the resident: -Was cognitively intact. -Received scheduled and Pro Re Nata (PRN - as needed) medications for pain and had non-medication interventions for pain as well. -Had pain intensity at approximately six on a pain scale of zero to 10, with 10 being the worst imaginable pain. -Took opioids seven out of the past seven days. Review of the resident's Physician Orders dated August 2023 showed Oxycodone HCI capsule three 5 milligrams (mg) (15 mg) every six hours as needed for moderate to severe pain starting 8/28/23. Review of the resident's Controlled Drug Receipt/Record/Disposition Form dated 8/28/23 through 9/6/23 showed: -Oxycodone 15 mg tablet by mouth every four hours as needed for pain starting 8/28/23. -On 8/29/23 at 2:15 A.M. one tablet was removed and 26 were left. -On 8/30/23 at 2:00 P.M. one tablet was removed and 21 were left. Note: The Controlled Drug Receipt/Record/Dispensation Form showed one 15 mg tablet every four hours as needed while the Physician Orders showed three 5 mg capsules every six hours as needed. Review of the resident's MAR dated August, 2023 showed: -Oxycodone HCI capsule 15 mg every six hours as needed for moderate to severe pain starting 8/28/23. -There was no documentation the medication was administered to the resident on the following dates and times: --8/29/23 at 2:15 A.M. --8/30/23 at 2:00 P.M. Review of the facility's monthly in-service training dated 9/1/23 and 9/2/23 showed: -One of the training's included documentation of PRN medications in the MAR and Treatment Administration Record (TAR). -Education showed that all PRN narcotic medications, including those pulled from the automated medication dispensing machine, needed to be documented in the MAR/TAR to show they had been administered. Review of the resident's Controlled Drug Receipt/Record/Disposition Form dated 8/28/23 through 9/6/23 showed: -Oxycodone 15 mg tablet by mouth every four hours as needed for pain starting 8/28/23. -On 9/2/23 at 10:00 P.M. one tablet was removed and eleven were left. -On 9/3/23 at 4:00 A.M. one tablet was removed and 10 were left. -On 9/4/23 at 4:00 A.M. one tablet was removed and seven were left. -On 9/6/23 at 4:45 A.M. one tablet was removed and none were left. Note: The Controlled Drug Receipt/Record/Dispensation Form showed one 15 mg tablet every four hours as needed while the Physician Orders showed three 5 mg capsules every six hours as needed. Review of the facility's automated medication dispensing system report for September 2023 showed Oxycodone 15 mg was pulled on 9/6/23 at 6:30 A.M. for the day shift. Review of the resident's MAR dated September 2023 showed: -Oxycodone HCI capsule 5 mg. Give three capsules by mouth (15 mg) every six hours as needed for moderate to severe pain starting 8/28/23 and discontinuing on 9/6/23. -There was no documentation the medication was administered to the resident on the following dates and times: --9/2/23 at 10:00 P.M. --9/3/23 at 4:00 A.M. --9/4/23 at 4:00 A.M. --9/6/23 at 4:45 A.M. -Oxycodone 15 mg was administered on 9/6/23 at 11:41 A.M. Review of the resident's Physician Orders dated September 2023 showed: -Oxycodone HCI capsule 15 mg every six hours as needed for moderate to severe pain starting 8/28/23. -Oxycodone HCI capsule 5 mg. Give one tablet by mouth every six hours as needed for moderate pain starting 9/6/23 and ending 9/7/23. -Oxycodone HCI capsule 5 mg. Give two tablets by mouth every six hours as needed for severe pain starting 9/6/23 and ending 9/7/23. -Oxycodone HCI capsule 5 mg. Give three capsules by mouth every six hours as needed for moderate to severe pain (15 mg) starting 9/7/23. Review of the resident's Controlled Drug Receipt/Record/Disposition Form beginning 9/6/23 showed: -Oxycodone 5 mg tablet. Take one to two tablets by mouth every six hours PRN for moderate to severe pain. This was crossed out and hand written was changed to 15 mg every six hours PRN for moderate to severe pain. -On 9/7/23 at 5:15 A.M. two 5 mg tablets were removed and 26 were left. -On 9/7/23 at 11:15 A.M. two 5 mg tables were removed and 24 were left. -On 9/9/23 at 7:30 P.M. three 5 mg tablets were removed and zero were left. Review of the resident's MAR dated September 2023 showed: -Oxycodone HCI capsule 5 mg. Give two tablets every six hours as needed for severe pain starting 9/6/23 and ending 9/7/23. -Oxycodone HCI capsule 5 mg. Give three capsules every six hours as needed for moderate to severe pain (15 mg) starting 9/7/23. -There was no documentation the medication was administered to the resident on the following dates and times: --9/7/23 at 5:15 A.M. --9/7/23 at 11:15 A.M. --9/9/23 at 7:30 P.M. Review of the facility's PRN Narcotic Audit sheets dated 9/8/23 showed: -Oxycodone 15 mg was not documented as administered on the following dates and times: --8/30/23 at 2:00 P.M. --9/2/23 at 10:00 P.M. --9/3/23 at 4:00 A.M. --9/4/23 (a time was not noted). --9/6/23 at 4:45 A.M. --9/7/23 in the A.M. -The audit sheets showed nursing staff responsible for narcotic documentation discrepancies between 8/30/23 through 9/7/23 were re-educated on 9/8/23 related to documenting narcotic medication administration. 2. During an interview on 9/11/23 at 9:39 A.M., the resident said: -He/she took medication for pain. -He/she felt staff did not want to give pain medications, especially at night. -Staff have told him/her the facility was out of his/her narcotic pain medication and he/she would have to wait until the following day for pain medication. During an interview on 9/13/23 6:30 A.M., Licensed Practical Nurse (LPN) C said: -Staff should document on the narcotic count sheet (Controlled Drug Receipt/Record/Disposition Form) and the MAR when a narcotic medication is administered. If a scheduled narcotic is not given the nurse should document that on the MAR and document the reason. -The narcotic count sheet and the MAR should match. -When the narcotic medication card (a card in which medications are dispensed from a blister pack) is completed the medication card and narcotic count sheet will be placed in the mailbox of Assistant Director of Nursing (ADON) B who gives them to the DON. -He/she thought they may be the ones that audit to make sure the narcotic count sheets and MARs match, but wasn't sure. During an interview on 9/14/23 at 8:36 A.M., LPN D said: -The charge nurse should be documenting narcotic medication administration on the narcotic count sheet as well as on the electronic MAR. -The administration time documented on the narcotic count sheet should match the time documented in the MAR. During an interview on 9/14/23 at 1:08 P.M. with the DON and Corporate Nurse, the DON said: -Nurses were responsible for documenting in the narcotic count book and on the electronic MAR any time a narcotic was administered. -Agency nurses and CMTs have access to the electronic MAR for documentation purposes. -The facility had not been auditing the residents' narcotic administration documentation. -An issue was discovered related to narcotics at a sister facility and narcotic audits were started at all corporate facilities. -The issue of narcotic documentation discrepancies was discovered for the resident during the facility's narcotic audit which was completed within the past two weeks. -The facility did an in-service on 9/1/23 as well as subsequent narcotic education as needed to address the issue.

Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (5%) when staff failed to prime then insulin pen needle prior to administering insulin to two sampled residents (Residents #26 and #38) out of two sampled residents for insulin administration for an error rate of 9.68%. The facility census was 70 residents. A policy for insulin administration was requested and not received at the time of exit. Review of the product information guide for Lantus Insulin (a long acting insulin) updated 6/22 showed: -Do a safety test before each injection to make sure the pen and needle are working properly and the proper dose is administered. -Prime the needle with 2 units of insulin, if insulin comes out of the top of the needle, the pen and needle are working properly. Review of the product information guide for Novolog Insulin (a fast acting insulin) updated 2/2023 showed: -Before each injection, small amounts of air may collect in the cartridge during normal use. -To avoid injection air and to ensure proper dosing, turn the dose selector to 2 units and press. If a drop of insulin appears at the needle tip, the pen and needle are working properly. 1. Review of Resident #38's September 2023 Medication Administration Record (MAR) showed: -He/she had a diagnosis of Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -He/she had a physician's order for Novolog 5 units with meals three times daily. Observation on 9/13/23 at 7:03 A.M. with Licensed Practical Nurse (LPN) C showed: -He/she obtained the resident's blood glucose level. -He/she removed the resident's Novolog Insulin pen from the medication cart, applied the needle to the insulin pen, and dialed up 5 units of insulin without priming the pen prior to administration. 2. Review of Resident #26's September 2023 MAR showed: -He/she had a diagnosis of diabetes. -He/she had a physician's order for 15 units Novolog with meals three times daily and 22 units Lantus in the morning. Observation on 9/13/23 at 7:12 A.M. with LPN C showed: -He/she obtained the resident's blood glucose level. -He/she removed the resident's Novolog Insulin pen from the medication cart, applied the needle to the insulin pen, and dialed up 15 units of insulin without priming the pen with 2 units of insulin prior to administration. -He/she removed the resident's Lantus Insulin pen from the medication cart, applied the needle to the insulin pen, and dialed up 22 units of insulin without priming the pen with 2 units of insulin prior to administration. 3. During an interview on 9/13/23 at 7:34 A.M., LPN C said he/she would not have done anything differently related to the medication administrations observed. During an interview on 9/14/23 at 8:49 A.M., LPN C said he/she should have primed the insulin pens with 2 units of insulin prior to administering the medications to the residents. During an interview on 9/14/23 at 1:05 P.M., the Director of Nursing (DON) said: -He/She expected staff to follow manufacture guidelines related to insulin pen medication administration. -Staff should prime the insulin pen with 2 units of insulin prior to dialing up the dosage to administer to the resident.

Based on observation, interview and record review, the facility failed to ensure services to prevent and heel pressure ulcers (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) for two sampled residents (Resident #37 and #67) with pressure ulcers out of 18 sampled residents. The facility census was 70 residents. Review of www.medline.com/strategies/skin-health/evidence-based-best-practices-heels-npiap-guidelines-help-prevent-pressure-injuries/ dated July 2020 showed: -For residents at risk of heel pressure injuries (pressure ulcers) and/or with Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) or Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow or foam cushion. -Be sure to offload (minimize or removing weight placed on the foot to help prevent and heal ulcers) the heel completely to distribute the weight of the leg along the calf. -With individuals who already have a Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) or greater heel pressure injury, the same applies. However, it is not recommended to use pillows or foam cushions, only specifically designed heel suspension devices. 1. Resident #37's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/21/23 showed: -He/she was admitted to the facility on [DATE] -He/she had two unstageable (not stageable due to coverage of the wound bed with slough - tan/yellow dead tissue or eschar - dry, black hard dead tissue) pressure ulcers that were present on his/her facility admission. Review of the resident's care plan initiated on 8/3/23 showed: -He/she had an actual skin impairment to his/her right heel. -Interventions included to float (position in such a way as to remove all contact between the heel and the bed) his/her heels while he/she was in bed as tolerated. Observation on 9/11/23 at 1:26 P.M. showed: -The resident lying in bed on his/her back. -His/her heels were resting directly on his/her mattress. Review of the resident's physician's orders showed the following order dated 9/12/23: -Cleanse right heel with wound cleanser (solution used to remove contaminants, foreign debris, and fluid from wounds), pat dry then place Xeroform (a protective product designed for open wounds that traps moisture against the skin and provides a moist environment for wound healing) to wound bed. -Cover with bordered gauze dressing (a foam dressing that effectively absorbs and retains drainage and maintains a moist wound environment for wound healing), wrap with Kerlix (woven gauze) daily and as needed for wound. -Ensure right heel is elevated when in bed. Observations on 9/12/23 at 11:11 A.M., 9/13/23 at 3:16 A.M., and 9/13/23 at 6:32 A.M., showed: -The resident lying in bed on his/her back. - His/her heels were resting directly on his/her mattress. Observation on 9/14/23 at 8:57 A.M. of the resident's right heel treatment showed: -He/she had an unstageable pressure ulcer on his/her right heel approximately one and one half inches long and two inches wide that was covered with dark eschar (dry, black, hard dead tissue). -There was a small open area with pink tissue at the right edge of the wound. -Licensed Practical Nurse (LPN) D applied Xerform to the entire wound, including all of the area with eschar, and then placed a bordered gauze dressing over the residents wound. -LPN D did not wrap the resident's right heel with Kerlix. During an interview on 9/14/23 at 9:07 A.M., LPN D said: -Most of the resident's right heel wound was necrotic and black. -There was a small area on the right edge that was open and red. -He/she put the Xerform on the entire wound, including the black necrotic area. -He/she did not wrap the resident's right heel with Kerlix. -Nursing staff were to have gone into the resident's room every so often during their shift and checked that the resident's heels were floated. -He/she knew the resident's heels were to have been floated by looking at the physician's orders for his/her treatment. -He/she could not say how the Certified Nursing Assistants (CNAs) were to know which residents heels were to be floated. During an interview on 9/14/23 at 9: 50 A.M., the wound nurse said: -He/she saw the resident's right heel pressure ulcer on 9/13/23; at that time it measured 4.6 centimeters (cm) X 5.8 cm with an unknown depth, had 90% eschar and had an open area that was red and moist on the right edge. -Xerform was to be used for open skin, not for eschar covered areas. -LPN D should have cut a small piece of Xerform in a shape to cover only the resident's open area and should not have placed a large piece of Xerform that covered the entire wound with the eschar. -The resident's current physician's order for his/her right heel should have been clarified to specify that the Xerform gauze was to be applied only to the open area on the resident's right heel rather than over the entire wound that included the area of eschar. -He/she would clarify the order with the prescriber to state that Xerform was to be placed on the small open area on the right edge of the wound, would ask the prescriber if the order could include application of skin prep around the outside edge of the entire wound and on the area of eschar and if an ABD pad (a large absorbant dressing) could be placed over the resident's heel after placement of bordered gauze dressing before wrapping the wound with Kerlix. -The resident's heels should have been floated when he/she was in bed; licensed nurses were to have ensured each shift that the resident's heels were floated. 2. Review of Resident #67's admission MDS dated [DATE] showed: -He/she was admitted to the facility on [DATE]. -He/she had no pressure ulcers. Review of the resident's physician's order's dated 9/5/23 showed: -Cleanse right buttock with normal saline or wound cleanser, pat dry, apply collagen, cover with dry dressing one time a day every Tuesday, Thursday and Saturday and as needed for wound care. -Clean left heel with normal saline or wound a, pat dry, apply collagen, cover with dry dressing one time a day every Tuesday, Thursday and Saturday and as needed for wound care. -Nurse to ensure heels are floating at all times when in bed, every shift for wound care. Observation on 9/11/23 at 2:07 P.M. showed: -The resident lying in bed on his/her back. -His/her heels were resting directly on his/her mattress. Observation on 9/12/23 at 11:08 A.M. showed: -The resident lying in bed on his/her back. -His/her heels were resting directly on his/her mattress. -He/she had a pressure ulcer on his/her left heel, that was about 3/4 inches long and one and 3/4 inches wide that was open with red tissue in the wound bed. -Registered Nurse (RN) A completed the residents treatment and failed to float the resident's heels prior to leaving the resident's room. Observation on 9/13/23 at 3:13 A.M., 4:52 A.M., and 6:29 A.M. showed: -The resident lying in bed on his/her back. -His/her heels were resting directly on his/her mattress. During an interview on 9/14/23 at 9: 50 A.M., the wound nurse said: -He/she saw the resident's right heel pressure ulcer on 9/12/23; at that time it measured 2.2 cm long and 4.0 cm wide with granulation (pink) tissue. -The resident's heels should have been floated when he/she was in bed; licensed nurses were to have ensured each shift that the resident's heels were floated. 3. During an interview on 9/14/23 at 1:05 P.M., the Director of Nursing (DON) said: -Resident's #37 and #67 should have their heels floated at all times when in bed and should have protective boots (soft boots that provide protection from pressure to heels). -Skin prep should have been applied around the entire wound and if ordered over the eschar on Resident #37's heel and the resident's heel should have been wrapped with Kerlix if ordered. -Xerform should be applied to open areas only.

Based on observation, interview, and record review, the facility failed to follow physician orders for a Low Air Loss Mattress (LAL- an air mattress covered with tiny holes which are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture), to follow physician orders to apply topical medication to the resident's skin as needed for moisture and redness and to apply protective barrier cream after resident incontinent episodes with moisture associated skin breakdown per professional standards of practice for one sampled resident (Resident #32) out of 18 sampled residents. The facility census was 70 residents. A policy and procedure for physician orders, and use of barrier cream was requested and was not provided prior to exit from the facility. 1. Review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Clostridium Difficile (C-diff- a disruption of normal healthy bacteria in the colon, causing diarrhea, abdominal pain and fever). Review of the resident's electronic medical record Weekly Skin Assessment showed the resident had blanchable redness on perineal area on 8/21/23. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 8/27/23 showed: -He/she was cognitively intact. -He/she needed total assist of two caregivers with toileting and hygiene. -He/she was always incontinent of bowels. -He/she was at risk for developing skin pressure sores. -He/she had moisture associated skin breakdown. -He/she had a pressure reducing device for chair and bed. -He/she had application of ointments to skin. Review of the resident's electronic medical record Weekly Skin Assessment showed the resident had redness with sores on perineal area on 8/28/23 and no new treatment ordered. Review of the resident's undated electronic medical record Physician Order Summary Report showed: -Low air loss mattress set to comfort every shift with start date of 8/21/23. -Macatin Cream (a topical cream applied to skin for fungal and yeast related skin irritations) 2% apply to perineal area topically every eight hours as needed for moisture and redness to groin. Start date 8/21/23. Review of the resident's Treatment Administration Record (TAR) dated 8/2023 showed dates 8/21/23 through 8/31/23 as needed medication Macatin Cream 2% had not been administered to the resident's perineal area for moisture and redness. Review of the resident's undated electronic medical record Physician Order Summary Report showed: -Low air loss mattress set to comfort every shift with start date of 8/21/23. -Macatin Cream (a topical cream applied to skin for fungal and yeast related skin irritations) 2% apply to perineal area topically every eight hours as needed for moisture and redness to groin. Start date 8/21/23. Review of the resident's TAR dated 9/23 showed: -Dates 9/1/23 through 9/14/23 as needed medication Macatin Cream 2% had not been administered to the resident's perineal area for moisture and redness. -Dates 9/11/23 through 9/14/23 nursing staff initialized that the LAL mattress was in place. Review of the resident's care plan dated 9/2/23 showed: -He/she required isolation precautions for C-diff. -He/she had self-care deficits with goal to maintain dignity. Interventions included the resident required two staff to turn and reposition in bed, the resident required two staff for toileting and hygiene. -He/she has actual impairment of skin with goal to not have any complications with skin impairments. Interventions included pressure redistributing mattress on bed (LAL). Review of the resident's electronic medical record Weekly Skin Assessment showed: -The resident had blanchable redness on perineal area on 9/5/23 and cream was used. -The resident had blanchable redness on perineal area on 9/12/23. Observations 9/11/23 at 10:06 A.M. showed the resident in bed on his/her back without a LAL on. Observation on 9/11/23 at 9:45 A.M. of Certified Nursing Assistant (CNA) A providing perineal care showed: -The resident had skin irritation that was red and inflamed on buttocks, perineal and genitals. -He/she did not apply barrier cream to his/her buttocks, perineal or genital area after incontinence care that was readily available at the resident's bedside. Observations of the resident showed: -He/she in bed on back without a LAL on 9/12/23 at 2:20 P.M. -He/she in bed on back without a LAL on 9/13/23 at 5:00 A.M. -He/she in bed on back without a LAL on 9/14/23 at 10:00 A.M. 2. During an interview on 9/12/23 at 10:20 A.M., CNA A said: -He/she would use barrier cream on resident's who are incontinent of bowel and/or bladder. -He/she should have applied barrier cream to the resident after incontinent care. During an interview on 9/14/23 at 9:03 A.M., CNA B said: -Barrier cream should be used anytime a resident has a red perineal area or if they are incontinent. -He/she would use barrier cream on the resident and he/she does need a LAL mattress. -He/she would know if a LAL mattress should be in place through the electronic task charting. During an interview on 9/14/23 at 9:15 A.M., Licensed Practical Nurse (LPN) C said: -He/she would apply barrier cream to all incontinent residents. -He/she would expect the resident to have barrier cream applied after incontinent care. -He/she would not sign off on TAR if a resident did not have a LAL mattress. -He/she would notify Assistant Director of Nursing (ADON), Hospice (end of life care) and the medical doctor if a LAL mattress was ordered and not on the bed. -He/she was not aware of as needed use cream was available for the resident's perineal moisture and redness. During an interview on 9/14/23 at 9:22 A.M., ADON B said: -All incontinent resident should have a barrier cream applied after perineal care. -He/she would expect caregivers to use a barrier cream on Resident #32 after incontinent episodes. -He/she would expect nursing staff to let him/her know if a LAL mattress is not in place as ordered. -He/she would not expect nursing to sign off on TAR that LAL mattress is on bed when it is not. -He/she would expect to follow physician orders on TAR for ointments/creams that are ordered. During an interview on 9/14/23 at 1:04 P.M., the Director of Nursing (DON) said: -He/she would expect nursing staff to follow physician orders. -He/she would expect nursing staff to use barrier cream on incontinent residents as a preventative measure. -He/she was not aware the resident did not have a LAL mattress.

Based on interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for one sampled resident (Resident #49) out of 18 sampled residents. The facility census was 70 residents. A policy for PASARR was requested from the facility and not provided. 1. Review of Resident #49's Admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Senile degeneration of the brain (the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age). -Generalized anxiety disorder (a condition of excessive worry about everyday issues and situations). -Cognitive communication deficit (difficulty with thinking and how someone uses language). -Stroke. -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Memory deficit following cerebral infarction (stroke). On 9/12/23 a copy of the residents PASARR was requested and not provided. During an interview on 9/12/23 at 9:54 A.M., the Administrator said: -The resident was a private pay resident. -The resident had transferred in from another facility. -The resident did not have a PASARR on file at the facility. During an interview on 9/12/23 at 2:03 P.M., Social Services Director (SSD) said: -He/she did not realize that this resident did not have a PASARR Level One performed at the prior facility. -He/she thought that since the resident was a private pay resident that a PASARR was not needed. -He/she was responsible to ensure all residents had a PASARR performed. -He/she had submitted a PASARR Level One that day for the resident. During an interview on 9/14/23 at 1:04 P.M., the Director of Nursing (DON) said: -It was his/her expectation that all residents would have a PASARR performed and on file at the facility. -The SSD was the person responsible to ensure that all residents had a PASARR performed.

Based on interview and record review, the facility failed to follow facility policies and procedures for medication reconciliation by not performing required narcotic counts at the beginning/end of each shift, resulting in the misappropriation on 28 tablets of Oxycodone (a narcotic medication for pain) for one sampled resident (Resident #1) out of three sampled residents. The facility census was 77 residents. On 7/29/22 the Administrator was notified of the past noncompliance which occurred on 7/14/22. On 7/14/22 the facility administration was notified of the incident and the investigation was started. The deficiency was corrected on 7/17/22 as evidenced by the facility replacing the resident's Oxycodone without charge and staff in-service. Record review of the facility policy titled Controlled Substance Policy dated 2/2021 showed: -Controlled substances are subject to special handling, storage, disposal and record-keeping requirements. -The facility will maintain compliance with these special provisions. -The persons performing the inventory will sign to verify that the inventory was done. -All controlled substances are to be counted every shift. -The count is to be performed by the on-coming licensed nurse and the off-going licensed nurse. -The oncoming nurse will be responsible for looking at the medication to verify the amount of medication present at the time of the count. -The off-going nurse will be responsible for viewing the Controlled Substance Proof of Use Record to verify the amount on the record at the time of the count,. -Both nurses will sign on the Narcotic Sign in and out Sheet that the count was completed. -Any discrepancy in the inventory of a controlled substance is to be reported to the Director of Nursing (DON) immediately. -The DON is responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. -The discrepancy of a controlled substance is to be reported to the Administrator and the Regional Nurse immediately. -If a discrepancy is not reconciled, the DON is to document the details on the audit record, including the possible shift or persons responsible for the discrepancy, and the efforts made to reconcile it. Record review of the facility policy titled Abuse, Prevention and Prohibition Policy dated 11/2018 showed: -This facility prohibits mistreatment, neglect or abuse of residents. -This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. -The facility also prohibits misappropriation of resident property. -The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. -Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resent's belongings or money without the resident's consent. -If an item that has been reported as missing cannot be located within a period not to exceed 24 hours, the Social Service Designee will notify the Administrator of an allegation of possible misappropriation. -The Administrator will make the appropriate notifications and initiate an investigation of the allegation of misappropriation of resident property. 1. Record review of Resident #1's facility face sheet showed: -admitted to the facility as 7/11/2022 with diagnoses that included: --Metabolic Encephalopathy (A problem in the brain caused by a chemical imbalance in the blood). --Cellulitis (a potentially serious bacterial skin infection) of his/her left and right leg. --Acute and Chronic respiratory failure. --Chronic kidney disease. --History of traumatic brain injury. Record review of the resident's admission Minimum Data Set (MDS -a federally mandated assessment tool used by facilities for care planning) dated 7/18/22 showed: -Brief Interview of Mental Status (BIMS) score of 15, which indicates the resident was cognitively intact. -Extensive assistance is required for all Activities of Daily Living (ADL's - activities related to personal care such as bathing, dressing, getting in and out of bed, walking, using the toilet and eating) except for eating and personal hygiene, which require supervision. Record review of the resident's care plan dated 7/18/22 showed: -The resident has pain related to neuropathy, low back, neck, left foot pain status post surgical removal of infected hardware, peripheral vascular disease, neuralgia, neuritis and gout. -His/her Musculoskeletal status was impaired requiring rehabilitation therapy related to hardware to left foot screws from previous arthrodesis (surgical immobilization of a joint by fusion of the adjacent bones) and status post surgical removal, osteophyte (a bony growth that develops on the edge of a bone), thoracic disc degeneration, radiculopathy (disease of the root of a nerve) cervical and thoracic regions, calcaneal spur to his/her left foot. During an interview on 7/29/22 at 1:45 P.M., the resident said: -He/she had received pain medication whenever he/she needed it. -The as needed (PRN) medication, he/she just has to ask for, but the facility staff usually just ask him/her if he/she was in pain, and if so, they give him/her the as needed medication. -The staff had told him/her the Oxycodone was missing, but he/she never would have been aware of that, as he/she received the medication whenever he/she requested it. He/she understood that the facility replaced the Oxycodone at no charge to him/her. . Record review of the facility investigation dated 7/16/22 showed: -On 7/13/22 Licensed Practical Nurse (LPN) D signed in 30 tablets of Oxycodone 5 milligrams (mg) at 11:54 A.M. for Resident #1. --The medication was signed into the narcotic log and added to the locked medication cart. --At 3:32 P.M., LPN E gave resident an Oxycodone tablet which left 29 tablets. --LPN E then left the facility somewhere around 6:00 P.M. --Registered Nurse (RN) F then took over the medication cart. --All counts were correct and all medications were accounted for. -On 7/14/22 LPN G worked 6:00 A.M. - 6:00 P.M. and gave the resident an Oxycodone at 10:14 A.M. --LPN H worked from 6:00 P.M. - 6:00 A.M., with no more Oxycodone signed out. -On 7/15/22 LPN I worked 6:00 A.M. - 5:00 P.M. --The medication was reported missing at 7:53 P.M., by RN J who was just helping out on the unit. --RN J did take the keys from LPN I. --Resident #1 requested a pain pill. --RN J went to get the medication which was not in the cart. --RN J called the pharmacy and the pharmacy reported when it had been delivered. --RN J notified the DON, who instructed RN J to go through all the medication carts and the medication room. --DON notified the Administrator. -On 7/16/22 At 7:00 A.M., the Administrator was present in the building to assure all narcotic counts were complete, medication carts searched. --At 10:30 A.M., medication reordered from the pharmacy. -- At 10:57 A.M., the Corporate Nurse was notified of the missing medication, Medication Administration Record and Treatment Administration Record audits were completed. --At 1200 Noon Physician for Resident #1 notified. --At 12:30 P.M., Responsible party notified. --At 12:40 P.M., the Pharmacy was notified with missing medication, reordered the resident's medication and the facility was to be charged, not the resident. --In-servicing began. --Local Police were notified at 1:30 P.M. During an interview on 7/29/22 at 12:45 P.M., the DON said: -LPN I failed to perform a count of the narcotics at the end of his/her shift and has since been counseled. -The facility immediately put a performance improvement plan in place and were performing random checks of the narcotic sheets on a schedule. -The facility has not found the narcotics. During an interview on 7/29/22 at 1:00 P.M., LPN I said: -He/she had to leave early that shift and handed over the keys without counting. -He/she definitely knew to count the narcotics, no matter what. -He/she should have counted. -They educated him/her and all of the licensed staff, and weekend and night licensed staff as well as all the agency licensed staff. During an interview on 8/2/22 at 2:00 P.M., Nurse Practitioner (NP) M said: -The facility staff had made his/her office aware of the misappropriation of Resident #1's narcotic. -He/she said that it was her/his understanding that the facility replaced the narcotic at no charge to the resident and that the investigation is ongoing, with added provisions to mitigate the risk of further narcotics missing. MO00204068

Based on observation, interview and record review, the facility failed to prevent resident abuse for one sampled resident (Resident #2), when Certified Nursing Assistant (CNA) A shared a video of the resident on Instagram (a social networking service) without consent from the resident or family out of three sampled residents. The facility census was 77 residents. On [DATE] the Administrator was notified of the past noncompliance which occurred on [DATE]. On [DATE] the facility administration was notified of the incident and the investigation was started. The deficiency was corrected on [DATE] as evidenced by staff in-services. Record review of the facility policy and procedure titled, Abuse, Prevention and Prohibition Policy dated ,d+[DATE] showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. -Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies servicing the resident, family members or legal guardians, friends, or other individuals. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. -Additional in-services may include: --Difference between violations of resident privacy and mental abuse. --Taking pictures or recordings of residents without the residents or residents' responsible party's consent is a violation of the resident's right to privacy. -Mental abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. -Mental abuse includes but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. 1. Record review of Resident #2's facility face sheet showed: -The resident was admitted to the facility on [DATE] with diagnoses that included: --Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). --Dementia (a group of thinking and social symptoms that interferes with daily functioning). --Chronic kidney disease. --Major depression. --Psychosis (a mental disorder characterized by a disconnection from reality). --Anxiety. Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated [DATE] showed: -His/her BIMS (Brief Interview for Mental Status) score of 3, which indicates the resident had severe cognitive impairment. -He/she required one person assist for all Activities of Daily Living (ADL's - bathing, dressing, getting in and out of bed or a chair, waling, using the toilet and eating). Record review of the resident's care plan dated [DATE] showed: -The resident has impaired cognitive function/impaired thought processes due to Alzheimer's and Dementia. -The resident has a potential psychosocial well-being problem due to restriction on visitation related to COVID-19. -The resident has a potential communication problem due to cognitive deficits and usually able to understand content. -The resident has a behavior problem at times, he/she confabulates stories, becomes verbally aggressive and demanding and accuses staff of not giving his/her medications. -The resident is delusional and at times believes his/her husband is alive and outside waiting to pick him/her up. -The resident has anxiety with psychosis and agitation, depression and insomnia, and requires psychoactive medications to manage. Observation on [DATE] at 10:30 A.M., showed the resident was not interviewable and alert to his/herself only. Record review of the facility investigation dated [DATE] showed: -A video showing CNA A face and a clear picture of the resident. -CNA A was notified that he/she was suspended pending an investigation regarding the video. -CNA A denies it was him/her that made the video. -Local police department called and report was made. -Self report was made to State of Missouri. -The Regional Nurse was present in the building and notified after the video was reviewed. -The resident's family was notified of the incident by Social Services. Observation on [DATE] of the video obtained from the facility showed: -CNA A was identifiable in the front of the video, CNA A turned and pointed the video toward the resident. -The resident was in the background in a wheelchair in his/her doorway of his/her room wearing a housegown. -The resident was identifiable. -The video had no audio. -The video caption read, He/she wants his/her dead husband to come pick him/her up and take him/her home. During an interview on [DATE] at 10:30 A.M., the Administrator said: -A video was sent to another employee of CNA A and Resident #2 sitting in his/her wheelchair in his/her room from the employee's Instagram. -The video read, he/she wants his/her deceased husband to come and get him/her and take him/her home. -When he/she contacted CNA A to discuss the video, the CNA denied posting the video on Instagram. -CNA A is no longer employed at the facility. -Education began with all staff immediately. During an interview on [DATE] at 11:00 A.M., the Director of Nursing (DON) said: -The video was discovered on [DATE]. -To his/her knowledge this has not happened before. -All employees were educated upon hire on the facility Abuse policy and procedure which of course includes not taking pictures, recording or videoing any residents. During an interview on [DATE] at 11:30 A.M., Registered Nurse (RN) C said: -The resident had no idea he/she was being recorded or that it was posted on Instagram. -The resident's cognitive status would not allow her/him to understand. -All of the staff were educated on the facility Abuse policy when they were hired, including taking pictures or videoing the residents. During an interview on [DATE] at 12:05 P.M., Licensed Practical Nurse (LPN) D said: -He/she had never heard of this happening before at the facility. -All staff were educated on this policy when they started work at the facility, and received additional training at least once throughout the year. During an interview on [DATE] at 3:00 P.M., Nurse Practitioner M said: -His/her office was aware of the Instagram posting. -He/she felt confident that the facility had educated the staff on the policy regarding this type of behavior. -He/she did not feel that the resident was aware enough to be upset by the recording. MO00204209

Based on observation, interview, and record review, the facility failed to maintain a record of one employee (Employee B's) exemption form; to ensure Employee F filled out an exemption form before working in a resident care capacity; to have a section in its' policy on how the facility would coordinate with various contract agencies that supply employees to the facility; and to ensure one employee, (Employee G) wore two surgical masks or an N95 mask while he/she delivered food to several residents during the lunch meal. The facility census was 75 residents. 1. Review of the facility ' s COVID-19 staff vaccination documentation showed, the facility had 59 employees. Documentation showed 93.2% of employees received either one or both doses of vaccination, or had a pending or approved exemption. Review of the facility's COVID-19 resident outbreak documentation showed no residents tested positive for COVID-19 in the four weeks prior to the onsite review. 2. Record review of page 4 of the facility's policy entitled Covid Universal Vaccination, showed: All community based employees will be required to complete the COVID-19 vaccination consent/attestation for or the Covid-19 vaccination/attestation form. This will be placed in the employee's confidential medical file. During an interview on 2/28/22 at 3:44 P.M., the Administrator said: - Employee B was at the facility for orientation on 2/22/22 and has worked three shifts during the week of 2/20/22 through 2/26/22. - Employee B filled out the form for a religious exemption (a rule published by Centers for Medicare and Medicaid Services (CMS) which allows qualifying healthcare facilities to exempt their employees from the vaccination mandate due to a sincerely held religious belief), but facility staff could not find the form for Employee B. 3. Record review of page 4 of the facility's policy entitled Covid Universal Vaccination, showed: Individuals who decline vaccination for any reason, must have a qualified medical or religious reason for exemption. Those who fail to meet this requirement will be removed from the schedule pending a review of the reasons for declining or obtaining the vaccination. To protect our employee and residents and because unvaccinated personnel may pose a direct threat to the health and safety of others in the workplace. The unvaccinated personnel may be subject to leave of absence, suspension or termination of employment/services. During an interview on 2/28/22 at 3: 48 P.M., the Administrator said Employee F did not fill out the religious exemption form before he/she worked the shift on 2/26/22. 4. Record review of pages 3 and 4 of the Facility Policy entitled Covid Universal Vaccination, showed: -Applicable to Federal and State agencies that require mandatory vaccination for all healthcare employees against COVID-19 including, but not limited to: -- All Community based employees and personnel, and -- All corporate, Regional, Divisional or Field employees who regularly, routinely or intermittently work in and/or visit Community or Company offices, and -- All office based employees and personnel who regularly, routinely or intermittently work and/or visit Communities, and -- All office based or remote employees who regularly, routinely, or intermittently work with, interact or engage with Community based employees, and -- All Company leaders. -All employees and personnel must: -- Have receive at least one dose of Covid-19 vaccine by specified deadline, or -- Have intentions and consent to do so within 30 days of hire, or -- Have a pending request for exemption, or -- Have been granted a qualifying exemption, or --Have a temporary delay for vaccination as recommended by the CDC. -The process for seeking an accommodation: -- If vaccination cannot be completed due to being temporarily postponed, then the employee must submit written documentation from a medical provider indicating when the vaccine can or will be administered. -- Employees who do not fulfill any of these requirements will be placed on unpaid leave and their status will be evaluated periodically. Record review of the Facility Policy entitled Covid Universal Vaccination showed the absence of a policy on how the facility would coordinate with contract agencies to obtain the vaccination status of agency employees who are sent to work at the facility. Record review of facility records showed 36 of 95 total employees were employees supplied by contract agencies. During an interview on 2/28/22 at 3:31 P.M., the Administrator said: - The facility practice was to review the vaccination status of staff from the Staffing Agency was to pull the information about the potential employee off of the agency's website. - The Therapy Department Director was in charge of tracking the vaccination status of therapy department employees. - The process of how coordination with the various agencies which supply employees to the facility, was not included within the written policy. 5. Record review of page 5 of the Facility Policy entitled Covid Universal Vaccination, showed: - Unvaccinated employees who are granted exemption will be required to wear an N 95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles in which the edges of the respirator are designed to form a seal around the nose and mouth) respirator( mask) or equivalent (2 surgical masks (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment.) or one KN 95 (N95s are the U.S. standard, while KN95s are the Chinese standard for these close-fitting filtration devices) mask with a surgical mask over the KN 95 mask, while in the building. Observation on 2/28/22 at 12:55 P.M., just before Employee G, who was unvaccinated, started to deliver lunch meals to residents located in resident rooms 138 through 150, showed Employee G wore a single blue surgical mask. Observation on 2/28/22 at 1:35 P.M., showed Employee G wore a single blue surgical mask. During an interview on 2/28/22 at 1:36 P.M., Employee G said he/she had worked for two days and that he/she and another employee just finished delivering lunch meals to the rooms. During an interview on 2/28/22 at 2:58 P.M., the Assistant Director of Nursing (ADON) said: - The facility had done in-services with employees who were not vaccinated, which covered how those employees should wear masks. - Employee G should have been wearing two surgical masks or an N95 mask when he/she delivered food. During a phone interview on 3/2/22 at 1:46 P.M., Employee G said: - He/she did not know that he/she needed to wear two surgical masks or an N 95 mask. - He/she did not mention the KN 95. - He/she did not attend the in-service which covered what kinds of masks unvaccinated employees should wear.

Based on interview and record review, the facility failed to call emergency personnel in a timely manner and to provide basic life support, including cardiopulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped), for one sampled resident (Resident #1) out of six sampled residents. The facility census was 59 residents. The Executive Director was notified on [DATE] at 11:51 A.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the Executive Director became aware of the violation of the facility's CPR policy. The facility in-serviced the staff on the CPR policy and procedures. The IJ was removed and corrected on [DATE]. Record review of the facility's CPR policy, dated ,[DATE], showed the following: - Personnel have completed training on the initiation of CPR/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION] (cessation of respirations and/or pulse). - If an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR BLS shall initiate CPR unless: - It is known that a Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) order that specifically prohibits CPR and/or external defibrillation exists for that individual. 1. Record review of Resident #1's Health Care Directive dated [DATE], showed: - The resident wanted everyone who cared for him/her to understand his/her wishes if he/she could not communicate or make decisions on his/her own; - He/she made this directive to provide clear and convincing proof of his/her wishes and instructions about health care and treatment; and - If his/her doctor believed a medical treatment would lead to recovery, he/she wanted to have any and all necessary and/or available treatment including CPR. Record review of the resident's face sheet showed he/she admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. - [MEDICAL CONDITION]/[MEDICAL CONDITION] (paralysis/weakness affecting one side of the body) that affected his/her dominant side; - Generalized muscle weakness; - Pain; - Diabetes Mellitus; and - Hypertension (high blood pressure). Record review of the resident's care plan updated on [DATE], showed he/she: - Had a terminal prognosis related to [MEDICAL CONDITION] disease; and - Was under the care of hospice (end of life care). Record review of the resident's Order Summary Report dated [DATE] at 12:10 P.M., showed the resident's code status was a full code. Review of the nurses' notes dated [DATE] at 1:30 A.M. showed: - Licensed Practical Nurse (LPN) #1 entered the resident's room shortly after the night shift started to provide wound dressing cares; - The resident presented with no signs of life to include no pulse, respirations, blood pressure or pupillary dilation; - LPN #1 notified hospice, left messages for the Executive Director and doctor; - LPN #1 called a second nurse (LPN #2) to verify code status; - CPR was initiated by LPN #1 when code status was confirmed; - LPN #1 alerted a Certified Nursing Assistant (CNA) to call 911 while LPN #1 performed CPR; - Emergency Medical Service (EMS) arrived and continued CPR; - EMS shortly thereafter called time of death and ceased CPR; - The hospice nurse stated he/she would notify appropriate parties; and - LPN #1 notified the Executive Director, Director of Nursing (DON) and Physician with an order received to release the resident's body to the funeral home. Record review of the facility's investigation showed LPN #1 wrote the following timeline dated [DATE]: - He/she was told they had a new resident and that resident was a hospice patient at the 2:00 P.M. shift change report; - The resident had a drastic decline, was not eating, medications were stopped and the resident was receiving comfort medications only; - He/she spoke with the hospice nurse regarding the resident's comfort medications at 2:20 P.M.; - He/she called the hospice nurse again to double check confirmation of comfort medications at 3:20 P.M.; - He/she received confirmation to administer comfort medications; - He/she administered comfort medications to the resident; - He/she administered the second dose of comfort medications as the resident displayed increased grimacing/moaning/groaning at 4:30 P.M.; - He/she administered the third dose of comfort medications as the resident displayed increased grimacing/moaning/groaning at 7:00 P.M.; - He/she asked the CNAs to clean the resident in order for him/her to perform a dressing change on the resident's wounds at 9:30 P.M.; - The shift change occurred at 10:00 P.M.; - The LPN entered the resident's room to perform a dressing change on the resident's wounds and the resident was non-responsive with no pulse, no breathing, no pupillary response at 10:13 P.M.; - The LPN immediately summoned a second nurse for assessment of the patient's status; - The second nurse concurred with absence of pulse, respiration and pupillary response; - The Executive Director was notified; - The physician was notified of patient assessment including absence of vitals at 10:38 P.M.; - The Executive Director called to inform him/her of the resident's code status at 11:00 P.M.; - He/she immediately initiated CPR with another staff member and delegated another staff member to call 911; and - The EMTs arrived five minutes later and took over CPR. Record review of the facility's Executive Director's typed statement showed in part: - On [DATE], he/she spoke with LPN #1 at approximately 11:00 P.M. and after review of the resident's condition and code status, the LPN was given the directive to start CPR and call 911; - At approximately 11:15 P.M., the Executive Director called back to the facility and asked to speak with the hospice nurse; - The hospice nurse explained CPR was being performed when she arrived and she called the family who expressed their wishes that CPR be discontinued. Record review of CNA #1's typed statement showed: - At approximately 10:30 P.M., he/she went into Resident #1's room to check on him/her and noted the resident to have no signs of life; - He/she went to grab the other nurse to confirm the resident's passing; - He/she was passing by the nurse's station and LPN #1 asked him/her to go with him/her to the resident's room to assist with CPR; and - He/she gave breaths while LPN #1 performed chest compressions until EMS arrived. Record review of CNA #2's typed statement showed: - On [DATE], prior to the shift change at 9:20 P.M., he/she and CNA #3 went to perform cares on Resident #1 and to help the resident be more comfortable; and - The charge nurse had instructed them to perform a bed bath so he/she could do wound care treatment on the resident and to help the resident be more comfortable. Record review of CNA #3's typed statement showed: - On [DATE] at approximately 9:20 P.M., he/she and another CNA went into the resident's room to give the resident a bed bath per the charge nurse's request, so the charge nurse could address the resident's wounds; - The resident was breathing, but was non-responsive; - During the bed bath, the resident did open his/her eyes once; - The resident didn't seem to be in too much pain as he/she did not hear any noises coming from the resident; and - He/she noticed the charge nurse heading towards the resident's room when shift change occurred around 10:00 P.M. on [DATE]. Record review of LPN #2's typed statement showed: - On [DATE], a CNA came to have him/her go to the long-term care side of the building to verify a resident's passing; - He/she went to verify the resident had no signs of life; - He/she was called by the Executive Director asking him/her to check CPR status on the long-term care resident; and - Upon arriving to the long-term care side, he/she noted EMS at the resident's bedside. During an interview on [DATE] at 9:53 A.M., Registered Nurse (RN) #1 said: - If he/she came upon a resident that was unresponsive, he/she would check for a pulse and respirations; - If no pulse or respirations, he/she would call for help; - He/she would obtain the code status for the resident which is kept on the crash cart (emergency airway and other emergency equipment kept at the nurses station), in the front of the licensed nurses' narcotic count book, on the 24 hour report and on the Certified Nursing Assistant (CNA) daily care sheet; and - If the resident was a full code, he/she would have someone announce a Code Blue and grab the crash cart and immediately start CardioPulmonary Resuscitation (CPR - the manual application of chest compressions and breaths in patients with [MEDICAL CONDITION], done in an effort to maintain viability until advanced help arrives.) During an interview on [DATE] at 10:02 A.M., RN #2 said: - If he/she came upon a person that was unresponsive, he/she would check the crash cart for the person's code status; and - If the person was a full code, he/she would grab the crash cart, have someone announce Code Blue and he/she would start CPR. During an interview on [DATE] at 10:53 A.M., Resident #1's family member said: - The resident and family did not have any plans to change the resident's code status from full code to a DNR; - He/she received a telephone call from the facility on [DATE] at approximately 11:00 P.M. and was told CPR was being performed on the resident, but he/she needed to tell the Emergency Medical Technicians (EMT's - a specially trained medical technician certified to provide basic emergency services before and during transport to the hospital) to stop CPR. During an interview on [DATE] at 11:10 A.M., CNA #1 said: - He/she made rounds with LPN #1 approximately 20 minutes into his/her shift (approximately 10:20 P.M.); - The resident was not responsive; - He/she called the nurse on the other side of the building to confirm the resident's passing; - Approximately thirty minutes later, he/she was passing by the nurse's station and noticed LPN #1 hang up the telephone and he/she appeared to be in a panic; - LPN #1 grabbed him/her and said come on, we have to start CPR on Resident #1; - CNA #1 was confused as the resident had been without a pulse or respirations; - LPN #1 called for the other staff to call 911; - LPN #1 and CNA #1 entered the resident's room and LPN #1 began chest compressions; - CNA #1 performed rescue breathing; and - The ambulance arrived and Emergency Medical Service (EMS) took over the code. During an interview on [DATE] at 11:16 A.M., CNA #2 said: - The resident was crying in pain when he/she arrived at the facility; - LPN #1 administered medication to the resident; - He/she saved this resident for last to give him/her a bed bath; - The resident did not respond to the bed bath and oral care other than groaning every now and then; and - The resident was still breathing and looked comfortable after the bed bath towards the end of his/her 2:00 P.M. - 10:00 P.M. shift. During an interview on [DATE] at 11:48 A.M., CNA #3 said: - He/she did not know the resident was being admitted to their unit; - The resident arrived screaming, moaning and groaning in pain; - The resident was placed in the bed; - The nurse gave the resident some pain medication; - He/she assisted in giving the resident a bed bath toward the end of his/her 2:00 P.M. - 10:00 P.M. shift; and - The resident was still breathing when he/she left the room. During an interview on [DATE] at 8:08 A.M., LPN #2 said: - He/she was called to go to the other side of the building to check a resident for a pulse at approximately 10:20 P.M.; - He/she checked the resident and the resident did not have a pulse; - LPN #1 had not informed him/her the resident was a full code; and - LPN #1 said the resident was a hospice patient. During an interview on [DATE] at 12:20 P.M., the Executive Director said: - He/she had spoken with LPN #1 on the telephone around 11:00 P.M. on [DATE]; - He/she informed LPN #1 the resident was a full code; - He/she instructed LPN #1 to begin CPR and to call 911; and - He/she expected CPR to be performed if a person is found without pulse and respirations. During an interview on [DATE] at 8:56 A.M., LPN #1 said: - If he/she came upon a resident or was informed a resident was unresponsive, he/she would make sure of the person's code status; - If the person was a full code, he/she would call a Code Blue and begin CPR; - At approximately 9:30 P.M. on [DATE], he/she asked the CNAs to clean the resident so he/she could perform a dressing change; - At approximately 10:13 P.M., he/she and a CNA checked on the resident and the resident was without signs of life; - He/she thought because the resident was hospice, that he/she was a DNR, as hospice residents are usually a DNR; - CPR was initiated at approximately 11:00 P.M. on [DATE] as it was discovered at some point the resident was a full code; - A resident's code status is located on the crash cart and in the computer; - He/she talked with the ED after chest compressions had begun and the ED mentioned the resident was a full code; and - When questioned as to why this statement was different than his/her typed and signed statement, the LPN said all times were a rough estimate. During an interview on [DATE] at 11:42 A.M., Physician #1 said when a resident was unresponsive, not breathing and without a pulse he/she expected: - The nurse to assess the resident for breathing and a pulse; - Obtain confirmation of the person's code status; - Call for assistance; and - Begin CPR when the resident was a full code. MO 010