Every finding on record at Good Shepherd Care Center

Based on observation, interview and record review, facility staff failed to store food in a manner to prevent contamination and outdated used. The facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to maintain the kitchen floors clean and in good repair to prevent the growth and harborage of bacteria. The facility staff also failed to ensure the ice machine, used to supply ice to residents, drained through an air gap to prevent cross-contamination. The facility census was 51. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded; -Rotate products so the oldest are used first. Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers; -Never leave any food item uncovered and not labeled. Review of the facility's Labeling and Dating Foods (Date Marking) policy, dated 2020, showed: -Unopened cases of dry food items will be dated with the date the case was received into the facility and will be using first in-first out method of rotation; -Once a case is opened, the individual food items from the cases are dated with the date the item was received in the facility and placed in/on the proper storage unit utilizing the first in-first out method of rotation; -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date. Observation on [DATE] at 8:50 A.M., showed the reach-in freezer contained opened and undated bags of steak fries and potato wedges. Observations on [DATE] at 9:06 A.M., showed the dry goods pantry contained: -A opened and undated 25 pound (lb) bag of nonfat dry milk; -Six 18 ounce (oz) cans of world horizons mushrooms pieces and stems with an expiration date of [DATE]; -To large bags tortilla chips with an expiration date of ,d+[DATE]; -Four large bags of tortilla chips with an expiration date of ,d+[DATE]; -Two five lbs bags of biscuit mix with a date of ,d+[DATE] for the date received, but no expiration date; -A dented 6 lb 8 oz can of fruit cocktail; -A dented 6 lb 10 oz can of tropical fruit. During an interview on [DATE] at 9:34 A.M., the Dietary Manager (DM) said he/she and any staff put away food from the trucks are responsible to check for dented cans. The DM said he/she did not know why the two dented cans were on the shelf and dented cans are to be placed in the garage until the items can be returned to the supplier. The said he/she was responsible to check the dry goods room weekly for dented cans, expired foods and ensure opened items are dated with the date opened. The DM said he/she assumed the food received from the distributor was not expired, so he/she did not look at the manufacturer date. The DM said staff who open the food items are responsible to date the package with an opened date and the dry milk should have had an open date on it. The DM said if there is no used by date or date the item was received, those items should be discarded. Observation on [DATE] at 12:06 P.M., showed the reach-in freezer contained an undated bag of tater tots opened to the air and an undated and an open bag of hashbrown patties stored inside an undated plastic resealable bag. Observation on [DATE] at 2:16 P.M., the walk-in refrigerator contained: -A large pan of raw meat stored next to a pan of ready-to-eat fruit cocktail; -A container of previously prepared sage chicken dated ,d+[DATE] stored next to a pan of ready-to-eat tossed lettuce salad dated ,d+[DATE]; -A container of previously prepared chicken gravy dated ,d+[DATE] and an undated container of previously prepared sausage gravy stored over prepared, ready-to-eat egg and cheese sandwiches. Observations on [DATE] at 12:00 P.M. and on [DATE] at 2:11 P.M., showed the glass-front reach-in refrigerator contained a five pound container of factory prepared chicken salad with a handwritten received date of ,d+[DATE], opened date of ,d+[DATE] and use by date of ,d+[DATE]. Observation showed a manufacturer's expiration date of [DATE] printed on the container. During an interview on [DATE] at 2:37 P.M., the DM said staff should label opened food items with the opened and use by dates, store them in sealed containers, and they should not store raw or previously prepared food items near ready-to-eat food items and staff are trained on these requirements. The DM said the cooks are responsible to review the food storage in all areas at the end of their shifts to ensure foods are stored appropriately. The DM said staff probably do not think to check the use by or expiration dates from the manufacturer, but he/she would hope that they pay attention to those dates. The DM said he/she tries to audit food storage at least weekly when he/she prepares the food truck order. During an interview on [DATE] at 3:07 P.M., the administrator said staff should label and date opened food items with opened and used by dates and ensure they are stored covered and in a manner to protect them from contamination. The administrator said staff should not store food items that need cooked near ready-to-eat food items. The administrator said staff are trained on these requirements upon hire and as needed. 2. Review of the facility's Handwashing/Hand Hygiene policy, dated [DATE], showed the policy directed: -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Wash hands with soap when hands are visibly soiled; -Use an alcohol-based hand rub containing at least 62 percent alcohol or alternatively soap and water before and after coming on duty, eating or handling food, and assisting a resident with meals; -Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands; -Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers; -Rinse hands with water and dry thoroughly with a disposable towel; -Use a towel to turn off the faucet. Observation on [DATE] at 9:36 A.M., showed Cook A washed his/her hands at the handwashing sink. Observation showed the cook scrubbed his/her hands with soap for 10 seconds and then returned to prepare food items for service to residents. Observation on [DATE] at 9:42 A.M., showed Cook B washed soiled dishes in the mechanical dishwashing station and then he/she washed his/her hands at the handwashing sink. Observation showed the cook scrubbed his/her hands with soap under running water from the faucet for 15 seconds and then put dishes away from the clean side of the station. Observation on [DATE] at 9:53 A.M. and 9:56 A.M., showed the DM washed his/her hands at handwashing sink and scrubbed his/her hands with soap for five seconds. Observation showed the DM then obtained food items from the reach-in refrigerator and prepared a cheeseball in the mixer for service to the residents. [DATE] 01:54 PM Observation showed DA D washed his/her hands at the handwashing sink. Observation showed the DA scrubbed his/her hands with soap under running water for five seconds, turned the faucet off with bare hands and put away dishes from the clean side of the mechanical dishwashing station. Observation on [DATE] at 1:55 P.M., showed the Cook C washed his/her hands at the handwashing sink and scrubbed his/her hands with soap for three seconds under running water and then turned faucet off with bare hands. Observation on [DATE] at 2:02 P.M. and 2:15 P.M., showed Dietary Aide (DA) D washed soiled dishes in the mechanical dishwashing station and then washed his/her hands at the handwashing sink. Observation showed the DA scrubbed his/her hands with soap for five seconds, turned faucet off with his/her bare hand and then put away dishes from the clean side of the station. Observation showed the DA used his/her bare hand to turn the door handle to exit the kitchen and then he/she returned to the kitchen and, without performing hand hygiene, continued to put away dishes from the clean side of the mechanical dishwashing station. During an interview on [DATE] at 2:15 P.M., DA D said he/she had worked at the facility for about four weeks, staff trained him/her on hand hygiene upon hire and staff are to wash their hands before they put away clean dishes. The DA said staff should also wash their hands when they enter the kitchen if they touched something dirty while out of the kitchen. The DA said he/she did not touch anything while out of the kitchen, but door handles would be considered dirty and he/she did not think about that. The DA said he/she did not remember being told how long he/she needed to scrub his/her hands with soap, but guessed he/she should do so for 20 or 30 seconds and he/she did not do so because he/she was in a hurry. The DA said staff should also turn the faucet off with paper towel when they wash their hands so they do not recontaminate their hands and he/she was just not good at thinking about that stuff before he/she does it. During an interview on [DATE] at 2:22 P.M., Cook C said he/she had worked at the facility since [DATE]. The cook said staff should scrub their hands with soap for 20 seconds out of the water, rinse and then turn the faucet off with a paper towel. The cook said he/she had been trained to wash his/her hands the right way, but he/she just not do it the right way because he/she does not think about it and is just focused on making food. During an interview on [DATE] at 2:29 P.M., the DM said staff should wash their hands when they enter the kitchen, between dirty and clean dishes and anytime they go from touching something dirty to something clean and staff are trained on hand hygiene during their orientation. The DM said staff should scrub their hands with soap for 20 seconds out of the water, rinse and turn the faucet off with paper towel so they do not recontaminate their hands. The DM said he/she is responsible to monitor hand hygiene, probably did not do that as often as he/she should, and he/she could not remember the last time he/she monitored staff's hand hygiene practices. During an interview on [DATE] at 2:56 P.M., the administrator said staff should wash their hands when they enter the kitchen and after they touch anything dirty. The administrator said staff should scrub their hands with soap for 20 seconds out of the water and turn the faucet with a paper towel so they do not recontaminate their hands. The administrator said all staff are trained on hand hygiene upon hire, annually and as needed. 3. Review of the facility's Sanitation of Dining and Food Service Areas policy, dated 2020, showed: -The Dining Services Manager will record the necessary cleaning and sanitation tasks for the department; -Tasks ill be designated to specific departmental positions; -All staff will be trained on the frequency of cleaning; -Staff will be held responsible for all cleaning tasks. Review showed the policy did not contain information related specifically to the cleaning and maintenance of the kitchen floors. Observations on [DATE] at 2:34 P.M., showed: -an excessive build-up of food debris and a white dried liquid substance under the clean side of the mechanical dishwashing station; -broken and missing pieces of tile in the water pitcher storage area; -an excessive build-up of dirt and debris along the edges of the kitchen floor next to the walls. During an interview on [DATE] at 2:34 P.M., the DM said the night shift staff are responsible for maintenance of the kitchen floor daily as well as when needed during other times by the other dietary staff. The DM said the staff should sweep and mop the entire kitchen floor when they clean it and he/she struggles with staff cleaning the floor in the dishwashing area. The DM said if something is broken it should be reported to maintenance for repair, but he/she thought maintenance already knew about the broken tiles. During an interview on [DATE] at 3:01 P.M., the administrator said the DM is responsible over all for the cleanliness and maintenance of the kitchen, but the evening shift staff are responsible to clean all of the kitchen floor daily and dietary staff should clean them as necessary. The administrator said if something in the kitchen, including the flooring, is broken they should notify maintenance for repair and they were making plans to do some work on the kitchen floor around the dishwasher. The administrator said he/she knew the kitchen floors were not very clean and, while he/she had tried to clean them, they needed to scrubbed and deep cleaned. 4. Review of the facility's Ice Handling and Cleaning policy, dated 2020, showed the policy directed that ice storage bins shall be drained through an air gap. Observation on [DATE] at 10:35 A.M., showed the kitchen ice machine drain located adjacent to two other plastic unidentified lines. Observation showed all three plastic lines were inserted into a larger piece of white plastic pipe that connected to the drain. Observation showed the ice machine drain did not have an air gap. Observation on [DATE] at 12:05 P.M., showed the ice machine located behind nurse station one contained a drain connected to a sink drain with white plastic piping glued to the sink drain. Observation showed the ice machine drain did not contain an air gap. During an interview on [DATE] at 12:05 P.M., the maintenance assistant said the ice machines were used to provide ice to all residents. The maintenance assistant said he/she did not know what an air gap was and did not know an air gap was required on ice machine drains. During an interview on [DATE] at 2:36 P.M., the DM said the maintenance staff are responsible for the maintenance of the ice machine and he/she did not know the ice machine drain did not have an air gap. During an interview an [DATE] at 3:05 P.M., the administrator said the maintenance staff are responsible for the maintenance of the ice machine and he/she did not know ice machines were supposed to have an air gap.

Based on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 51. 1. Review of the facility's Dining Services Manager Roles and Responsibilities policy, dated 2020, showed the policy directed for the dining services manager to comply with current public health and safety standards in all phases of the department's operation. Review showed the policy did not contain information related to the education and experience requirements for the dining services manager. Review of dietary manager's (DM) personnel records, showed a hire date of 05/11/23 as the Director of Food Services and an invoice for a certified dietary manager course enrollment dated 12/12/23. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 02/14/24 at 9:15 A.M., the administrator said the DM had been the DM for the last six to seven months. The administrator said the DM did not have prior dietary manager experience in a nursing facility or the certification or other education required to be the director of nutritional services, but they did enroll him/her into a certification course in December 2023. The administrator said they did not get the DM enrolled into the course until December because they had to figure out what course the DM needed to take and he/she believed the DM had started the course, but had not completed the first lesson to date. The administrator said the facility has a part-time registered dietician consultant and they did not have any certified or clinically qualified nutrition staff employed full-time. During an interview on 02/14/24 at 10:06 A.M., the DM said he/she had been employed as the facility's DM for eight months. The DM said he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or certification related to food service management. The DM said he/she started a food service management certification course about a month ago, but was still working on completion of the first lesson. The DM said it took so long to get him/her enrolled in the course, because they had to figure out what course he/she needed to take. The DM said the facility has a part-time consultant registered dietician that comes to the facility on ce a month and they did not have any certified or clinically qualified nutrition staff employed full-time.

Based on observation, interview, and record review, facility staff failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) for four cognitively impaired residents (Resident #11, #36, #39 and #41) after unwitnessed falls. The facility census was 51. 1. Review of the facility's policies showed staff did not provide a post fall policy for cognitively impaired residents. Review of the facility's Neurological Assessment Flow Sheet, showed neurological assessments are to be completed as followed: -Every 15 minutes for four times; -Every 30 minutes for two times; -Every 1 hour for two times; -Every 2 hours for two times; -Every 4 hours for two times; -Every 8 hours for four times. 2. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/12/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent with transfers, and toileting; -Has had two or more falls since admission, one fall with major injury; -Diagnosis of Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of the resident's nurse's notes, showed staff documented: -09/22/23 at 5:32 A.M., the resident had an unwitnessed fall; -09/30/23 at 9:10 A.M., the resident had an unwitnessed fall; -11/13/23 at 4:50 A.M., the resident had an unwitnessed fall. Review of the resident's medical record showed staff did not document a complete neurological assessment or document the continuous monitoring of the resident for 72 hours following the incident for the three unwitnessed falls. 3. Review of Resident #36's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Has had a fall with injury since admission; -Diagnosis of cerebral palsy (congenital disorder of movement, muscle tone, or posture, resulting in exaggerated reflexes, floppy or rigid limbs, and involuntary motions), epilepsy (a disorder of the brain characterized by repeated seizures), and intellectual disabilities (a term used when a person has certain limitations in cognitive functioning and skills, including conceptual, social and practical skills, such as language, social and self-care skills). Review of the resident's nurse's notes, showed staff documented the following: -08/27/23 at 4:11 A.M., the resident had an unwitnessed fall; -08/21/23 at 1:41 P.M., the resident had an unwitnessed fall; -09/07/23 at 1:28 A.M., the resident had an unwitnessed fall; -09/10/23 at 7:11 P.M., the resident had an unwitnessed fall; -10/20/23 at 11:00 A.M., the resident had an unwitnessed fall. Review of the resident's medical record showed staff did not document a complete neurological assessment or document the continuous monitoring of the resident for 72 hours following the incident for the five unwitnessed falls. During an interview on 02/16/24 at 11:08 A.M., the Assistant Director of Nursing (ADON)/Charge nurse said the resident has some cognitive deficit and might be a good historian post fall if asked right away if he/she was hurt. He/She said if the resident were asked 20-30 minutes later he/she would not be reliable. 4. Review of Resident #39's discharge MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Has had a fall with injury since admission; -Diagnosis of Ischemic stroke (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and dementia. Review of the resident's nurse's notes showed staff documented the following: -10/18/23 at 06:56 A.M., the resident had an unwitnessed fall; -12/21/23 at 09:47 P.M., the resident had an unwitnessed fall; -01/21/24 at 07:10 A.M., the resident had an unwitnessed fall. Review of the resident's nursing notes, dated 01/02/24, showed the resident had an Xray of his/her pelvis and bilateral hips and transferred to the hospital for an acute right hip fracture from the fall on 12/21/23. Review of the resident's medical record showed staff did not document a complete neurological assessment or document the continuous monitoring of the resident for 72 hours following the incident for the three unwitnessed falls. During an interview on 02/16/24 at 11:08 A.M., the ADON/Charge nurse said the resident is not cognitive enough to be reliable about events. He/She said he/she would initiate neuros if he/she had a fall. 5. Review of Resident #41's significant change MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Diagnosis of dementia, Hemiplegia (paralysis of on side of the body), and stroke (Damage to the brain from interruption of its blood supply). Review of the resident's nurse's notes showed staff documented the following: -08/13/23 at 4:26 P.M., the resident had an unwitnessed fall; -09/15/23 at 5:30 P.M., the resident had an unwitnessed fall; -12/11/23 at 6:14 A.M., the resident had an unwitnessed fall, found with head and neck on the pedals of his/her wheelchair, pupils were slow to respond and had complaints of neck and lower back pain, Resident was sent out to the hospital and returned at 12:30P.M.; -02/09/24 at 1:24 A.M., the resident had an unwitnessed fall. Review of the resident's medical record showed staff did not document a complete neurological assessment or document the continuous monitoring of the resident for 72 hours following the incident for the four unwitnessed falls. During an interview on 02/16/24 at 11:08 A.M., the ADON/Charge nurse said he/she would not consider this resident to be cognitive enough to recall if he/she hit his/her head. He/She said the resident has been getting more and more confused over the last 6 months. 6. During an interview on 02/16/24 at 11:08 A.M., the ADON/Charge nurse said basic falls require monitoring for 3 days post fall. He/She said that includes a full set of vital signs, including blood pressure, heart rate, pulse, respirations, oxygen saturation, temperature and pain, and general assessment. He/She said if the resident experienced any injury staff are expected to do a focused assessment on injury and if they hit their head then they also do neurological exams for the three days. He/She said when a fall occurs, they always call the family or responsible party and make sure they do not want the resident sent to the hospital for further evaluation. He/She said they notify the physician and verify there are no further orders needed. He/She said if they are a resident who is not cognitive, he/she likes to monitor them through his/her shift because resident who are not cognitive maybe be unsure of events and some may not even know they hit the floor. During an interview on 02/16/24 at 11:23 A.M., the DON said his/her expectation is that when a resident has fallen the charge nurse assessed the resident from head to toe, looking for any signs of broken skin, bones, or trauma, provides any first aide that is needed, and does a complete set of vitals including pain level. He/She said if the resident denies hitting his or her head and neuros are not warranted, based off of the nurse's assessment, then the resident is on a post fall assessment for 72 hours. If the resident shows signs of trauma to the head or neck and/or if the resident says they hit their head or was witnessed hitting their head, then the resident gets neuros and a post fall assessment for 72 hours. He/She said for residents who are not cognitive or reliable historians, the need for obtaining neurological exams is based off of nursing assessments. During an interview on 02/16/24 at 11:36 A.M., the administrator said his/her expectation post fall is that staff ensure the resident is safe for assessments, that they treat according to the type of injury, and follow nurse protocols and policy. 47193

Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments for the use of bed rails for five residents (Resident #3, #6, #7, #27 and #30). The facility census was 51. 1. Review of facility's policies showed staff did not provide a bed rail policy. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/05/23, showed staff assessed the resident as: -Cognitively intact; -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's electronic medical record (EMR), showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/13/24 at 10:40 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/14/24 at 9:23 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/16/24 at 9:15 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. 3. Review of Resident #6's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of multiple sclerosis (A disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage disrupts communication between the brain and the body); -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's EMR, showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/15/24 at 11:25 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/15/24 at 5:30 P.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/16/24 at 9:13 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. 4. Review of Resident #7's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of stroke (Damage to the brain from interruption of its blood supply); -Required partial assistance for lying to sitting, sitting to lying, and rolling left to right; -Bed rails not used. Review of the resident's EMR showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/15/24 at 11:11 A.M., showed the resident's had bilateral bed rails in the upright position. Observation on 02/16/24 at 9:30 A.M., showed the resident in bed with bilateral bed rails in the upright position. 5. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of heart failure; -Required full dependence for assistance with sit to stand, lying to sitting, sitting to lying, and rolling left to right; -Bed rails not used. Review of the resident's EMR, showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/14/24 at 3:49 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/15/24 at 9:30 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/16/24 at 9:18 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. 6. Review of Resident #30's Significant change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease); -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's EMR, showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/13/24 at 11:32 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/15/24 at 11:36 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/16/24 at 9:12 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. 7. During an interview on 02/16/24 at 10:55 A.M., the Assistant Maintenance Director said he only knows when to do entrapment assessments when told to do them by the Maintenance Director. He/She said he/she is unsure when or how often the assessment are to be done. During an interview on 02/16/24 at 11:08 A.M., Assistant director of nursing said residents must go through therapy to be evaluated to ensure the assistive bars are safe for the resident's mobility. He/She said once assessed and approved the Director of nursing (DON) obtains handles the rest. He/She is not sure of the process after that point. During an interview on 01/16/24 at 11:23 A.M., the Director of Nursing (DON) said if staff feel a resident can benefit from assistive bars therapy does an assessment and evaluates if a resident can safely use the bars for mobility. He/She said if the resident is approved by therapy, they fill an approval form and give it to him/her. He/She said after receiving the form he/she goes in and assesses the resident, puts a request for maintenance to put the bars on the bed in the TELS (a system used for maintenance that keeps track of their work orders and due dates) system and obtains an order from the physician to put in the resident's EMR. He/She is not sure how often maintenance does entrapment assessments. He/She knows he/she does do them when he/she installs the rails and if there is a change to the mattress or bed. He/She said he/she was not aware entrapment assessments were supposed to be done quarterly. He/She said if there is not an entrapment assessment in the resident's EMR then it is not done. During an interview on 02/16/24 at 11:36 A.M., the Administrator said in morning meetings they discuss the residents, therapy assessments and approving the device. He/She said the DON takes care of the nursing assessments and maintenance is responsible for the entrapment assessments and installation. He/She said maintenance does the entrapment assessments once the work orders are put into TELS, but he/she is not sure of how often maintenance is doing the entrapment assessments after that and he/she does not think he/she is doing them quarterly.

Based on interview and record review, facility staff failed to ensure two residents (Resident #18 and #44) have appropriate access to their trust fund account to include on the weekends. The facility census was 51. 1. Review of facility policies showed the facility did not have a policvy for availability of funds. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/3/23, showed staff assessed the resident as cognitively intact. During an interview on 02/15/24 at 1:30 P.M., the resident said, We don't have anyone at the facility on the weekend to give us money. The resident said he/she did not know what they would do if they needed money on the weekend. 3. Review of Resident #44's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 02/15/24 at 5:45 P.M., the resident said if the office is closed we don't get money, there is no one here on the weekends to give out money. The resident said we have to wait until the office is open during the day, during the week. The resident said, It sucks not to be able to get money in the evenings or weekends. He/She said sometimes if they want something out of the vending machine or a soda they just can't get it. During an interview on 02/16/24 at 9:45 A.M., the Account [NAME] Specialist (ABS) said the facility does not have petty cash. If a resident needs cash they come up to the office and we go to the bank that day and get them their money. The ABS said during nonbanking hours, there's not much they can do, it then depends on the family. These guidelines are discussed during admission, money is only available to the residents during banking hours. During an interview on 02/16/24 at 9:30 A.M., the Business Office Manager (BOM) said the facility does not keep petty cash for the residents, and his/her understanding is money only had to be available for the residents during business hours. The BOM said nothing she has read stated otherwise. The BOM said there is no policy but it is discussed at admission with the resident or their representative that money is only available during banking hours. During an interview on 02/16/24 at 11:45 A.M., the administrator said she was not aware that residents should have access to their money other then during business hours.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. Facility staff also failed to maintain food storage equipment clean and in good repair. The facility census was 61. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. -Rotate products so the oldest are used first. Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date. -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. -Store raw animal foods such as eggs, meat, poultry, and fish separately from cook and ready-to-eat food. If they cannot be stored separately, place raw meat, poultry and fish items on shelves beneath cooked and ready-to-eat items. If multiple shelves are available, the raw animal food with the highest final cooking temperatures should be stored on the lowest level, i.e. poultry and stuffed foods. -Never leave any food item uncovered and not labeled. Review of the facility's Labeling and Dating Foods (Date Marking) policy, dated 2020, showed: -Unopened cases of dry food items will be dated with the date the case was received into the facility and will be using first in-first out method of rotation. -Once a case is opened, the individual food items from the cases are dated with the date the item was received in the facility and placed in/on the proper storage unit utilizing the first in-first out method of rotation. -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date. Review of the facility's Maintenance Service policy, dated December 2009, showed: -The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. -Functions of the maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines. b. Providing routinely scheduled maintenance service to all areas. Observation on 11/01/22 at 9:30 A.M., showed the service station with the cereal and beverage dispensers contained a plastic container of fruit whirls cereal removed from the original packaging undated on top of the microwave and a dispensing scoop inside the coffee ground container with the handle of the scoop touching coffee grounds. Observation on 11/01/22 at 9:32 A.M., showed the first glass front reach-in refrigerator contained: -an opened one gallon bottle of italian dressing with a received date of 09/28/22; the bottle did not contain an opened date; -an opened 138 ounce (oz.) bottle of picante sauce with a received date of 07/27/22; the bottle did not contain an opened date. Observation on 11/01/22 at 9:33 A.M., showed the second glass front reach-in refrigerator contained an opened and undated one quart carton of half and half. Observation on 11/01/22 at 9:36 A.M., showed the reach-in freezer contained: -two opened and undated bags of tater tots; -a case of beef country fried steaks opened to the air and undated. Further observation showed a case of vanilla ice cream cups stacked on top of steaks where the bottom of the box touched the exposed steaks; -a case of seasoned beef patties opened to the air and undated; -a plastic bag of chicken tenders opened to the air and undated; -an opened and undated plastic bag of french fries; -an opened and undated plastic bag of hashbrowns; -a torn left facing door gasket seal. Observation on 11/01/22 at 9:47 A.M., showed the aide's preparation station contained: -two opened and undated five pound containers of peanut butter; -an opened and undated 20 oz. bottle of strawberry spread. Review of the product label showed instruction to refrigerate the product after it is opened; -a 24 oz. bag of gelatin dessert, dated 10/18/22, opened to the air; -an opened and undated 24 oz. bag of gelatin dessert; -an opened and undated 8.5 oz. bag of cheese puffs; -four opened and undated 16 oz. bags of classic potato chips. Observation on 11/01/22 at 9:50 A.M., showed the nonfunctional reach-in refrigerator used for the storage of dry goods with an accumulation of food debris on the bottom shelf. Review also showed the refrigerator contained: -an opened one gallon bottle fine red wine vinegar with a received date of 10/18 and an opened date of 4/15; -a second opened one gallon bottle fine red wine vinegar with a received date 10/18; the bottle did not contain an opened date; -an opened and undated one gallon bottle imitation vanilla flavoring; -two opened and undated one gallon bottles of apple cider vinegar; -an opened one gallon bottle of balsamic vinegar dated 12/21; -two opened one gallon bottles of corn syrup dated 11/24; -an opened one gallon bottle of soy sauce with a received date of 06/15/22; the bottle did not contain an opened date. Observation on 11/01/22 at 10:12 A.M., showed the cook's station contained: -a bulk container which contained an opened 25 pound bag of brown sugar. Observation showed a dispensing scoop inside the bag with the handle of the scoop in the brown sugar. Observation also showed the exterior of the container excessively soiled with food debris; -a bulk container which contained an opened 50 pound bag of granulated sugar. Observation showed a measuring cup inside the bag with the handle of measuring cup in the sugar. Observation showed the exterior of the container excessively soiled with food debris; -a bulk container which contained flour removed from the original packaging. Observation showed a dispensing scoop inside the bin and the handle of of scoop in the flour. Observation also showed the exterior of the container excessively soiled with food debris; -a bulk container which contained bread crumbs removed from the original packaging, dated 09/13/21. Observation also showed the exterior of container excessively soiled with food debris; -a bulk container which contained an opened 50 pound bag of yellow cornmeal. Observation showed both the container and bag were undated. Observation also showed the exterior of container excessively soiled with food debris; -a bulk container which contained an opened 50 pound bag of oats. Observation showed a measuring cup inside the bag with the handle of measuring cup in the oats. Observation also showed the exterior of the container excessively soiled with food debris; -a bulk container which contained corn starch removed from the original packaging, dated 10/20/21 with a dispensing scoop buried in the cornstarch. Observation also showed the exterior of container excessively soiled with food debris; -a bulk container, which contained navy beans, with the exterior of the container excessively soiled with food debris. Observation at this time also showed the exterior of the convection oven and the upper portion of the stand mixer, where attachments are inserted, covered with dried food debris and an accumulation of dirt, food debris and trash on the floor beneath the cooking equipment. Observation on 11/01/22 at 10:34 A.M., showed raw eggs stored above gallons of milk in the walk-in refrigerator. Further observation showed the door gasket seal torn and covered with an unidentifiable black substance. Observation on 11/01/22 at 10:37 A.M., showed the door gasket seal to the walk-in freezer torn and covered with an unidentifiable black substance. During an interview on 11/01/22 at 2:05 P.M., the administrator said he/she had trained one of the cooks to do some of the kitchen management duties, but he/she was currently in charge of the kitchen since the facility had not had a dietary manager since September 2022. The administrator said he/she was working on developing a cleaning schedule and felt the condition of the kitchen was a lot better than it was considering they had experienced staffing issues and most of the kitchen staff were new. The administrator said during his/her last visit, the registered dietician recommended someone to come in a do a deep cleaning of the kitchen just so they could get caught up. The administrator said opened food items should be covered, dated with a use by date, which is three days for prepared food items, or an opened date for already prepared items, like gallons of milk. The administrator said staff should use one thing before opening another like another so they ensure what came in or was opened first is used first. The administrator said raw food products that requiring cooking should not be stored by or above ready to eat food products. The administrator said he/she monitors the food storage a couple times a week when he/she puts the truck away and looks to see if food items are labeled, dated and sealed. The administrator said he/she does not look in the nonfunctioning reach-in refrigerator that is used for storage nor does he/she look at the bulk containers. The administrator said scoops should not be stored in the foods inside the bulk containers, but he/she did not think that he/she had trained staff on that requirement. The administrator also said he/she and the maintenance director work together to access things that need to be fixed and, while he/she knew about the gasket seal on the freezer door, he/she did not know about the other maintenance issues.

Based on staff interview and record review, the facility failed to electronically transmit quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments in a timely manner and in accordance with guidelines for three residents (Residents #5, #44, and #51). The facility census was 61. 1. Review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual, Version 1.17.1 dated October 2019 showed the following: -An Omnibus Budget Reconciliation Act of 1987 (OBRA) assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments; -Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). 2. Review of Resident #5's medical record showed: -An accepted quarterly MDS dated [DATE]; -A quarterly MDS dated [DATE] as in process; -The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date. 3. Review of Resident #44's medical record showed: -An accepted significant change MDS dated [DATE]; -A quarterly MDS dated [DATE] as in process; -The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date. 4. Review of Resident #51's medical record showed: -An accepted admission MDS dated [DATE]; -A quarterly MDS dated [DATE] as in in process; -The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date. During an interview on 11/04/22 at 11:20 A.M., the MDS coordinator said he/she tries to review and submit MDS data at least every other week. He/She said in process means the MDS is open and available for completion but not finished. He/She said he/she uses a dashboard to review MDS status' and all three residents' MDS submissions are late. During an interview on 11/04/22 at 11:42 A.M., the administrator said nursing staff sign off on the MDS and the MDS coordinator is responsible to ensure timely submissions.

Based on observations, staff interviews, and record review, the facility failed to provide safe mechanical lift transfers for four residents (Resident #3, #10, #12, and #16) in a manner to prevent accidents. Additionally, staff failed to safely store medications by leaving the medication cart unlocked and unattended. The facility census was 61. 1. Review of the facility's Storage of Medications policy, revised April 2019, directed staff to do the following: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner; - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use; - Unlocked medication carts are not left unattended. Observation on 11/01/22 at 4:11 P.M., showed a medication cart in the Covid isolation unit with the lock in the open position, with several layers of tape on it. The top drawer was able to be opened with little difficulty, and was stocked with over-the-counter medications. Further observation showed the remaining seven drawers could be opened, with the second drawer containing medication packets for residents on the unit; one packet identified contained [MEDICATION(S)], (an antidepressant and sedative medication used to treat depression). There were four residents in the Covid isolation unit without staff present. Observation on 11/04/22 at 9:00 A.M. showed the medication cart on the Covid isolation unit unlocked and without staff present. During an interview on 11/04/22 at 9:02 A.M., Certified Medication Aide/Certified Nurse Assistant (CMT/CNA) A said medication carts go into the med room when not in use, behind a locked door, and when in use, should be locked before leaving the cart. He/She said he/she was aware the medication cart was broken, and he/she notified other staff including maintenance. He/she said he/she did not know how long the medication cart has been broken. During an interview on 11/04/22 at 9:07 A.M., Registered Nurse (RN) F said medication carts should always be locked when staff are not with them. He/She said the medication cart in the Covid unit cart has tape around the lock and the lock is broken. RN F said staff use the TELS system (a building management software platform to track Life Safety tasks) to notify maintenance to repair broken items. He/She said he/she believed a key was locked in the cart and the lock had to be drilled out, and was unaware the lock was still not working. During an interview on 11/04/22 at 9:22 A.M., CMT/CNA C said medication carts should be locked all the time, especially if they are out in the open, otherwise they should be behind a locked med room door. CMT/CNA C said he/she would notify the DON, put the medication cart into a locked medication room, and enter a request into the TELS system for maintenance. He/She said the last time he/she worked in the Covid unit was a month ago and the lock was broken at that time. During an interview on 11/04/22 at 9:27 A.M., RN G said staff should always lock medication carts when staff are not with them, or should be locked in the medication storage room. He/She said staff should talk to maintenance to get it fixed as soon as possible, or use an extra medication cart that can be locked. The RN said if an extra cart is not available, then staff should keep the medication cart in a locked medication room. He/She said it has been several weeks since he/she last worked on the unit, and he/she was aware the medication cart lock was broken because maintenance had to drill the lock because keys were locked into it. During an interview on 11/04/22 at 9:34 A.M., the Director of Nursing (DON) said medication carts should always be locked when not in use or staff are away from them. If a cart needs repair, staff notify maintenance. He/She said he/she was aware of the medication cart in the Covid unit not locking, but thought maintenance fixed it. He/She was not aware it was still unable to be locked. During an interview on 11/04/22 at 11:25 A.M., the administrator said medication carts should remain locked at all times, and should only be accessible by appropriate certified personnel. The administrator said he/she was unaware the medication cart in Covid unit did not lock and just found out about it. He/She said staff should use TELS to notify maintenance, and the maintenance director should have followed up with company that owns the cart. During an interview on 11/04/22 at 11:28 A.M., the maintenance director said staff put requests into the TELS system and he/she checks every morning to see if there are any requests. He/She said the lock was drilled out after keys were locked in it, and he/she did not replace the lock. The maintenance director said it was an extra cart that had been in storage, and was supplied by the previous pharmacy the facility used. He/She said he/she should have called the company to get a new medication cart. He/She said he/she would dispose of the cart since it is unable to be repaired by the new pharmacy company. 2. Review of the facility's Lifting Machine, Using a Mechanical procedure guide, revised July 2017, showed staff are to check for proper sling placement, make sure the lift is stable and locked, and to gently support the resident during the transfer. Review of the mechanical lift instruction guide, undated, showed the guide instructed operators of the mechanical lift to keep the legs in the maximum opened/locked position while transferring the resident. 3. Review of Resident #16's quarterly Review Minimum Data Set (MDS) a federally mandated assessment tool, dated 8/5/22, showed staff assessed the resident as follows: -Cognitively intact; -Totally dependent on two staff for transfers, toileting, and personal hygiene; -Diagnosis of Parkinson disease. Observation on 11/1/22 at 2:08 P.M., showed CNA K and NA L transferred the resident from his/her wheelchair to a bed with a mechanical lift. CNA K and NA L placed the lift sling under the resident and attached the sling to the lift. The CNAs used the mechanical lift to transfer the resident from the wheelchair without spreading the legs of the lift to the fully open position as instructed. NA L did not assist with the guidance of the resident from the wheelchair to the bed. 4. Review of Resident #3's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers, toilet use, and personal hygiene; - Diagnosis of non-traumatic [CONDITION(S)] and Alzheimer's disease. Observation on 11/2/22 at 10:00 A.M., showed Certified Nurse Assistant (CNA) J and Nurse Aide (NA) L transferred the resident from his/her wheelchair to a bed with a mechanical lift. CNA J and NA L placed the sling under the resident and attached the sling to the lift. The CNAs used the mechanical lift to transfer the resident from the wheelchair without spreading the legs of the lift to the fully open position as instructed. NA L did not assist with the guidance of the resident from the wheelchair to the bed. During an interview on 11/2/22 at 10:15 A.M., CNA J said he/she does not spread the legs of the mechanical lift because the legs have to go under the wheelchair from the side. 5. Review of Resident #10's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers, toilet use, and personal hygiene; -Diagnosis of non-traumatic [CONDITION(S)]. Observation on 11/3/22 at 9:30 A.M., showed CNA K and NA L transferred the resident from his/her wheelchair to a bed with a mechanical lift. CNA K and NA L placed the sling under the resident and attached the sling to the lift. The CNAs used the mechanical lift to transfer the resident from the wheelchair without spreading the legs of the lift to the fully open position as instructed. NA L did not assist with the guidance of the resident from the wheelchair to the bed. 6. Review of Resident #12's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate Cognitive impairment; -Totally dependent on two plus staff for transfers, and toilet use; -Diagnosis of [CONDITION(S)]. Observation on 11/3/22 at 11:39 A.M., showed CNA K and NA L transferred the resident from his/her bed to a wheelchair with a mechanical lift. CNA K and NA L placed the sling under the resident and attached the sling to the lift. The CNAs used the mechanical lift to transfer the resident from the wheelchair without spreading the legs of the lift to the fully open position as instructed. NA L did not assist with the guidance of the resident from the wheelchair to the bed. 7. During an interview on 11/04/22 at 9:11 A.M., NA L said the hoyer lift should be done with two staff, one will guide the lift, one staff helps support or steady the resident. Staff should not walk away and leave only one staff controlling the lift. Staff are to close the legs of the lift when staff move away form the wheelchair to add more movability. During an interview on 11/04/22 at 9:15 A.M., CMT C said staff should get the sling organized correctly then hook it to the mechanical lift, then lift the resident and transport the resident to the bed or chair and while staff guides the resident. He/She said staff spread the mechanical lift legs when they get to the wheelchair. During an interview on 11/04/22 at 9:27 A.M., the DON said staff should get the resident ready to be transported, position the sling and use two staff. The mechanical lift goes under the bed with legs opened, staff then attach the sling to the lift. Staff should lift the resident, one staff drives the lift, and one staff supports the resident. He/She said staff go to the next position to lower the resident. The DON said the lift legs should remain open at all time with the resident is on the lift. During an interview on 11/04/22 at 9:47 A.M., the administrator said staff should put the sling on the resident correctly. Two staff operate the lift, one guides the resident and another operates the lift, and they should lower the resident. The mechanical lift legs should be open when moving the resident.

Based on observation, staff interview and record review, facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of [CONDITION(S)] medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for three residents (Residents #11, #19 and #27). The facility census was 61. Review of American Geriatrics Society (AGS) 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults showed: -Avoid antipsychotics for behavioral problems of dementia or [CONDITION(S)] unless nonpharmacological options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. -Strength of recommendation - Strong Review of [MEDICATION(S)] ([MEDICATION(S)]) product monograph (a factual, scientific document on a drug product that, devoid of promotional material, describes the properties, claims, indications and conditions of use of the drug and contains any other information that may be required for optimal, safe and effective use of the drug) revised 11/29/2021 showed: -[MEDICATION(S)] indications for use include [CONDITION(S)] and [CONDITION(S)] disorder; -[MEDICATION(S)] is not indicated for the treatment of elderly patients with dementia-related [CONDITION(S)]. Review of the prescribing information for [MEDICATION(S)]/[MEDICATION(S)] (antipsychotic) showed: -[MEDICATION(S)] is an atypical antipsychotic indicated for treatment of [CONDITION(S)] (a disorder that affects a person's ability to think, feel, and behave clearly), [CONDITION(S)] I disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and as an add on treatment for Major Depressive Disorder; -Elderly people with dementia-related [CONDITION(S)] (a mental disorder characterized by a disconnection from reality) treated with antipsychotic drugs are at an increased risk of death; -[MEDICATION(S)] is not approved for the treatment of patients with dementia-related [CONDITION(S)]. Review of FDA prescribing information showed [MEDICATION(S)] ([MEDICATION(S)] - an anticonvulsant) is indicated for single or add on therapy in the treatment of partial seizures. Review of the facility's Antipsychotic Medication Use, revised December 2016, showed the following: -Residents will only receive [CONDITION(S)] medications when necessary to treat specific conditions for which they are indicated and effective; -Diagnoses alone do not warrant the use of [CONDITION(S)] medications; -Antipsychotic medications shall generally be used only for the following conditions: [CONDITION(S)], schizo-affective disorder, schizophreniform disorder, [CONDITION(S)] disorder, [CONDITION(S)] in the absence of dementia, and [CONDITION(S)] disease; -Residents who are admitted from the community or transferred from a hospital and who are already receiving [CONDITION(S)] medications will be evaluated for the appropriateness and indications for use; -The interdisciplinary team will: re-evaluate the use of [CONDITION(S)] medication at the time of admission to consider whether or not the medication can be reduced, tapered, or discontinued. 1. Review of Resident #11's quarterly Minimum Data Set (a federally required assessment tool), dated 8/16/22, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Verbal behaviors directed toward others, one of three days of the look back period (seven day period of time before the assessment is completed to capture the status of a resident); -Received antipsychotic, antianxiety, antidepressant, and opioid medications seven out of seven days in the look back period; -Diagnoses of non-Alzheimer's dementia (a group of symptoms that can affect thinking, memory, reasoning, personality, mood and behavior), anxiety (feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), depression, high blood pressure, and non-traumatic brain dysfunction (injuries to the brain that are not caused by an external physical force to the head). Review of the resident's Physician Order Sheets (POS), dated November 2022, showed an order on 1/10/20 for [MEDICATION(S)] ([MEDICATION(S)] - antipsychotic) 2 milligram (mg) tablet at bedtime for generalized anxiety disorder. Review of the resident's medical record showed it did not contain an appropriate diagnosis for the use of the [CONDITION(S)] medication [MEDICATION(S)]. 2. Review of Resident #19's significant change MDS dated [DATE] showed staff assessed the resident as follows: -Moderate cognitive impairment -Minimal depression -No behaviors -Diagnoses included stroke, dementia, depression, [CONDITION(S)], peripheral vascular disease, kidney disease, diabetes, [CONDITION(S)] (rapid beating of upper heart chambers) -Received antidepressants six of the last seven days Review of the resident's POS, dated November 2022, showed an medication order on 9/29/22 for [MEDICATION(S)] (anticonvulsant) 300 mg twice a day for occlusion and stenosis of left carotid artery. Review of the resident's medical record showed it did not contain a documented history or diagnosis of seizures or an appropriate diagnosis for the use of the [CONDITION(S)] medication. 3. Review of Resident #27's quarterly MDS dated [DATE] showed staff assessed the resident as follows: -Moderate cognitive impairment -Minimal depression -No behaviors -Diagnoses included [CONDITION(S)] disease, dementia, depression, [CONDITION(S)], [CONDITION(S)] -Received antipsychotics and antidepressants for seven of the last seven days. Review of the resident's POS, dated November 2022, showed an order on 7/15/22 for [MEDICATION(S)] ([MEDICATION(S)] - antipsychotic) 50 mg tablet at bedtime for unspecified dementia with behavioral disturbance. Review of the resident's medical record showed it did not contain documentation to show an appropriate diagnosis for the use of the [CONDITION(S)] medications. 5. During an interview on 11/04/22 at 9:07 A.M., Registered Nurse (RN) F said for [CONDITION(S)] and antipsychotic medications it is not appropriate to have a diagnosis of anxiety or dementia. He/She said appropriate diagnoses would be [CONDITION(S)], [CONDITION(S)] disease and [CONDITION(S)]. During an interview on 11/04/22 at 9:27 A.M., RN G said it would be inappropriate to have a diagnosis of disruptive behaviors or anxiety as an indication for antipsychotic medications. It would be appropriate to have antipsychotic medications for hallucinations and delusions. RN G said he/she would look to see if the resident has an appropriate diagnosis, and if there were not an appropriate diagnosis, he/she would contact the physician to get an appropriate diagnosis for the medication. During an interview on 11/04/22 at 9:34 A.M., the Director of Nursing (DON) said appropriate diagnoses for psychotropics and antipsychotics would be [CONDITION(S)] disorder, [CONDITION(S)], manic depression, major depressive disorder. It would not be appropriate for diagnoses of anxiety or dementia. The DON said he/she would investigate if an error occurred with the diagnosis; did the resident have the appropriate diagnosis, and would then talk to the facility physician to get it corrected. He/She said the pharmacy review usually catches it and the facility physician is good about following gradual dose reductions and titration recommendations from the pharmacy. During an interview on 11/04/22 at 11:25 A.M., the administrator said he/she did not have a clinical background, but there should be appropriate diagnosis for pyschotropic and antipsychotic medication use. He/She said the DON is responsible for updating and checking to ensure the appropriate diagnosis is in place.

Based on observation, staff interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility staff also failed to keep the required daily staffing records for eighteen months. The facility census was 61. 1. Review of the facility's Posting Direct Care Daily Staffing Numbers, revised July 2016, showed the following: -Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; -Within two hours of the beginning of each shift, the number of Licensed Nurses (Registered Nurses, Licensed Practical Nurses, and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (Certified Nurses Aids) directly responsible for resident care will be posted in a prominent locations (accessible to residents and visitors) and in a clear and readable format; -Shift staffing information shall be recorded and the information recorded on the form shall include: - The name of the facility; - The date for which the information is posted; - The resident census at the beginning of the shift; - Type and category of nursing staff working during that shift; - Total number of licensed and non-licensed nursing staff working for the posted shift; - Records of staffing information for each shift will be kept for a minimum of eighteen months or as required by state law (whichever is greater). Review of the facility's records showed the facility did not retain nurse staff posting for the period of May 2022 through November 2022. Observations on 11/1/22 through 11/4/22 showed the nurse staffing hours were not posted. During an interview on 11/04/22 at 9:02 A.M., Certified Medication Technician/Certified Nurses Aid (CMT/CNA) A said the assignment sheet is posted at the nurse's station, but not the daily nurse posting. During an interview on 11/04/22 at 9:07 A.M., Registered Nurse (RN) F said nurse staffing should be posted near the front entrance in the display box, otherwise he/she has the daily assignment sheet at the nurse's stations. During an interview on 11/04/22 at 9:22 A.M., CMT/CNA C said the daily assignment is posted in the medication room or nurse's stations. He/She expects the nursing hours to be posted near the front entrance. During an interview on 11/04/22 at 9:27 A.M., RN G said he/she has not seen the daily staffing numbers, and is not sure where it would be unless it is posted near the entrance. During an interview on 11/04/22 at 9:34 A.M., the Director of Nursing (DON) said the if the nurse staffing hours were posted, it would be near the entrance, but it is not being done. The staffing coordinator is responsible and since the last staffing coordinator left, it has fallen through the cracks. The DON said he/she is responsible otherwise. The last staffing coordinator left in May 2022 and the daily nurse staffing hours have not been posted or saved since then, and there is no particular reason or excuse he/she could give for not getting it done. During an interview on 11/04/22 at 11:25 A.M., the administrator said he/she was not aware nurse staffing hours were not posted and he/she just found out today. He/She said the staffing coordinator should be responsible to ensure posting is done, and he/she failed to educate the staffing coordinator on his/her role to make sure the posting was complete. The administrator said the night charge nurse should post the information provided by the staffing coordinator at midnight for the next day.

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse, when a staff member slapped the resident's arm during care. The facility census was 63. The administrator was notified on 7/20/21 of past Non-Compliance which occurred on 7/10/21. On 7/10/21, the administrator identified Certified Nursing Assistant (CNA) C, slapped Resident #1 on the arm during care. Upon discovery, staff suspended CNA C on 7/10/21, conducted an investigation, notified appropriate parties, and terminated CNA C on 7/12/21. Facility staff were in-serviced on the facility abuse and neglect policies. Staff corrected the deficient practice on 7/10/21. 1. Review of the facility's abuse and neglect policy, dated March 2018, showed the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse or neglect. Review showed the management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 5/27/21, showed staff assessed the resident as: -Severe cognitive impairment; -Delusions, physical behaviors; -Extensive assistance two plus persons for mobility; -Extensive assistance toileting two plus persons; -Frequently incontinent of bladder; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's investigation, dated 7/10/21, showed the administrator documented she received a notice on 7/10/21 from Registered Nurse (RN) A of an allegation of physical abuse against Certified Nurse Assistant (CNA) C. Review showed CNA B said he/she witnessed CNA C slap the resident's arm, squeeze the resident's arm and dig his/her nails into the resident's skin. Review showed CNA B said he/she was in the room when this occurred. Review showed RN A informed the director of nursing (DON) immediately. Review showed CNA B documented in a written statement he/she witnessed CNA C slap the resident. Review showed CNA C documented in a written statement I was in a resident's room about 4:40 A.M. to get the resident ready for the day, he/she was getting combative with me and the other CNA. The resident grabbed my arm and out of reaction I slapped his/her hand. Review showed staff documented on 07/10/21 CNA C was suspended and terminated on 07/12/21. During a phone interview on 7/21/21 at 1:46 P.M., CNA B said CNA C and him/her were doing care with the resident who began to grab at them. CNA C got frustrated with the resident and called the resident a [OBSCENITY] and then grabbed his/her arm hard. CNA B said CNA C slapped the resident's arm hard as well as dug her/his nails into the resident's arm. CNA C then asked me not to tell. During a phone interview on 7/20/21 at 3:20 P.M., CNA C said he/she slapped the resident's arm to keep the resident from scratching him/her during care. We receive training on abuse by the facility. CNA C said he/she did not dig his/her nails into the resident's arm. During an interview on 7/20/251 at 11:45 A.M., the administrator said she suspended the CNA during the investigation and later terminated the employee. MO 876

Based on interview and record review, the facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when a staff member hit the resident on the forehead with an open palm, which resulted in a bruise. The facility census was 73. The administrator was notified on 09/01/2020 of Past Non-Compliance which occurred on. On 08/07/20, the administrator identified Certified Nursing Assistant (CNA) A physically abused the resident. Upon discovery, staff suspended the employee, conducted an investigation, notified appropriate parties, and terminated the CNA. Facility staff reviewed their abuse and neglect policies, and in-serviced all employees on abuse and neglect. Staff corrected the deficient practice on 08/07/20. 1. Review of the facility's Abuse Prevention Program, revised December 2016, showed residents right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint nt required to treat the resident's symptoms. Something about dignity. Additional review showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. -Required staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. -Develop and implement policies and procedure to aid the facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally required assessment, dated 6/12/20, showed staff assessed the resident as: -Severe cognitive impairment; -Behaviors directed toward others; -Required extensive assistance for bed mobility, dressing, toileting, personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's plan of care, updated 8/7/20, showed staff assessed the resident having altered skin integrity related to combativeness toward care staff. Review showed staff interventions to provide care from multiple staff may cause combativeness, reapproach later with less staff unless it is an immediate need, and reapproach later if need is not immediate when combative. Review of the facility's abuse and neglect investigation, dated 8/8/20, showed: -On 08/07/20, licensed practical nurse (LPN) D and LPN E, reported the resident had a bruise of unknown origin on her head. The bruise had been reported to LPN E from a nursing assistant (NA) that afternoon and reported to immediately to the administrator. NA B and NA C, recalled an incident when they were giving care to the resident when the bruise may have occurred. The incident involved a third staff member, NA A. Statements were obtained. In response to statements from NA B, and NA C; -The administrator, DON and LPN F, called NA A for his/her statement. NA A said, during care, the resident was biting him/her and he/she hit the resident with the palm of his/her hand out of reflex; -NA A was suspended immediately. NA A to be terminated when final wages are prepared. -Self report was made through online reporting system at approximately 5:00 P.M. on August 7th, 2020; -Interventions include: notified physician, resident representative,and Hospice. -Self report to Department of Health and Senior Services, suspended staff member under investigation, resident skin assessment, documented bruise event, order to monitor bruise, updated care plan, contact hospice in regards to needing help with the resident's behaviors and order recommendation, inserviced staff on resident abuse; reporting; dealing with combative residents. Social Services gathered resident statements, and documentation inservice. Review of a written statement, dated 8/7/20, showed NA B documented NA A hit resident #1 on the forehead with an open palm on July 21st, 2020, when the resident was biting NA C during incontinent care. NA B continued, NA C showed NA B the bite and a start of a left chest bruise from where the resident punched him/her. NA B then said she told LPN G of the discoloration on the resident's forehead and a skin tear on the resident's hand. LPN G observed the resident's forehead and said nothing and then applied steri-strips to the resident's hand. Review of a written statement, dated 8/7/20, showed NA C documented the resident was hitting, scratching, and biting him/her and NA A during incontinent care. NA A hit the resident on his/her forehead to get him/her to stop biting NA C. At some point during this situation, the resident also bit NA A. LPN G came into the room and asked who was bit. That is when NA A and NA C went to the treatment cart to get their wounds cleaned and bandaged by LPN G. During an interview on 8/24/20 at 1:00 P.M., NA B said NA A made contact with the resident's forehead with the heel of her hand when the resident was biting him/her and NA C during incontinent care. NA B said she thought NA C reported the incident to LPN G when he/she cleaned NA C's bite wound at the treatment cart in the hall. During an interview on 8/24/20 at 1:15 P.M., NA C said NA A made contact to Resident #1's forehead with the heel of his/her hand when the resident was biting NA C. NA C continued to say he/she did not know that the resident had a bruise on forehead until the next day. He/She said he/she believed that LPN G was told about the incident by NA A. LPN G cleaned NA C's and NA A's bite wounds after incident. He/She went in the rersident's room to help the NAs. He/She said he/she was not aware NA A hit the resident and if he/she would have known, he/she would have walked NA A out of the building immediately. He/She did not document the incident and did not do an incident report. During an interview, dated 8/7/20 at 1:30 P.M., LPN G said CNA A and CNA C was bit by the resident during incontinent care. He/She continued, the resident had a fresh skin tear on hand afterward. The resident bruises easily and has many bruises from being combative. On the day of the incident, he/she went in the resident's room to help the NAs. He/She said he/she was not aware NA A hit the resident and if he/she would have known, he/she would have walked NA A out of the building immediately. He/She did not document the incident and did not do an incident report. Review of the resident's progress notes, dated 8/7/20 at 4:37 P.M., showed LPN D documented that he/she was informed the resident had bruising of unknown origin on the forehead, back of head, and bicep. The DON and ADM was notified immediately upon discovery. Review showed the resident's representative was notified by telephone, as was Hospice, and the resident's doctor. During an interview on 8/14/20 at 11:41 A.M., LPN D said NA C told him/her and LPN H that on 7/21/20, NA A had bopped the resident on the forehead when the resident was biting the NA's arm during incontinent care. LPN D said he/she and LPN H reported this to the ADM and DON immediately. During an interview on 8/14/20 at 3:20 P.M., LPN H said he/she and LPN D, noted and assessed the bruise on the resident's forehead at about 4:30 P.M. on 8/7/20. Review showed staff documented they determined the bruise of unknown origin and reported to the ADM and DON immediately. During an interview on 8/14/20 at 11:41 A.M., LPN D said NA C said on 7/21/20, NA A had bopped the resident on the forehead when the resident was biting him/her on the arm during incontinent care. During an interview on 8/14/20 at 2:40 P.M., LPN E said on 8/7/20 he/she observed a bruise on the resident's forehead. He/She said NA B and NA C said that on 7/21/20, NA A hit the resident on the forehead when the resident was biting his/her arm during incontinent care. LPN E immediately reported this to the ADM and DON. During an interview on 8/14/20 at 11:41 A.M., LPN D said NA C said on 7/21/20, NA A had bopped the resident on the forehead when the resident was biting him/her on the arm during incontinent care. During a telephone interview on 9/1/20 at 10:53 A.M., NA A, said on July 21, 2020, at the beginning of evening shift, the resident was extremely combative by hitting, kicking, and biting the nursing assistants as they were cleaning the resident up from a liquid bowel movement that had soaked through his/her clothing. The resident bit him/her on the arm and his/her arm was pinched in the resident's teeth. The resident would not let go, and out of reflex, NA A open hand bopped the resident on the forehead. He /She said he/she wishes to God he/she had not done it. The resident would not let go. He/She said he/she ripped his/her arm out of the resident's mouth and it took a chunk of skin. The bruise on the resident's forehead did not show up right away. MO 731

Based on observation and interview, facility staff failed to allow kitchenware to air dry prior to stacking in storage or use to prevent the growth of food-borne pathogens. The facility census was 76. 1. Observation on 09/24/19 at 9:57 [NAME]M., showed Dietary Aide (DA) B removed sanitized dishes from the mechanical dishwasher and stacked the dishes while wet. 2. Observation on 09/24/19 at 10:25 [NAME]M., showed 40 metal food preparation and service pans of various sizes stacked together wet on the shelf beneath the countertop in cook's station. During an interview on 09/24/19 at 10:27 [NAME]M., the Certified Dietary Manager (CDM) said all dishes should air dry before they are put away and all staff are staff are trained on this requirement. 3. Observation on 09/24/19 at 10:30 [NAME]M., showed Cook C removed two wet metal pans from the clean side of the dishwashing station, used paper towels to dry the pans and then filled the pans with prepared mashed potatoes for service to the residents at the noon meal. 4. During an interview on 09/26/19 at 3:53 P.M., the administrator said staff should allow dishes to air dry prior to stacking in storage and all staff are trained on this requirement. The administrator said he/she expects the CDM to monitor dishwashing and storage daily when he/she is working and staff had not reported any issues with dish storage recently.

Based on interview and record review, facility staff failed to complete a significant change in status (SCSA) Minimum Data set (MDS) for four resident's (Resident #21, #32, #49 and #57) following a significant change in condition. The facility census was 76. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/18, directs staff as follows: -Comprehensive Assessments are required comprehensive assessments include the completion of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. They consist of: -Admission Assessment -Annual Assessment -Significant Change in Status Assessment -Significant Correction to Prior Comprehensive Assessment -The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an Admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change. A significant change is a major decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; -Impacts more than one area of the resident's health status; and -Requires interdisciplinary review and/or revision of the care plan. o An SCSA is appropriate when: - There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and - The resident's condition is not expected to return to baseline within two weeks. o A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. 1. Review of Resident #21's annual Minimum Data Set (MDS), a federally mandated assessment, dated 4/17/19, showed the staff assessed the resident as: -Severe cognitive impairment; -Weight 149 pounds (lbs.); -No pressure ulcers. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Weight 173 lbs.(16% significant weight gain); -Stage 3 pressure ulcer. Review of the resident's MDS's showed staff did not complete a SCSA after significant changes to the resident's weight, and development of a stage 3 pressure ulcer. 2. Review of Resident #32's annual MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment (brief interview for mental status-BIM score of 10); -Ambulation did not occur; -Required limited physical assistance from staff for bed mobility, transfers, dressing, toilet use, and hygiene; -No pain present, and did not receive pain medication. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment (BIM score of 3); -Required extensive physical assistance from staff for bed mobility, transfers, ambulation in the room and corridor, dressing, toilet use, and hygiene; -Required as needed pain medication; -Presence of moderate pain occasionally. Review of the resident's MDS's showed staff did not complete a SCSA after significant changes to the resident's Activities of Daily Living (ADL's), cognition, and new pain. 3. Review of Resident #49's SCSA MDS, dated [DATE], showed the staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance of two or more staff members for transfers and toilet use; -Did not received scheduled pain medication; -No signs of pain; -No shortness of breath; -No diuretic medication. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff for transfers, and toilet use; -Received scheduled pain medication -Vocal and facial expressions of pain or possible pain; -Shortness of breath while lying flat; -Diuretic medication received daily. Review of the resident's MDSs showed the staff did not complete a SCSA when the resident required more assistance with his/her ADLs, new pain, new shortness of breath, and required the new use of diuretic medication. 4. Review of Resident #57's annual MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment (BIM 9); -Independent with bed mobility, transfers, and toilet use; -Always continent of bowel and bladder. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment (BIM 9); -Occasionally incontinent of urine; -Always continent of bowel; -Required staff supervision with dressing, toilet use and hygiene. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment (BIM 5); -Frequently incontinent of urine -Frequently incontinent of bowel; -Required limited assistance (one person physical assist) from staff for dressing, toilet use and hygiene. Review of the resident's MDSs showed the staff did not complete a SCSA when the resident required more assistance with his/her cognition, ADL's and decline in urine and bowel continence. 5. During an interview on 9/27/19, at 2:59 P.M., the MDS coordinator (MDSC) said SCSAs are done with two changes in ADLs or Hospice, or two care areas. He/She said he/she compares the current assessment to the last assessment, but does not compare it to the last comprehensive assessment. He/She said the facility does not have a process in place to catch the changes that happen over time. During an interview on 9/27/19, at 3:05 P.M., the director of nursing (DON) said he/she expects the MDSC to complete the SCSA according to the RAI Manual.

Based on observation, interview, and record review, facility staff failed to update the plan of care with changes in residents' needs for four residents (Resident #21, #32, #41, and #62). The facility census was 76. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/18, showed the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan is an interdisciplinary communication tool. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. The Care Area Assessments (CAA)'s provide a link between the Minimum Data Set (MDS), a federally mandated assessment tool, completed by facility staff, and care planning. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. Review of the facility's care plan policy, dated (MONTH) (YEAR), showed it directs the staff as follows: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; -Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. -The interdisciplinary team must review and update the care plan: a. With a significant change in the resident's condition; b. Desired outcome is not met; c. readmitted to the facility from a hospital stay, and d. Quarterly in conjunction with the required quarterly MDS assessment. 2. Review of Resident #21's annual Minimum Data Set (MDS), a federally mandated assessment, dated 4/17/19, showed staff assessed the resident as: -Severe cognitive impairment; -Weight 149 pounds (lbs.); -No pressure ulcers. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Weight 173 lbs.(16% significant weight gain); -Stage 3 pressure ulcer. Review of the resident's care plan, last updated 8/1/19, showed it directed the staff: -At risk for pressure ulcers; -Goal: the resident will not develop any pressure ulcers; -Nutrition Risk related to dysphagia (difficulty swallowing), nutritional [MEDICAL CONDITION], anorexia, and [MEDICAL CONDITION]; -Goal: Maintain current weight -Supplement for weight gain (med pass) three times a day; Review of the resident's care plan showed it did not address the resident's development of a wound with new interventions to treat the wound, or the resident's significant weight gain with a [DIAGNOSES REDACTED]. 3. Review of Resident #32's annual MDS, dated [DATE], showed the staff assessed the resident as: -Moderate cognitive impairment; -Ambulation did not occur; -Required limited physical assistance from staff for bed mobility, transfers, dressing, toilet use, and hygiene; -No pain present, and did not receive pain medication. Review of the resident's quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Severe cognitive impairment; -Required extensive physical assistance from staff for bed mobility, transfers, ambulation in the room and corridor, dressing, toilet use, and hygiene; -Required as needed pain medication; -Presence of moderate pain occasionally. Review of the resident's care plan, last updated 9/20/19, showed it directed the staff: -Unable to perform activities of daily living (ADL's) independently; -Requires limited assistance with bed mobility, dressing, toilet use, and transfers. The care plan showed it did not contain directions or interventions to the staff to reflect the ADL changes on the most recent MDS. 4. Review of Resident #41's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Bed mobility extensive assistance 2 plus persons; -Transfer extensive assistance 2 plus persons; -Eating extensive assistance 1 person. Review of the resident's care plan, last updated 8/8/19, showed staff assessed the resident as: -Unable to perform ADL's independently; -Requires extensive assistance with bed mobility, dressing, and transfer; -Eating as independent provide tray set up. The care plan did not contain directions or interventions to the staff to reflect the ADL changes on the most recent MDS. 5. Review of Resident #62's admission MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited assistance with bed mobility, and transfers; -Required extensive physical assistance from staff members with toilet use; -One fall with injury and one fall without injury. Review of the resident's care plan, last updated 9/5/19, showed staff documented the following: -At risk for falls; -Fall on 8/9/19, and 8/15/19; -Goal: will not have falls with injury; -Independent with mobility, assist as needed; -Extensive assistance with transfers; -Fall mats at bedside; -Hi/low bed; -Ensure call light is in reach. Review of the resident's nurses notes, dated 9/16/19, showed staff documented the resident was found lying on the floor on his/her stomach. The resident had an abrasion to his/her left forehead with slight swelling and bruising to his/her left eye. Review of the resident's nurses notes, dated 9/17/19, showed staff documented the resident was sent to the emergency room for a CAT scan of his/her head. Observation on 9/25/19, at 11:15 [NAME]M., showed the resident in his/her wheelchair in the hallway. Observation showed the resident with bruising to his/her forehead, around his/her eyes, down both cheeks to his/her chin, with a large knot on his/her head with a laceration. Review of the resident's care plan showed it did not contain staff documentation of reevaluation, new interventions to prevent future falls, or updates after the resident had a significant fall. 6. During an interview on 9/27/19, at 2:38 P.M., registered nurse (RN) A said the charge nurses are expected to fill out a change notification and send to the Care Plan coordinator (CPC) to update the care plans immediately. During an interview on 9/27/19, at 2:59 P.M., the MDSC said the CPC updates and the care plans are expected be up to date with the resident's current condition. He/She said he/she and the CPC discuss the changes that need to be made from the MDS, and the charge nurses send change notifications when changes occur. During an interview on 9/27/19, at 3:00 P.M., the CPC said he/she is responsible for updating the care plans. He/She said he/she does the updates he/she is notified about, so if they are not updated then he/she did not get the information. During an interview on 9/27/19, at 2:39 P.M., the director of nursing (DON) said the care plans are expected to be updated with any kind of change. He/She said the care plans are expected to reflect the resident's current care needs.

Based on interview, and record review, facility staff failed to follow physician's orders for notification of the physician for blood glucose (sugar) results out of the acceptable range of parameters set by the physician for one resident (Resident #13) out of 2 sampled residents. The facility census was 76. Review of the facility's policy Change in a Resident's Condition or Status, dated (MONTH) (YEAR), showed it directed the staff: -Promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status; -The nurse will notify the resident's attending physician or physician on call when there has been a (an) specific instruction to notify the physician of changes in the resident's condition. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 7/19/19, showed the staff assessed the resident as: -Cognitively intact; -[DIAGNOSES REDACTED]. -Received Insulin daily; -Orders for insulin seven out of the last seven days. Review of the resident's Physician's Orders, dated 7/1/19-7/31/19, showed it directed the staff to: -Obtain blood glucose checks before meals and at bedtime, and call the physician for blood glucose less than 60 or greater than 400; -Administer [MEDICATION NAME] U-100 insulin 100 unit/ml (milliliter), sliding scale, if below 60 call physician, 200-249 give 2 units, 250-299 give 4 units; 300-349 give 6 units; 350-399 give 8 units; 450-499 give 12 units, before meals; -Administer [MEDICATION NAME] U-100 insulin 100 unit/ml, 15 units before meals, hold if blood glucose less than 200; -7/1/19-7/14/19 [MEDICATION NAME] 100 units/ml administer 60 units twice daily; -7/1619-7/17/19 [MEDICATION NAME] 100 units/ml administer 60 units twice daily; -7/17/19-7/24/19 [MEDICATION NAME] 100 units/ml administer 50 units daily; -7/24/19-7/29/19 [MEDICATION NAME] 100 units/ml administer 50 units twice daily; -7/29/19-7/31/19 [MEDICATION NAME] 100 units/ml administer 55 units twice daily. Review of the resident's Medication Administration Record [REDACTED] -7/1/19 7:00 P.M.-10:00 P.M., blood glucose 414; -7/20/19 4:00 P.M.-5:00 P.M., blood glucose 431; -7/21/19 4:00 P.M.-5:00 P.M., blood glucose 478; -7/22/19 4:00 P.M.-5:00 P.M., blood glucose 436; -7/22/19 7:00 P.M.-10:00 P.M., blood glucose 499; -7/23/19 11:00 [NAME]M.-12:00 P.M., blood glucose 413; -7/23/19 4:00 P.M.-5:00 P.M., blood glucose 500; -7/25/19 11:00 [NAME]M.-12:00 P.M., blood glucose 430; -7/26/19 4:00 P.M.-5:00 P.M., blood glucose 468; -7/27/19 4:00 P.M.-5:00 P.M., blood glucose 425. Review of the resident's nurses notes, dated 7/1/19-7/23/19, showed it did not contain documentation to show the staff notified the physician of the blood glucose results when they were outside of the physician ordered parameters. Review of the resident's nurses notes, dated 7/25/19-7/27/19, showed it did not contain documentation to show the staff notified the physician of the blood glucose results when they were outside of the physician ordered parameters. Review of the resident's Physician's Orders, dated 8/1/19-8/31/19, showed staff are directed as follows: -Obtain blood glucose checks before meals and at bedtime, and call the physician for blood glucose less than 60 or greater than 400; -Administer [MEDICATION NAME] U-100 insulin 100 unit/ml (milliliter), sliding scale, if below 60 call physician, 200-249 give 2 units, 250-299 give 4 units; 300-349 give 6 units; 350-399 give 8 units; 450-499 give 12 units, before meals; -Administer [MEDICATION NAME] U-100 insulin 100 unit/ml, 15 units before meals, hold if blood glucose less than 200; -8/1/19-8/9/19 [MEDICATION NAME] 100 units/ml administer 55 units twice daily; -8/9/19-8/31/19 [MEDICATION NAME] 100 units/ml administer 60 units twice daily. Review of the resident's Medication Administration Record [REDACTED] -8/3/19 4:00 P.M.-5:00 P.M., blood glucose 468; -8/26/19 7:00 P.M.-10:00 P.M., blood glucose 524; -8/28/19 4:00 P.M.-5:00 P.M., blood glucose 522; -8/28/19 7:00 P.M.-10:00 P.M., blood glucose 522; -8/29/19 4:00 P.M.-5:00 P.M., blood glucose 425; -8/29/19 7:00 P.M.-10:00 P.M., blood glucose 525. Review of the resident's nurses notes, dated 8/1/19-8/27/19, showed it did not contain documentation to show the staff notified the physician of the blood glucose results when they were outside of the physician ordered parameters. Review of the resident's nurses notes, dated 8/28/2019, showed the staff documented they notified the physician after the 4:00 P.M. to 5:00 P.M. blood glucose level. Additional review showed the physician ordered to administer the prescribed sliding scale dose and recheck at bedtime and notify the physician if the blood glucose is elevated. Further review showed the documentation did not contain documentation to show staff notified the physician when the bedtime blood glucose continued to be elevated. Review of the resident's nurses notes, dated 8/29/19-8/31/19, showed it did not contain documentation to show the staff notified the physician of the blood glucose results when they were outside of the physician ordered parameters. Review of the resident's Physician's Orders, dated 9/1/19-9/27/19, showed staff are directed as follows: -Obtain blood glucose checks before meals and at bedtime, and call the physician for blood glucose less than 60 or greater than 400; -Administer [MEDICATION NAME] U-100 insulin 100 unit/ml (milliliter), sliding scale, if below 60 call physician, 200-249 give 2 units, 250-299 give 4 units; 300-349 give 6 units; 350-399 give 8 units; 450-499 give 12 units, before meals; -Administer [MEDICATION NAME] U-100 insulin 100 unit/ml, 15 units before meals, hold if blood glucose less than 200; -9/1/19-9/11/19 [MEDICATION NAME] 100 units/ml administer 60 units twice daily; -9/11/19-9/27/19 [MEDICATION NAME] 100 units/ml administer 55 units twice daily. Review of the resident's Medication Administration Record [REDACTED] -9/19/19 11:00 [NAME]M.-12:00 P.M., blood glucose 491; -9/24/19 7:00 P.M.-10:00 P.M., blood glucose 57. Review of the resident's nurses notes, dated 9/19/19-9/24/19, showed the documentation did not contain documentation to show the staff notified the physician with blood glucose levels that were out of the parameters the physician ordered. During an interview on 9/27/19, at 2:30 P.M., the registered nurse (RN) A said if a diabetic resident's blood glucose is out of physician parameters, then staff are expected to call the physician for further orders. He/She said staff are expected to document the physician notification in the resident's progress notes, or there may be a one time order. He/She did not know why staff did not document the physician was notified, or if the physician was notified. During an interview on 9/27/19, at 2:36 P.M., the director of nursing (DON) said if a diabetic resident's blood glucose is out of physician parameters, then staff are expected to call the physician for further orders. He/She said staff are expected to document the physician notification in the resident's progress notes.

Based on interview and record review, facility staff failed to develop and implement policies and procedures for the inspection, testing and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). Facility staff also failed to sanitize resident glucometers (machine used to test blood sugar levels) appropriately for five residents (Residents #1, #10, #22, #23, and #44), and failed to provide perineal care in a manner to prevent the spread of infection for two residents (Residents #1 and #3). The facility census was 83. 1. Review of the facility's building maintenance, inspection and testing records, showed the records did not contain documentation of a water management program to monitor the facility's water systems for the growth of waterborne pathogens and prevent LD. During an interview on 12/06/18 at 1:07 P.M., the administrator said he/she did not have policies and procedures for the inspection, testing and maintenance of the facility water systems and he/she did not know of the requirement to develop a water management program to prevent the growth of waterborne pathogens. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppressive. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In (YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. 2. Review of the facility's Obtaining a Fingerstick Glucose Level Policy, dated (MONTH) 2011, showed staff are directed to ensure glucometers are cleaned and disinfected between resident uses. Review of the glucometer's manufacturer disinfecting instructions showed the manufacturer recommends disinfecting the meter after use on each patient. Further review showed that the manufacturer recommended following disinfectant wipe instructions to properly disinfect the meters. Observation on 12/6/18 at 11:17 A.M., showed Certified Medication Technician (CMT) G placed Resident #1's glucometer directly onto the resident's bed. Further observation showed the CMT did not place a protective barrier prior to placing the glucometer on the bed. The CMT did not sanitize the glucometer, placed it on top of the medication cart, and then placed the glucometer into the medication cart with other residents' glucometers. Observation on 12/6/18 at 11:25 A.M., showed CMT G placed Resident #22's glucometer directly onto the counter. Further observation showed the CMT did not place a protective barrier on the counter or sanitize the surface prior to placing the glucometer onto the surface. Observation showed the CMT then placed the glucometer directly on the medication cart without a protective barrier in place. The CMT wiped the glucometer quickly with a sanitizing wipe, and placed the glucometer into the medication cart on top of other residents' glucometers. Observation of the sanitizing wipes package showed it directed staff to disinfect items allow treated surface to remain wet for two minutes. Observation on 12/6/18 at 11:40 A.M., showed CMT G placed Resident #10's glucometer directly onto the resident's bare leg. Further observation showed the CMT did not place a protective barrier on the residents' leg. Observation showed the CMT then placed the glucometer directly on the medication cart without a protective barrier in place. The CMT then wiped the glucometer quickly with a sanitizing wipe, and placed the glucometer back onto the medication cart without a protective barrier in place. Observation of the sanitizing wipes package showed it directed staff to disinfect items allow treated surface to remain wet for two minutes. Observation on 12/7/18 at 11:05 A.M., showed CMT H placed Resident #44's glucometer and lancet directly onto magazines on the resident's bedside table without a protective barrier. Observation showed the CMT then placed the glucometer directly on the counter without a protective barrier to wash his/her hands.The CMT wiped the glucometer with a sanitizing wipe quickly and placed it into the medication cart with other residents' glucometers. Observation of the sanitizing wipes package showed it directed staff to disinfect items allow treated surface to remain wet for two minutes. During an interview on 12/7/18 at 11:40 A.M., CMT H said staff are instructed to wipe the glucometers down before going into the residents' room and again when they come out of the room. During an interview on 12/7/18 at 2:03 P.M., Director of Nursing (DON) said that they use the purple sanitizing wipes on the glucometers before and after each use. He/she said that they sanitize the glucometers according to the manufacturer instructions which say to use the wipes. He/she said they then sanitize according to what the wipes say. The DON said that he/she expects staff to lay the glucometer on a clean surface and not directly on a table without a protective barrier. The DON said that he/she expects staff to sanitize scissors before and after use and when going from dirty to clean just like handwashing. During an interview on 12/7/18 at 2:03 P.M., the administrator said he/she expects staff to keep the glucometer moist as long as the wipes indicate. 3.Review of the facility's policy for Perineal Care, dated (MONTH) 2010, instructs staff to cleanse perineal area, wiping front to back. Instruct or assist the resident to turn on his/her side with top leg slightly bent, if able. Cleanse the rectal area thoroughly, wiping from the base towards and extending over the buttocks. 4. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Severely Impaired Cognition; -Extensive, two person assist with bed mobility, dressing and toilet use; -Extensive, one person assist with personal hygeine; -Total, one person assist with bathing; -Always incontinent of bowel and bladder. Observation on 12/05/18 at 09:57 A.M., showed Certified Nursing Assistant (CNA) D and CNA C entered the resident's room to provide incontinence care. The CNAs washed their hands and donned gloves. Further observation showed the resident incontinent of bowel and bladder. CNA D cleansed the bowel movement from the resident's buttocks. CNA D turned the resident on his/her back and provided front perineal care with the same contaminated gloves. The CNA did not provide care in a manner to prevent the spread of infection. 5. Review of Resident #3's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately impaired cognition; -Extensive, one person assist with bed mobility, dressing and personal hygeine; -Extensive, two person assist with transfers and toilet use; -Total, one person assist with bathing; -Always incontinent of urine; -Frequently incontinent of bowel. Observation on 12/07/18 at 09:34 A.M., showed CNA C and CNA B entered the resident's room to provide incontinence care. Further observation showed the resident incontinent of bowel and bladder. CNA B and CNA C washed hands and donned gloves. CNA B cleansed the bowel movement from the resident's buttocks and then cleansed the resident's front perineal area, without changing his/her gloves or washing his/her hands. CNA B then touched the resident's clean brief before he/she washed his/her hands or removed his/her gloves. The CNA did not provide care in a manner to prevent the spread of infection. 6. During an interview on 12/07/18 at 09:44 A.M., CNA B said staff should wash hands and put on gloves when they enter the resident's room. If staff get dirty on their gloves during care staff should change them. After the resident is changed staff should take gloves off and wash hands, cover the resident up and wash hands before leaving room. When staff provide incontinence care staff should go front to back staff should never go back to front. CNA B said, I did the residents backside first because I do the dirty first. I forgot to change my gloves I know I should have. During an interview on 12/07/18 at 10:36 A.M., Licensed Practical Nurse (LPN) A said when staff provide incontinence care, they should enter a room ,wash hands, put on gloves, and designate a clean staff and a dirty staff. Dirty staff are expected to clean the front everywhere the brief touches, use clean wipe with each swipe, wash hands change gloves then clean the back perineal area. Staff are also expected to wipe residents front to back. Staff should wash hands and put clean gloves on before they touched clean resident items, and wash hands before leaving the resident's room. During an interview on 12/7/18 at 2:03 P.M., theDirector of Nursing (DON) said that they use the purple sanitizing wipes on the glucometers before and after each use. He/she said that they sanitize the glucometers according to the manufacturer instructions which say to use the wipes. He/she said they then sanitize according to what the wipes say. The DON said that he/she expects staff to lay the glucometer on a clean surface and not directly on a table without a protective barrier. The DON said that he/she expects staff to sanitize scissors before and after use and when going from dirty to clean just like handwashing. During an interview on 12/7/18 at 2:03 P.M., Administrator said that he/she expects to keep the glucometer moist as long as the sanitizing wipe manufacturer's recommendations indicate.

Based on interview and record review, facility staff failed to obtain stop dates of 14 days or less on as needed (PRN) [MEDICAL CONDITION] medications (chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior), for four sampled residents (Residents #13, #24, #28, and #64). The facility census was 83. 1. Review of the facility's policy, Pharmacy Plan for review over the next several months, dated 10/26/18, showed staff are directed as needed (PRN) orders for [MEDICAL CONDITION] medications should have a stop date assigned and entered into the electronic medical record. 2. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 8/31/18, showed staff assessed the resident as: -Cognitive; -[DIAGNOSES REDACTED].>-No behaviors; -No anti-anxiety medications administered during the seven day look back period. Review of the resident's care plan, dated 12/4/18, shows staff documented the resident has the potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. Review of the resident's physician's orders [REDACTED]. Staff documented the order as open ended, and did not document a clinical rationale for extending the order beyond 14 days. Review of the resident's Pharmacist Medication Regimen Review, dated 3/6/18 and 10/24/18, showed the pharmacist documented: -On 3/6/18 the pharmacist recommended please put a 14-day stop on Resident's PRN [MEDICATION NAME] orders (or may write for a longer duration as long as it is specific; cannot be indefinite due to new CMS regulations; if writing for a longer duration you must include rationale in the patients' medical record); -On 10/24/18 the pharmacist recommended please take the following action described below: see report for request to add stop date or duration of therapy to the PRN [MEDICATION NAME] order per CMS regulation. Review of the residents' medical chart showed the physician did not include a rationale or stop date for the [MEDICATION NAME] on 3/6/18. Further review of the resident's medical chart showed a note to Attending Physician/Prescriber, signed 11/28/18, indicating the physician agreed to a stop date of 3 months due to end of life care. Additional review showed staff did not transcribe the stop date order to the resident's POS. 3. Review of Resident #24's Physician order [REDACTED]. The order is dated 11/18/18. Staff documented the order as open ended, and did not document a clinical rationale for extending the order beyond 14 days. 4. Review of Resident #28's POS, dated (MONTH) (YEAR), showed the physician ordered [MEDICATION NAME] 0.5 mg every four hours PRN. The order is dated 10/31/18. Staff documented the order as open ended, and did not document a clinical rationale for extending the order beyond 14 days. 5. Review of Resident #64's POS, dated (MONTH) (YEAR), showed the physician ordered [MEDICATION NAME] 0.5mg twice a day PRN. The order is dated 9/21/18. Staff documented the order as open ended, and did not document a clinical rationale for extending the order beyond 14 days. 6. During an interview on 12/07/18 at 11:51 AM, Licensed Practical Nurse (LPN) A said staff are expected to obtain a stop date for all PRN [MEDICAL CONDITION] medications. He/She said the charge nurses are expected to follow up on orders with the physician. During an interview on 12/07/18 at 2:03 PM, the Director of Nursing (DON) said that all PRN medication must have the 14 day stop date due to new regulations. He/she said that if a doctor is against a GDR then the doctor needs to have a face to face with the resident and provide documentation as to why the medication is to continue as prescribed. He/she said a line through a GDR request is not an appropriate response. He/she said that the nurse that receives an order or change from a doctor updates the system to reflect the new changes and they should be updated immediately.

Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, five errors occurred, resulting in a 19% error rate, which affected five sampled residents (Resident # 1, Resident #10, Resident # 22, Resident #23, and Resident #44). The facility census was 85. 1. Review of the facility's Insulin (injectable medication to lower blood sugar) Administration Policy, revised (MONTH) 2014, showed staff are directed to depress the plunger of the insulin administration pen and remove the needle after approximately five seconds. Review of the facility's How to Use An Insulin Pen handout, dated (YEAR), showed staff are directed to clear out the air out of the pen by doing the following prior to administration: -Turn the dose dial to 2 units; -Hold the pen so the needle is up in the air; -Push the end of the pen in to clear the air; and -Watch the tip of the needle for a drop of insulin; -Inject the insulin slowly until dial reads zero; -If using a pen needled larger than 8 mm let go of the pinch of skin and wait a few seconds. 2. Review of manufacturer's recommendations for an insulin [MEDICATION NAME], dated 2009, showed the manufacturer directed the following steps to administer insulin: -Dial two units; -Hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to the top of needle; -Press the push button on your syringe as far as it will go until a drop of insulin appears; -Dial the number of units you need to inject; -Inject the insulin by pressing the push button all the way in; -Leave the need under your skin for at least 10 seconds after injecting your insulin. 2. Review of Resident #1's physician order [REDACTED]. Observation on 12/6/18 at 11:17 A.M., showed Certified Medication Technician (CMT) G took the insulin pen out of the medication cart and dialed six units of insulin without first priming it. Further observation showed the CMT held the insulin pen for approximately four seconds, not ten seconds, after the final click of the pen. 3. Review of Resident #10's POS, dated (MONTH) (YEAR), showed an order to administer Insulin [MEDICATION NAME] 100 mL 14 units plus sliding scale at meals. Observation on 12/6/18 at 11:40 A.M., showed CMT G took the insulin pen out of the medication cart and dialed 22 units of insulin without first priming it. Further observations showed the CMT held the insulin pen for approximately four seconds, not ten seconds, after the final click of the pen. 4. Review of Resident #22's POS, dated (MONTH) (YEAR), showed an order to administer Insulin [MEDICATION NAME] 100 mL eight units plus sliding scale before meals. Observation on 12/6/18 at 11:25 A.M., showed CMT G took the insulin pen out of the medication cart and dialed 14 units of insulin without first priming it. Further observations showed the CMT held the insulin pen for approximately four seconds, not ten seconds, after the final click of the pen. 5. Review of Resident #23's POS, dated (MONTH) (YEAR), showed an order to administer Insulin [MEDICATION NAME] 100 mL on a sliding scale four times a day. Observation on 12/7/18 at 11:21 A.M., showed CMT H removed the insulin pen from the medication cart and dialed four units of insulin without first priming it. 6. Review of Resident #44's POS, dated (MONTH) (YEAR), showed an order to administer Insulin [MEDICATION NAME] 100 mL 11 units three times a day. Observation on 12/7/18 at 11:21 A.M., showed CMT H took the insulin pen out of the medication cart and dialed 11 units of insulin without first priming it. 7. During an interview on 12/6/18 at 11:17 A.M., CMT G said staff are directed to only prime the pen the first time they use it and after that they do not need to. During an interview on 12/7/18 at 11:40 A.M., CMT H said he/she has heard two different answers on whether to prime before use or not. He/she said that he/she asked other CMT's and was told that priming just wastes insulin. The CMT said the Director of Nursing (DON) has not instructed him/her to prime the pens either. During an interview on 12/7/18 at 2:03 P.M., the DON said staff should prime insulin pens when first opened for use but not after that. He/she said staff should hold the pen in place for five to ten seconds before removing the needle from the resident's skin to allow all the medicine to enter the body.

Based on record review and interviews, the facility staff failed to ensure residents were allowed to make choices about aspects of their lives in the facility. Facility staff failed to allow one resident (Resident #1), who was his/her own responsible person to smoke and took the resident right to smoke as a consequence for his/her behaviors for two weeks. The facility census was 88. 1. Review of the facility's Smoking Policy, dated (MONTH) of (YEAR), showed the following: -Staff shall consult with the attending physician and the Director of Nursing to determine if safety restrictions needs to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation; -The facility may impose smoking restrictions on a resident at any time if it is determined the resident cannot smoke safely with the available levels of support and supervision; -Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking; -Resident's may not keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. Violation may lead to revocation of smoking privileges. 2. Review of the facility's policy on Resident's Rights, dated (MONTH) of (YEAR), showed the policy stated, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -Self Determination; -Exercise his/her rights as a resident of the facility and as a citizen of the United States; -Be supported by the facility in exercising his/her rights; -Exercise his/her rights without reprisal from the facility. 2. Review of Resident #1's face sheet, showed the resident is his/her own responsible party. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment, dated 10/10/18, showed the staff assessed the resident as follows: -Does not have cognitive impairments. -No behaviors exhibited by the resident. Review of the resident's smoking assessment, dated 10/8/18, showed staff assessed the resident as potentially an unsafe smoker. Staff documented the reason as the resident begs and borrows smoking materials from other residents, and smokes in unauthorized smoking areas. During an interview on 11/7/18 at 1:40 P.M., the resident said, I had my smoking privileges taken away for two weeks and it pissed me off. I think it is stupid, we shouldn't have to wait to go smoke. During an interview on 11/7/18 at 11:02 A.M., The Social Service Director (SSD) said the resident was on smoking restriction. The resident was caught smoking unsupervised. The SSD said he/she and the administrator placed the resident on a two week smoking restriction. The SSD said the resident was not allowed to go out and smoke with the group supervised while he/she was restricted to smoke. During an interview on 11/7/18 at 1:59 P.M., Licensed Practical Nurse (LPN) A said he/she did not see the resident smoking. LPN A said he/she could smell smoke. The LPN said he/she asked the resident to give him/her the cigarettes and the resident said he/she didn't have any. LPN A said the resident had an empty pack of cigarettes and a lighter on him/her. During an interview on 11/7/18 at 2:14 P.M., the administrator said the resident's smoking privileges were revoked for two weeks. MO 167