Every finding on record at Delta South Nursing & Rehabilitation

Based on interview and record review, the facility failed to electronically transmit a Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) in a timely manner and in accordance with guidelines for six residents (Residents #6, #7, #14, #16, #22, and #45) out of 12 sampled residents. The facility census was 48. Review of the facility's policy titled, Electronic Transmission of the MDS, revised November 2019, showed: - All MDS assessments (admission, annual, significant change, quarterly review, etc) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to Center for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation Service (QIES) Assessment Submission and Processing (ASAP) system in accordance with current (omnibus Budget Reconciliation Act (OBRA) regulations governing the transmission of MDS data; - All staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the MDS Resident Assessment Instrument (RAI) Instruction Manual is maintained by the resident assessment coordinator; - The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. 1. Review of Resident #6's MDS record showed: - admitted on [DATE]; - Quarterly MDS with a completion date of 11/27/25 and accepted/transmitted date of 01/07/26 (41 days late). 2. Review of #7's MDS record showed: - admitted on [DATE]; - Quarterly MDS with a completion date of 11/27/25 and accepted/transmitted date of 01/07/2026 (39 days late). 3. Review of 14's MDS record showed: - admitted on [DATE]; - Quarterly MDS with a completion date of 11/28/25 and accepted/transmitted date of 01/07/26 (40 days late). 4. Review of 16's MDS record showed: - admitted on [DATE]; - Quarterly MDS with a completion date of 11/27/25 and accepted/transmitted date of 01/07/26 (39 days late). 5. Review of 22's MDS record showed: - admitted on [DATE]; - Quarterly MDS with a completion date of 11/27/25, and accepted/transmitted date of 01/07/26 (41 days late). 6. Review of 45's MDS record showed: - admitted on [DATE]; - Quarterly MDS with a completion date of 12/18/25, and accepted/transmitted date of 01/13/26 (26 days late). During an interview on 01/08/26 at 10:23 A.M., the Social Service Director (SSD) said he/she assisted with the MDS process and notified the MDS Coordinator when a resident's assessment was completed and ready for review. The assessment should be reviewed by a Registered Nurse (RN) for accuracy and submitted within 14 days of completion. During an interview on 01/08/26 at 10:39 A.M., the Assistant Director of Nursing (ADON) said a resident's MDS assessment should be reviewed for accuracy and submitted upon completion in a timely manner. During an interview on 01/08/26 at 10:51 A.M., the Director of Nursing (DON) said a resident's MDS assessment should be reviewed for accuracy and submitted upon completion in a timely manner. The MDS Coordinator was responsible for submitting the resident's assessment in a timely manner. During an interview on 01/08/26 at 11:49 A.M., the Administrator said a resident's MDS assessment should be reviewed for accuracy and submitted upon completion in a timely manner. The MDS Coordinator was responsible for ensuring resident assessments were completed, reviewed, and submitted within 14 days of completion. During an interview on 01/08/26 at 1:00 P.M., the MDS Coordinator said he/she checked the system to see when an assessment was due. He/She waited until there was a batch of assessments due, completed, and then would submit them. He/She forgot sometimes and did not always submit resident assessments in a timely manner. MDS assessments should be submitted upon completion within 14 days and in a timely manner.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for two residents (Residents #59 and #60) out of two sampled residents that included the instructions needed to provide effective and person-centered care to meet professional standards of quality care. The facility census was 48.Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed:- A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission;- The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, discussion with the resident/representative and physician orders;- The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed;- Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Review of Resident #59's medical record showed:- admission date of 01/02/26:- No documentation of a baseline care plan;- The facility did not complete the resident's baseline care plan within 48 hours after admission to the facility. 2. Review of Resident #60's medical record showed:- admission date of 01/02/26:- No documentation of a baseline care plan;- The facility did not complete the resident's baseline care plan within 48 hours after admission to the facility. During an interview on 01/06/26 at 2:21 P.M., the Assistant Director of Nursing (ADON) said he/she would expect a resident to have a baseline care plan completed upon admission and within 48 hours with care areas addressed. The charge nurse on duty should start the baseline care plan and complete it if able on his/her shift. If not, the oncoming charge nurse should follow up and complete it in a timely manner.During an interview on 01/06/26 at 2:21 P.M., the Director of Nursing (DON) said she would expect a baseline care plan to be completed within 48 hours of a resident being admitted to the facility with care areas addressed so proper care could be given. Baseline care plans were not completed in a timely manner for these two residents because she thought since both admissions were on a Friday, there would be enough time to finish them on Monday.During an interview on 01/08/26 at 2:21 P.M., the Administrator said she would expect a baseline care plan to be completed within 48 hours of a resident being admitted to the facility with care areas addressed so proper care could be given. The charge nurse on duty should be initiating the baseline care plan upon admission, and a designee should be following up to make sure it had been completed in a timely manner.

Based on interview and record review, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM for four residents (Resident #3, #6, #7, and #45) out of five sampled residents. The facility census was 48. Review of the facility's policy titled, Restorative Nursing Services, revised July 2017, showed: - Residents will receive restorative nursing care as needed to help promote optimal safety and independence; - Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services such as physical, occupational, or speech therapies; - Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care; - Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care; - Restorative goals may include, but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining, or strengthening his/her physiological (body functions) and psychological (mental or emotional) resources; c. maintaining his/her dignity, independence, and self-esteem; d. participating in the development and implementation of his/her plan of care. 1.Review of Resident #3's medical record showed: - admitted on [DATE]; - Diagnoses of fracture of unspecified part of the neck of the left femur (a break in the upper part of the thigh bone), congestive heart failure (a condition where the heart cannot pump blood properly), dislocation of unspecified parts of left shoulder girdle (when the upper arm bone pops out of socket of the shoulder blade), and dementia (a decline in the mental ability affecting the memory and daily life). Review of the resident's Care Plan, revised 12/19/25, showed: - Limited physical mobility related to weakness; - Monitor, document, and report any signs or symptoms of worsening immobility; - Physical Therapy (PT) and Occupational Therapy (OT) referrals as needed. Review of the resident's Restorative Nursing Plan, dated 07/30/25, showed: - Therapy program to include: ROM, bed mobility/walking, transfers, dressing grooming, and toileting; - Frequency: two to three times weekly; - Precaution: fall risk and dementia; - Goal: maintain level of functioning/strength/independence; - Interventions: lower extremity strengthening/standing – three sets of 10 repetitions, standing balance/tolerance activities, and transfers – three sets of five repetitions. Review of the resident's Restorative Nursing Services documentation, dated 12/01/25 - 01/08/26, showed: - November 2025 calendar with 12 missed opportunities out of 12 opportunities for restorative nursing services; - December 2025 calendar with 12 missed opportunities out of 12 opportunities for restorative nursing services; - January 2026 calendar with six missed opportunities out of six opportunities for restorative nursing services. 2. Review of Resident #6's medical record showed: - admitted on [DATE]; - Diagnoses of paraplegia (inability to move in the lower half of the body), edema (a buildup of fluid), osteoporosis (a disease that weakens the bone), peripheral vascular disease (PVD - a slow and progressive disorder of the blood vessels) and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act). Review of the resident's Care Plan, revised 12/19/25, showed: - Limited physical mobility; - Monitor, document, and report any signs or symptoms of worsening immobility; - Provide gentle ROM as tolerated with daily care; - Provide supportive care and assistance with mobility as needed; - Document assistance as needed. Review of the resident's Restorative Nursing Plan, dated 08/18/25, showed: - Physical therapy program to include: ROM and transfer training; - Frequency: three times a week; - Precaution: fall risk; - Goal: maintain strength, transfers, endurance, and bed mobility; - Interventions: bilateral lower extremity ([NAME]) strengthening with two-pound weights - two sets of 15 repetitions, sit-to-stand exercises, parallel bars exercises, seated forward leans - two sets of 10 repetitions, and seated reaching activities. Review of the resident's Restorative Nursing Services documentation, dated 11/01/25 - 01/08/26, showed: - November 2025 calendar with 12 missed opportunities out of 12 opportunities for restorative nursing services; - December 2025 calendar with 12 missed opportunities out of 14 opportunities for restorative nursing services; - January 2026 calendar with five missed opportunities out of six opportunities for restorative nursing services. During an interview on 01/06/2026 at 9:27 A.M., Resident #6 said he/she did not get restorative nursing services on a regular basis. He/She might get restorative services once every other week if that. The restorative aide took him/her to the therapy room and placed her legs on a chair for stretching. After about 15 minutes, he/she was taken back to his/her room. He/She would like to have more exercises than just stretching his/her legs. No other exercises were provided. 3. Review of Resident #7's medical record showed: - admitted on [DATE]; - Diagnoses of kidney failure (when kidneys lose ability to effectively filter waste), bilateral above the knee amputation (removal of both legs above the knee), PVD, and atrial fibrillation (the heart's upper chambers beat irregularly causing an unsteady rhythm). Review of the resident's Care Plan, revised 12/22/25, showed: - Limited physical mobility related to bilateral above the knee amputations; - Monitor, document, and report any signs or symptoms of worsening immobility; - Provide gentle ROM as tolerated with daily care; - Document assistance as needed. Review of the resident's Restorative Nursing Plan, dated 10/08/25, showed: - Therapy program to include: ROM, bed mobility/walking, transfers, dressing grooming, and toileting; - Frequency: three times weekly; - Precaution: fall risk and bilateral above the knee amputations; - Goal: maintain level of functioning/strength/mobility; - Interventions: seated reaching activity, upper extremity bike – endurance, wheelchair propulsion (walking and pushing with hands on wheelchair handles) 100 -150 feet independently, postural exercise – two sets of 10 repetitions, scapula (shoulder blade) squeeze, roll shoulders forward/backward, and shoulder shrugs. Review of the resident's Restorative Nursing Services documentation, dated 12/01/25 - 01/08/26, showed: - November 2025 calendar with 12 missed opportunities out of 12 opportunities for restorative nursing services; - December 2025 calendar with 12 missed opportunities out of 12 opportunities for restorative nursing services; - January 2026 calendar with six missed opportunities out of six opportunities for restorative nursing services. 4. Review of Resident #45's medical record showed: - admitted on [DATE]; - Diagnoses of stroke, abnormalities of gait (walk) and mobility, muscle weakness, osteoarthritis (joint pain where cartilage wears down causing bones to rub), hemiplegia (paralysis of one side of the body) of the left side, and abnormal posture. Review of the resident's Care Plan, revised 11/14/25, showed: - Decreased physical mobility related to stroke; - Monitor, document, and report any signs or symptoms of worsening immobility; - Provide gentle ROM as tolerated with daily care; - Document assistance as needed. Review of the resident's Restorative Nursing Plan, dated 04/30/25, showed: - Therapy program to include: ROM, bed mobility/walking, and transfers; - Frequency: three times weekly; - Precaution: fall risk and left lower/upper extremity weakness; - Goal: maintain current strength and mobility; - Interventions: sit to stands, Nu-step (a type of exercise machine), lower extremity generalized strength exercises, encourage use of the left side, left sided stretches, and range of motion. Review of the resident's Restorative Nursing Services documentation, dated 12/01/25 - 01/08/26, showed: - November 2025 calendar with 12 missed opportunities out of 12 opportunities for restorative nursing services; - December 2025 calendar with 12 missed opportunities out of 12 opportunities for restorative nursing services; - January 2026 calendar with six missed opportunities out of six opportunities for restorative nursing services. During an interview on 01/07/26, at 1:11 P.M., Resident #45 said he/she did not get restorative services on a weekly basis. He/She received restorative services today for the first time in probably six months and would like to do restorative therapy on a regular basis because he/she needed the exercise. During an interview on 1/08/26, at 10:06 A.M., the Restorative Nurse Aide (RNA) said there were weeks he/she was pulled to the floor and missed completing the restorative nursing services for the residents. He/She did not tell anyone when restorative was getting missed because he/she felt like the nursing department should know because they were the ones that pulled him/her to the floor. He/She had not been properly trained and was under the impression activities of daily living (ADLs) would count as restorative exercises. During an interview on 01/08/26 at 10:32 A.M., the Rehabilitation Director said residents were screened quarterly and when there was a change in condition. A restorative plan was put in place by the therapist with the duration, frequency, and the individualized exercises for the resident. The individualized program was given to the restorative aide who in return ensured the resident received the plan of care. He/She would expect the restorative aide to follow the plans given for restorative therapy and make someone aware when they were unable to be followed. He/She felt the restorative program needed to be revamped to ensure better communication between nursing and therapy. During an interview on 01/08/26 at 11: 28A.M., the Assistant Director of Nursing (ADON) said a resident should receive restorative nursing services based on how many times it was recommended by the therapist. If the restorative aide was pulled to the floor to work for a particular day, restorative nursing services should be provided to the resident the next day based on the frequency. During an interview on 01/08/26 at 11:33 A.M., the Director of Nursing (DON) said a resident should receive restorative nursing services based on how many times it was recommended by the therapist. If the restorative aide was pulled to the floor to work for a particular day, restorative nursing services should be provided to the resident the next day based on the frequency. During an interview on 01/08/26 at 11:48 A.M., the Administrator said residents on restorative nursing services should receive what was outlined in the therapy recommendation including the exercises listed, the duration, and the frequency of services. The RNA should be documenting when restorative services were given, refused by the resident, and notifying nursing if restorative services couldn't be provided if pulled to the floor. In those cases, a designee from the therapy department could possibly assist the residents with their restorative nursing services.

Based on observation, interview and record review, the facility failed to reconcile narcotics (a process to count and document the exact narcotic inventory on hand) for seven residents (Residents #9, #18, #39, #42, #43, #50, & #58) out of 13 sampled residents. The facility census was 48.Review of the facility's policy titled, Controlled Substances, revised July 2017, showed:- Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up;- The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following:A. Records of personal access and usage;B. Medication administration records;C. Declining inventory records;D. Destruction, waste, and return to pharmacy records. 1. Review of Resident #9's January 2026 Physician Order Sheet (POS) showed:- An order for alprazolam (an anxiety medication) 0.5 milligrams (mg) by mouth three times a day for anxiety, dated 09/05/25. Review of the resident's Medication Administration Record (MAR), dated 01/06/26, showed: - The resident's alprazolam 0.5 mg dose administered on 01/06/26 at 8:00 A.M. Review of the 300 Hall Certified Medication Technician (CMT) Narcotic Medication Count Log on 01/06/26 at 1:32 P.M. showed: - One card of alprazolam 0.5 mg with 42 tablets remained for the resident. Observation of the 300 Hall CMT medication cart on 01/06/26 at 1:32 P.M. showed:- One card of alprazolam 0.5 mg with 41 tablets remained for the resident. 2. Review of Resident #18's January 2026 POS showed:- An order for tramadol (a pain medication) 25 mg by mouth every 12 hours as needed for pain, dated 09/30/25. Review of the resident's MAR, dated 01/06/26, showed:- The resident's tramadol 25 mg dose administered on 01/06/26 at 8:00 A.M. Review of the 300 Hall CMT Narcotic Medication Count Log on 01/06/26 at 1:33 P.M. showed:- One card of tramadol 25 mg with 14 tablets remained for the resident. Observation of the 300 Hall CMT medication cart on 01/06/26 at 1:33 P.M. showed:- One card of tramadol 25 mg with 13 tablets remained for the resident. 3. Review of Resident #39's January 2026 POS showed:- An order for tramadol 50 mg by mouth every 6 hours as needed for pain, dated 05/07/25. Review of the resident's MAR, dated 01/06/26, showed:- The resident's tramadol 50 mg dose administered on 01/06/26 at 8:00 A.M. Review of the 300 Hall CMT Narcotic Medication Count Log on 01/06/26 at 1:36 P.M. showed:- One card of tramadol 50 mg with 19 tablets remained for the resident. Observation of the 300 Hall CMT medication cart on 01/06/26 at 1:36 P.M. showed:- One card of tramadol 50 mg with 18 tablets remained for the resident. 4. Review of Resident #42's January 2026 POS showed:- An order for tramadol 50 mg by mouth two times a day for pain, dated 04/25/25. Review of the resident's MAR, dated 01/06/26, showed:- The resident's tramadol 50 mg dose administered on 01/06/26 at 8:00 A.M. Review of the 300 Hall CMT Narcotic Medication Count Log on 01/06/26 at 1:35 P.M. showed:- One card of tramadol 50 mg with 35 tablets remained for the resident. Observation of the 300 Hall CMT medication cart on 01/06/26 at 1:35 P.M. showed:- One card of tramadol 50 mg with 34 tablets remained for the resident. 5. Review of Resident #43's January 2026 POS showed:- An order for alprazolam 0.5 mg by mouth two times a day for anxiety, dated 04/23/25. Review of the resident's MAR, dated 01/06/26, showed:- The resident's alprazolam 0.5 mg dose administered on 01/06/26 at 8:00 A.M. Review of the 300 Hall CMT Narcotic Medication Count Log on 01/06/26 at 1:34 P.M. showed:- One card of alprazolam 0.5 mg with 44 tablets remained for the resident. Observation of the 300 Hall CMT medication cart on 01/06/26 at 1:34 P.M. showed:- One card of alprazolam 0.5 mg with 43 tablets remained for the resident. 6. Review of Resident #50's January 2026 POS showed:- An order for alprazolam 0.5 mg by mouth every 6 hours for anxiety, dated 10/21/25. Review of the resident's MAR, dated 01/06/26, showed:- The resident's alprazolam 0.5 mg dose administered on 01/06/26 at 12:00 P.M. Review of the 300 Hall CMT Narcotic Medication Count Log on 01/06/26 at 1:37 P.M. showed:- One card of alprazolam 0.5 mg with 27 tablets remained for the resident. Observation of the 300 Hall CMT medication cart on 01/06/26 at 1:37 P.M. showed:- One card of alprazolam 0.5 mg with 26 tablets remained for the resident. 7. Review of Resident #58's January 2026 POS showed:- An order for Ativan (an anxiety medication) 0.5 mg by mouth in the morning, dated 12/26/25. Review of the resident's MAR, dated 01/06/26, showed:- The resident's Ativan 0.5 mg dose administered on 01/06/26 at 8:00 A.M. Review of the 300 Hall CMT Narcotic Medication Count Log on 01/06/26 at 1:38 P.M. showed:- One card of Ativan 0.5 mg with 20 tablets remained for the resident. Observation of the 300 Hall CMT medication cart on 01/06/26 at 1:38 P.M. showed:- One card of Ativan 0.5 mg with 19 tablets remained for the resident. During an interview on 01/06/26 at 1:48 P.M., CMT C said he/she knew medications should be signed off in the book as soon as they were given, but he/she got busy and did not have time to chart the medications administered yet. During an interview on 01/06/26 at 3:36 P.M., the Director of Nursing (DON) said she would expect the CMT to chart medications as soon as they were given. The residents' medication count log should always reconcile with the correct number of medications in the facility. During an interview on 01/07/26 2:42 P.M., the Administrator said she would expect the CMT and all nursing staff to chart immediately after giving a controlled scheduled or an as needed medication.

Based on interviews and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about specific aspects of their lives which included food choices and dislikes. This affected two residents (Resident #2 and #14) out of 12 sampled residents and eight residents (Residents #18, #21, #33, #42, #43, #44, #50, and #51) outside the sample. The facility census was 48.Review of the facility's policy titled, Resident Food Choices, revised July 2017, showed:- Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team (IDT - a group of healthcare professionals from diverse fields who work in a coordinated effort toward a common goal for a resident);- Upon the resident's admission (or within 24-hours after admission) the dietitian or nursing staff will identify a resident's food preferences;- When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes;- Nursing staff will document the resident's food and eating choices in the care plan;- The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night;- The facility's quality assurance assessment and performance improvement (QAPI - a systemic data-driven approach used in healthcare facilities to monitor, evaluate, and improve the quality of care and the overall quality of life for residents) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparations, etc. 1. Review of Resident #2's medical record showed: - admitted on [DATE];- Diagnoses of type II diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), heart failure, urinary tract infection (UTI (a bacterial infection in the kidneys and/or bladder causing the urge to urinate) and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act)). Review of the resident's Care Plan, revised 08/05/25, showed:- Independent for meeting social needs and activities of daily living (ADLs);- Dietary consult for nutritional regimen and ongoing monitoring;- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of food likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/06/26 at 2:42 P.M., the resident said he/she did not like pulled pork and potato salad, but still received it at meals. He/She would love to have a sandwich at lunch or a cup of soup instead of what was served. Staff had never asked what his/her food dislikes were since admission and was not aware of an alternative list of food choices. 2. Review of Resident #14's medical record showed:- admitted on [DATE];- Diagnoses of stroke, hypertension (high blood pressure), anxiety (a natural feeling of unease, worry or fear), and depression. Review of the resident's Care Plan, dated 11/20/25, showed:- Independent for meeting social needs and activities of daily living (ADL's);- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of food likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/05/26 at 12:15 P.M., staff had never asked what his/her dislikes were so he/she didn't know how the kitchen staff were aware of them. 3. Review of Resident #18's medical record showed: - admitted on [DATE];- Diagnoses of type II DM, UTI, depression, and anxiety. Review of the resident's Care Plan, revised 12/02/25, showed:- Requires staff assistance with ADLs;- Dietary consult for nutritional regimen and ongoing monitoring;- Provide and serve diet as ordered;- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/06/26 at 2:28 P.M., the resident said he/she didn't like onions, tomatoes, or dill pickles and would push those foods to the side of the plate. Staff took the food tray and didn't ask questions. Staff had never asked what his/her likes and dislikes in food choices were that he/she could remember. It was a shame to throw away good food that someone else could eat. He/She didn't know what the alternative food choices were in the kitchen. 4. Review of Resident #21's medical record showed:- admitted on [DATE];- Diagnoses of hypertension and depression. Review of the resident's Care Plan, dated 12/12/25, showed:- Requires staff assistance with self-care performance due to weakness;- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/07/26 at 1:10 P.M., the resident said staff had never asked what his/her dislikes were. 5. Review of Resident #33's medical record showed: - admitted on [DATE];- Diagnoses of hypertension, congestive heart failure (heart is too weak to pump blood effectively causing fluid to back up and build in the lungs), and depression. Review of the resident's Care Plan, revised 09/23/25, showed:- Requires staff assistance with self-care performance due to weakness;- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/06/26 at 1:47 P.M., the resident said he/she did not like mixed vegetables because of the butter beans and carrots. He/She had never been asked what his/her dislikes were since admission and didn't know he/she could ask for something else in its place. He/She did not know there was alternative food choices. 6. Review of Resident #42's medical record showed:- admitted [DATE];- Diagnoses of hypertension, heart failure, and DM. Review of the resident's Care Plan, dated 12/19/25, showed:- Requires staff assistance with self-care performance;- Dietary consult for nutritional regimen;- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/07/26 at 1:20 P.M., the resident said staff never discussed food items whether it be likes or dislikes with him/her. 7. Review of Resident #43's medical record showed: - admitted on [DATE];- Diagnoses of weight loss, hypertension, depression, and UTI. Review of the resident's Care Plan, revised 08/13/25, showed:- Requires staff assistance with self-care performance due to weakness;- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/06/26 at 1:57 P.M., the resident said the food didn't taste the same since his/her teeth had been pulled back in October 2025. He/She didn't like green beans, carrots, and didn't want lettuce because he/she couldn't chew it. These food items were often served on his/her plate. Staff had not asked what his/her dislikes were since admission or after his/her teeth were pulled. 8. Review of Resident #44's medical record showed:- admitted [DATE];- Diagnoses of hypertension, anxiety, and depression, Review of the resident's Care Plan, dated 11/14/25, showed:- Independent for meeting social needs and ADL's;- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/07/25 at 1:25 P.M., the resident said staff had not discussed his/her likes and dislikes of food with him/her. 9. Review of Resident #50's medical record showed: - admitted on [DATE];- Diagnoses of hypertension, depression, anxiety, and rheumatoid arthritis (a chronic disease marked by inflammation of multiple joints). Review of the resident's Care Plan, revised 08/13/25, showed:- Independent for meeting social needs and activities of daily living (ADLs);- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/06/26 at 2:17 P.M., the resident said he/she skipped some meals because there was no variety to the meals. He/She did not like the precooked eggs or sour kraut. Staff had never asked what his/her likes/dislikes were since admission and did not want to say anything because he/she didn't want to be a problem. He/She was aware there were food substitutions, but didn't know what they were. 10. Review of Resident #51's medical record showed:- admitted on [DATE];- Diagnoses of hypertension, DM, and kidney failure (when the kidneys lose the ability to filter waste). Review of the resident's Care Plan, dated 12/22/25, showed:- Requires staff assistance with self-care performance;- Dietary consult for nutritional regimen;- Did not address diet, food likes or dislikes. Review of the resident's Dietary Card showed:- No documentation of likes and/or dislikes;- The facility failed to address the resident's food likes and/or dislikes. During an interview on 01/07/25 at 1:30 P.M., the resident said facility staff had not discussed his/her dislikes of food with him/her at all since admission to the facility. Observation on 01/05/26 at 10:32 A.M., of the kitchen showed:- A Resident Alternative Foods and/or Substitutions Always Available list located on the DM's office door. Observations on 01/05/26 at 10:58 A.M. and 01/06/26 at 1:29 P.M., of the facility showed:- No posting of the Resident Alternative Foods and/or Substitutions Always Available list for the residents to view. Review of the Resident Alternative Foods and/or Substitutions Always Available list, undated, showed:- Chef salad with turkey, chicken salad, baked chicken, deli sandwich, tuna salad sandwich, grilled cheese sandwich, hamburger on a bun, cheeseburger on a bun, cottage cheese, fresh fruit, ice cream, cookie, and pudding. During an interview on 01/05/26 at 3:18 P.M., the Dietary Manager (DM) said the dietary cards were updated when he/she received a new dietary communication form. Dietary cards should include a resident's current likes/dislikes and updated as needed. Residents should be informed of the alternative foods and/or substitutions if there was a certain food he/she didn't like. During an interview at 01/08/26 at 9:40 A.M., the Assistant Director of Nursing (ADON) said she would expect a resident's food likes/dislikes to be included on the dietary card with his/her food preferences and updated as needed. Residents should be informed of alternative foods and/or substitutions if there was a certain food he/she didn't like. During an interview at 01/08/26 at 9:47 A.M., the Director of Nursing (DON) said she would expect a resident's food likes/dislikes to be included on the dietary card with his/her food preferences and updated as needed. Residents should be informed of alternative foods and/or substitutions if there was a certain food he/she did not like. During an interview at 01/08/26 at 10:10 A.M., the Administrator said she would expect a resident's food likes/dislikes to be included on the dietary card with his/her food preference and updated as needed. Residents should be informed of alternative foods and/or substitutions if there was a certain food he/she did not like.

Based on interview and record review, the facility failed to consistently document a code status for one resident (Resident #101) out of 14 sampled residents. The facility census was 53. Review of the facility's policy titled, Advanced Directives, dated 2001, showed: - The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy; - The facility defines the Do Not Resuscitate (DNR - in case of respiratory cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR - an emergency life-saving procedure done when someone's breathing or heartbeat has stopped)) or other life-sustaining treatments or methods are to be used; - Prior to or upon admission of a resident, the Social Services Director or designee inquires of the resident, his/her family members and/or his/her legal representative, about the existence of any written advance directives. 1, Review of the Resident #101's medical record showed: - An admitted [DATE]; - The face sheet, dated [DATE], showed a full code status; - A DNR status indicated by a red dot on the outside spine of the resident's hard chart; - The Physician's Order Sheet (POS), dated [DATE], showed a full code status; - A DNR form signed by the resident and the physician on [DATE]. During an interview on [DATE] at 9:25 A.M., Medical Records Staff E said green dots indicated a full code status and the red dots indicated a DNR. During an interview on [DATE] at 9:30 A.M., the Director of Nursing (DON) said he did not have an explanation for the code status being different. During an interview on [DATE] at 9:45 A.M., the Social Services Director (SSD) said he/she did not know how the DNR sheet got in the resident's chart, due to it being dated on [DATE]. The resident had been admitted and discharged previously. The form was in the admission packet and when someone was admitted , he/she and the resident or resident representative discussed the code status. The resident was considered a full code status. The SSD remembered the resident and a family member being in his/her office at the time of admission and no one signed a DNR form. During an interview on [DATE] at 10:20 A.M., the resident said he/she wanted to be a full code. During an interview on [DATE] at 1:00 P.M., the Administrator said she would expect the code status to be documented accurately and consistently throughout the resident's medical record.

Based on observation and interview, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 26. The facility did not provide a homelike environment policy. 1. Observations on 11/04/24 at 1:41 P.M., 11/05/24 at 8:47 A.M., 11/06/24 at 3:22 P.M. and 11/07/24 at 8:06 A.M., showed an unhung shower curtain lay on top of a shower chair in the shower area located in room [ROOM NUMBER]. 2. Observations on 11/04/24 at 1:55 at P.M., 11/05/24 at 3:22 P.M., 11/06/24 at 3:02 P.M., and 11/07/24 at 11:06 A.M., of the 200 Hall showed several small dried dark areas on the floor in front of the decorative table and the beside recliner located in front of the window in room [ROOM NUMBER]. 3. Observation on 11/04/24 at 2:46 P.M., of the 400 Hall showed a large hole and missing sheetrock on the resident closet door located in room [ROOM NUMBER]. 4. Observations on 11/06/24 9:58 A.M., 11/07/24 at 11:50 A.M., of the 300 Hall showed: - Six medium-sized stuffed animals on top of the over-the-bed light located in room [ROOM NUMBER]; - A six inch (in.) x one foot (ft.) ceiling tile with a large brown stain near room [ROOM NUMBER]. 5. Observation on 11/06/24 at 1:20 P.M., of the 100 and 200 Hall nurses' station showed: - Several areas of exposed sheetrock located on the front side panel; - Several long black lines and scraped areas located on the the side panel near the 200 Hall entrance. During an interview on 11/07/24 at 9:04 A.M., Housekeeper A said if there was anything that needed to be fixed in the facility, he/she told the Maintenance Supervisor. There was also a daily rounds sheet that could be filled out and given to his/her supervisor. He/She had not seen anything during rounds that needed to be addressed in terms of the environment. During an interview on 11/07/24 at 9:14 A.M., Housekeeper B said if there was anything that needed to be fixed in the facility, he/she told the Maintenance Supervisor. There was also a daily rounds sheet kept on the housekeeping cart that could be filled out if there was a repair needed. He/She had not seen any environmental issues during his/her rounds that needed to be addressed. During an interview on 11/07/24 at 11:34 A.M., the Maintenance Supervisor said staff normally told him/her when something needed repaired or fixed. There used to be a maintenance log for staff to write down issues or concerns but was no longer used. He/She did not keep copies of the housekeeping sheets with environmental concerns made during daily rounds for documentation. During an interview on 11/07/24 at 12:46 P.M., the Administrator said she would expect department heads to address any environmental concerns during the morning meetings. She would expect housekeeping to address and document any environmental concerns as well as line staff so the Maintenance Supervisor could address the issues in a timely manner.

Based on interview and record review, the facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments, a federally mandated assessment instrument completed by the facility, in a timely manner and in accordance with the guidelines for four residents (Residents #7, #19, #28 and #35) outside of the 14 sampled residents. The facility's census was 53. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed: - The facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes; - The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to Centers of Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines; - Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. 1. Review of Resident #7's medical record showed: - admitted to the facility on [DATE]; - An admission MDS, dated [DATE], completed and submitted; - The next scheduled quarterly MDS, not submitted (49 days late), and over 120 days from the last MDS, dated [DATE]. 2. Review of Resident #19's medical record showed: - admitted to the facility on [DATE]; - A quarterly MDS, dated [DATE], completed and submitted; - The next scheduled quarterly MDS, not submitted (43 days late), and over 120 days from the last MDS, dated [DATE]. 3. Review of Resident #28's medical record showed: - admitted to the facility on [DATE]; - An annual MDS, dated [DATE], completed and submitted; - The next scheduled quarterly MDS, not submitted (33 days late), and over 120 days from the last MDS, dated [DATE]. 4. Review of Resident #35's medical record showed: - admitted to the facility on [DATE]; - An annual MDS, dated [DATE], completed and submitted; - The next quarterly MDS, dated [DATE], not submitted (35 days late), and over 120 days from the last MDS, dated [DATE]. During an interview on 11/07/24 at 10:20 A.M., the Social Service Director (SSD) said he/she was a Licensed Practical Nurse (LPN) and completed what he/she could on the MDS's. The Registered Nurse (RN) reviewed, completed, and submitted the MDS's. During an interview on 11/07/24 at 12:50 P.M., the Administrator said she did not know much about the MDS's and the facility had an off-site MDS Coordinator. During an interview on 11/15/24 at 9:20 A.M., the Director of Nursing (DON) said he does not know anything about the MDS's and when they should be submitted.

Based on observation, interview, and record review the facility failed to provide proper incontinent care for two residents (Residents #1 and #19) and failed to provide scheduled showers for one resident (Resident #37) for activities of daily living (ADLs) outside the 14 sampled residents. The facility census was 53. Review of the facility's policy titled, Activities of Daily Living, revised March 2018, showed: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; - Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; - The policy did not address incontinent care and showers. Review of the Perineal Care Return Demonstration check sheet, undated, showed: - Clean the front peri area; - Proceed to clean the rectal and buttocks area. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed: - Documentation: the date and time the shower/tub bath was performed; the name and title of the individual(s) who assisted the resident with the shower/tub bath; all assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath; if the resident refused the shower/tub bath, the reason(s); - Reporting: notify the supervisor if the resident refused the shower/tub bath; notify the physician of any skin areas that may need to be treated; report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #1's admission Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 08/05/24, showed: - Impairment on one side of the upper and lower extremity; - Always incontinent of bowel and bladder; - Required partial to moderate assist of staff for toileting and personal hygiene. Observation on 11/07/24 at 11:42 A.M., of the resident's incontinent care showed: - Certified Nurse Assistant (CNA) D cleaned the resident's front peri area; - CNA D rolled the resident to his/her right side and removed the urine soaked brief; - CNA D cleaned the resident's rectal area, left buttock and left hip; - CNA D failed to clean the resident's right hip or right buttock. 2. Review of Resident #19's annual MDS, dated [DATE], showed: - Always incontinent of bowel and bladder; - Required maximum assist of staff for toileting and personal hygiene. Observation on 11/06/24 at 9:58 A.M., of the resident's incontinent care showed: - CNA M clean resident's rectal area, buttocks, and hips of fecal material; - CNA M applied barrier cream to the resident's buttocks; - CNA M placed a clean brief on the resident; - CNA M failed to clean the resident's front peri area. During an interview on 11/06/24 at 10:07 A.M., CNA M said when providing peri care, should clean from front to back. During an interview on 11/07/24 at 12:45 P.M., CNA D said he/she was nervous and knew he/she had not provided appropriate incontinent care to the resident. During an interview on 11/07/24 at 12:56 P.M., the Administrator said any skin that was dirty should be washed. The resident's peri area should be washed from front to back when providing incontinent care for the resident. 3. Review of Resident #37's medical record showed: - An admitted [DATE]; - Diagnoses of congestive heart failure (an inability of the heart to pump sufficient blood flow to meet the body's needs), urinary tract infection, acute kidney failure (the kidneys suddenly stop working properly), anemia (low blood levels of iron) and dislocations (separation of two bones) of unspecified parts of the left shoulder girdle (shoulder blade, upper arm and collar bone). Review of the resident's quarterly MDS, dated [DATE], showed: - Partial/moderate assistance for shower/bathing; - Supervision or touching assistance for tub/shower transfer. Review of the resident's care plan, revised 06/13/24, showed: - Did not address showers/bathing frequency; - Did not address assistance required. Review of the shower schedule, dated November 2024, showed the resident received showers on Wednesdays and Saturdays. Review of the resident's shower sheets, dated 10/02/24 through 11/02/24, showed: - No documentation of scheduled showers on 10/12/24, 10/16/24, 10/19/24, 10/23/24 and 11/02/24; - Five missed out of 10 opportunities for scheduled showers. During an interview on 11/04/24 at 2:18 P.M., and 11/06/24 at 3:40 P.M., the resident said he/she was supposed to get showers on Wednesdays and Saturdays. He/She did not always get showers on Saturdays and was sometimes not asked if he/she would like a shower. A CNA told him/her this past Saturday there was not enough staff to give him/her a shower, but he/she knew other residents had received a shower. His/Her family came to visit on Sunday and gave him/her a shower. During an interview on 11/07/24 at 10:27 A.M., CNA C said on the days a resident was scheduled to receive a bath/shower, a shower sheet should be completed to show the resident received a shower or if the resident refused. There should be a shower sheet for every time a resident was scheduled a shower. During an interview on 11/07/24 at 10:29 A.M., CNA D said on the days a resident was scheduled to receive a bath/shower, a shower sheet should be completed to show the resident received a shower or if the resident refused. If a resident refused a shower, he/she would go back and ask the resident again later. During an interview on 11/07/24 at 10:44 A.M., the Assistant Director of Nursing (ADON) said showers should be documented. There should be documentation that showers had been given and/or if a resident had refused a bath/shower. Staff should be asking residents if he/she wanted a shower and if refused, another attempt should be made and documented. During an interview on 11/06/24 at 11:15 A.M., the Director of Nursing (DON) said he would expect a shower sheet to be filled out for each resident who received a bath/shower by the person who gave the shower. It should also be documented when a resident refused a shower. Residents should be given bath/showers on the days scheduled. During an interview on 11/06/24 at 12:24 P.M., the Administrator said residents should be given a bath/shower on the days scheduled. She would expect a shower sheet to be filled out for each resident who received a bath/shower by the person who gave the shower. If a resident refused a shower, staff should be going back and asking the resident again if he/she wanted a bath/shower. It should also be documented when a resident refused a shower. Complaint #MO00243948

Based on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of, and reconciled for one resident (Resident #8) outside of the seven sampled residents. The facility census was 53. Review of the facility's policy titled, Controlled Substances, revised November 2022, showed: - Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up; - Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; - The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services; - The Director of Nursing (DON) services documents irreconcilable discrepancies in a report to the administrator; - Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed; - Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. 1. Review of Resident #8's medical record showed: - An admitted [DATE]; - An order for lorazepam (a controlled medication used to treat anxiety) 0.5 milliliter (ml) every hour for terminal restlessness and shortness of breath, dated 12/07/23, with a stop date of 02/02/24. Review of the Controlled Substance Record Book showed no individual controlled substance records for Resident #8's lorazepam 0.5 ml every hour for terminal restlessness/shortness of breath. Observation on 11/06/24 at 4:27 P.M., of the locked refrigerator in the main medication room showed one bottle of opened liquid lorazepam 2 milligram (mg) per ml with 28 ml left in the 30 ml bottle for Resident #8. During an interview on 11/06/24 at 4:33 P.M., Licensed Practical Nurse (LPN) F said there should have been dates with the doses and a signature of the nurse administering the medication written in the narcotic count book for Resident #8's lorazepam. When residents were discharged , the unused controlled medications were given to the DON. During an interview on 11/06/24 at 4:40 P.M., the DON said he was unsure why the doses for Resident #8's lorazepam were not documented when they were given. The DON did not know why the lorazepam had not been brought to him for destruction. During an interview on 11/07/24 at 12:35 P.M., the Administrator said the nurse who received the order to discontinue the medication should remove the medication from the cart. Two nurses should witness the destruction of the medications and document. She was unsure why the medication was still being counted and in the facility.

Based on interview and record review, the facility failed to ensure an appropriate diagnosis and to identify specific behaviors and monitor the behaviors for the use of a psychotropic (drugs that can affect mood or mental state) medications for two residents (Residents #2 and #14) out of five sampled residents. The facility census was 53. Review of the facility policy titled, Antipsychotic Medication Use, revised on July 2022, showed: - Residents will only receive antipsychotics medications when necessary to treat specific conditions for which they are indicated and effective; - Antipsychotic (medications used to treat psychosis-related conditions and symptoms) medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, showed: - Behavioral or psychological symptoms of dementia (BPSD) describes behavioral symptoms in individuals with dementia that cannot be attribute to a specific medical or psychiatric cause. Appropriate assessment and treatment of behavioral symptoms requires differentiating between behavioral symptoms that can be managed by treating underlying factors and those that cannot; - Current guidelines recommend the use of non-pharmacological interventions for BPSD; - New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. 1. Review of Resident #2's medical record showed: - An admitted [DATE]; - Diagnoses of Alzheimer's (a progressive disease that destroys memory and other mental function) and dementia (memory loss that interferes with daily functioning) severe with agitation; - An order for risperidone (an antipsychotic medication) 0.5 milligram (mg) once a day for behaviors, dated; - No documentation of an appropriate diagnosis for the risperidone; - No documentation of any identified specific behaviors and monitoring of the behaviors for the use of the risperidone. 2. Review of Resident #14's medical record showed: - An admitted [DATE]; - Diagnoses of major depressive disorder (a mental disorder having persistent depressed mood or loss of interest) with psychotic features and Alzheimer's; - An order for Abilify (an antipsychotic medication) 5 mg once a day for depression, dated 08/06/24; - An order for sertraline (an antidepressant medication) 200 mg once a day for depression, dated 07/09/24; - An order for mirtazipine (an antidepressant medication) 15 mg at bedtime, dated 10/02/24; for diagnosis of dementia; - No documentation of an appropriate diagnosis or behaviors for the Abilify; - No documentation of any identified specific behaviors and monitoring of the behaviors for the use of the Abilify, sertraline, and mirtazipine. Review of the manufacturer recommendations for Abilify state drug is not approved for the treatment of patients with dementia-related psychosis and review of the manufacturer recommendations for Risdperidone (Risperdal) state drug is not approved for treatment of patients with dementia-related psychosis. During an interview on 11/06/24 at 10:01 A.M., Certified Medication Technician (CMT) G said he/she was unsure why Resident #2 received risperidone because the resident didn't have behaviors. During an interview on 11/06/24 at 1:50 P.M., the Director of Nursing (DON) said Resident #2's behaviors were yelling out at times. He said there was no documentation of the behaviors or any pharmacological or non-pharmacological routes taken for Resident #2. The facility didn't have any kind of monitoring process in place for the residents taking psychotropic medications. Resident #14's behaviors were confusion and yelling out on occasions. He would expect an appropriate diagnosis for a resident to be on an antipsychotic medication but he was new and was under the impression that the residents did have appropriate diagnoses. During an interview on 11/07/24 at 12:26 P.M., the Administrator said she would expect residents taking an antipsychotic medication to have an appropriate diagnosis supporting the medication. She would expect there to be some kind of monitoring system in place for residents that were taking an antipsychotic medication and appropriate charting of the behaviors.

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 30 opportunities with four errors made, for an error rate of 13.33%. This affected two residents (Residents #10 and #45) out of six sampled residents and had the potential to affect all residents. The facility census was 53. Review of the facility's policy titled, Documentation of Medication Administration, revised November 2022, showed: - A nurse of certified medication technician (CMT), where applicable, documents all medications administered to each resident on the resident's Medication Administration Record (MAR); - Administration of medication is documented immediately after it is given. Review of the facility's policy titled, Administering Oral Medications, revised October 2010, showed: - Verify that there is a physician's medication order for this procedure; - Place the MAR within easy viewing distance; - Check the label on the medication and confirm the medication name and dose with the MAR. 1. Review of Resident #10's Physician Order Sheet (POS), dated November 2024, showed: - An order for Macrobid (an antibiotic medication) 100 milligrams (mg) by mouth two times daily for 10 days, dated 11/03/24, with a discontinue date of 11/04/24; - An order for Refresh Plus Ophthalmic Solution (a medication used for itchy, burnings eyes) instill one drop in the right eye three times a day, dated 09/18/24; - An order for Flonase Allergy Relief Nasal Suspension (a medication used for seasonal allergies) 50 microgram (mcg) one spray in both nostrils two times a day for allergy relief, dated 09/18/24. Review of the resident's MAR, dated November 2024, showed: - Macrobid documented not administered on 11/06/24; - Refresh Plus documented administered on 11/06/24; - Flonase Nasal spray documented administered on 11/06/24. Observation of Resident #10's medication administration on 11/06/24 at 9:10 A.M., showed: - CMT G administered Macrobid; - CMT G did not administer the Refresh eye drops; - CMT G did not administer the Flonase nasal spray. During an interview on 11/06/24 at 10:46 A.M., Resident #10 said he/she was not on an antibiotic anymore and he/she usually got the eye drops and nasal spray with the morning medication pass. During an interview on 11/06/24 at 11:51 A.M., CMT G said he/she was nervous and administered the Macrobid by mistake. During an interview on 11/07/24 at 12:45 P.M., the Director of Nursing (DON) said he would expect staff to only administer medications as ordered. During an interview on 11/07/24 at 12:35 P.M., the Administrator said it was expected the staff not to chart medications that had not been administered. 2. Review of Resident #45's POS, dated November 2024, showed: - An order for Prevagen (a dietary supplement that aids in mild memory loss) 10 mg by mouth daily, dated 05/18/24. Observation of Resident #45's medication administration on 11/06/24 at 8:51 A.M., showed: - CMT G did not administer the Prevagen medication. During an interview on 11/06/24 at 9:00 A.M., CMT G said the family provided the medication. The medication wasn't in the medication cart to give. When medications were not in the medication cart, the charge nurse was notified. During an interview on 11/06/24 at 11:15 A.M., Licensed Practical Nurse (LPN) F said CMT G had not informed him/her of any medications not being in the medication cart. During an interview on 11/07/24 at 12:45 P.M., the DON said she expected staff to follow physician's orders for medication administration.

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 deficient practices had the potential to affect all residents. The facility census was 53. Review of the facility's policy titled, Sanitation, revised November 2022, showed; - Kitchen areas are kept clean, free from garbage and debris; - All kitchen equipment is kept clean. Review of the facility's policy titled, Food Receiving and Storage, undated, showed; - All foods stored in the refrigerator or freezer are covered, labeled and dated; - Refrigerated foods are labeled, dated and monitored so they are used by their use-by date; - Partially eaten food is not kept in the refrigerator. 1. Observations on 11/04/24 at 10:33 A.M., and 11/05/24 at 8:48 A.M., of the right side walk-in freezer showed; - An opened box of frozen and exposed catfish undated located on the left side; - An opened bag of frozen dinner rolls with no label and undated located on the left side; - An opened bag of frozen hushpuppies with no label and undated located on the left side; - A box of miscellaneous and unidentified frozen food items located on the bottom left shelf with no label and undated; - Five frozen corn dogs not in a sealed container with a buildup of frost lay on top of a box of miscellaneous food items with no label and undated. 2. Observations on 11/04/24 at 10:36 A.M., and 11/05/24 at 8:51 A.M., of the left side standup refrigerator showed; - Two sponge cakes with no label and undated; - A chocolate dessert in a styrofoam to-go container with no label and undated; - A half-eaten hot fudge sundae in an opened plastic container with a spoon inside with no label and undated. 3. Observations on 11/04/24 at 10:43 A.M., and 11/05/24 at 8:54 A.M., of the dishwashing room showed; - An empty paper towel dispenser located at the hand washing sink; - An empty soap dispenser located at the handwashing sink; - A storage crate with several dishes, a bottle of grease spray, a large drink dispenser, and grease wipes lay cluttered and stacked up between a metal shelf and the handwashing sink; - A buildup of dirt and debris on a beverage dispenser lay on a cart located under the three compartment-sink; - A buildup of a hard white substance located on the top and side surfaces of the dish machine; - Miscellaneous glass tumblers and a squeegee lay on top of the dish machine. 4. Observations on 11/04/24 at 10:57 A.M., and 11/05/24 at 8:59 A.M., of the kitchen equipment showed; - A buildup of grime located on the side surfaces of the plate warmer cart; - A buildup of grease and grime located on the stove/oven; - A buildup of grease located on the side surfaces of the double-fryer; - A buildup of grease and dirt located on the floor between the double fryer and the oven. During an interview on 11/04/24 at 11:02 A.M., Kitchen Employee I said he/she would expect open items in the freezers and/or refrigerators to be labeled and dated. There was no daily check off for cleaning in the kitchen and all the kitchen staff just looked around and do what needed to be done. The equipment should be free of grease, grime, be free of clutter, and organized. During an interview on 11/06/24 at 2:09 P.M., the Dietary Manager said he/she would expect clutter to be sorted and put away. There was a cleaning schedule that was hung up, but staff did not sign off daily because they all just knew what they should be doing and work together. He/She would not expect equipment to be greasy and grimey. He/She would expect any food items placed in the freezers and/or refrigerators that had been opened to be labeled, dated and in a sealed container. During an interview on 11/07/24 at 11:09 A.M., the Administrator said she would expect the kitchen staff to clean on a daily basis and the kitchen to be free of grease and grime on the the equipment and floors. She would expect the kitchen to have the paper towel and soap dispenser refilled as needed, be free of clutter. All foods once opened, should be labeled, dated, in a sealed container, and placed into the freezers and/or refrigerators.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and glove changes during incontinent care for three residents (Residents #1, #19 and #251) outside the six sampled residents. The facility census was 53. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 2001, showed: - The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections; - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors; - Hand hygiene is indicated: immediately before touching a resident; after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal; - The use of gloves does not replace hand washing/hand hygiene; Applying and Removing Gloves: Perform hand hygiene before applying gloves; when gloves are removed, then perform hand hygiene. 1. Observation on 11/07/24 at 11:42 A.M., of Resident #1's incontinent care showed: - Certified Nursing Assistant (CNA) D entered the resident's room; - CNA D performed hand hygiene and put on gloves; - CNA D cleaned the resident's front peri area; - CNA D did not change gloves, did not perform hand hygiene, rolled the resident to his/her right side, and removed the urine soaked brief; - CNA D did not change gloves, did not perform hand hygiene, touched the peri wash bottle, and sprayed the peri wash on the resident's back peri area; - CNA D did not change gloves, did not perform hand hygiene, and cleaned the resident's rectal area, the buttock, and the left hip; - CNA D did not change gloves, did not perform hand hygiene, and placed a clean brief under the resident; - CNA D did not change gloves, did not perform hand hygiene, rolled the resident to his/her back and fastened the brief; - CNA D did not change gloves, did not perform hand hygiene, touched the resident linens, and the over the bed table. 2. Observation on 11/06/24 at 9:58 A.M., of Resident #19's incontinent care showed: - CNA M entered the resident's room; - CNA M performed hand hygiene and put on gloves; - CNA M clean the resident's rectal area, buttocks, and hips of fecal material; - CNA M did not change gloves, did not perform hand hygiene, and applied barrier cream to the rectal area and buttocks; - CNA M did not change gloves, did not perform hand hygiene, and placed a clean brief on the resident; - CNA M did not change gloves, did not perform hand hygiene, rolled the resident to his/her back, and fastened the brief; - CNA M did not change gloves, did not perform hand hygiene, and pulled the resident's pants up. 3. Observation on 11/07/24 at 11:45 A.M., of Resident #251's incontinent care showed: - CNA C entered the resident's room; - CNA C did not perform hand hygiene and put on gloves; - CNA C cleaned the resident's front peri area; - CNA C did not perform hand hygiene and changed gloves; - CNA C rolled the resident and cleaned the rectal area and buttocks; - CNA C did not change gloves, did not perform hand hygiene, and applied a new brief; - CNA C pulled the resident's pants back up. During an interview on 11/06/24 at 10:07 A.M., CNA M said he/she should've changed gloves between dirty and clean care. During an interview on 11/07/24 at 12:45 P.M., CNA D said he/she was nervous and knew he/she had messed up by not changing his/her gloves. During an interview on 11/07/24 at 12:55 P.M., the Director of Nursing (DON) said he expected staff, while performing incontinent care, to change gloves when going from dirty to clean care and to clean from front to back when cleansing the peri area of a resident. During an interview on 11/07/24 at 12:56 P.M., the Administrator said any skin that was dirty should be washed. The resident's peri area should be washed from front to back when providing incontinent care for the resident. The gloves should be changed between dirty and clean tasks. During an interview on 11/07/24 at 1:09 P.M., CNA C said that he/she should have washed hands before starting peri care and should have changed gloves before applying a clean brief.

Based on observation, interview and record review, the facility failed to perform hand hygiene between glove changes during incontinent care for two residents (Residents #18 and #21) out of four sampled residents and one resident (Resident #4) outside the sample. The facility failed to perform hand hygiene between residents when medications were administered for three residents (Residents #33, #197, and #198) out of three sampled residents. The facility failed to ensure in the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) by not completing the admission TB screening and/or a yearly risk assessment for symptoms for five residents (Residents #3, #7, #12, #18, and #34) out of five sampled residents. The facility census was 45. Review of the facility's policy titled, Perineal Care, revised 02/2018, showed: - Assemble the equipment and supplies as needed; - Wash and dry hands thoroughly; - Put on gloves; - Provide pericare; - Remove gloves and discard into designated area; - Wash and dry hands thoroughly. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 08/2019, showed: - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents; before preparing or handling medications; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; and perform hand hygiene before applying non-sterile gloves. 1. Observation of Resident #4 on 08/30/23 at 1:45 P.M., showed: - Certified Nurse Assistant (CNA) F and Nurse Assistant (NA) G removed the resident's urine soiled brief, performed hand hygiene, and donned clean gloves; - CNA F provided incontinent care and placed a clean brief with the same soiled gloves; - CNA F, with the same soiled gloves, used the sit to stand (a mechanical lift designed to assist persons who have some mobility but need help to rise from a sitting position) lift to lower the resident to his/her wheelchair and touched the resident's right shoe and pant leg; - CNA F, with the same soiled gloves, reached in his/her pocket for a plastic bag for the resident's dirty clothing, opened the closet door to get clean pants, and moved the bedside table; - CNA F failed to remove soiled gloves and perform hand hygiene between dirty and clean care. During an interview on 08/30/23 at 1:55 P.M., CNA F said his/her hands should've been sanitized and clean gloves put on between dirty and clean care. Observation of Resident #18 on 08/30/23 at 9:55 A.M., showed: - CNA E and CNA H entered the resident's room, failed to perform hand hygiene, and put on gloves; - CNA E and CNA H provided incontinent care; - CNA E and CNA H removed the soiled gloves, failed to perform hand hygiene, and put on new gloves; - CNA H touched the resident's bedding to pull up the blanket; - CNA H removed the gloves, did not perform hand hygiene, and exited the room; - CNA H re-entered the resident's room and did not perform hand hygiene and put on new gloves; - CNA H, with new gloves on, and CNA E, with the same soiled gloves, touched the resident's bare arms and back to remove the resident's shirt; - CNA E and CNA H removed the soiled gloves, did not perform hand hygiene, and exited the room; - CNA E and CNA H failed to perform hand hygiene between dirty and clean care. Observation of Resident #21 on 08/30/23 at 11:15 A.M., showed: - CNA E entered the resident's room, did not perform hand hygiene, put on gloves, and closed the resident's window; - CNA E provided incontinent care to the resident; - CNA E removed the gloves, failed to perform hand hygiene, and put on new gloves; - CNA E touched the resident's right hip and shoulder; - CNA E removed the resident's dirty brief; - CNA E removed the gloves, failed to perform hand hygiene, and put on new gloves; - CNA E applied a new brief, pulled the resident's pants back up, touched the resident to assist him/her into a comfortable position, and touched the resident's pillow; - CNA E removed the gloves, did not perform hand hygiene, and exited the room; - CNA E failed to perform hand hygiene between dirty and clean care. During an interview on 08/30/23 at 11:30 A.M., CNA E said hand hygiene should be performed between glove changes. 2. Observation of the medication pass on 08/30/23, showed: - At 7:52 A.M., Certified Medication Technician(CMT) A did not perform hand hygiene prior to or after the medication administration to Resident #198; - At 8:01 A.M., CMT A did not perform hand hygiene prior to or after the medication administration to Resident #197; - At 8:11 A.M., CMT A did not perform hand hygiene to his/her hands prior to the medication administration to Resident #33. During an interview on 08/30/23 at 9:25 P.M., CMT A said his/her hands should be washed or sanitized prior to administering medication, and between every resident. During an interview on 08/31/23 at 3:00 P.M., the Director of Operations (DOP) said she would expect staff to sanitize their hands and change gloves when going from dirty to clean care. She would also expect staff to use hand sanitizer between each resident when passing medications and to wash his/her hands with soap and water after every third resident. 3. Review of the facility's policy titled, Testing for Latent Tuberculosis Infection (LTBI), revised May 2020, showed: - The control and prevention of TB in the elderly must be accomplished in order to eliminate TB as a public health problem; - All residents new to long-term care who do not have documentation of a previous skin test reaction or disease, should have the initial test of Mantoux (a TB skin test) two-step test to rule out TB within one month prior to or one week after admission; - If the initial result is 0-9 millimeter (mm), the second test, which can be given after admission, should be given at least one week and no more than three weeks after the first test; - Once TB disease is ruled out, it is important to record the results of the skin test in mm; - The policy did not address the annual TB evaluation of the residents. General requirements for TB testing for residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: - Long-term care facilities shall screen their residents for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; - Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; - If the resident's initial test is negative, the second test should be given one to three weeks later. The Centers for Disease Control (CDC) states TB tests should be read 48 to 72 hours after administration; - All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; - All positive findings shall require a chest x-ray to rule out active pulmonary disease; - Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. Review of Resident #3's medical record showed: - An admitted [DATE]; - An annual TB skin test (TST) administered on 11/08/22; - A result of negative with no results in mm documented; - No read date documented; - No documentation the resident received an annual TB screen or annual evaluation to rule out signs and symptoms of TB. Review of Resident #7's medical record showed: - An admitted [DATE]; - An annual TST administered on 11/08/22; - A result of negative with no results in mm documented; - No read date; - No documentation the resident received an annual TB screen or annual evaluation to rule out signs and symptoms of TB. Review of Resident #12's medical record showed: - An admitted [DATE]; - An annual TST administered on 11/8/22; - A result of negative with no documentation of results in mm; - No read date documented; - No documentation the resident received an annual TB screen or annual evaluation to rule out signs and symptoms of TB. Review of Resident #18's medical record showed: - An admitted [DATE]; - An annual TST administered on 03/29/23; - No read date or results documented; - No documentation the resident received an annual TB screen or annual evaluation to rule out signs and symptoms of TB. Review of Resident #34's medical record showed: - An admitted [DATE]; - A first step TST administered on 01/28/22; - A result of negative with 0 mm induration; - No read date documented; - No documentation the resident received the second step TST. During an interview on 08/31/23 at 12:20 P.M., the Assistant Director of Nursing (ADON) said the facility's electronic health record system did not reflect the date the TB tests were read. Therefore, they could not prove if the tests were read in the correct timeframe. All administered tests should be read within 48 to 72 hours after administered. During an interview on 08/31/23 at 2:00 P.M., the DOP said the electronic health record system did not allow the date the TB tests were read to be entered for any residents. Tests should be read 48 to 72 hours after administration. Residents should have an annual TB test or annual evaluation for TB symptoms. 46521 49150

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for two out of two medication carts and one medication storage room. This had the potential to affect all residents. The facility census was 45. Review of the facility's policy titled, Controlled Substances, dated April 2019, showed: - The facility will follow all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances; - Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; - Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together; - Policies and procedure for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. 1. Review of the 100/200 hall nurse narcotic count log for the controlled substances showed: - For 06/01/23 - 06/30/23, the staff missed 18 out of 90 opportunities; - For 07/0/123 - 07/31/23, the staff missed 21 out of 93 opportunities; - For 08/01/23 - 08/30/23, the staff missed 24 out of 90 opportunities. Review of the 300/400 hall nurse narcotic count log for the controlled substances showed: - For 06/01/23 - 06/30/23, the staff missed 22 out of 90 opportunities; - For 07/01/23 - 07/31/23, the staff missed 37 out of 93 opportunities; - For 08/01/23 - 08/30/23, the staff missed 24 out of 90 opportunities. Review of the medication storage room narcotic count log for the controlled substances showed: - For 06/01/23 - 06/30/23, the staff missed 45 out of 90 opportunities; - For 07/01/23 - 07/31/23, the staff missed 33 out of 93 opportunities; - For 08/01/23 - 08/30/23, the staff missed 30 out of 90 opportunities. During an interview on 08/31/23 at 10:46 A.M., Certified Medication Technician (CMT) D said the narcotics were supposed to be counted at each shift change by two staff and the log signed. During an interview on 08/31/23 at 11:55 A.M., the Assistant Director of Nursing (ADON) said the narcotics should be counted and logged by two staff with every shift change. It should be done by the oncoming and off going nurse or CMT. During an interview on 08/31/23 at 3:00 P.M., the Director of Operations said she would expect the narcotic count to be done by the on coming and off going nurse or CMT at each shift change.

Based on observation, interview and record review, the facility failed to obtain an order for a Foley catheter (a flexible tube inserted into the bladder to drain urine), catheter care and provide a diagnosis for the use of a catheter for two residents (Resident #34 and #42) out of two sampled residents and one resident (#197) outside the sample. The facility failed to ensure placement of the catheter tubing and drainage bags for one resident (Resident #42) out of two sampled residents and one resident (Resident #197) outside the sample. The facility census was 45. Review of the facility's policy titled, Catheters Insertion and Care, revised on 05/2017, showed: - The resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications; - Catheters will not be used unless the resident's clinical condition demonstrates that catheterization is necessary and a physician's order is obtained; - Properly position the bag below the level of the bladder (must not touch floor) and secure to the bed frame (never to the side rail); - Place the catheter bag in a cover to preserve the dignity of the resident. 1. Review of Resident #34's medical record showed: - admitted [DATE]; - No diagnoses for a Foley catheter; - The August 2023 Physician's Order Sheet, (POS) showed no order for the Foley catheter or for catheter care; - The facility failed to obtain a diagnosis, an order for the catheter placement, and for catheter care. Observations of the resident on 08/28/23 at 10:29 A.M., 08/29/23 at 2:55 P.M., 08/30/23 at 7:55 A.M., and 08/30/23 at 1:25 P.M., showed the resident with an indwelling catheter. Review of Resident #42's medical record showed: - admitted [DATE]; - No diagnosis for Foley catheter; - The August 2023 POS showed an order for the Foley catheter to drain at the bedside, dated 07/19/23; to flush the Foley catheter with 50 milliliters (ml) of sterile water daily in the morning for sediment (material that settles at the bottom of liquid), dated 07/19/23; and monitor urine output every shift, for anuria (no urine output), dated 07/19/23; - The facility failed to obtain a diagnosis, an order for catheter placement, and catheter care. Observations of the resident showed: - On 08/28/23 at 10:12 A.M., and 08/29/23 at 11:15 A.M., the resident sat in a Geri chair (a reclining chair on wheels), with the uncovered catheter drainage bag hung under the chair; - On 08/30/23 at 8:46 A.M., and 9:35 A.M., and on 08/31/23 at 1:30 P.M., the resident lay in bed with the bed in the lowest position and the uncovered Foley catheter draining bag hung on the bed frame with the bottom of the bag touched the floor and the spout not capped; - On 08/30/23 at 9:15 A.M., Certified Nursing Assistant (CNA) B in the resident's room and the bottom of the uncovered catheter drainage bag touched the floor with the spout uncapped. CNA B exited the resident's room; - On 08/30/23 at 9:45 A.M., Registered Nurse (RN) C entered the resident's room and the bottom of the catheter drainage bag touching the floor with the spout uncapped; - On 08/31/23 at 11:31 A.M., the resident lay in bed with the bed in the lowest position and the uncovered Foley catheter draining bag hung on the bed frame with half of the bag touching the floor; - On 08/31/23 at 2:22 P.M., the resident lay in bed with the catheter drainage bag lay uncovered on the floor at the end of the bed and not attached to the bed frame. Review of Resident #197's medical record showed: - admitted [DATE]; - No diagnosis for a Foley catheter; - The August 2023 POS showed no order for the Foley catheter or for catheter care. Observations on 08/30/23 at 8:01 A.M., showed the resident lay in bed with the Foley catheter drainage bag lay uncovered and touched the floor. Observations on 08/31/23 at 2:20 P.M., showed the resident sat in a reclining chair with the uncovered catheter drainage bag lay on the floor. During an interview on 08/31/23 at 3:00 P.M., the Assistant Director of Nursing (ADON) said a diagnosis, orders for catheters, and the care of catheters should be on the resident's POS. The drainage bag should never touch the floor. During an interview on 08/31/23 at 3:05 P.M., the Director of Operations (DOP) said she would expect catheters to have an order on the POS, along with a diagnosis and the required care. Anchors for the catheter tubing should be on the resident's thigh and the drainage bag should never touch the floor. During an interview on 08/31/23 at 3:10 P.M., the Administrator said orders for catheters, a diagnosis, and catheter care should be on the resident's POS. Anchors for the catheter tubing should be on the resident's thigh if they would allow it and the drainage bag should not touch the floor. 47445

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, within 14 days of an admission to hospice (health care focused on the quality of life of a terminally ill person) for one resident (Resident #21) out of four sampled residents. The facility's census was 45. Review of the facility's policy titled, Resident Assessments, revised March 2022, showed: - The resident assessment coordinator is responsible for ensuring that the appropriate resident assessments and reviews are completed; - The Resident Assessment Instrument (RAI) (the manual used to help staff gather definitive information on the resident's strengths and needs which must be addressed on the MDS and care plans) provides detailed information on timing and submission of the MDS assessments. 1. Review of Resident #21's medical record showed: - An admitted [DATE]; - admitted to hospice care on 05/22/23; - No significant change MDS dated on or after 05/22/23; - The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice. During an interview on 08/31/23 at 3:00 P.M., the Director of Operations (DOP) said a significant change MDS should be completed within 14 days after a significant change in the resident's condition, such as being admitted to hospice services. During an interview on 08/31/23 at 3:05 P.M., the Administrator said she would expect a significant change MDS to be completed during the appropriate timeframe.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff, for one resident (Resident #16) out of 12 sampled residents and one resident (Resident #44) out of three closed record reviews. The facility census was 45. Review of the facility's policy titled, Resident Assessments, revised March 2022, showed: - The resident assessment coordinator is responsible for ensuring the appropriate resident assessments and reviews are completed; - The Resident Assessment Instrument (RAI) (the manual used to help staff gather definitive information on the resident's strengths and needs which must be addressed on the MDS and care plans) provides detailed information on timing and submission of the MDS assessments. 1. Review of Resident #16's quarterly MDS, dated [DATE], showed the resident did not smoke. Review of the Residents' Smoking List, dated 08/28/23, showed Resident #16 smoked. Review of the resident's smoking assessment, dated 08/29/23, showed: - Resident to be a high risk of injury; - Resident not to keep lighter or cigarettes; - Resident required supervision during smoking; - Resident required a smoking apron. Observations on 08/28/23 at 11:43 A.M., and 08/29/23 at 10:00 A.M., showed Resident #16 sat outside smoking with staff with a smoking apron on. During an interview on 08/29/23 at 2:27 P.M., the Administrator said Resident #16 smoked and required a smoking apron, supervised smoking, and cigarettes and lighters were kept by the facility. The MDS should have indicated the resident smoked. 2. Review of Resident #44's discharge MDS, dated [DATE], showed the resident discharged to the hospital. Review of the resident's medical record showed: - A nurse's note, dated 06/23/23, showed the the resident to be discharged to another long term care facility on 06/24/23, per the resident's request; - A nurses's note, dated 06/24/23, showed the resident discharged to another long term care facility; - Discharge instructions, dated 06/24/23, showed the resident discharged to another long term care facility. During an interview on 08/31/23 at 10:00 A.M., the Administrator said the resident discharged to another long term care facility on 06/24/23, per the resident's request on short notice. During an interview on 08/31/23 at 2:30 P.M., the Director of Operations said the MDS should reflect accurate information.

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for five residents (Residents #3, #9, #16, #29, and #34) out of 12 sampled residents. The facility census was 45. Review of the facility's policy titled, Comprehensive Person-Centered Care Plans, revised December 2016, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs will be developed and implemented for each resident; - The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The comprehensive, person-centered care plan will incorporate identified problem areas and risk factors associated with the identified problems, aid in prevention or reduction of a decline in the resident's functional status and/or functional levels, and enhance the optimal function of the resident; - The comprehensive, person-centered care plan will be developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility staff. 1. Review or Resident #3's medical record showed: - An admitted [DATE]; - Diagnoses of pain in the right shoulder and generalized osteoarthritis (a type of arthritis marked by cartilage deterioration of joints and vertebrae); - The quarterly MDS, dated [DATE], showed the resident received opioid (medications prescribed by physicians to treat persistent or severe pain) medications. Review of the resident's Physician Order Sheet (POS), dated 08/31/23, showed: - Oxycodone (an opioid medication) 7.5 milligram (mg) by mouth every six hours as needed for pain, dated 07/07/23; - Oxycodone 7.5 mg. by mouth at bedtime for pain, dated 07-27-23; - Fentanyl patch (an opioid medication) 25 microgram 1 patch transdermally (a medication in a form for absorption through the skin into the bloodstream) every 72 hours for pain and apply with 12 mcg patch every 72 hours to equal 37 mcg, dated 08/04/21; - Fentanyl patch 12 mcg/hr 1 patch transdermally every 72 hours for pain and apply with 25 mcg patch to equal 37 mcg, dated 08/04/21. Review of the resident's Medication Administration Record (MAR), dated August 2023, showed: - Resident received Oxycodone Tablet 7.5 mg routinely at bedtime as ordered - Resident received Fentanyl patch 72 hour 12 mcg routinely every 72 hours as ordered; - Resident received Fentanyl patch 72 hour 25 mcg routinely every 72 hours as ordered; - Resident received Fentanyl patch checked daily for placement routinely one time daily as ordered. Review of the resident's care plan, last reviewed on 08/17/23, showed it did not address opioid use or pain management. Review of Resident #9's August 2023 POS showed: - admitted to the facility on [DATE]; - Diagnosis of end stage renal disease (chronic irreversible kidney failure); - Dialysis on Tuesday, Thursday, and Saturday. Review of the resident's care plan, last revised on 08/16/23, showed did not address the resident's dialysis treatments with individualized interventions. Review of Resident #16's medical record showed: - An admitted [DATE]; - A smoking assessment, dated 08/29/23, showed the resident required a smoking apron. Observations of the resident on 08/28/23 at 11:43 A.M., and on 08/29/23 at 10:00 A.M., showed the resident sat outside and smoked with supervision of staff with a smoking apron on. Review of the resident's care plan, revised on 01/13/23, showed it did not address the individualized intervention of requiring an apron to be worn while smoking. Review of Resident #29's medical record showed: - An admitted [DATE]; - Diagnoses of Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), and Alzheimer's (a brain disorder that slowly destroys the memory and thinking skills) disease; - The POS, dated 08/28/23, showed an order for hydrocodone (an opioid medication) 10/325 mg every six hours for pain, dated 09/08/22; - The MAR, dated August 2023, showed the resident received Hydrocodone 10/325 mg routinely every six hours as ordered; - The annual MDS, dated [DATE], showed the resident received opioid medications. Review of the resident's care plan, last revised on 08/14/23, showed it did not address the individualized interventions for opioid use or pain management. Review of Resident #34's medical record showed: - An admitted [DATE]; - Diagnoses of acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and chronic pain (persistent pain that lasts weeks to years); - The quarterly MDS, dated [DATE], showed an indwelling catheter (a flexible tube inserted into the bladder to drain the urine); - The POS, dated August 2023, showed an order for hydrocodone 7.5/325 mg every six hours as needed for pain, dated 08/04/23; - The MAR, dated August 2023, showed the hydrocodone was given eight times. Observations of the resident on 08/28/23 at 10:29 A.M., 08/29/23 at 2:55 P.M., 08/30/23 at 7:55 A.M., and 08/30/23 at 1:25 P.M., showed the resident with an indwelling catheter. Review of the resident's care plan, last revised on 06/21/23, showed: - Did not address the indwelling catheter with individualized interventions; - Did not address the use of an opioid or pain management with individualized interventions. During an interview on 08/31/23 at 2:20 P.M., the Director of Operations (DOP) said care plans should reflect the care required by the residents, should be accurate, and should be updated as needed. During an interview on 08/31/23 at 2:30 P.M., the Administrator said she expects the MDS Coordinator and the nurses to keep the care plan up to date and accurate. They have daily meetings to discuss changes and that should easily be carried over to care plans. 45693 47445 49150