Every finding on record at Country Meadows

Based on interview and record review, the facility failed to follow physician's orders when residents missed doses of medication due to being unavailable for six residents (Resident #1, #2, #3, #4, #5, and #6) out of six sampled residents. The facility's census was 68.The facility did not provide a policy regarding following physician orders or regarding residents missing doses of medications.1. Review of Resident #1's medical record showed:- An admission date of 05/06/21;- Diagnoses of constipation, type 2 diabetes mellitus, vitamin deficiency, nausea, pneumonia, low back pain, pain in right and left hip, and muscle spasm of back;- An order for Linzess (constipation medication), 145 micrograms (mcg), one capsule orally 30 minutes prior to meal for constipation, dated 08/29/25;- An order for Senna Plus tablet (constipation medication) 8.6-50 milligrams (mg), two tablets orally twice a day for constipation, dated 08/14/25;- An order for cholecalciferol (Vitamin D3), 1250 mcg, one capsule once a day on the 13th of every third month for vitamin deficiency, dated 08/12/25;- An order for Carafate (gastrointestinal protectant), one gram orally twice a day for nausea, dated 07/06/25;- An order for Farxiga (medication that lowers blood sugar), 5 mg, one tablet orally once a day for type 2 diabetes mellitus, dated 07/28/25;- An order for guaifenesin (medication to relieve congestion), 400 mg, one tablet orally twice a day for pneumonia, dated 07/06/25;- An order for Movantik (constipation medication), 25 mg, one tablet once a day for constipation, dated 07/06/25;- An order for Tresiba insulin, 100 units per milliliter (ml), 15 units subcutaneously (under the skin) once a day for type 2 diabetes mellitus, dated 07/06/25;- An order for hydrocodone-acetaminophen (pain medication), 10-325 mg, one tablet orally four times a day for pain in right hip, dated 09/24/25;- An order for lactulose (constipation medication), 10 grams/15 ml, 30 ml orally once a day for constipation, dated 09/05/25.Review of the resident's Medication Administration Record (MAR), dated August 2025, showed:- Linzess not administered due to being unavailable on 08/29 and 08/30, for a total of two missed doses out of 31 opportunities;- Senna Plus not administered due to being unavailable on 08/23, for a total of one missed dose out of 35 opportunities;- Cholecalciferol not administered due to being unavailable on 08/13, for a total of one missed dose out of one opportunity.Review of the resident's MAR, dated September 2025, showed:- Carafate not administered due to being unavailable on 09/21/25 (two doses), 09/22/25 (two doses, and 09/23/25 (two doses), for a total of six missed doses out of 60 opportunities;- Farxiga not administered due to being unavailable on 09/19, 09/20, 09/21, 09/22, 09/23, 09/24, 09/25, 09/26, 09/27, 09/28, and 09/29, for a total of 11 missed doses out of 30 opportunities;- Guaifenesin not administered due to being unavailable on 09/19, 09/23 (two doses), 09/24 (two doses), 09/25 (two doses), 09/26 (two doses), 09/27 (two doses), 09/28, and 09/29, for a total of 13 missed doses out of 60 opportunities;- Movantik not administered due to being unavailable on 09/23, for a total of one missed dose out of 30 opportunities.Review of the resident's MAR, dated October 2025, showed:- Movantik not administered due to being unavailable on 10/08, for a total of one missed dose out of 30 opportunities;- Tresiba not administered due to being unavailable on 10/20, for a total of one missed dose out of 31 opportunities;- Hydrocodone-acetaminophen not administered due to being unavailable on 10/30 (two doses), for a total of two missed doses out of 124 opportunities.Review of the resident's MAR, dated November 1 through November 12, 2025, showed:- Linzess not administered due to being unavailable on 11/03, for a total of one missed dose out of 12 opportunities;- Lactulose not administered due to being unavailable on 11/01/, 11/02, and 11/03, for a total of three missed doses out of 12 opportunities;- Tresiba not administered due to being unavailable on 11/02 and 11/03, for a total of two missed doses out of 12 opportunities;- Hydrocodone-acetaminophen not administered due to being unavailable on 11/03, for a total of one missed dose out of 46 opportunities.During an interview on 11/12/25 at 11:54 A.M., Resident #1 said the Director of Nursing told both him/her and his/her daughter that they had to give some of his/her pain medication to a resident on the rehab hall. He/She missed probably two doses recently of his/her scheduled pain medication. He/She is out of muscle relaxer right now and hasn't gotten it today. His/Her back hurts bad right now, about 8/10 on the pain scale. He/She should be getting a pain pill anytime now. His/her stomach gets messed up when they run out of his/her medicine for his/her bowels. He/She has run out of medication quite a few times. Sometimes they'll have it in the e-kit (emergency kit) - a supply of essential medications and supplies used to treat acute symptoms quickly), but sometimes they don't, and they didn't this time. 2. Review of Resident #2's medical record showed:- An admission date of 04/14/22;- Diagnoses of acute pain due to trauma, type 2 diabetes mellitus, chronic pain syndrome, anxiety disorder, vitamin deficiency, age-related cataract, disorders of the left eye following cataract surgery, and insomnia.- An order for baclofen (muscle relaxant), 10 mg, one tablet orally twice a day for chronic pain syndrome, dated 03/11/25 and discontinued 08/18/25;- An order for Farxiga, 10 mg, one tablet orally once a daily for type 2 diabetes mellitus, dated 03/15/24;- An order for melatonin (hormone supplement used for sleep), three mg, three tablets orally at bedtime for insomnia, dated 06/20/24;- An order for buspirone (anxiety medication), 10 mg, two tablets orally three times a day for anxiety disorder, dated 01/31/25;- An order for cholecalciferol (Vitamin D3), 25 mcg, two capsules once a day for vitamin deficiency, dated 03/15/24;- An order for ketorolac drops (drops for itching or pain in the eye), 0.5%, one drop to the affected eye three times a day for age-related cataract, dated 09/16/25 and discontinued 09/20/25;- An order for Ocuflox drops (antibiotic eye drops), 0.3%, one drop to left eye three times a day for disorders of the left eye following cataract surgery, dated 11/04/25 and discontinued 11/06/25.Review of the resident's MAR, dated August 2025, showed:- Baclofen not administered due to being unavailable on 08/07 and 08/08, for a total of two missed doses out of 35 opportunities;- Farxiga not administered due to being unavailable on 08/24 and 08/25, for a total of two missed doses out of 31 opportunities;- Melatonin not administered due to being unavailable on 08/16 and 08/17, for a total of two missed doses out of 31 opportunities.Review of the resident's MAR, dated September 2025, showed:- Buspirone not administered due to being unavailable on 09/16, for a total of one missed dose out of 90 opportunities;- Cholecalciferol not administered due to being unavailable on 09/25, 09/26, 09/27, 09/28, and 09/29, a total of five missed doses out of 30 opportunities;- Ketorolac drops not administered due to being unavailable on 09/16, 09/17 (three doses), 09/18 (three doses), 09/19 (two doses), for a total of nine missed doses out of 12 opportunities.Review of the resident's MAR, dated October 2025, showed:- Farxiga not administered due to being unavailable on 10/27, for a total of one missed dose out of 31 opportunities;- Melatonin not administered due to being unavailable on 10/26, 10/27, 10/28, 10/29, 10/30, and 10/31, for a total of six missed doses out of 31 opportunities.Review of the resident's MAR, dated November 1 through November 12, 2025, showed:- Melatonin not administered due to being unavailable on 11/01, 11/02, and 11/03, for a total of three missed doses out of 11 opportunities;- Ocuflox drops not administered due to being unavailable on 11/04 (two doses), for a total of two missed doses out of eight opportunities.3. Review of Resident #3's medical record showed:- An admission date of 05/26/23;- Diagnoses of retention of urine, insomnia, and chronic obstructive pulmonary disease (COPD - a progressive lung disease that makes breathing difficult). - An order for finasteride (medication for enlarged prostate), five mg, one tablet at bedtime for retention of urine, dated 05/26/23;- An order for melatonin, three mg, one tablet at bedtime for insomnia, dated 05/06/23;Review of the resident's MAR, dated August 2025, showed:- Finasteride not administered due to being unavailable on 08/08, for a total of one missed dose out of 31 opportunities;- Melatonin not administered due to being unavailable on 08/17/25, for a total of one missed dose out of 31 opportunities.Review of the resident's MAR, dated October 2025, showed:- Melatonin not administered due to being unavailable on 10/26, 10/27, 10/28, 10/29, 10/30, and 10/31, for a total of six missed doses out of 31 opportunities.Review of the resident's MAR, dated November 1 through November 12, 2025, showed:- Melatonin not administered due to being unavailable on 11/01, 11/02, and 11/03, for a total of three missed doses out of 11 opportunities.4. Review of Resident #4's medical record showed:- An admission date of 02/15/24;- Diagnoses of stroke, severe major depressive disorder with psychotic features, and chronic pain;- An order for duloxetine (antidepressant), 60 mg, two capsules orally once a day for severe major depressive disorder with psychotic features, dated 03/23/25.Review of the resident's MAR, dated October 2025, showed:- Duloxetine not administered due to being unavailable on 10/24, 10/25, 10/26, and 10/27, for a total of four missed doses out of 31 opportunities.During an interview on 11/12/25 at 11:30 A.M., the resident said he/she can't remember what kind of medication issues he/she brought up in the September Resident Council meeting and can't remember if there have been any medication issues. He/She thinks he/she is getting all his/her medications.5. Review of Resident #5's medical record showed:- An admission date of 11/06/25;- Diagnoses of peripheral vascular disease, embolism and thrombosis of arteries of the extremities, and schizophrenia;- An order for cilostazol, 50 mg, one tablet orally twice a day for embolism and thrombosis of arteries of extremities, dated 11/06/25;- An order for trihexyphenidyl, five mg, one tablet twice a day for schizophrenia, dated 11/06/25.Review of the resident's MAR, dated November 2025, showed:- Cilostazol not administered due to being unavailable on 11/06 and 11/07 (two doses), for a total of three missed doses out of 12 opportunities;- Trihexyphenidyl not administered due to being unavailable on 11/06 and 11/07 (two doses), for a total of three missed doses out of 12 opportunities.6. Review of Resident #6's medical record showed:- An admission date of 12/26/22;- Diagnoses of vitamin deficiency, dementia, and low back pain;- An order for Vitamin D3, 25 mcg, one tablet once a day for vitamin deficiency, dated 11/01/22.Review of the resident's MAR, dated September 2025, showed:- Vitamin D3 not administered due to being unavailable on 09/30, for a total of one missed dose out of 30 opportunities.Review of the resident's MAR, dated October 2025, showed:- Vitamin D3 not administered due to being unavailable on 10/01 and 10/02, for a total of two missed doses out of 30 opportunities.During an interview on 11/12/25 at 12:45 P.M., the resident said he/she could not remember what medication questions he/she brought up at the September Resident Council meeting. He/She gets his/her medications when they have a notion to give them to him/her. During an interview on 11/12/25 at 11:53 A.M., Certified Medication Technician (CMT) A said there are no real issues with running out of medications. The only issues he/she could think of would be with pain medications and getting scripts signed by the doctor. They have everything else, and they have an e-kit.During an interview on 11/12/25 at 12:30 P.M., Registered Nurse (RN) B and RN C both said if medications aren't in the cart, they have a stat kit they can pull from, and then they would order it from pharmacy. Nurses and CMTs who give medications can hit the resupply button on their computer to reorder a medication. The pharmacy is linked to the electronic health record (EHR), so it goes to the pharmacy and gets reordered. They aren't aware of any issues of running out of medication. They don't ever use one resident's medication for another resident who is out of a medication, and they aren't aware of any CMTs doing it either. During an interview on 11/12/25 at 12:40 P.M., the Director of Nursing (DON) said she runs a report daily that tells her what meds are not available, and she will find out why the meds aren't there or didn't come from pharmacy. For narcotics, sometimes they're waiting on a script from a physician. Some physicians take longer than others to sign a script. We have a stat safe that she will do an inventory of, and the stat safe communicates with pharmacy. We recently had a resident that missed a couple doses. We don't borrow medications from another resident when one resident is out. Meds can be ordered from the MAR. Controlled medications have to be ordered from the pharmacy website, and all nurses have access to do that. If they order a medication and it's too soon, pharmacy will fax them to let them know it's too soon. Pharmacy comes daily around 8:00 to 8:30 in the evening every day except Sunday. CMTs and nurses get training about reordering medications. We just had an in service about this.During an interview on 11/12/25 at 2:34 P.M., the Administrator said five days before residents are out of medications, med techs or nurses can scan and reorder. If they don't have a med in the cart, they should check overflow first and the e-kit. If it's too soon to order, the pharmacy will send a note. There are no issues that she's aware of and she hasn't heard of any in a long time. If a resident is out of an over-the-counter medication, they can run to the local pharmacy and get that. There shouldn't be any reason a resident would run out of medications. She isn't sure where the breakdown is, but she will figure it out.During an interview on 11/12/25 at 4:12 P.M., the Consultant Pharmacist said no one has talked to him about an issue, and he would be included on any kind of communication regarding medication issues. The administrator usually runs a report or has done so in the past to show which meds are unavailable.Complaint #2659480

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for two residents (Resident #3 and #44) out of 16 sampled residents and one resident (Resident #65) outside the sample. The facility's census was 65.The facility did not provide a policy regarding MDS accuracy.Review of the Resident Assessment Instrument (RAI) Manual, dated October 2024, showed:- J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services;- O0110K1, Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions.1. Review of Resident #3's medical record showed:- admission date of 03/27/25;- Diagnoses of chronic pulmonary obstructive disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), abnormal weight loss, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).Review of the resident's Physician's Order Sheet (POS), dated July 2025, showed an order to consult with hospice, dated 03/27/25.Review of the resident's progress notes showed on 05/01/2025 at 3:41 P.M., resident admitted to hospice with a primary diagnosis of abnormal weight loss and a secondary diagnosis of COPD.Review of the resident's significant change MDS assessment, dated 05/08/25, showed Section J1400 not marked yes.2. Review of Resident #44's medical record showed:- admission date of 02/11/25;- Diagnoses of COPD, congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), pain, and dementia (a group of thinking and social symptoms that interferes with daily functioning).Review of the resident's POS, dated July 2025, showed an order to admit to hospice with a primary diagnosis of CHF, dated 06/16/25.Review of the resident's significant change MDS assessment, dated 06/23/25, showed Section O0110K1 not marked for hospice.3. Review of Resident #65's medical record showed:- admission date of 07/26/21;- Diagnoses of COPD, repeated falls, and difficulty walking.Review of the resident's POS, dated July 2025, showed an order to admit to hospice, dated 03/19/25.Review of the resident's significant change MDS assessment, dated 03/27/25, showed Section O0110K1 not marked for hospice.During an interview on 07/25/25 3:03 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON)/MDS Coordinator said they would expect the MDS assessments to reflect the current condition of the resident.

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (the process for removal of waste and excess fluid from the blood due to kidney failure) center, failed to ensure physician orders were in place, and failed to assess and monitor the dialysis site for one resident (Resident #18) out of one sampled resident receiving dialysis. This failure had the potential to result in unmet needs or complications related to dialysis care. The facility census was 65. Review of the facility's policy, Dialysis, Care of a Resident Receiving, dated March 2015, showed:- Care of the arteriovenous (AV - surgically created connection between an artery and a vein) shunt fistula/graft (AV fistula connects an artery and a vein directly, while an AV shunt uses a synthetic graft (tube) to connect the artery and vein): Keep the area clean and dry; Feel for the thrill (a sensation of vibration or buzzing felt when palpating, or touching) sensation daily; Inspect the access for redness, swelling, or warmth; Avoid constrictive clothing or jewelry that may bind the access site; No blood pressure taking or intravenous (IV - into a vein) administration should be done in the arm of the access site; Avoid excessive pressure on the puncture site after dialysis; Watch for bleeding after dialysis; Monitor for signs of infection;- Checking the Thrill Sensation: Nurses will check the thrill daily and document daily. This will be documented on the resident's treatment record; At the AV site feel for a pulse. The pulse is the blood flow through the access; If no thrill sensation is felt, notify the physician;- Signs of Infection: Notify the physician if any of the following occurs: erythema (abnormal redness of the skin), induration (a hardening or thickening of tissue), tenderness and/or purulent (containing pus) drainage noted at the access site; Fever of unknown origin occurs;- When to Call the Physician: Redness or inflammation around the access site; Swelling of the arm or leg that contains the access; Fever that cannot be connected to a cold or flu; Drainage or pus at the access site; Numbness around the access site; Hand or foot feels much cooler than normal; Pain in or around the access site; Pain after dialysis; Loss or weakening of the thrill sensation at the access site; The shunt sustains a blow; Bleeding noted after returning from dialysis;- Emergency Care: If the fingers or toes below the access site turn blue, look pale or feel cold; If the resident suddenly has trouble breathing or states they are having chest pain (could be a sign of a blood clot in the lung or an allergy to a medication);- Signs of Bacteremia with Sepsis (the presence of bacteria in the bloodstream that can lead to a severe, potentially life-threatening condition): If the below stated symptoms appear, the physician is to be notified immediately: Fever (sudden onset, often spiking); Chills; Toxic looking (looks acutely ill); Changes in mental status: Irritable; Lethargic; Anxious; Agitated; Unresponsive; Comatose;- Signs of Septic Shock: If the below stated symptoms appear the physician is to be notified immediately: Acute circulatory failure usually with or followed by: Hypotension (low blood pressure); Skin warm even in presence of hypotension; Decreased urine output; Alertness decreased; Confusion increased; Rapid respirations; Rapid heartbeat;- Communication between the Facility and Dialysis Unit: The Dialysis Communication Record will be sent with the resident on each dialysis visit. All care concerns in last 24 hours will be addressed, including last medications given and facility contact person. The dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, medication given, follow up information and any new physician orders. These records will be maintained in the medical record. Review of Resident #18's medical record showed:- admission Date of 09/07/24;- Diagnoses of end-stage renal disease (kidneys no longer function), acute ischemic heart disease (reduced blood flow to the heart), infectious gastroenteritis with colitis (intestinal infection causing stomach upset and inflammation), type 1 diabetes mellitus (body does not make insulin), chronic kidney disease (long-term kidney damage), bipolar disorder (mood disorder with highs and lows), and anxiety disorder (persistent worry or fear).Review of Resident #18's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 03/12/25, showed dialysis marked on Section O0110B1.Review of Resident #18's care plan, dated 06/09/25, showed:- Risks included shortness of breath, chest pain, edema, elevated blood pressure, infection at the access site, itchy skin, nausea, vomiting related to dialysis, and bleeding due to heparin use;- Arrange for dialysis as ordered. Diet, medications, and fluid restriction if ordered. Encourage daily out-of-bed activity and social engagement. Monitor access area for redness or pain and report to the physician. No lab draws, needle sticks, or blood pressure to be performed in the affected extremity. Notify the physician if edema, chest pain, shortness of breath, elevated blood pressure, bleeding, or itching occurs;- The care plan did not include the following requirements as outlined in the facility's dialysis policy: Daily palpation of the AV access site to assess for thrill. Documentation of the thrill assessment on the resident's treatment record. Assessment for bruit (sound of blood flow through the access). Specific criteria for signs and symptoms of infection at the access site (such as induration, tenderness, drainage, or loss of thrill). Emergency response instructions if the site bleeds, the resident experiences pain, or the extremity becomes pale or cold. Instructions for staff to notify the physician immediately if no thrill is present or signs of sepsis are observed. Communication protocols with the dialysis center, including completion of a dialysis communication form with care concerns, last medications given, and contact information, and follow-up with new orders returned from dialysis.During an interview on 07/25/25 at 9:25 A.M., the Director of Nursing (DON) said Resident #18 went to dialysis on Monday, Wednesday, and Friday. The resident would have breakfast at the facility, and the facility would send a sack lunch and snacks with him/her. The DON said staff would sometimes palpate the resident's fistula, but was unsure if this occurred every shift or only on dialysis days. The DON also said a communication form was sent with the resident to the dialysis center to be completed and returned, and that the dialysis center would record the resident's pre- and post-treatment weights on the form. The DON said that at times the weights were not recorded by the center's staff, so facility staff would have to call the dialysis center to obtain the information. The DON said the resident requested to only be weighed weekly by the facility staff since he/she was getting weighed at the treatment center. When asked to verify orders, the DON accessed the electronic medical record and said there were no current dialysis orders. The DON said it was possible the orders had been discontinued during a prior hospitalization and not re-entered upon return.Review of the communication forms used for dialysis showed limited documentation, with only the date and pre and post treatment weights recorded. No other clinical information, nursing assessments, or instructions were documented.Review of the electronic medical record on 07/25/25 showed no active or discontinued orders related to dialysis, AV fistula care, or monitoring requirements.During an interview on 07/25/25 at 12:23 P.M., Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B said the resident took his/her medications each morning before dialysis and was sent with a communication form and a sack lunch. RN A said if there were concerns, staff might write them on the form, but often the forms were sent blank. RN A confirmed staff would visually check the resident's arm upon return to the facility, but did not perform vital signs or a physical assessment. LPN B said that as of 07/25/25, orders had just been received to assess the AV fistula site daily for thrill/bruit and to check for signs of infection. LPN B said that prior to this, there were no instructions or documentation requirements for monitoring the dialysis site.During an interview on 07/25/25 at 3:03 P.M., the Administrator, DON, and Assistant DON said there should be physician orders in place for residents receiving dialysis, including dietary restrictions, fluid management, and fistula monitoring. The Administrator said he/she was unsure of the exact orders required, but expected clinical leadership to know. The ADON and DON acknowledged the forms from the dialysis center often lack documentation and vital signs and site assessments were not routinely performed before or after dialysis. They collectively said the resident's care plan should accurately reflect his/her current status.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Resident #40 and #51) out of 15 sampled residents. The facility census was 60. Review of the facility's policy, Resident Assessment Instrument (RAI) General Guidelines, undated, showed: - Completion of the RAI process: Accurate and timely completion of MDS and Care Area Assessments (CAA) areas as assigned; - Accurate completion requires resident interviews, staff interviews, resident assessment, review of the clinical record including physician notes, and observation of the resident in the nursing home environment. Review of the RAI Manual, revised October 2023, showed: - A1805: Enter the two-digit code that best describes the setting the resident was in immediately preceding this admission/entry or reentry. 1. Review of Resident #40's medical record showed: - An admitted [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), presence of cardiac defibrillator (a device that gives an electric charge to restore a normal heartbeat), and history of myocardial infarction (when blood flow to the heart muscle is blocked); - An order for Eliquis (blood thinner medication that reduces blood clotting) five milligrams(mg) twice a day, dated 03/12/24. Review of the resident's quarterly MDS, dated [DATE], showed anticoagulant not marked on section N of the assessment. 2. Review of Resident #51's medical record showed: - An admitted [DATE]; - The latest admission on 04/26/24 from the hospital; - Diagnoses of cerebral infarction (stroke), type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), and muscle weakness. Review of the resident's MDS assessments showed: - An entry tracking record, dated 04/26/24; - A significant change MDS assessment, dated 05/03/24; - Resident entered from home/community recorded on entry tracking record and significant change MDS; - The facility failed to complete the MDS entry tracking record and significant change MDS with correct entry location (A1805). During an interview on 05/23/24 at 11:01 A.M., the MDS Coordinator said she would expect the MDS assessments to accurately reflect the current condition of the resident. Medications should be reflected correctly. She follows the RAI Manual for MDS assessment accuracy. During an interview on 05/23/24 at 12:15 P.M., the Administrator and Director of Nursing (DON) said they would expect the MDS assessments to be completed accurately per the RAI Manual. 47678

Based on interview and record review, the facility failed to follow physician's orders for four residents (Resident #3, #21, #34, and #36) out of 15 sampled residents and one resident (Resident #174) outside the sample. The facility's census was 60. The facility did not provide a policy regarding following physician orders. 1. Review of Resident #3's medical record showed: - An admitted [DATE]; - Diagnoses of dysphagia (difficulty swallowing foods or liquids), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations); - An order for biotin (B vitamin) 10 milligrams (mg), one tablet daily, dated 01/25/24; - An order for Namzaric (dementia medication) 28-10 mg, one capsule daily at bedtime, dated 01/25/24; - An order for pantoprazole (reflux medication) 40 mg, one packet daily, dated 02/08/24; - An order for Vitamin D3, 125 micrograms (mcg), one daily, dated 01/25/24. Review of the resident's Medication Administration Record (MAR), dated April 2024, showed: - Biotin not administered due to being unavailable on 04/14, 04/17, 04/18, 04/19, 04/20, 04/24, 04/25, 04/26, 04/28, 04/29, and 04/30, for a total of 11 missed doses out of 30 opportunities; - Namzaric not administered due to being unavailable on 04/03, for a total of one missed dose of 30 opportunities; - Pantoprazole not administered due to being unavailable on 04/02, 04/17, 04/23, 04/24, 04/28, and 04/29, for a total of six missed doses out of 30 opportunities. Review of the resident's MAR, dated 05/01/24 - 05/23/24, showed: - Biotin not administered due to being unavailable on 05/01 through 05/23, for a total of 23 missed doses out of 23 opportunities; - Pantoprazole not administered due to being unavailable on 05/11, for a total of one missed dose out of 23 opportunities; - Vitamin D3 not administered due to being unavailable on 05/12, 05/13, 05/14, 05/15, 05/16, 05/21, 05/22, and 05/23, for a total of eight missed doses out of 23 opportunities. 2. Review of Resident #21's medical record showed: - An admitted [DATE]; - Diagnoses of type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar), muscle weakness, and dementia; - An order for Lexapro (antidepressant) 20 mg, one tablet daily, dated 09/15/23; - An order for Xarelto (medication used to prevent blood clots) 10 mg, two tablets daily, dated 05/19/22; - An order for Dyazide (water pill) 37.5-25 mg, one capsule daily, dated 07/19/18; - An order for Vitamin D3, 25 mcg, one capsule daily, dated 05/07/20. Review of the resident's MAR, dated April 2024, showed: - Lexapro not administered due to being unavailable on 04/21, for a total of one missed dose out of 30 opportunities; - Xarelto not administered due to being unavailable on 04/06, for a total of one missed dose out of 30 opportunities. Review of the resident's MAR, dated 05/01/24 - 05/23/24, showed: - Dyazide not administered due to being unavailable on 05/21, 05/22, and 05/23, for a total of three missed doses out of 23 opportunities; - Vitamin D3 not administered due to being unavailable on 05/11, 05/12, 05/13, 05/14, 05/15, and 05/16, for a total of six missed doses out of 23 opportunities. 3. Review of Resident #34's medical record showed: - An admitted [DATE]; - Diagnoses of chronic kidney disease (a gradual loss of kidney function over time), major depressive disorder, and hypertension (high blood pressure); - An order for atenolol (blood pressure medication), 25 mg, 1/2 tablet twice daily, dated 04/18/24; - An order for brimonidine 0.2 % (eye drop for glaucoma - an eye disease that can cause vision loss and blindness ), one drop in both eyes twice daily, dated 04/22/24; - An order for Creon (pancreatic enzymes) 6,000-19,000-30,000 international units (IU), one capsule three times daily, dated 04/18/24; - An order for Eliquis (medication to help prevent blood clots) 2.5 mg, one tablet twice daily, dated 04/18/24; - An order for Flomax (medication for an enlarged prostate) 0.4 mg, daily at bedtime, dated 04/18/24; - An order for hydroxyzine (medication used for itching or anxiety) 25 mg, one tablet twice daily, dated 04/22/24; - An order for pravastatin (cholesterol medication) 80 mg, one tablet daily at bedtime, dated 04/18/24; - An order for Remeron (antidepressant) 30 mg, one tablet daily at bedtime, dated 04/18/24; - An order for Azo Bladder Control, 300 mg, one capsule three times daily, dated 05/04/24 and discontinued 05/17/24; - An order for Miralax (laxative) 17 grams, twice daily, dated 04/18/24; - An order for spironolactone (water pill), 25 mg, one tablet daily, dated 04/22/24. Review of the resident's MAR, dated April 2024, showed: - Atenolol not administered due to being unavailable on 04/22, for a total of one missed dose out of 17 opportunities; - Brimonidine not administered due to being unavailable on 04/22, for a total of one missed dose out of 17 opportunities; - Creon not administered due to being unavailable on 04/22 and 04/23, for a total of two missed doses out of 25 opportunities; - Eliquis not administered due to being unavailable on 04/22, for a total of one missed dose out of 17 opportunities; - Flomax not administered due to being unavailable on 04/22, for a total of one missed dose out of nine opportunities; - Hydroxyzine not administered due to being unavailable on 04/22, for a total of one missed dose out of 17 opportunities; - Pravastatin not administered due to being unavailable on 04/22, for a total of one missed dose out of nine opportunities; - Remeron not administered due to being unavailable on 04/22, for a total of one missed dose out of nine opportunities. Review of the resident's MAR, dated 05/01/24 - 05/23/24, showed: - Azo Bladder Control not administered due to being unavailable on 05/04, 05/05, 05/06, 05/07, and 05/08, for a total of 13 missed doses out of 42 opportunities; - Creon not administered due to being unavailable on 05/06 and 05/17, for a total of four missed doses out of 67 opportunities; - Miralax not administered due to being unavailable on 05/18, 05/19, 05/20, 05/21, and 05/22, for a total of eight missed doses out of 45 opportunities; - Spironolactone not administered due to being unavailable on 05/21, 05/22, and 05/23, for a total of three missed doses out of 23 opportunities. 4. Review of Resident #36's medical record showed: - An admitted [DATE]; - Diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dysphagia, and pain; - An order for Paxil (antidepressant) 30 mg, one tablet daily, dated 04/04/24; - An order for Protonix (reflux medication) granules, 40 mg, one packet daily, dated 09/06/23 and discontinued 04/04/24; - An order for Protonix (reflux medication) granules, 40 mg, one packet daily, dated 04/04/24; - An order for Tramadol (pain medication) 50 mg, one tablet every six hours, dated 04/08/24. Review of the resident's MAR, dated April 2024, showed: - Paxil not administered due to being unavailable on 04/19 and 04/20, for a total of two missed doses out of 26 opportunities; - Protonix not administered due to being unavailable on 04/01, 04/05, 04/06, 04/07, 04/09, 04/10, 04/11, 04/12, 04/13, 04/14, 04/15, 04/16, 04/18, 04/19, and 04/20, for a total of 15 missed doses out of 21 opportunities; - Tramadol not administered due to being unavailable on 04/08, 04/09, 04/10, and 04/12, for a total of seven missed doses out of 88 opportunities. 5. Review of Resident #174's medical record showed: - An admitted [DATE]; - Diagnoses of chronic kidney disease, type II diabetes mellitus, and weakness; - An order for erythromycin (antibiotic) ointment 0.5%, administer one drop to left eye, daily at bedtime, dated 01/08/24 and discontinued 01/09/24; - An order for erythromycin ointment 0.5%, administer one drop to left eye, daily at bedtime, dated 01/23/24 and discontinued 01/24/24; - A order for Flonase Allergy Relief spray, 50 mcg/actuation, one spray nasally daily at bedtime, dated 01/05/24 and discontinued 01/23/24; - A order for Flonase Allergy Relief spray, 50 mcg/actuation, two sprays nasally daily at bedtime, dated 01/23/24; - An order for levothyroxine (thyroid hormone) 125 mcg, one tablet daily at bedtime, dated 01/05/24 and discontinued 01/23/24; - An order for levothyroxine, 125 mcg, one tablet daily at bedtime, dated 01/23/24; - An order for moxifloxacin (antibiotic) drops 0.5%, one drop to left eye every two hours, dated 01/23/24 and discontinued 01/24/24; - An order for nortriptyline (antidepressant) 50 mg, one tablet three times daily, dated 01/05/24 and discontinued 01/23/24; - An order for pregabalin (nerve pain medication) 50 mg, one capsule three times daily, dated 01/05/24 and discontinued 01/23/24; - An order for pyridoxine (Vitamin B6) 100 mg, one tablet daily, dated 01/23/24; - An order for simvastatin (cholesterol medication) 20 mg, one tablet daily at bedtime, dated 01/05/24 and discontinued 01/24/24; - An order for Systane (lubricant) drops 0.4-0.3%, two drops per eye twice daily, dated 01/10/24 and discontinued 01/23/24; - An order for Systane drops 0.4-0.3%, two drops per eye twice daily, dated 01/23/24; - An order for vancomycin (antibiotic), 125 mg, one capsule every six hours, dated 01/05/24 and discontinued 01/07/24; - An order for Temovate (a cream to treat skin conditions) 0.05%, apply to affected area twice daily, dated 01/23/24. Review of the resident's MAR, dated January 2024, showed: - Erythromycin not administered due to being unavailable on 01/08 and 01/23/24, for a total of two missed doses out of two opportunities; - Flonase not administered due to being unavailable on 01/05, 01/07, 01/10, and 01/23, for a total of four missed doses out of 14 opportunities (resident hospitalized ,d+[DATE] to 01/23); - Levothyroxine not administered due to being unavailable on 01/05, 01/09, and 01/23, for a total of three missed doses out of 14 opportunities (resident hospitalized ,d+[DATE] to 01/23); - Moxifloxacin not administered due to being unavailable on 01/23 and 01/24, for a total of five missed doses out of eight opportunities; - Nortriptyline not administered due to being unavailable on 01/05 and 01/06, for a total of two missed doses out of 30 opportunities (resident hospitalized ,d+[DATE] to 01/23); - Pregabalin not administered due to being unavailable on 01/05 and 01/06, for a total of three missed doses out of 30 opportunities (resident hospitalized ,d+[DATE] to 01/23); - Pyridoxine not administered due to being unavailable on 01/24, for a total of one missed dose out of one opportunity; - Simvastatin not administered due to being unavailable on 01/05, for a total of one missed dose out of 11 opportunities; - Systane not administered due to being unavailable on 01/10, 01/11, 01/12, 01/13, 01/14, 01/15, 01/23, and 01/24, for a total of 12 missed doses out of 12 opportunities (resident hospitalized ,d+[DATE] to 01/23); - Vancomycin not administered due to being unavailable on 01/05, not administered due to being too close together on 01/06, and not administered due to resident being asleep on 01/07, for a total of three missed doses out of eight opportunities; - Temovate not administered due to being unavailable on 01/23 and 01/24, for a total of two missed doses out of three opportunities. During an interview on 05/22/24 at 11:00 A.M., Certified Medication Technician (CMT) F said that Licensed Practical Nurse (LPN) D checks medication carts and stock rooms for expired medications often, and pharmacy was just here to check our carts. During an interview on 05/22/24 at 11:30 A.M., Registered Nurse (RN) E said when medications are not available, they send a fax to pharmacy, and if it's something that's needed right away, he/she will call the pharmacy. They can also use meds out of the emergency kit (E-kit). The pharmacy typically gets medications to the facility the same day as ordered; they do an 8:00 P.M. run. During an interview on 05/22/24 at 11:35 P.M., the Administrator said if a medication is a stock medication and they don't have it, they can run to a local pharmacy to get the medication. The electronic medical record system will be linked with the pharmacy starting in June or July. During an interview on 05/23/24 at 12:15 P.M., the Director of Nursing (DON) said CMTs and nurses will notify the charge nurse if they are getting low or are out of a medication. The charge nurse will then notify the pharmacy, and they can get those medications on the same day. If it's an over-the-counter medication, they can use stock medication or staff will drive to one of the local pharmacies and purchase it. There is no reason for a resident to go several days without receiving their medication unless it's a specialty medication or prior authorization is needed. During an interview on 05/29/24 at 2:44 P.M., the Administrator said staff have been told that they can access most medications out of the Stat Safe but if medication is not in there, there is always a pharmacist on call. There should not be any reason that a resident would not receive their medication. Cmp #MO00236261

Based on observation and interview, the facility failed to maintain proper infection control practices during perineal care (washing the genital and rectal areas of the body) for two residents (Resident #14 and Resident #46) outside of the 15 sampled residents. The facility's census was 60. Review of the facility's policy, Gloves, dated March 2015, showed: - Wear gloves when anticipating that hands will be in contact with mucous membranes, non-intact skin, and body substances such as blood, urine, feces, drainage, oral secretions, vomit, or items soiled with these substances; - Gloves must be changed between residents and between contact with different body sites of same resident; - Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to skin; - Handling medical equipment and devices with contaminated gloves is not acceptable. Review of the facility's policy, Perineal Care, dated March 2015, showed to remove gloves and wash hands after providing care. Review of the facility's policy, Handwashing, dated March 2015, showed handwashing is to be done to reduce transmission of organisms. 1. Observation of perineal care for Resident #14 on 05/23/24 at 9:16 A.M., showed: - Certified Nursing Assistant (CNA) A washed hands and donned gloves; - CNA A obtained a washcloth, sprayed perineal cleanser onto cloth, placed spray bottle onto bedside table without a barrier, and provided perineal care for the resident; - Wearing the same soiled gloves, CNA A picked up cleanser from bedside table, sprayed onto a different part of the washcloth, and returned cleanser to bedside table without barrier; - Wearing the same soiled gloves, CNA A picked up cleanser again, sprayed onto back of the washcloth, and placed back onto bedside table without barrier; - Wearing the same soiled gloves, CNA A placed a clean brief on the resident, removed gloves, and did not wash hands; - With soiled hands, CNA A obtained pants from the closet and placed on the resident; - With soiled hands, CNA A placed oxygen via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) under the resident's nose, placed call light in reach, and pulled the blanket over the resident; - With soiled hands, CNA A gave the resident a drink and placed water container onto the bedside table beside the soiled perineal cleanser spray bottle; - With soiled hands, CNA A placed dirty clothes into a bag and left the room without washing hands. During an interview on 5/23/24 at 9:40 A.M., CNA A said he/she should have washed hands between dirty and clean, after removing gloves, before touching clean blankets and call light, and before leaving the room. 2. Observation of perineal/catheter care for Resident #46 on 05/22/24 at 1:35 P.M. showed: - CNA B washed his/her hands and donned gloves; - CNA B provided perineal care and catheter care; - Wearing the same soiled gloves, CNA B placed a clean bed pad under the resident and pulled blankets over the resident; - CNA B removed gloves and washed hands. During an interview on 5/23/24 at 12:50 P.M., CNA B said he/she should have washed his/her hands when going from dirty to clean and before touching the resident's clean blanket. During an interview on 5/23/24 at 12:15 P.M., the Director of Nursing (DON) said staff should absolutely wash their hands between dirty and clean as well as prior to leaving a room, and supplies should not be placed directly onto a bedside table. During an interview on 5/23/24 at 12:26 P.M., the Administrator said staff should wash hands and change gloves between dirty and clean, and a barrier should be placed when using a bedside table for supplies. 49754

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents. The facility's census was 63. Record review of the facility's Receiving and Storage of Food policy, dated April 2006, showed: -The dietary manager is responsible for receiving and storing food and nonfood items; - A table of safe temperatures for refrigerators and freezers (frozen food should be kept at -10 to 0 degrees Fahrenheit); -The policy did not address freezer cleaning/maintenance. Record review of the dietician's monthly kitchen recommendations showed: -On 8/22/22, door to freezer continues to not fully close due to significant ice build up; -On 9/15/22, door to freezer continues to not fully close due to significant ice build up; -On 11/07/22, freezer door continues to not shut, build up of ice on edge of door; -On 12/12/22, freezer door continues to not shut, build up of ice on edge of door. Observations of the kitchen on 12/13/22 at 2:00 P.M., on 12/14/22 at 1:30 P.M., on 12/15/22 at 9:50 A.M., and on 12/16/22 at 9:00 A.M. showed: - A build-up of ice, one inch thick on the top right door seal of the walk in freezer, as well as the right side door seal; - The walk in freezer door did not close completely at the top right corner and top right side of the door. During an interview on 12/15/22 at 10:00 A.M. , the Dietary Manager (DM) said the freezer door has been an issue and the door may have to be replaced. The DM said the Administrator and Maintenance Manager are aware of the issue and he/she believes there is a plan in place. The freezer door appears to have settled and the new closure latch and new seals have not helped. During an interview on 12/15/22 at 2:00 P.M., the Maintenance Manager said the freezer is old and the door has had a new closure latch and seal kit replaced on 7/25/22 due to the door not shutting and ice build up. The Maintenance Manager said he/she would have to schedule the refrigerator/freezer maintenance company to come back and assess the door again and see if a new door is required or if a hinge kit should be tried first. During an interview on 12/15/22 at 1:00 P.M., the Administrator said she was not aware there was still an issue with the freezer door not closing and having ice build up. She said she will have the refrigerator/freezer maintenance company come out to assess the freezer again and see if it is going to require a replacement door, which will be costly.

Based on observation, interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS), a federal mandated assessment to be completed by the facility for two residents (Resident #22 and #45) out of 16 sampled residents. The facility's census was 63. The facility did not provide an MDS policy. 1. Record review of Resident #22's medical record showed: - An admitted [DATE]; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and shortness of breath; - An order for oxygen two to four liters per minute per nasal cannula continuous during hours of sleep, dated 11/29/22; - An order for oxygen two to four liters per minute per nasal cannula as needed for shortness of breath, dated 12/19/2019; - A Treatment Administration History report, including dates of 11/28/22 through 12/15/22, showing staff initialed completion of the order for oxygen two to four liters per minute per nasal cannula continuous at bedtime. Record review of the resident's comprehensive annual MDS assessment, dated 12/16/22, showed: - Oxygen use was not marked on Section O of the assessment. During an interview on 12/13/22 at 2:36 P.M., Resident #22 said she wears oxygen every night for shortness of breath. 2. Record review of Resident #45's Physician Order Sheet (POS) showed: - On 10/10/2021, an order for Cefdinir (an antibiotic) 300 milligrams, one capsule by mouth, twice daily for seven days for pneumonia (an infection that inflames the air sacs of the lungs, which may fill with fluid); - On 10/10/21, an order for ipratropium-albuteral (a breathing treatment used to treat air flow blockage) four times daily for diagnosis of pneumonia; - On 5/31/2022, an order for a chest X-ray to rule out aspiration pneumonia (an infection in the lungs caused by inhaling saliva, food or liquid). Results of chest X-ray on 5/31/22 showed no pneumonia. Record review of the Resident's Comprehensive MDS, dated [DATE], showed pneumonia not marked on section I for Active Diagnosis Infections. Record review of the Resident's Quarterly MDS, dated [DATE], showed pneumonia marked on section I for Active Diagnosis. During an interview on 12/16/22 at 09:52 A.M., the Assistant Director of Nursing (ADON) and MDS Coordinator said she normally would look through the chart to see if a resident had a certain diagnosis. Pneumonia could have been missed as far as unchecking it for Resident #45. Normally, she would look at the orders to see if the resident had a prescribed antibiotic and/or chest x-ray. During an interview on 12/16/22 at 10:00 A.M., the Director of Nursing (DON) said if a resident is on oxygen, it would be documented on the Treatment Administration Record (TAR) that the order was completed. During an interview on 12/16/22 at 11:39 A.M., the ADON/MDS Coordinator said she looks at the monthly summary, observations, events, and nurses notes in the resident's medical record to complete an MDS assessment. She will also look at the TAR for oxygen use. Active diagnoses come from the face sheet, and they don't change for most people, except for diagnoses like pneumonia and urinary tract infections. During an interview on 12/16/22 at 11:56 A.M., the DON said Resident #45 had not had any respiratory infections this year. During an interview on 12/16/22 at 12:35 P.M., the Administrator said the facility does not have an MDS policy. The MDS Coordinator should follow the RAI Manual. 46460

Based on record review and interview, the facility failed to include the infection preventionist in quarterly quality assessment and assurance (QAA) meetings. The facility's census was 63. 1. Record review of the first quarter QAA Committee sign in sheet, dated 4/13/22, and the second Quarter QAA Committee sign in sheet, dated 7/27/22 showed the following members attended: - Administrator; - Medical Director; - Director of Nurses (DON); - Assistant Director of Nurses (ADON); - Social Services Director (SSD). Record review of the third quarter QAA Committee sign in sheet, dated 10/12/22, showed the following members attended: - Administrator; - Medical Director; - Director of Nursing; - Assistant Director of Nursing. During an interview on 12/16/22 at 11:09 A.M., the Administrator said QAA meets every three months and the DON, ADON, Administrator, and Medical Director attend the meetings. The Infection Preventionist does not attend QAA meetings, and the Administrator was not aware that he/she was supposed to be there. During an interview on 12/16/22 at 11:24 A.M., the DON said QAA meetings are held quarterly, and the Medical Director, DON, Administrator, ADON, and SSD attend the meetings. The Infection Preventionist attends only if they are going to be talking about infection control. The dietician does not attend meetings and they do not keep minutes. The facility did not provide a policy.

Based on interviews and record review, the facility failed to ensure a comfortable homelike environment by not providing reasonable care for the protection of resident's property from loss or theft for four residents (Resident #36, #46, #48, and #55) out of 17 sampled residents and five residents (Resident #3, #12, #43, #59, and #61) outside the sample. This practice has the potential to affect all residents. The facility's census was 67. Record review of the facility's policy titled, Grievance Protocol, dated [DATE], showed: - Any member of the Social Services staff can complete the Grievance Complaint Report; - The appropriate situations for use of the Grievance Complaint Report are: - Resident articles that are lost or cannot be located; continual concern of lost resident items. This would include laundry concerns; - Resident care or personal hygiene issues that cannot be immediately resolved; - Resident or family concerns with dietary issues: diet or temperature of the meals; - Any resident or family concern with a staff member; - Any resident or family issue that would require a resolution. Record review of the facility's policy titled, Resident Rights, dated [DATE], showed: - The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; - A facility must protect and promote the rights of each resident; - Rights include: voice grievance, manage own finances, confidentiality, privacy and respect, keep your possessions, and purchase goods and services. Record review of the Resident Council Minutes, dated ,[DATE], showed during supper time, things are missing and cameras are needed. Record review of the Resident Council Minutes, dated [DATE], showed: - Check room while resident is there; - Things missing from room, two watches one was a $200 watch and necklace, and later earrings, frogs, and nail polish; - Did room search, watch on top of dresser. During an interview on [DATE] at 12:18 P.M., Resident #46 said they have had problems with things missing. He/she received a coffee cup for Christmas and it is missing. He/she reported it to the Administrator, but nothing was done. He/she said many other people have things missing too. During an interview on [DATE] at 12:45 P.M., Resident #12 said things have been missing for about the last six months. The resident had about 200 CDs stolen. The resident reported it and the Administrative staff said they'd look in the storage room. During an interview on [DATE] at 4:18 P.M., Resident #48 said he/she has things missing from his/her room sometimes. The resident wants a lock on his/her door but they will not let the resident have one. He/she is missing two unicorn statues that were on a shelf in the room. During interviews at the Resident Council meeting on [DATE] at 10:28 A.M., the resident's said the following: - Residents #3, #36, #43, #59 and #61 were in attendance and each said, there has been an increase in theft lately: - Resident #59 said $[AGE] had been stolen from a bag under his/her bed cover. The resident reported the missing cash and the staff told the resident that he/she wasn't supposed to have cash and nothing else was done; - Resident #61 said $40 had been stolen from his/her recliner bag during mealtime. The resident reported it to a Certified Nurse Assistant (CNA). The resident didn't know if the report was given to anyone else. The residents have asked for cameras to be installed and have been told the facility is working on it; - Resident #43 said a large amount of their cash had been stolen from his/her locked file cabinet. The resident was going to use the money for Christmas shopping. The resident reported it and was told the residents were not supposed to have cash; - Resident #3 said other things come up missing like body lotion, body wash and trinkets. Sometimes when residents report things missing the staff are not nice about it. Record review of the facility's Concern/Grievance Reports showed: - On [DATE] for Resident #59, unknown facts, no action taken, grievance/complaint resolved, resident stated he/she didn't have anything stolen, his/her son or daughter boyfriend is on drugs. His/her daughter recently died of overdose; - On [DATE] for Resident #61, resident is alert and oriented times four, resident stated he/she had received a Christmas card with $40 from friend, not able to be resolved at this time, no money was found or determined to be present in room; - On [DATE] for Resident #55, resident stated his/her daughter-in-law gave her $25 and it was placed in his/her wallet, when he/she went to get it to purchase a snack it was gone. Did speak with daughter-in-law and confirmed she did give resident $25 on [DATE]. Not able to be resolved at this time. Reviewed cameras, found no suspicious activities. Did go through the resident's purse with him/her per nurse. Encouraged to allow money to be in front office and independently let administration be aware; -There were no additional investigations regarding missing items. During an interview on [DATE] at 12:22 P.M., the Administrator said she would expect the residents to be able to keep small amounts of cash and other personal items in their room without fear of loss or theft. The facility does room searches, looks at the monitors and talks to staff.

Based on interview and record review, the facility failed to ensure the accuracy of assessments for one resident (Resident #27) out of 17 sampled residents. The facility's census was 67. Record review of nurse progress notes, dated 11/19/19 at 12:44 P.M. showed Resident #27 was in shower with assist when he/she slid to bilateral buttocks onto floor. No injuries noted. Notified physician and family. Monitoring for [AGE] hours. Record review of the resident's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility), dated 11/23/19, showed Section J1[AGE]0 (any falls since admission or prior assessment, whichever is more recent) documented as no falls since prior assessment, significant change MDS, dated [DATE]. Record review of Resident #27's February 2020 physician's orders [REDACTED].M., to admit to hospice (care for terminally ill usually prognosis of less than six months) for abnormal weight loss. Record review of the resident's significant change MDS, dated [DATE], showed Section J1400 (prognosis) documented as no for prognosis of less than six months. During an interview on [DATE] at 12:22 P.M., the Administrator and Director of Nursing said they would expect section J1[AGE]0 of the MDS to reflect any falls since the prior assessment and section J1400 to reflect a prognosis of six months or less for a resident on hospice. The facility did not provide a policy for accuracy of assessments. They refer to the Resident Assessment Instrument (RAI) manual.

Based on interview and record review, the facility failed to revise and update comprehensive care plans with specific interventions to meet the individual needs of two residents (Resident #5 and Resident #30) out of 17 sampled residents. The facility's census was 67. 1. Record review of Resident #5's wound assessment report, dated 1/7/20, showed: - Sacral wound assessment, stage four (a pressure ulcer/injury or wound which extends deep, exposing underlying muscle, tendon, cartilage, or bone), pressure injury outcome resolved; - Additional orders for discharge from wound care services. Record review of Registered Dietitian (RD) notes dated, 1/7/20 at 3:00 P.M., showed wound now healed. Record review of Resident #5's care plan, last reviewed on 1/29/20, showed no update documented as the pressure ulcer/wound as healed. During an interview on 2/5/20 at 10:10 A.M., Resident #5 said the wound was much better now and added it may be healed. 2. Record review of Resident #30's medical record showed: - [DIAGNOSES REDACTED]. - Moderate cognitive impairment; - Weight on [DATE] recorded as 218.6 pounds (lbs); - Weight on 12/3/19 recorded as 199.3, loss of 19.3 lbs, 8.8 percent (%) loss in one month; - Quarterly MDS dated [DATE] documented as the resident had a weight loss; - A physician's orders [REDACTED]. - A physician's orders [REDACTED]. - Weight on 2/3/20 recorded as 200.3 lbs, 8.3% loss in three months. Record review of the resident's care plan, last up-dated 9/10/19 for nutritional status showed: - Diet: Regular RCS with a line drawn through RCS to indicate the RCS as discontinue without a specific date documented as discontinued; - No documentation of a significant weight loss and no new interventions for significant weight loss. During an interview on [DATE] at 12:22 P.M., the Administrator and Director of Nursing said they would expect the care plan to be updated with new interventions for a resident with a significant weight loss. Record review of the facility's policy titled, Care Planning - Interdisciplinary Team, dated March 2015, showed: - The facility care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident; - A comprehensive care plan for each resident is to be developed within seven days of completion of the resident assessment (Minimum Data Set; MDS: a federally mandated assessment instrument completed by the facility).

Based on observation, interview, and record review, the facility failed to maintain the palatability and attractiveness of food for two residents (Resident #5 and #46) out of 17 sampled residents and nine residents (Resident #3, #6, #43, #47, #51, #59, #61, #62, and #166) outside the sample. The facility's census was 67. Record review of the facility's menu for the lunch meal on 2/4/20 showed: - Baked ham; - Baked sweet potatoes; - Black-eyed peas; - Cornbread; - Chocolate cake with icing. During an interview on 2/4/20 at 12:18 P.M., Resident #46 said, The food could be better! Observation of the main dining room on 2/4/20 at 12:35 P.M. showed: - Residents served a small, two inch by three inch, 1/4 inch thick, dark brown slice of ham, sweet potatoes, black-eyed peas, and cornbread; - Residents who asked for a chef salad, received it on a disposable plate; - Residents served a choice of dessert of gelatin, pudding, canned fruit, or chocolate dessert served in disposable bowls, no chocolate cake available; - Resident #3, #62, and #47 said salads and desserts are always served on disposable plates. Observation on 2/4/20 at 1:15 P.M. of a test tray of ham, black-eyed peas, sweet potatoes and cornbread showed ham very dark brown, tasted burned, and cornbread gooey in the middle and undercooked. No dessert available. During an interview on 2/4/20 at 4:14 P.M., Resident #6 said the only complaint about the facility is that the food is not very good. Record review of the Resident Council Minutes, dated 11/13/19, showed: - The facility staff changed the chef surprise to what the staff want and we (the residents) are stuck with it. We don't get a say on the chef's surprise.; - Always available menu discussed. Response from the facility showed: - On chef's surprise, they can always look at the menu board to see what is offered for the day and the residents can ask because the surprise will be decided that specific day. Record review of the Resident Council Minutes, dated 1/16/20, showed: - Last week, Saturday, was bad; - Chicken pot pie was slop, send back bad food and get substitute and snack sandwiches not always available in the evening; - One resident needs hot coffee with meals; - One resident did not get his/her meal, addressed it and got it late; - Dinner does not allow different options; - No fried eggs until the end of February; - Drink trays taking too soon; Response from the facility showed: - Encourage to ask for hot coffee. During the Resident Council interviews on 2/5/20 at 10:28 A.M., residents #3, #36, #43, #59 and #61 said: - Food is awful, always the same things; - There wasn't enough ham yesterday, but it was overcooked anyway; - They serve black-eyed peas and greens too often; - There is not enough variety; - Chicken pot pie last night was a bowl of vegetables with a cold, hard biscuit on the side, no crust on the pot pie; - They serve hard grilled cheese sandwiches with tomato soup often and the grilled cheese is too hard to eat; - Resident #61 bought his/her own sausage at local store and asked them to cook it for him/her. He/she was told the cook let it go too long on the grill and burned it; - Desserts and alternate choices are usually served in disposable plates or bowls; - They serve the same cake three days in a row, it gets stale and hard; - They usually do not have enough food for a second serving because the staff eats what is left and residents aren't able to have second servings; - Can't get fried eggs right now, something to do with the company that supplies the food and they can't buy eggs from local stores; - Scrambled eggs are made with water and they are watery; - They can't get popcorn. Observations on 2/5/20 at 12:55 P.M. of the main dining room showed: - Most desserts served in disposable bowls and some on plates; - Three residents with runny scrambled eggs and sausage served on disposable plates; - Resident #51 served grilled cheese and cheese-flavored chips on a disposable plate; - Four residents, each were served a loaded-baked potato, hard in the middle and not hot enough to melt butter; - Two residents with gelatin not set completely, lumpy and served in disposable bowls. During interviews on 2/5/20 at 12:57 P.M. showed the following: - Resident #62 said We were excited thinking we were going to have a good dessert today, but that don't taste like apple pie. I've made apple pie and that's not it!; - Resident #51 said the grilled cheese was hard and difficult to eat; - Residents #5, #43, #46, and #166, each said the loaded-baked potato was cold and the butter would not melt. During an interview on [DATE] at 12:22 P.M., the Administrator said she would expect food to be cooked properly, not over-cooked or under-cooked. Record review of the facility's policy titled, Food Preparation and Distribution, dated April 2006, showed: - The Dietary Department will prepare foods by methods that are safe and sanitary while conserving nutritive value as well as enhancing flavor; - Foods are prepared by methods that conserve nutritive value, flavor, and appearance; - Adequate amount of food is prepared to serve residents, allowing for seconds; - Staff and visitors are permitted to purchase meals according to facility guidelines and availability. Record review of the facility's policy titled, Tray Assembly for In Room Dining, dated April 2011, showed: - The Dining Services Manager or designee is responsible for seeing that all individual resident meals assembled meet the therapeutic requirements of the diet prescriptions, consistency and personal preferences on the meal card; - Special attention will be used in the plate presentation. All trays should be palatable and attractive.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices for one resident (Resident #37) out of 17 sampled residents and two residents (Resident #17 and #45) outside the sample. The facility's census was 67. Record review of the facility's policy titled, Perineal Care, dated March 2015, showed: - (After care) remove gloves and wash hands; - Put top sheet over resident and have resident hold it at top while you remove the bath blanket; - Replace blanket and spread. Record review of the facility's policy titled, Wound Care and Treatment, dated March 2012, showed: - Wash your hands and put on clean gloves; - Clean the wound according to the order; - Clean from the center outward; - Place soiled gauze in the trash bag; - Remove gloves, place in trash bag, and put on clean pair of gloves; - Apply clean dressing as ordered. 1. Observation of Resident #17 on 2/5/20 at 12:07 P.M. showed: - Resident sat in recliner; - Certified Nurse Aide (CNA) A and CNA B wore gloves and assisted the resident to stand; - The resident stood, CNA A wore gloves and provided incontinent care; - CNA A with soiled gloves, picked up oxygen tubing from the floor and placed it on the resident's bed. During an interview on 2/5/20 at 1:39 P.M., CNA A said he/she knew to remove his/her gloves. 2. Observation of Resident #45 on 2/5/20 at 12:23 P.M. showed: - Resident lay in bed; - CNA B wore gloves, moved floor mat, arranged shoes, moved wheelchair, and closed door; - CNA B with soiled gloves, arranged clean supplies including brief and turned down bed covers; - CNA B continued to wear soiled gloves and provided incontinent care; - CNA B with soiled gloves, turned resident to right side, cleaned hips, placed clean brief, turned resident to left side, pulled clean brief under resident, turned resident to back, secured brief, pulled up resident's socks, put pants on the resident, and put shoes on the resident. During an interview on 2/5/20 at 12:40 P.M., CNA B said he/she should have changed gloves after they were soiled before moving on to clean the resident. He/she was nervous. 3. Record review of Resident #37's physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. Symptoms may include swelling, pain, tenderness, skin changes, or open areas), of right lower extremity, [MEDICAL CONDITION] (MRSA; an infection that is resistant to antibiotic treatment and easily spread from person to person); - Order, dated [DATE], to clean wound of right superior lower leg with pure and clean wound cleanser, apply skin prep daily; - Order, dated 1/28/20, to cleanse area of right lateral lower leg with hypochlorous acid (disinfectant), skin prep to peri-wound skin, apply [MED] (ointment used to debride a wound) nickel thick with [MEDICATION NAME] ointment (antibiotic) to wound bed followed with dry dressing, cover with dry dressing; - Order, dated 1/28/20, to cleanse area to right inferior leg with hypochlorous acid, skin prep to peri-wound skin, apply [MED] nickel thick and [MEDICATION NAME] ointment to wound bed followed by dry dressing, cover with dry dressing. Observation of wound care on 2/6/20 at 11:07 A.M. showed: - Resident lay in bed; - Licensed Practical Nurse (LPN) C wore gloves and removed the soiled dressing from resident's right lower leg; - The resident had two open wounds; - LPN C wore soiled gloves and placed 4 x 4 gauze soaked in hypochlorous acid on each wound bed; - LPN C wore soiled gloves and removed 4x4s; - LPN C wore soiled gloves, opened skin prep pad and applied skin prep around the lower wound; - LPN C wore soiled gloves, held the wrapper in his/her right hand, opened a second skin prep pad and applied skin prep around the upper wound; - LPN C continued to wear soiled gloves and covered each wound with a 2x2 gauze with [MEDICATION NAME] ointment on them; - LPN C wore soiled gloves, wrapped the leg in gauze and secured with tape. During an interview on [DATE] at 9:45 A.M., LPN C said he/she should have cleaned one wound, removed gloves, washed hands and put on new gloves for the second wound. He/she is aware that the wound cultured positive [MEDICAL CONDITION]. During an interview on 2/7/19 at 12:22 P.M., the Director of Nursing (DON) said she expects staff to remove soiled gloves before touching equipment or other surfaces. The DON said each wound should be treated separately.

Based on interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for one resident (Resident #16) out of 16 sampled residents. The facility's census was 62. 1. Record review of Resident #16's physician's orders [REDACTED]. Record review of Nurse's Notes for Resident #16 showed: - On 11/2/18 at 11:54 A.M., resident fell in room while ambulating from bathroom to bedroom; - On 11/2/18 at 2:43 P.M., results returned from x-ray of a fracture, thumb is splinted and taped in place; - On 11/14/18 at 12:00 P.M., resident returned from surgery center after having surgery with cast on left hand and forearm, dressing to remain clean, dry and intact until follow up appointment on 11/26/18. Record review of Resident #16's care plan, updated 11/02/18, showed: - No instructions on how to care for broken thumb or cast. During an interview on 12/14/18 at 10:00 A.M., the Minimum Data Set (MDS) Coordinator said she did not care plan the cast. During an interview on 12/14/18 at 10:00 A.M., the Administrator said she was not sure if it needed to be care planned. Record review of the facility's policy titled Care Plan Comprehensive, dated (MONTH) (YEAR), showed: - The interdisciplinary care plan team, with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The interdisciplinary care plan team is responsible for the periodic review and updating care plans when a change occurs that impacts the resident care.

Based on observation, interview, and record review the facility failed to follow physician's orders for one resident (Resident #12) out of 16 sampled residents. The facility's census was 62. Record review of Resident #12's Physician's Order Sheet, dated 12/01/18, showed: - [DIAGNOSES REDACTED]. enough blood through the body), hypertension (high blood pressure), [MEDICAL CONDITIONS] (a disease in which plaque builds up inside arteries), and [MEDICAL CONDITION] (an irregular, rapid heart rate that may cause symptoms like heart palpitations, fatigue, and shortness of breath); - An order, dated 7/18/18, for Topral XL (a medication that affects the heart and blood flow through arteries and veins and used to treat chest pain and high blood pressure) 50 milligrams (mg) to be given one time daily, hold if systolic blood pressure (SBP) is less than 100 and/or HR (heart rate) is less than 60. During an observation on 12/13/18 at 8:33 A.M., Certified Medication Technician (CMT) A failed to assess the resident's heart rate and administered Topral XL 50 mg. During an interview on 12/13/18 at 8:41 A.M., CMT A said he/she did not assess the resident's heart rate because the less than 60 HR means the bottom number of the blood pressure. CMT A did not know HR meant heart rate. Record review of the resident's Medication Administration Records (MAR) showed: - In (MONTH) (YEAR), staff failed to check heart rate three of 14 days; - In (MONTH) (YEAR), staff failed to check heart rate seven of 31 days; - In (MONTH) (YEAR), staff failed to check heart rate 17 of 30 days; - In (MONTH) (YEAR), staff failed to check heart rate 13 of 31 days; - In (MONTH) (YEAR), staff failed to check heart rate two of 13 days. During an interview on 12/14/18 at 9:56 A.M., the Director of Nursing (DON) said she would expect the CMT to know what HR meant and that the resident's heart rate should be taken prior to Topral administration as ordered. Record review of the facility's policy titled Medication Administration, dated (MONTH) (YEAR), showed for administration of [MEDICATION NAME] and other medication that alter pulse rate to count the pulse for one minute before administration of the medication. If the pulse rate is below 60 or above 100, notify the nurse.

Based on observation, interview, and record review, the facility failed to ensure staff used proper technique during a gait belt transfer for two residents (Resident #42 and #44) outside of the 16 sampled residents. The facility's census was 62. Record review of the facility's policy titled, Gait Belt Use, dated (MONTH) (YEAR), showed: - Apply belt to resident's waist; tighten to fit snugly with the buckle at the side; - Bend your knees and place your hands around the gait belt on each side of the resident's waist; - Bring resident to a standing position while straightening your knees; - After the resident is standing, the belt provides assistance stabilizing and turning the resident. 1. Observation on 12/13/18 at 1:15 P.M., showed Certified Nurse Assistant (CNA) C and CNA B transferred Resident #44 from the wheelchair to the bed. CNA C applied a gait belt (a device used by caregivers to transfer care receivers with mobility issues from one position to another or from one location to another) above the resident's waist then transferred the resident. During an interview on 12/13/18 at 1:25 P.M., CNA C said he/she should put the gait belt under the resident's breast. Record review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff), dated 11/12/18, showed: - Limited physical assistance of two staff for transfers; - Moving from seated to standing position: not steady, only able to stabilize with human assistance; - Surface-to-surface transfers (transfers between bed and chair or wheelchair): Not steady, only able to stabilize with human assistance. 2. Observation on 12/13/18 at 1:40 P.M., showed CNA C and CNA E transferred Resident #42 from the wheelchair to the bed. CNA C applied a gait belt above the resident's waist then transferred the resident. Record review of the resident's quarterly MDS, dated [DATE], showed: - [DIAGNOSES REDACTED]. - Severe cognitive impairment; - Limited physical assistance of one staff for transfers. During an interview on 12/14/18 at 9:56 A.M., the Director of Nursing (DON) said the gait belt should be snug up underneath the waist and the Administrator said the gait belt should be under the breast.

Based on observation, interview and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were given. There were 37 opportunities with two errors made, for an error rate of 5.41%. This affected one resident (Resident #43). The facility's census was 62. Record review of the facility's policy titled, INSULIN PEN ADMINISTRATION, dated 12/2018, showed: - Prime the pen. You must prime the pen before you set your dose and inject the insulin. This removes the air bubbles and ensures the pen and needle are working properly; - Dial 2 units (to the number 2) on the dose selector; - Point the needle up. Press the plunger button and push out the 2 units of insulin. The dose selector dial will return to zero if all the units were pushed out; - If necessary, repeat these steps until a drop or stream of insulin appears at the needle tip. If you are using a brand new pen, you may have to prime it up to 3 times to get a drop of insulin at the tip; - Set your dose. Record review of Resident #43's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Basaglar KwikPen (insulin [MEDICATION NAME] injection, a medication used to lower blood glucose levels) 58 units subcutaneous (applied under the skin) twice a day. Observation on 12/14/18 at 7:30 A.M., showed: - Licensed Practical Nurse (LPN) B obtained the resident's Basaglar KwikPen for administration; - Basaglar KwikPen showed 36 units remaining; - LPN B failed to prime the Basaglar KwikPen prior to administration; - LPN B counted 36 units administered; - LPN B obtained a new, unopened Basaglar KwikPen: - LPN B failed to prime the new Basaglar KwikPen: - LPN B counted 22 units administered for a total of 58 units. During an interview on 12/14/18 at 9:56 A.M., the Director of Nursing (DON) said she was not sure how the insulin pens worked and they were just getting acclimated to the pens.

Based on observation, interview and record review, the facility failed to ensure that one sampled resident (Resident #43) out of 16 sampled residents were free from significant medication errors. The facility census was 62. Record review of the facility's policy titled, INSULIN PEN ADMINISTRATION, dated 12/2018, showed: - Prime the pen. You must prime the pen before you set your dose and inject the insulin. This removes the air bubbles and ensures the pen and needle are working properly; - Dial 2 units on the dose selector; - Point the needle up. Press the plunger button and push out the 2 units of insulin. The dose selector dial will return to zero if all the units were pushed out; - If necessary, repeat these steps until a drop or stream of insulin appears at the needle tip. If you are using a brand new pen, you may have to prime it up to 3 times to get a drop of insulin at the tip; - Set your dose. Record review of the manufacturer's instructions for use showed: -Prime pen before each injection; -Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly; -If you do not prime before each injection, you may get too much or too little insulin. Record review of Resident #43's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -Basaglar KwikPen (insulin [MEDICATION NAME] injection, a medication used to lower blood glucose levels) 58 units subcutaneous (applied under the skin) twice a day. Observation on 12/14/18 at 7:30 A.M., showed: - Licensed Practical Nurse (LPN) B obtained the resident's Basaglar KwikPen for administration; - Basaglar KwikPen showed 36 units remaining; - LPN B failed to prime the Basaglar KwikPen prior to administration; - LPN B counted 36 units administered; - LPN B obtained a new, unopened Basaglar KwikPen: - LPN B failed to prime the new Basaglar KwikPen: - LPN B counted 22 units administered for a total of 58 units. During an interview on 12/14/18 at 9:56 A.M., the Director of Nursing (DON) said she was not sure how the insulin pens worked and they were just getting acclimated to the pens.

Based on observation, record review, and interview, the facility failed to properly label one medication for one resident (Resident #163) outside of the 16 sampled residents. The facility's census was 62. Record review of the physician's orders [REDACTED].#163 showed: - [DIAGNOSES REDACTED]. - An order, dated 12/6/18, for [MEDICATION NAME] (a medicine for the treatment of [REDACTED]. During an observation on 12/13/18 at 8:33 A.M., Certified Medication Technician (CMT) A administered [MEDICATION NAME] 160/4.5 one puff from an opened inhaler, without an identifying resident's name, to Resident #163. During an interview on 12/13/18 8:41 A.M., CMT A said there is only one other resident who takes [MEDICATION NAME] and that inhaler is labeled with their name. The inhaler he/she used was newer and Resident #163 is a new admission so the CMT assumed it belonged to the resident. The CMT wrote Resident #163's name on the inhaler after using it for administration and said it should be labeled. During an interview on 12/14/18 at 9:56 A.M., the Director of Nursing (DON) said she would expect all medications to be labeled with the resident's name and order. Record review of the facility's policy titled, Labeling Drugs and Medications, dated (MONTH) (YEAR), showed labels for individual drug containers must contain the following: -Resident's full name and room number; -Prescribing physician's name; -Name, address, and phone number of the issuing pharmacy; -Initials of the pharmacist filling the prescription; -Name, strength, and quantity of the drug; -Appropriate cautionary and/or accessory labels; -Prescription number; -Expiration date (when applicable); -Date of issue; -Other appropriate information.